CEP Workshop Series 2013 Module 4: Assessment  

Fraser Todd and Michelle Fowler 2013

Workshop Introduction  

Workshop Agenda  

Mihi and Introductions

Housekeeping & Workshop overview

Levels of Assessment

Screening

Brief Assessment

Comprehensive Assessment and Formulation

Action Planning

Three Dimensions of CEP Practice  Spirit – Principles - Techniques:

Spirit  

7 Key Principles

Techniques

1. Cultural Considerations

2. Recovery & Well-being

3. Engagement 4. Motivation

5. Assessment

6. Management

7. Integrated Care

Person-focused care

Well-being orientated care Integrated care

Walk the Talk

Exercise 1: Mindfulness Introduction  

Levels of Assessment and Intervention  

Principle 5: Assessment  Stepped Care:

Step  1  Primary  Care  with  Support  

Basic  Psychotherapy    Medica7on  

+  Brief  AOD  Interven7on  

Step  2  CEP  Capable  MH  or  AOD  Teams  

Step  3  Highly  capable/enhanced    

specialist    teams  

Te  Ariari  Approach  Focus  on  common    individualised  

underlying  factors  

Combine  standard  MH  and  AOD  treatments  

+  MI/CBT  +  standard  approaches  

Increasing  Treatment  Intensity  

Mild  dependence/problems  

Principle 5: Assessment  Levels of Assessment:

Step  1  

Screening  

Step  2   Step  3  

Comprehensive  Assessment  1  

 Mul7-­‐dimensional    /Comprehensive    Assessment  2  

Brief  Assessment  

Increasing  Problem  Complexity  

No  further  ac7on   Brief  Interven7on  Step  3+  

Moderate-­‐Severe  

Screening  

Principle 5: Assessment  Recommended Screening Instruments:

•   WHO-­‐ASSIST  •   Substances  and  Choices  Scale  (SACS)  -­‐  adolescents  •   AUDIT  (alcohol  only)  •   Modified  MINI  Screen  for  mental  health  •   EIGHT  Gambling  Screen  

Exercise 2: Screening  

See  workbook  

Brief Assessment and Intervention  

Principle 5: Assessment  Brief Assessment - Structure:

History  1.  Demographics  2.  Current  use  -­‐  quan7ty/frequency  in  the  past  six  months  3.  Beginnings  -­‐  age  at  1st  use,  1st  regular  use,  first  alcohol-­‐related  problem  4.  PaXern  –  paXern  of  use  since  onset  5.  Dependence  -­‐  DSMIV  criteria  to  the  heaviest  six  month  Period  of  use  6.  Other  drug  use    7.  Treatment  -­‐  brief  A&D  treatment  history  8.  Psychiatric  -­‐  brief  psychiatric  history  9.  Medical  -­‐  current  significant  medical  condi7ons  10.  Family  History  (AOD,  MH)  11.  Miscellaneous  -­‐  is  there  anything  else  you  would  like  to  tell  me?  12.  Readiness  to  Change  

Examina.on  General  Appearance  

Wkbk  32  

Principle 5: Assessment  DSMIV Abuse Criteria:

A.  A  maladap7ve  paXern  of  substance  use  leading  to  clinically  significant  impairment  or  distress,  as  manifested  by  one  (or  more)  of  the  following,  occurring  within  a  12-­‐month  period:  

Recurrent  substance  use:  1.  Resul7ng  in  a  failure  to  fulfill  major  role  obliga7ons  at  work,  school,  or  home  

2.  In  situa7ons  in  which  it  is  physically  hazardous  

3.  Substance-­‐related  legal  problems  

4.  Con7nued  substance  use  despite  having  persistent  or  recurrent  social  or  interpersonal  problems  caused  or  exacerbated  by  the  effects  of  the  substance  

B.  Never  met  criteria  for  Substance  Dependence  for  this  class  of  substance  

Principle 5: Assessment  DSMIV Dependence Criteria:

1.  Alcohol  taken  in  larger  amounts  or  for  longer  periods  of  7me  than  intended  

2.  Persistent  desire/unsuccessful  aXempts  to  cut  down/control  alcohol  use  

3.  A  great  deal  of  7me  spent  in  ac7vi7es  necessary  to  get,  drink  or  recover  from  its  effects  

4.  Important  social,  occupa7onal  or  recrea7onal  ac7vi7es  given  up/reduced  because  of  alcohol  use  

5.  Con7nued  use  despite  knowledge  of  having  a  persistent  or  recurrent  medical  or  psychological  problem  likely  to  have  been  caused  or  exacerbated  by  alcohol  

6.  Tolerance  -­‐  using  a  lot  more  to  get  the  same  effect,  or  reduced  effects  (DSMIII  =  50%)  

7.  Withdrawal  symptoms  or  relief  use  

Wkbk  33  

Principle 5: Assessment  DSM5 Substance Use Disorder Criteria:

•   11  criteria  

 Abuse  +  Dependence  

 -­‐  Legal  

 +  Craving    

Principle 5: Assessment  Brief Intervention – FRAMES for AOD:

(Ask  permission)  

Feedback    •   Feedback  based  on  screening  instrument/brief  assessment  re  substance  use  

Responsibility  •   Acknowledge  the  client  is  responsible  for  their  own  behaviour  and  decisions  

Advice  • Clear  objec7ve  advice  regarding  how  to  reduce  harms  associated  with  con7nued  use  

Menu  •   Menu  of  op7ons  or  strategies  to  reduce/stop  use  

Empathy  • Support  self-­‐efficacy  (MI)  

Summarise  •   Summarise  and  reflect  clients  concerns  

(Nego7ate  follow-­‐up)  

Principle 5: Assessment  HPA Safe Drinking Guidelines:

Reduce  long-­‐term  health  risks  by  drinking  no  more  than:  

Females:    2  standard  drinks  a  day    4  standard  drinks  on  any  single  occasion    10  standard  drinks  a  week  

Males:    3  standard  drinks  a  day      5  standard  drinks  on  any  single  occasion    15  standard  drinks  a  week  

and  at  least  two  alcohol-­‐free  days  every  week.  

Advice  for  pregnant  women  or  those  planning  to  get  pregnant:    no  alcohol  for  pregnant  women  or  those  planning  to  get  pregnant    (no  known  safe  level  of  alcohol  use  at  any  stage  of  pregnancy)  

Principle 5: Assessment  HPA safe drinking guidelines:

Principle 5: Assessment  Standard drinks:

Standard

 Beer    335ml  can  of  4%    

Wine    100ml  glass  of  12.7%  

Spirits  700ml  40%  

1

1

1

22  

Spirits  Double  nip   Wine    

750l  boXle  of  13%  

7.7  

Principle 5: Assessment  Standard Drinks - Beer:

Principle 5: Assessment  Standard Drinks – Wine:

Principle 5: Assessment  Standard Drinks – Wine & RTD’s:

Principle 5: Assessment  Standard Drinks - Spirits:

Principle 5: Assessment  Brief Alcohol Intervention:

Step  1:  Summarise  Assessment  Findings  •   Drinking  paXern  (quan7ty  and  frequency)  •   Drinking-­‐related  problems  •   Symptoms  of  dependence  •   Presence  of  contra-­‐indica7ons  •   Posi7ve  family  history  

Step  2:  Brief  Tutorial  •   Outline  ALAC  drinking  guidelines  •   Educate  about  what  is  a  standard  drink  •   Relate  these  guidelines  to  their  own  drinking,  by  calcula7ng  number  of  standard  drinks  consumed  per  session/week,  and  presence  of  contraindica7ons  (driving,  liver  damage  etc)  •   Give  the  informa7on  that  about  20-­‐30%  of  New  Zealanders  misuse    alcohol  •   Invite  their  comment  

Step  3:  Giving  Advice  •   Advise  of  risk  of  con7nued  heavy  drinking  (individualise)  •   Advise  drinking  within  the  ALAC  drinking  guidelines  which  may  include  abs7nence  •   In  an  engaging  interac7ve  way,  suggest  several  drinking  behaviour  changes    

Step  4:  Nego.a.ng  Change  • Nego7ate  what  a  new  drinking  goal  and/or  change  in  drinking  behaviour  will  be  • Nego7ate  how  this  reduc7on  will  be  brought  about  • Nego7ate  when  a  review  of  this  goal  (normally  less  than  three  months)  can  occur  

Wkbk  35  

Principle 5: Assessment  Strategy for the Assessment of Mental Health Problems:

1.  For  condi7ons  where  there  is  a  clear  trigger  or  onset  (e.g.  PTSD)  

2.  For  condi7ons  where  there  is  NO  clear  trigger  or  onset  

1.  Onset   2.  Dx  at  Maximal  Intensity  

4.  Current  func7on  and  Dx  criteria  

3.  Periods  symptoms  free  or  mild  

1.  Current  func7on  and  Dx  criteria  

2.  Periods    like  this  in  the  past?    

4.  Course  (mild/no  symptoms)  

3.  Onset  (vague)  

The Comprehensive Assessment & Aetiologicl Formulation  

Principle 5: Assessment  Assessing the relationship between Mental Health and Substance Use:

1.  Likely  rela7onship  between  substances  and  MH

2.  Timing  of  onset  

3.  Family  history    

4.  Symptoms  during  abs7nence    

Principle 5: Assessment  Assessing the relationship between Mental Health and Substance Use:

Primary  versus  Secondary?  

alcohol   Major  depressive  sx  

Cannabis/s7mulants   psychosis  

Bipolar   SUDS    

PTSD   SUDS  (esp  alc)  

Social  phobia   SUDS  (esp  alc)  

Principle 4: Assessment  Functional analysis:

The  Payoff  Matrix  

Using  substance   Not  using  substances  

Advantages  

Disadvantage  

What  the  behaviour  (substance  use)  maximizes  and  minimizes  in  a  person’s  life  

Principle 5: Assessment  TImelines:

Exercise 4:  

See  Workbook  Pg  46  

The Aetiological (Causal) Formulation  

Principle 5: Assessment  The Opinion:

Three  perspec.ves  given  equal  weight:  

 1.  Diagnos7c  (nomothe7c)  

 2.  Individualised  (idiographic)  

 3.  Ae7ological  (causal)    

Principle 5: Assessment  :

•  INTEGRATES  mul7ple  theore7cal  perspec7ves  

•  makes  MEANING  of  tangata  whaiora’s  situa7on  •  HEALING  in  its  own  right  

•  iden7fies  important  DEEPER  factors  that  are  important  targets  of  treatment  •  EXTENDS  the  clinician  beyond  commonly  recognized  paXerns  

•  grows  clinicians  INTUITION  •  TRANSITIONS  novice  to  expert  assessor  

Why is the Formulation Important?  

1.  Iden7fy  key  explanatory  factors  from  history  

2.  Draw  a  4x4  Grid  

4.  Enter  factors  in  each  box  of  the  grid  

3.  Label  the  grid:    bio/psycho/social/spiritual  predisposing/precipita7ng/perpetua7ng/protec7ng  

5.  Four  paragraphs  to  make  a  narra7ve  paXern/predisposing&precipita7ng/perpetua7ng/protec7ng  

How Do You Do a Formulation?  

Predisposing (Vulnerability)!

Precipitating (Triggers)!

Perpetuating (Maintaining)!

Protecting (Strengths)!

Biological!

Psychological!

Social!

Spiritual!

The 4x4 Grid  

•  Chose  factors  that  predict  treatments  

•  No  right  or    placement  in  grid  •  Specula7ve  but  evidence-­‐informed  

•  Basic  -­‐  use  whatever  models  you  are  familiar  with    •  Advanced  -­‐  use  complex,  evidence-­‐informed  models  

Choice of Factors  

PaXern:  Descrip(on  of  the    pa0erns  of  the  presenta(on  e.g.  chronic,  relapsing,  mul(-­‐problem  self-­‐sustaining  system,  intermi0ent  etc    

Predisposing  and  Precipita7ng  Factors:  

Perpetua7ng  Factors:  

Protec7ng  Factors:  

Four Paragraphs  

The  main  targets  are  ooen  the  perpetua7ng/maintaining  and  protec7ve/strengths  factors    

Priori7ze:  Urgent  issues  (safety  &  stabiliza7on),  serious  problems,  pivotal  issues  from  the  formula7on,  easily  achieved  goals  

Set  key  goals  for  early,  middle,  late  and  independence  stages  of  treatment  in  decreasing  detail  

Goal Setting  

Exercise 4: Rachel – Aetiological Formulation  

See  Workbook  pg  37  

Aetiological Models  

"   Normal  varia7ons  -­‐  polymorphisms  "   e.g.  bipolar  vulnerability  

๏  impaired  PFC  func7oning  -­‐  aXen7on,  mood  modula7on  

๏  increase  in  behavioural  approach  system  (BAS)  -­‐  goal  mo7va7on,  perfec7onism  ๏  physiological  arousal  

"   Kendler’s  four  MH  gene7c  vulnerabili7es  

Major Mental Illness! Personality!

Internalizing!

Externalizing!ASPD   BPD  

Genes  

gene7c  vulnerability  

externalizing  factor  

externalizing  behaviour  /  non-­‐specific  childhood  behaviour  disinhibi7on  

impaired  aVen.on  =  impaired  coping  

emo7on  dysregula7on  

ADHD   Substance  Use   Conduct  Disorder  

(ASPD)  

30%  of  bipolar  

Efforqul  control  +  impulsivity   (nega7ve  urgency)  

Externalising Behaviours  

THREAT  PERCEIVED  APPRAISAL   STRESS RESPONSE!

CHRONIC!

ACUTE  

HPA Activation!

Flight/Fright!

CRH/Cortisol/Adrenaline!

Prefrontal Cortex Damage!attention!working memory!emotional control!behaviour control!

Stress  

Coping  Resources   Coping  Processes  

✴  optimism!✴  mastery!✴  self-esteem!✴  social support!

Coping   +!=!

approach!v!

avoidance!

Coping  resources  lower  cor7sol/  physiological  ac7va7on  

Lessens  the  impact  of  chronic  stress  

Coping  resources  predict  more  approach  coping  

Emo7onal  social  support  =  oxytocin  =  powerful  anxioly7c  

Approach  coping  =  lower  stress  

Avoidance  coping  =  increased  stress  

Coping  

Oxytocine  

Social Support

Emotional vulnerability heightened sensitivity and reactivity, delayed return to baseline high anxiety temperament a crucial predisposing factor

Invalidating environment punishing, ignoring or trivializing of thoughts and emotions abuse

Emotional dysregulation intense experiences and expressions of emotion

Borderline Personality Disorder 1  

Emotional vulnerability

Invalidating environment Emotional dysregulation

Disrupted emotional, cognitive and behavioural responses

Maladaptive patterns of coping (self-harm, binge eating, substance abuse)

Borderline Personality Disorder 2  

Mild genetic influence – both for anxiety in general and for social anxiety

Temperament – behavioral inhibition -  children respond to new situations with caution withdrawal and a tendency not to avoid

Cognitive/Thinking Distortions in social information processing and thoughts, attitudes and beliefs = thoughts that social interactions will lead to negative outcomes

Anticipate negative outcomes, evaluate their own performance more negatively higher level of negative cognitions about social tasks – limited to social situations    Often have recurrent negative spontaneous memories of negative social interactions

Vicious cycle – see next slide

Social Phobia 1  

Social Phobia 2  

Trauma   Severity  of  trauma  Dissocia7on  

Efforqul  Avoidance  

Re-­‐experiencing  &  Intrusive  thoughts  

Numbing  &  Dysphoria  

Arousal  

Substance  Use  

Gender  (male)  Avoidant  Coping  

Tension  reduc7on  expectancies  

Rumina7on   Anger  PTSD  

PTSD