Fluent Essays

Please see attachment for assignments. There are 4 assignments All Assignments will be submitted through safe assign for plagiarism Assignment 1: At least 250 words APA format, cite scholarly sources What would you do as a counselor if you notice symptoms of addiction in a client who has NOT acknowledged using/abusing substances?    Assignment 2: At least 250 words APA format, cite scholarly sources Which should be treated first: mental disorder or the substance abuse?  You may not discuss how this is a standing issue; instead, you must choose one.   Assignment 3: At least 250 words APA format, cite scholarly sources What are some of the more common drugs used to treat people with addictions?  Argue the pros and cons of harm reduction.  Assignment 4: Discuss two (2) instruments discussed in chapter 7 that you think would or could be useful to you. Explain why.  Prepare your response in a one-page, double spaced document using formal English, APA format, and be sure to credit your source(s) of information properly. Please see chapter 7 below Textbook: van Wormer, K., & Davis, D. R. (2018). (4th ed.). Belmont, MA: Brooks/Cole, Cengage Publishing. 7-1Introduction The process of screening and assessment is changing as the addiction field moves steadily in the direction of client-centered, strength-based practices and into more diverse health care settings because of the  2013 Affordable Care Act . In the traditional framework, screening and assessment has been the centerpiece of the initial point of client contact within the agency or treatment program, where clients may spend a great deal of time filling out various assessment instruments or being interviewed by designated intake workers. This arrangement serves three purposes: it “qualifies” the client with an appropriate problem so that it is clear the client is in the right place, it allows the agency or treatment program to get reimbursed based on the client having an appropriate diagnosis, and it quickly furnishes information to the counselor who will eventually be assigned to work with the person. There are, however, unintended consequences to such an arrangement (Miller, Forcehimes, Zweben, & McClellan, 2011). Asking a lot of questions initially can set up an expectation that the agency (counselor) is the expert on the client’s condition, and given enough information, can come up with the right answer to fix the problem. Spending a lot of time on filling out assessments can delay the important business of building a trusting relationship between the client and the counselor. The delay can be especially critical if the client is not 100% motivated to be “helped.” A more strength-based approach is to find ways to integrate screening and assessment into the ongoing process of treatment and keep it centered on how exactly this information will be useful to identifying and achieving goals that reflect what the client wants. Some clients who have serious trauma history or are currently struggling to maintain survival status cannot tolerate formal questioning. The Harm Reduction Therapy Center in San Francisco, which typically works with homeless and seriously marginalized clients, conducts their formal assessments over long periods of time (Little & Franskoviak, 2010). They call this “assessment as treatment,” where the therapist continually observes and inquires about the client’s experience as the relationship builds, offering recommendations only when the clients have given their permission to do so. Using assessment tools with persons who are part of ethnic minority groups or who do not use English as a first language requires additional cautions. Measurement error can occur because not many instruments have been normed on clients of color (Blume & Lovato, 2010). When the only instruments available are those developed from the majority culture (often white college students), then care must be taken in interpreting the results. In addition, the clients may have a different cultural worldview than the Western definitions of the particular addiction. Among some Native Americans, for example, peyote use may be considered a ritualized experience, not a destructive practice associated with loss of control. Questions on assessment forms concerning hallucinations need to take into account cultural practices of some persons where participants go to great lengths to induce hallucinations for spiritual purposes. When clients and therapists speak different first languages, translation problems and misunderstandings are rampant, whether through written forms or with personal translators. As an example, the English word craving is neither easily translated into Spanish, nor is the concept easily understood (Blume, Morera, & de la Cruz, 2005). In Norway, in van Wormer’s experience, the term powerless (as in “powerless over alcohol”) was most commonly translated with the word hjelpeløs or “helpless” in English. With these cautions in mind, there are many screening and assessment tools in the addiction field that can be helpful and effective, ranging from one question screens that can be incorporated into any intake process to more complex instruments that require training and scoring. With the advent of the Affordable Care Act and the expansion of both mental health and substance use disorder benefits, screening and assessment for these problems has expanded into many health care arenas. The  SBIRT model  (Screening, Brief Intervention, and Referral for Treatment) is being advocated by SAMHSA as a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with addiction disorders and/or mental health problems. SBIRT includes the universal screening for addiction and mental health problems, further assessment and brief intervention for those at a risky or harmful level of problem, and referral to treatment for those who may have a disorder (SAMHSA, 2015). The function of screening and assessment will vary, depending on the context and environment of the first meeting with the client. Does it take place in the emergency room after a person has come in with injuries from a motor vehicle accident? Is it a meeting with a client who comes to his family doctor for an annual check-up? Does the assessment take place in prison, or a homeless shelter, or an outpatient treatment program for problem gamblers or alcohol or drug users? This chapter will describe several common brief screens and assessment tools for alcohol, drug, gambling, and mental health problems and their use in various settings. We will also suggest a toolbox of screening and assessment types of questions that can be helpful in building a relationship with the client, increasing motivation for change, assessing client strengths, and finding supports available to help clients through the change process. 7-2Screening Instruments and Strategies Screening instruments are the first step of the SBIRT process. They are tools (one question or a short series of questions) that can quickly help detect the possibility of a problem with substance use, gambling, or whatever problem is of interest. Screens cast a wide, more imprecise net than assessment tools, so sometimes people show up “positive” on a screen, when in fact they have no problem at all, or they are “negative” on a screen when they actually do have a problem. Screening questions can be asked in a variety of settings, such as the emergency room, the doctor’s office, the mental health center, and addiction treatment programs (for other disorders). Because of the Affordable Care Act, screening and brief intervention services are increasingly covered by insurance plans. However, only one of six U.S. adults, including binge drinkers, reported ever discussing their alcohol use with a health professional (McKnight-Eily, Liu, Brewer, Kanny, Lu, Denny, Balluz, & Collins, 2014). It is becoming increasingly clear that it is critical to screen for a gambling problem at a substance abuse treatment program. One recent study on 300 individuals recruited from intensive outpatient substance use treatment or methadone maintenance found that 4 out of 10 people had a DSM-5 diagnosis of Gambling Disorder (Himelhoch, Miles-McLean, Medoff, Kreyenbuhl, Rugle, Bailey-Kloch, Potts, Welsh, & Brownley, 2015). Initial studies on the implementation of SBIRT in primary care settings show positive results for reducing the frequency and intensity of alcohol use in heavy drinkers and preventing the development of many physical and mental health conditions associated with excessive alcohol use. Additional research is needed to measure the impact of SBIRT on clients who are using drugs (Sacks, Gotham, Johnson, Padwa, Murphy, & Krom, 2015). The examples that follow are screens that are short, simple, and easy to work into the intake process in any setting and context, and have a reasonable chance of screening accurately. Because of the stigma that surrounds addiction, or even the possibility of having these kinds of problems, it is a good idea to let people know that the screening questions are routine and asked of all clients. It is also helpful to first ask, “Do you sometimes drink?” or “Do you sometimes gamble?” or “Do you sometimes use drugs of any kind?” as a prescreening question to rule out people who never engage in any of these behaviors. The Lie/Bet questionnaire (Johnson, Hamer, Nora, Tan, Eistenstein, & Englehart, 1988) is valid and reliable for ruling out gambling disorders, that is, these two questions differentiate between disordered and nonproblem gambling and tell the clinician if further assessment is warranted. If the client answers “yes” to one or both questions, further assessment is needed. The Lie/Bet questions are: 1. Have you ever felt the need to bet more and more money? 2. Have you ever had to lie to people important to you about how much you gambled? A “yes” answer to either of these questions also calls for a follow-up open-ended question like “Tell me more about that …” to further understand the client’s experience. The Brief Biosocial Gambling Screener (BBGS) is the only screen that assesses for gambling disorder in a 12-month time frame, which is the frame that has been established by the DSM-5 to diagnose gambling disorder (Gebauer, LaBrie, & Shaffer, 2010). The BBGS is a three-item screen that evaluates withdrawal, lying, and borrowing money (see Box 7.1). In an evaluation of the accuracy of brief screens for gambling disorder in the substance use treatment setting, the BBGS was slightly more accurate than the Lie/Bet although both screens had excellent accuracy (Himelhoch et al., 2015). Box 7.1 Brief Biosocial Gambling Screen (BBGS) 1. During the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling? 2. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? 3. During the past 12 months, did you have such financial trouble that you had to get help from family or friends? BBGS Scoring: Answering “yes” to one or more questions indicates likely disordered gambling. Source: Gebauer, L., LaBrie, R. A., & Shaffer, H. J. (2010). Optimizing DSM-IV classification accuracy: A brief bio-social screen for gambling disorders among the general household population. Canadian Journal of Psychiatry, 55(2), 82–90. A simple one-question screen for men or women to rule out alcohol and drug problems is recommended to clinicians by SAMHSA and is used to implement the SBIRT model (OHSU, 2015). A study by Williams and Vinson (2001) found that this one question identified 86% of individuals who had an alcohol use disorder. In this screen, one or more heavy drinking days indicates the client is an at-risk drinker, and further assessment is warranted, such as the AUDIT explained below. One standard drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. (For men): “How many times in the past year have you had five or more drinks in a day?” (For women): “How many times in the past year have you had four or more drinks in a day?” With a slight change, the same question can be used with good results for ruling out illicit drug or prescription drug problems (Smith, Schmidt, Allensworth-Davis, & Suitz, 2010). The question becomes: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” Clients who answer “one or more” should receive a full drug screen (such as the DAST explained below). To quickly screen possible mood disorders, these two questions can be used: 1. “During the past two weeks, have you been bothered by little interest or pleasure in doing things?” 2. “During the past two weeks, have you been bothered by feeling down, depressed, or hopeless?” Clients who answer “yes” to either question should receive a full screen for depression (such as the PHQ-9) (OHSU, 2015). The Patient Health Questionnaire (PHQ-9) is a nine-question screen that is the most common tool used to identify depression. It is readily available for free download (www.integration.samhsa.gov/clinical-practice/screening-tools), is available in Spanish as well as a modified version for adolescents. These simple screening questions are especially helpful in primary care settings or other helping contexts (family agencies, vocational rehabilitation, child welfare, etc.) where the presenting problem is something other than problematic substance use or problem gambling. Davis recently conducted a local training with child welfare workers on problem gamblers and found that there is no gambling screen in the state-wide intake protocol. However, as the participants in the workshop pointed out, there are cases coming to their attention where problem gambling is the primary cause behind child neglect. Utilizing a simple screen could help pinpoint the problem in a timely manner. Slightly more complicated and longer screens have also proven helpful and are still simple enough to carry around in the clinician’s head in acronym form. The CAGE, developed by Ewing (1984) for screening alcohol problems, is probably the most familiar and has been validated extensively (Abbott, 2011). A later version, the CAGE-AID, changed the wording to include drug problems (Brown, Leonard, Saunders, & Papasouliotis, 1998). If the client answers “yes” to two or more questions, then further assessment is warranted: C Have you ever felt you ought to cut down on your drinking or drug use? A Have people annoyed you by criticizing your drinking or drug use? G Have you ever felt bad or guilty about your drinking or drug use? E Have you ever had a drink or used drugs early in the morning to steady your nerves or get rid of a hangover? According to Bradley and colleagues (1998), the CAGE and TWEAK were the optimal screening tests for identification of alcohol problems in women. However, effectiveness varied by ethnicity. For Black obstetric patients and for White women, questionnaires that asked about tolerance for alcohol (e.g., TWEAK) were more sensitive. For use with mixed populations, therefore, the researchers recommend TWEAK. Again, an answer of “yes” to two or more of these indicates a problem: T Tolerance: How many drinks can you hold? (six or more drinks indicates tolerance) or How many drinks does it take before you begin to feel the first effect of the alcohol? (three or more drinks indicates tolerance) W Worried: Have close friends or relatives worried or complained about your drinking in the past year? E Eye openers: Do you sometimes take a drink in the morning when you first get up? A Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? K Kut down: Do you sometimes feel the need to cut down on your drinking? The Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), is the only screening test designed and validated for international use in a wide variety of populations, cultures, and languages. It is brief, rapid, and flexible, and it can be used in many contexts: primary care health clinics, emergency rooms, outpatient clinics, jails and prisons, and other human service agencies. The AUDIT is comprised of 10 items that cover amount and frequency of drinking, alcohol dependence symptoms, personal problems, and social problems (e.g., “Have you or someone else been injured because of your drinking?”). The scoring is designed to discriminate between different levels of risk—hazardous, harmful, and possible dependence—so it can be used as a prevention tool to help clients assess their current status and the road ahead if things do not change. The AUDIT can be given to the client as a questionnaire to fill out, or it can be used as interview questions. It takes approximately two minutes to complete the AUDIT. Both versions can be downloaded for free on the Website http://apps.who.int/iris/bitstream/10665/67205/1/WHO_MSD_MSB_01.6a.pdf. This helpful Website also provides complete scoring and interpretation instructions (which are not complicated), as well as a wealth of suggestions on how to introduce the screen and use the results in a client-centered, strength-based manner. SAMHSA has developed a free SBIRT app for physicians and mental health professionals, which provides evidence-based screening questions for alcohol, drugs, and tobacco use. This includes the CRAFFT to assess substance use in adolescents, the AUDIT for alcohol use in adults, and the DAST for drug use in adults. The app can be found, along with many other SBIRT resources, on www.integration.samhsa.gov/clinical-practice/sbirt. There are also a number of Internet-based screening tools available through a simple Google search of “Alcohol Screens,” or whatever behavior you are focusing on. One good example, “About my drinking,” has been developed by Hazelden using the AUDIT as the basis for the screen (http://www.aboutmydrinking.org). Depending on how one answers the questions, the interpretation will rate your risk of alcohol-related harm and discuss possible physical consequences, prevention strategies, and reasons for seeking further assistance if indicated. As a counselor, taking this test for yourself is an easy way to be introduced to the usefulness of the AUDIT. 7-3Assessment Tools Screening and assessment are not the same process. While a screen can point you in the right direction, the assessment defines the nature of the problem and assists in developing specific treatment recommendations for addressing the problem. There are all kinds of ways to do that, ranging from simply telling the client you are “interested in what brought them in to see you and what they want to get out of your time together,” to using formal assessment tools to get a deeper picture of the client’s readiness to change, problem areas, their severity, and the client’s strengths and “recovery capital.” As Miller and his colleagues (2011) remind us, “neither screening nor diagnosis, however, provides much information about what is actually happening in a particular person’s life and substance use, why problems are emerging, and what treatment options would be most appropriate to try” (p. 71). That kind of information develops through the careful effort of building a trusting relationship with the client. As a working relationship is built, there are assessment tools that can be helpful in pinpointing the uniqueness of the person’s experience. Many times clients figure out for themselves they have a problem with substance use or gambling. Perhaps they attended a Gamblers Anonymous (GA) meeting, and chimed in with the rest of the group to answer GA 20 Questions, which are usually read aloud at every meeting. In GA, as in other 12-Step groups, it does not matter how many signs you have of the problem, or whether an expert has diagnosed you with the problem. The real issue is to figure out for yourself if you want to quit gambling. The GA 20 Questions help people figure that out (see Box 7.2) by raising their awareness of the consequences of continuing to gamble. According to GA, most compulsive gamblers will answer “yes” to at least seven of the questions. Self-described compulsive gamblers, not treatment providers or researchers, developed these questions in the 1950s. However, two researchers (Ursua & Uribelarrea, 1998) tested the Spanish version of the GA 20 Questions and found it to have high reliability and validity in discriminating between problem gamblers and social gamblers. They recommend it “as good as the best clinical and diagnostic instruments proposed at present” (p. 11). A more recent psychometric study by Toneatto (2008), using the English version, confirmed high reliability and a high correlation with the DSM-IV-R as well as the South Oaks Gambling Screen. Box 7.2 Gamblers Anonymous 20 Questions 1. Did you ever lose time from work or school due to gambling? 2. Has gambling ever made your home life unhappy? 3. Did gambling affect your reputation? 4. Have you ever felt remorse after gambling? 5. Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties? 6. Did gambling cause a decrease in your ambition or efficiency? 7. After losing, did you feel you must return as soon as possible and win back your losses? 8. After a win did you have a strong urge to return and win more? 9. Did you often gamble until your last dollar was gone? 10. Did you ever borrow to finance your gambling? 11. Have you ever sold anything to finance gambling? 12. Were you reluctant to use “gambling money” for normal expenditures? 13. Did gambling make you careless of the welfare of yourself or your family? 14. Did you ever gamble longer than was planned? 15. Have you ever gambled to escape worry or trouble? 16. Have you ever committed, or considered committing, an illegal act to finance gambling? 17. Did gambling cause you to have difficulty in sleeping? 18. Do arguments, disappointments, or frustrations create within you an urge to gamble? 19. Did you ever have an urge to celebrate any good fortune by a few hours of gambling? 20. Have you ever considered self-destruction or suicide as a result of your gambling? Source: Reprinted from the official Gamblers Anonymous Website, www.gamblersanonymous.org, with permission. Since the advent of the DSM-5 (APA, 2013), the criteria for disordered gambling has changed. One item was eliminated (“has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling”), and the threshold for diagnosis was lowered from five criteria to four criteria. In addition, instead of being classified as an impulse-control disorder it is now called a Gambling Disorder and classified as a Substance-Related and Addictive Disorder. The following is an assessment re-written from the DSM-5 criteria and phrased as “yes” or “no” questions (Himelhoch et al., 2015, p. 465): Assessment of DSM-5 Gambling Disorder Instructions: Now, I have a few questions about your gambling over the last 12 months. Please respond “yes” or “no.” 1. Over the last year, do you need to gamble with increasing amounts of money in order to achieve the desired excitement? 2. Over the last year, are you restless or irritable when attempting to cut down or stop gambling? 3. Over the last year, have you made repeated unsuccessful efforts to control, cut back, or stop gambling? 4. Over the last year, are you often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)? 5. Over the last year, do you often gamble when feeling distressed (e.g., helpless, guilty, anxious, depressed)? 6. Over the last year, after losing money gambling, do you often return another day to get even (i.e., “chasing” losses)? 7. Over the last year, do you lie to conceal the extent of involvement with gambling? 8. Over the last year, have you jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling? 9. Over the last year, do you rely on others to provide money to relieve desperate financial situations caused by gambling? Based on DSM-5 criteria, persons who scored a “yes” in four or above were considered to have Gambling Disorder. It’s interesting to compare these DSM-5 related assessment questions developed by experts to the Gambler’s Anonymous 20 Questions developed by recovering gamblers from their own experience and see the similarities and differences. A good start to finding out the nature and severity of substance use problems is to ask the client some open-ended questions about what he or she has been using, how he or she is using the substance, how often, and what have been the costs and benefits of the use. If you want to cover all the possibilities, there are many instruments available. The Alcohol and Drug Abuse Institute Library at the University of Washington maintains an extensive Website that will help you access screening and assessment instruments and  documentation  from various sources. The instruments whose validity and reliability have been well-documented are marked. The Website is http://lib.adai.washington.edu/instruments. Another source is the SAMHSA Website, which also includes suicide risk, bipolar, anxiety, and trauma screening tools. To help narrow down your many choices, Miller and colleagues (2011) recommend the following structured assessments: the Addiction Severity Index (ASI), the Alcohol Dependence Scale, the Drinker Inventory of Consequences (Drinc), the Inventory of Drug Use Consequences (InDUC), and the Severity of Alcohol Dependence Questionnaire (SADQ). An example of one of the recommended instruments that is in the public domain is The Drinker Inventory of Consequences (Drinc) (Forcehimes, Tonigan, Miller, Kenna, & Baer, 2007). Originally designed for Project MATCH, it is a 50-item questionnaire that covers physical, social, intrapersonal, impulse control, and interpersonal problem areas.  Psychometric testing  suggests it is reliable, valid, and can be clinically useful. Sample questions include some potential positives from drinking (“How often has drinking helped me to relax?”), and mostly negative possibilities (“How often has my ability to be a good parent been harmed by my drinking”). The Drinc can be downloaded free at http://casaa.unm.edu/instruments. The Inventory of Drug Use Consequences (InDUC) (Tonigan & Miller, 2002) has the same purpose and format only changed to assess drug consequences. It is also in the public domain and can be downloaded free at http://casaa.unm.edu/instruments. The Substance Abuse Subtle Screening Inventory (SASSI) (Miller & Lazowski, 1999) is a somewhat different approach to assessment instruments. Known by some as the “stealth assessment,” most of the true/false items on one side of the form do not inquire directly about alcohol or drug use. Items such as “I am often resentful,” and “I like to obey the law” can indicate whether the respondent fits the profile of a chemically dependent person in areas such as defensiveness, willingness to acknowledge problematic behavior, depressed affect, likelihood of legal problems, and so on. The reverse side of the form inquires directly about alcohol and drug use. The use of less obvious measures at the beginning of the form is designed to minimize client defensiveness. However, in a review of the effectiveness of the SASSI, no empirical evidence was found for the SASSI’s claimed unique advantage in detecting substance use disorders through its indirect (subtle) scales to circumvent client denial or dishonesty (Feldstein & Miller, 2007). 7-4Assessing Levels of Care There are several systems for assessing the appropriate level of care for a person with substance use problems. The ASAM Criteria—Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (Mee-Lee, Shulman, Fishman, Gastfriend, & Miller, Eds., 2013), formerly known as the ASAM Patient Placement Criteria is one of the most widely recognized systems for guiding addiction treatment. Over 30 states and the Department of Defense addiction programs around the world use the ASAM criteria as guidelines for assessment, service planning, placement, continued stay and transfer/discharge of individuals with addiction and co-occurring disorders (Mee-Lee, 2014). The ASAM system outlines treatment as a continuum within which there are five broad levels of care: 1. Level 0.5: Early Intervention 2. Level 1: Outpatient Treatment 3. …