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Assessment (Part II)
Contributor: Yvette McBride Thomas
Assessment—the procedures and processes of collecting information and measures of human behavior outside of test data .
- Can be obtained “through a variety of formal and informal techniques including standardized tests, diagnostic interviews, projective personality measures, questionnaires, mental status examinations, checklists, behavioral observation, and reports by significant others (medical, educational, social, legal, etc.)”
- The concept of assessment emphasizes the humanness of counseling…a total picture of the person being evaluated.
- “The term assessment is being used increasingly to refer to the intensive study of an individual, leading to recommendations for action in solving a particular problem.”
- The goal of the assessment process is a comprehensive evaluation of individuals, usually in the present.
- Often it includes a formulation of a treatment plan that will result in positive and predictable outcomes.
- Ways to conduct assessments include:
- Structured clinical interviews
- DSM-IV-TR (2000)—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, published by the American Psychiatric Association (APA)
- Mental Status Exam (MSE) is being “increasingly used by counselors in work settings requiring assessment, diagnosis, and treatment of mental disorders”
- Overall, assessment is crucial because it allows counselors not only to determine what a client’s problem is but to learn the client’s orientation to problem solving.
Resource: Gladding, S.T. (2011). Counseling: A comprehensive profession (7th ed.). Upper Saddle, NJ: Pearson-Merrill.
7. Documentation
Documentation involves the recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data.
The competencies in this area, are:
1. Demonstrate knowledge of accepted principles of client record management.
- Regulations pertaining to client records.
- The essential components of client records, including release forms, assessments, treatment plans, progress notes, and discharge summaries and plans.
- Composing timely, clear, complete, and concise records that comply with regulations.
- Documenting information in an objective manner.
- Writing legibly.
- Using new technologies in the production of client records.
2. Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties. Our knowledge and skills in this area, are:
- Federal, State, and program confidentiality rules and regulations.
- The application of confidentiality rules and regulations.
- Confidentiality rules and regulations regarding infectious diseases.
- Apply infectious disease regulations as they relate to addictions treatment.
- The legal nature of records.
- Request, prepare, and complete release of information when appropriate.
- Protect and communicate clients’ rights.
- Explain regulations to clients and third parties.
- Provide security for clinical records.
- Willingness to seek and accept supervision regarding confidentiality rules and regulations.
- Respect for clients’ rights to privacy and confidentiality.
- Commitment to professionalism.
- Recognition of the absolute necessity of safeguarding records.
3. Prepare accurate and concise screening, intake, and assessment reports. Essential elements of screening, intake, and assessment reports, include:
- psychoactive substance use and abuse history
- physical health
- psychological information
- social information
- history of criminality
- spiritual information
- recreational information
- nutritional information
- educational or vocational information
- sexual information
- legal information
4. Record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.
- Current Federal, State, local, and program regulations.
- Regulations regarding informed consent.
5. Record progress of client in relation to treatment goals and objectives.
- Appropriate clinical terminology used to describe client’s response to intervention and progress made toward completing treatment goals and objectives.
- How to review and update records:
- Prepare clear and legible documents.
- Document changes in the treatment plan, client status, client response to and outcome of interventions, level of care provided, and discharge status.
- Use appropriate clinical terminology and standardized abbreviations.
- Note client’s strengths and limitations in achieving treatment goals.
- Record client’s response to and outcome of interventions.
- Record changes in client’s status, behavior, and level of functioning.
- Note limitations of treatment provided to client.
6. Prepare accurate and concise discharge summaries. The components of a discharge summary, include:
- client profile and demographics
- presenting symptoms
- diagnoses
- selected interventions
- critical incidents
- progress toward treatment goals
- outcome
- continuing care plan
- prognosis
- recommendations
6. Client, Family, and Community Education
Addiction counselors play an important role in providing clients, families, significant others, and community groups with information about the risks involved with alcohol, tobacco, and other drugs use, as well as available prevention, treatment and recovery resources.
Our competencies in this area are:
- To provide education both formal and informal about substance abuse prevention and treatment programs, and the recovery process. In order to help people from multicultural backgrounds, we need to keep in mind:
- Cultural differences among diverse communities.
- Cultural differences in substance use behaviors.
- Delivery of educational programs that are culturally relevant.
- Research and theory on prevention of substance abuse problems.
- Learning styles and teaching methods that we can adapt to our clients.
- How to facilitate discussions in a safe and respectful environment.
- How to preparing outlines and handout materials.
- How to make public presentations to deliver the information effectively.
- Cultural issues in planning prevention and treatment programs.
- Age and gender differences in substance use patterns.
- Culture, gender, and age-appropriate prevention, treatment, and recovery resources.
- Awareness of our own cultural biases.
- To describe the risk and protective factors that increase and decrease the likelihood for an individual, community, or group to develop a substance use disorder. Our knowledge in this area includes:
- Risk and protective factors for the onset of substance use disorders.
- How to present the issues from a non-judgmental perspective.
- To describe the warning signs, symptoms, and the course of substance use disorders. We must be familiar with:
- The continuum of use and abuse, including the warning signs and symptoms of a developing substance use disorder.
- The current Diagnostic and Statistical Manual of Mental Disorders (DSM) categories or other diagnostic standards associated with psychoactive substance use.
- To describe how substance use disorders affect families and significant others. We need to educate our client about:
- How psychoactive substance use by one family member affects other family members or significant others.
- The family’s influence on the development and continuation of a substance use disorder.
- The role of the family, couple, or significant others in treatment and recovery.
- To describe the continuum of care and resources available to the family and significant others. Our goals are:
- To present available treatment options, including local health, allied health, and behavioral health resources.
- To motivate both family members and the client to seek out resources and services from the full continuum of care.
- To describe different treatment modalities.
- To identify and make referrals to local health, allied health, and behavioral health resources.
- Although this may sounds easy to do, we need to keep in mind the difficulties families and significant others go through when seeking help. We must work from a strengths-based principle, which emphasizes client autonomy.
- We must be familiar with the models for substance abuse prevention and treatment, and recovery from substance use disorders.
- Awareness of our own biases when presenting the information.
- Delivering educational sessions.
Answers to Some FAQs
Contributor: Yvette McBride Thomas
1. What happens if a patient has no progress for a long time?
Sometimes when a patient goes along time with no progress it can be one or a combination of several things: 1) The patient has become comfortable with the progress made up to that point and could possibly be afraid to move on; 2) sometimes patients sabotage their own progress because they are not use to having any success in their lives; 3) the relationship with the counselor may be the only positive relationship in their lives and they don’t want it to end. This list is not limited; it will be up to the counselor to help the client discover why they are not progressing further. This is where the stages of change will be very helpful and ASAM dimension 4. Treatment acceptance/resistance (Process of change). It is sometimes helpful to walk the client through each stage and help them discover where they are in their recovery and why they are stuck. Being stuck is a setup for relapse and if the client is unaware of their relapse triggers they may return to using and sometimes they will relapse to stay in treatment.
2. Will treatment be stopped?
Treatment usually will not be stopped until all avenues have been explored. Using the ASAM guidelines will help identify the possible challenges facing the client. They may not know what the challenge may be or if they do they do not know how to put it into words. If the client is really resistant to treatment and is not ready to make the necessary change or do the required work they will discontinue treatment on their own.
ASAM Dimension 4. Treatment acceptance/resistance/stages of changes:
a. Denial
b. Surrender and compliance
c. Process of recovery
d. Treatment issues
e. 12-step philosopy
f. Attitudes in recovery and addiction
g. Patient in need of information on treatment and program tools
3. Or would treatment be changed to something else?
The treatment goals can change based on the new information discovered. This may also be an opportunity to introduce the client to a new person via referral and explain to the client that based on the treatment changes it maybe beyond your scope of expertise (except when the client states that there has been some physical/sexual abuse) You can also suggest that the client attend a 12step support meeting for a specific area (i.e. ACOA or Coda)
5. Counseling – Part III Family and Significant Others Counseling
This is third component of the 5th practice domain: Counseling. (check out Part I Individual Counseling and Part II Group Counseling)
Addictions affect the person who has them and also her/his family members and significant others. Counseling addicted families should be required, and offered, as part of every treatment service. Unfortunately, some treatment agencies can only afford treating the person with the addiction, and due to lack of resources and funding they cannot get the family and significant others involved.
Regardless for this situation, substance abuse counselors can offer a competent practice when they have the following knowledge:
- Systems theory and dynamics.
- Dynamics associated with substance use, abuse, dependence, and recovery in families and significant others.
- Interaction patterns on substance abuse behaviors.
- Cultural factors associated with family dynamics and substance abuse disorders.
- Signs and patterns of domestic violence.
Although it is difficult to accept sometimes, the truth is that family members contribute in different ways to the substance abuse behavior. It is not about putting the blame on someone, but inevitably each member of a family plays a specific role in a family’s issue; understanding family dynamics helps us understand why addiction is called a family disease.
As I mentioned in a previous post, in family counseling the client is the family as a whole, always considering individual differences. The required experience an addictions counselor must have in this area includes:
- Models of diagnosis for families
- Intervention strategies appropriate for different stages of the problem.
- Intervention strategies for violence within the family.
- Laws and resources regarding violence within the family.
- Methods for engaging family members and significant others in the treatment and recovery processes.
- Confidentiality and regulations regarding family counseling.
Our goals in family counseling are:
- To help families and significant others understand the effect of their interactions on substance use.
- To assist them in identifying and stopping harmful patterns of interaction.
- To help them learn healthy strategies and behaviors that maintain recovery and promote healthy relationships.
- To assist them with referral to appropriate support resources.
5. Counseling – Part II Group Counseling
This is the second part of the 5th practice domain, counseling (go to Part I Individual Counseling).
During group counseling, our client is the group as a whole, just as in couples counseling the client is the couple and not the individual members. However, we still have to consider individual differences when forming a group. Things to consider are:
- Group type
- Purpose of the group
- Group size
- Member selection criteria
- Group goals
- Behavioral ground rules for participating
- Outcomes
- Criteria and methods for termination or graduation from group
Group counseling is an important part of treatment. It is very common that a counselor will facilitate in a group where some of her/his clients from individual counseling will participate. A competent counselor must know:
- Group methods appropriate to help the client achieve objectives.
- The effectiveness of various models and strategies for group counseling for populations with substance abuse problems and with members of multicultural backgrounds.
- How to accommodate individual needs within the group.
- How to apply confidentiality rules in group.
- Developmental processes affecting groups over time.
- Transition stages in therapeutic groups.
- How to effectively address resistant behaviors, transference issues, and countertransference issues within group.
- How to facilitate the entry on new members and the transition of exiting members.
Group counseling could be challenging at times, especially when the counselor does not have a clear idea of what her/his role is in group. In order to conduct group counseling effectively, without getting all our energy drained in the first 10 minutes of session, we must know:
- Leadership, facilitator, and counselor methods appropriate for each group type and therapeutic setting.
- Types and uses of power and authority in group counseling.
- When and how to use appropriate power.
Documentation is part of group counseling too. We must document measurable progress toward group and individual goals; know the concepts of process and content, in order to make appropriate process interventions.
We must be able to describe and summarize the client’s behavior within group. This will help us identify the client’s progress as well as issues and needs that may require a modification in the treatment plan.
5. Counseling – Part I Individual Counseling
Counseling is a set of methods adapted to individual clients, and designed to help that client progress toward mutually determined goals about her/his recovery.
A competent counselor understands and has the ability to apply the many different models of addiction counseling. Counseling includes:
- Individual counseling
- Group counseling
- Couples counseling
- Families counseling
Individual Counseling
Our main goal is to establish a helping relationship with our client. A helping relationship is non-judgmental, which creates an environment of warmth, respect, genuineness, and empathy in which our client can feel safe to talk about the most difficult issues in her/his life.
Counseling is not about just listening people talk about their problems. Being non-judgmental is not something we decide to do, but someone we learn how to be. To accomplish this, drug addictions counselors need to know:
- Approaches to counseling that are person-centered and have demonstrated effectiveness in the treatment of substance abuse disorders
- Meaning of warmth, respect, genuineness, concreteness, and empathy ( not your personal definition, but the meaning of these concepts as they apply to the helping relationship)
- Active listening
- Transference and countertransference
Counseling is all about getting our client engaged in her/his own treatment and recovery process. Addictions counseling is not about telling people what to do and how to live their lives, or imposing our morals and values on them. As I have mentioned before, counselors need to know:
- theories and research about client’s motivation
- counseling theories to promote client engagement
- stages of change
Our goals (as counselors) in counseling, are:
- To work with our client to establish realistic and achievable goals
- To promote our client’s knowledge, skills, and attitudes towards positive change, including the maintenance of health and prevention of HIV/AIDS, tubeculosis, STDs, hepatitis C, and other infectious diseases
- To work appropriately with our client to recognize and discourage all behaviors inconsistent with the progress in recovery
- To know when, how, and why to involve the client’s significant others
- To facilitate the development of basic life and social skills
- To make constructive therapeutic responses when the client’s behavior is inconsistent with the agreed recovery goals.
- To apply crisis prevention and crisis intervention skills
LCDC Exam Review 