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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:
SpiriL
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:
SLep 1
rlmary Care wlLh SupporL
8aslc sychoLherapy
Medlcauon
+
8rlef ACu lnLervenuon
SLep 2
CL Capable MP or ACu 1eams
SLep 3
Plghly capable/enhanced
speclallsL Leams
1e Arlarl Approach
locus on common
lndlvlduallsed
underlylng facLors
Comblne sLandard
MP and ACu LreaLmenLs
+ Ml/C81
+ sLandard approaches
lncreaslng 1reaLmenL lnLenslLy
Mlld dependence/problems
Principle 5: Assessment
Levels of Assessment:
SLep 1
Screenlng
SLep 2 SLep 3
Comprehenslve AssessmenL 1
Mulu-dlmenslonal
/Comprehenslve
AssessmenL 2
8rlef AssessmenL
lncreaslng roblem ComplexlLy
no furLher acuon 8rlef lnLervenuon
SLep 3+
ModeraLe-Severe
Screening
Principle 5: Assessment
Recommended Screening Instruments:
WPC-ASSlS1
SubsLances and Cholces Scale (SACS) - adolescenLs
Auul1 (alcohol only)
Modled Mlnl Screen for menLal healLh
LlCP1 Cambllng Screen
Exercise 2: Screening
See workbook
Brief Assessment and Intervention
Principle 5: Assessment
Brief Assessment - Structure:
"#$%&'(
1. uemographlcs
2. CurrenL use - quanuLy/frequency ln Lhe pasL slx monLhs
3. 8eglnnlngs - age aL 1sL use, 1
sL
regular use, rsL alcohol-relaLed
problem
4. auern - pauern of use slnce onseL
3. uependence - uSMlv crlLerla Lo Lhe heavlesL slx monLh
erlod of use
6. CLher drug use
7. 1reaLmenL - brlef A&u LreaLmenL hlsLory
8. sychlaLrlc - brlef psychlaLrlc hlsLory
9. Medlcal - currenL slgnlcanL medlcal condluons
10. lamlly PlsLory (ACu, MP)
11. Mlscellaneous - ls Lhere anyLhlng else you would llke Lo Lell me?
12. 8eadlness Lo Change
)*+,#-+.&-
Ceneral Appearance
Wkbk 32
Principle 5: Assessment
DSMIV Abuse Criteria:
A. A maladapuve pauern of subsLance use leadlng Lo cllnlcally slgnlcanL lmpalrmenL or dlsLress,
as manlfesLed by one (or more) of Lhe followlng, occurrlng wlLhln a 12-monLh perlod:
8ecurrenL subsLance use:
1. 8esulung ln a fallure Lo fulll ma[or role obllgauons aL work, school, or home
2. ln slLuauons ln whlch lL ls physlcally hazardous
3. SubsLance-relaLed legal problems
4. Conunued subsLance use desplLe havlng perslsLenL or recurrenL soclal or lnLerpersonal problems
caused or exacerbaLed by Lhe eecLs of Lhe subsLance
8. never meL crlLerla for SubsLance uependence for Lhls class of subsLance
Principle 5: Assessment
DSMIV Dependence Criteria:
1. Alcohol Laken ln larger amounLs or for longer perlods of ume Lhan lnLended
2. erslsLenL deslre/unsuccessful auempLs Lo cuL down/conLrol alcohol use
3. A greaL deal of ume spenL ln acuvlues necessary Lo geL, drlnk or recover from lLs eecLs
4. lmporLanL soclal, occupauonal or recreauonal acuvlues glven up/reduced because of alcohol use
3. Conunued use desplLe knowledge of havlng a perslsLenL or recurrenL medlcal or psychologlcal
problem llkely Lo have been caused or exacerbaLed by alcohol
6. 1olerance - uslng a loL more Lo geL Lhe same eecL, or reduced eecLs (uSMlll = 30)
7. WlLhdrawal sympLoms or rellef use
Wkbk 33
Principle 5: Assessment
DSM5 Substance Use Disorder Criteria:
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9 :1;+<
5 ='+>#-;
Principle 5: Assessment
Brief Intervention FRAMES for AOD:
(Ask permlsslon)
?eedback
leedback based on screenlng lnsLrumenL/brlef assessmenL re subsLance use
@esponslblllLy
Acknowledge Lhe cllenL ls responslble for Lhelr own behavlour and declslons
2dvlce
Clear ob[ecuve advlce regardlng how Lo reduce harms assoclaLed wlLh
conunued use
Aenu
Menu of opuons or sLraLegles Lo reduce/sLop use
)mpaLhy
SupporL self-emcacy (Ml)
Bummarlse
Summarlse and reecL cllenLs concerns
(negouaLe follow-up)
Principle 5: Assessment
HPA Safe Drinking Guidelines:
8educe long-Lerm healLh rlsks by drlnklng no more Lhan:
?1,+<1$:
2 sLandard drlnks a day
4 sLandard drlnks on any slngle occaslon
10 sLandard drlnks a week
A+<1$:
3 sLandard drlnks a day
3 sLandard drlnks on any slngle occaslon
13 sLandard drlnks a week
+-8 aL leasL Lwo alcohol-free days every week.
Advlce for pregnanL women or Lhose plannlng Lo geL pregnanL:
no alcohol for pregnanL women or Lhose plannlng Lo geL pregnanL
(no known safe level of alcohol use aL any sLage of pregnancy)
Principle 5: Assessment
HPA safe drinking guidelines:
Principle 5: Assessment
Standard drinks:
Standard
8eer
333ml can of 4
Wlne
100ml glass of 12.7
SplrlLs
700ml 40
1
1
1
22
SplrlLs
uouble nlp
Wlne
730l boule of 13
7.7
Principle 5: Assessment
Standard Drinks - Beer:
Principle 5: Assessment
Standard Drinks Wine:
Principle 5: Assessment
Standard Drinks Wine & RTDs:
Principle 5: Assessment
Standard Drinks - Spirits:
Principle 5: Assessment
Brief Alcohol Intervention:
B%17 /C B4,,+'#$1 2$$1$$,1-% ?#-8#-;$
urlnklng pauern (quanuLy and frequency)
urlnklng-relaLed problems
SympLoms of dependence
resence of conLra-lndlcauons
osluve famlly hlsLory
B%17 DC E'#1F G4%&'#+<
CuLllne ALAC drlnklng guldellnes
LducaLe abouL whaL ls a sLandard drlnk
8elaLe Lhese guldellnes Lo Lhelr own drlnklng, by calculaung number of sLandard drlnks consumed
per sesslon/week, and presence of conLralndlcauons (drlvlng, llver damage eLc)
Clve Lhe lnformauon LhaL abouL 20-30 of new Zealanders mlsuse alcohol
lnvlLe Lhelr commenL
B%17 HC I#>#-; 28>#01
Advlse of rlsk of conunued heavy drlnklng (lndlvlduallse)
Advlse drlnklng wlLhln Lhe ALAC drlnklng guldellnes whlch may lnclude absunence
ln an engaglng lnLeracuve way, suggesL several drlnklng behavlour changes
B%17 JC K1;&.+.-; =L+-;1
negouaLe whaL a new drlnklng goal and/or change ln drlnklng behavlour wlll be
negouaLe how Lhls reducuon wlll be broughL abouL
negouaLe when a revlew of Lhls goal (normally less Lhan Lhree monLhs) can occur
Wkbk 33
Principle 5: Assessment
Strategy for the Assessment of Mental Health Problems:
1. lor condluons where Lhere ls a clear Lrlgger or onseL (e.g. 1Su)
2. lor condluons where Lhere ls KM clear Lrlgger or onseL
1. CnseL 2. ux aL
Maxlmal
lnLenslLy
4. CurrenL
funcuon and
ux crlLerla
3. erlods
sympLoms
free or mlld
1. CurrenL
funcuon and
ux crlLerla
2. erlods
llke Lhls ln
Lhe pasL?
4. Course
(mlld/no
sympLoms)
3. CnseL
(vague)
The Comprehensive Assessment
& Aetiologicl Formulation
Principle 5: Assessment
Assessing the relationship between Mental Health and Substance Use:
1. Llkely relauonshlp beLween subsLances and MP
2. 1lmlng of onseL
3. lamlly hlsLory
4. SympLoms durlng absunence
Principle 5: Assessment
Assessing the relationship between Mental Health and Substance Use:
N'#,+'( >1'$4$ B10&-8+'(O
alcohol Ma[or depresslve sx
Cannabls/sumulanLs psychosls
8lpolar SuuS
1Su SuuS (esp alc)
Soclal phobla SuuS (esp alc)
Principle 4: Assessment
Functional analysis:
GL1 N+(&P A+%'#*
uslng subsLance noL uslng subsLances
AdvanLages
ulsadvanLage
WhaL Lhe behavlour (subsLance use) maxlmlzes and mlnlmlzes ln a person's llfe
Principle 5: Assessment
TImelines:
Exercise 4:
See Workbook g 46
The Aetiological (Causal) Formulation
Principle 5: Assessment
The Opinion:
GL'11 71'$710.>1$ ;#>1- 1Q4+< R1#;L%C
1. ulagnosuc (nomoLheuc)
2. lndlvlduallsed (ldlographlc)
3. Aeuologlcal (causal)
Principle 5: Assessment
:
SKG)I@2G)B muluple Lheoreucal perspecuves
makes A)2KSKI of LangaLa whalora's slLuauon
")2:SKI ln lLs own rlghL
ldenues lmporLanL 6))N)@ facLors LhaL are lmporLanL LargeLs of LreaLmenL
)TG)K6B Lhe cllnlclan beyond commonly recognlzed pauerns
grows cllnlclans SKGUSGSMK
G@2KBSGSMKB novlce Lo experL assessor
Why is the Formulation Important?
1. ldenufy key explanaLory facLors from hlsLory
2. uraw a 4x4 Crld
4. LnLer facLors ln each box of Lhe grld
3. Label Lhe grld:
blo/psycho/soclal/splrlLual
predlsposlng/preclplLaung/perpeLuaung/proLecung
3. lour paragraphs Lo make a narrauve
pauern/predlsposlng&preclplLaung/perpeLuaung/proLecung
How Do You Do a Formulation?
Predisposing
(Vulnerability)
Precipitating
(Triggers)
Perpetuating
(Maintaining)
Protecting
(Strengths)
Biological
Psychological
Social
Spiritual
The 4x4 Grid
Chose facLors LhaL predlcL LreaLmenLs
no rlghL or placemenL ln grld
Speculauve buL evldence-lnformed
8aslc - use whaLever models you are famlllar wlLh
Advanced - use complex, evldence-lnformed models
Choice of Factors
auern: !"#$%&'()* ), -." '/0"%*# ), -." '%"#"*-/()* "121 $.%)*&$3 %"4/'#&*23
564(7'%)84"5 #"4,7#6#-/&*&*2 #9#-"53 &*-"%5&0"*- "-$
redlsposlng and reclplLaung lacLors:
erpeLuaung lacLors:
roLecung lacLors:
Four Paragraphs
1he maln LargeLs are oen Lhe perpeLuaung/malnLalnlng and proLecuve/sLrengLhs facLors
rlorluze: urgenL lssues (safeLy & sLablllzauon), serlous problems, plvoLal lssues from
Lhe formulauon, easlly achleved goals
SeL key goals for early, mlddle, laLe and lndependence sLages of LreaLmenL ln decreaslng deLall
Goal Setting
Exercise 4: Rachel Aetiological Formulation
See Workbook pg 37
Aetiological Models
normal varlauons - polymorphlsms
e.g. blpolar vulnerablllLy
! lmpalred lC funcuonlng - auenuon, mood modulauon
! lncrease ln behavloural approach sysLem (8AS) - goal mouvauon, perfecuonlsm
! physlologlcal arousal
kendler's four MP geneuc vulnerablllues
Major Mental Illness Personality
Internalizing
Externalizing
ASu 8u
Genes
geneuc vulnerablllLy
exLernallzlng facLor
exLernallzlng behavlour / non-speclc chlldhood behavlour dlslnhlbluon
lmpalred +V1-.&- = lmpalred coplng
emouon dysregulauon
AuPu SubsLance use
ConducL ulsorder
(ASu)
30 of blpolar
Loruul conLrol + lmpulslvlLy (negauve urgency)
Externalising Behaviours
1P8LA1 L8CLlvLu A8AlSAL STRESS RESPONSE
CHRONIC
ACu1L
HPA Activation
Flight/Fright
CRH/Cortisol/Adrenaline
Prefrontal Cortex Damage
attention
working memory
emotional control
behaviour control
Stress
Coplng 8esources Coplng rocesses
! optimism
! mastery
! self-esteem
! social support
Coplng
+ =
approach
v
avoidance
Coplng resources lower corusol/ physlologlcal acuvauon
Lessens Lhe lmpacL of chronlc sLress
Coplng resources predlcL more approach coplng
Lmouonal soclal supporL = oxyLocln = powerful anxlolyuc
Approach coplng = lower sLress
Avoldance coplng = lncreased sLress
Coping
M*(%&0#-1
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
G'+4,+
SeverlLy of Lrauma
ulssoclauon
Loruul
Avoldance
8e-experlenclng
& lnLruslve LhoughLs
numblng
& uysphorla
Arousal
SubsLance use
Cender (male)
AvoldanL Coplng
1enslon reducuon expecLancles
8umlnauon Anger
1Su
PTSD