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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Co-Occurring Disorders:
Integrated Dual Disorders Treatment

Integrated Dual Disorders Treatment Workbook

Chapter 7: Assessment

INTRODUCTION
Half of all people with severe mental illness also have a substance use disorder sometime in their life. Those with dual disorders tend to have more problems with symptoms and with just about every area of their lives. Integrated dual disorders treatment can help clients work toward recovery and to improve their lives. As a clinician, you first have to identify those who have dual disorders and to understand both illnesses before you can provide treatment. This chapter begins with the story of a woman with bipolar disorder and substance abuse, and the following discussion addresses both how to assess substance abuse and what aspects to assess.

VIGNETTE
Marie is a 22-year-old single unemployed woman with bipolar disorder and polysubstance use disorder. She has had brief contacts with the mental health center following two hospitalizations for mania, but her story begins with a subsequent emergency room visit.

Picked up by the police for disturbing the peace, Marie was brought to the local emergency room for evaluation because she was talking about escaping from demons. On examination, she was dirty, agitated, and yelling as if there were someone else in the room. Although she smelled of alcohol, Marie refused to answer questions about alcohol or other drugs. Because she was clearly unable to care for herself, she was admitted to the hospital for further evaluation and treatment of psychosis and possible substance abuse.

The next day in the hospital, Marie was calmer and seemed more oriented to reality, though she continued to focus on her special relationship with God, who she felt would protect her from demons. Staff asked Marie again about her substance use and learned that she had been drinking alcohol since she was 13 years old and smoking pot since she was 15. Her urine screen on admission was positive for alcohol, cannabis, and cocaine. When shown the report of the urine screen, Marie said it must be a mistake. She reported drinking "a few" beers and smoking "a few" joints daily for the past six months, but denied using cocaine. She said she liked to get high with her boyfriend after work and then go to the bar and drink beer with him. She also said she couldn't relax and sleep if she didn't smoke pot, and that she was smoking more than she used to because she didn't get the same effect that she had before. She hadn't tried to cut down on alcohol or cannabis because she felt they hadn't caused her any problems.

Marie said she had been living at home with her parents and working part-time at a local record store until she stopped going to work two months ago. She hadn't really paid her parents for rent and there were disagreements about that. She felt that they had criticized her constantly and said they had threatened to kick her out of the house. Marie was vague about her activities over the past several months. With Marie's permission, the counselor called her parents, who verified the information Marie had given, and also told the counselor that Marie had had trouble with cocaine in the past and that in fact she had moved out of their house two months ago. They had feared she had been using drugs, and when they had confronted her about this, Marie had disappeared.

Marie spent six weeks in the hospital. Initially she refused to take medications, wandered the halls at night, and spent all day in bed. She remained preoccupied with God and wanted to end her life to join God in the fight against demons. Eventually she decided to try medication, and after three weeks, she became less focused on demons, no longer wished for death, and was getting out of bed for activities during the day.

When her boyfriend came to visit in the middle of Marie's hospitalization, the staff asked him if he had any particular concerns about Marie. He reported that they had both been on a cocaine binge for several weeks before Marie was picked up and that he had just gotten out of a detoxification program himself. Marie became angry and insisted that she had had nothing to do with cocaine.

DUAL ASSESSMENT
Assessment and treatment of mental illness and substance abuse are often done separately, at different times, by different people, and in different agencies. This is a mistake because assessing and treating dual disorders separately is ineffective. All mental health assessments should include screening for the presence of possible co-morbid substance disorders (and vice versa). If the screen is positive, in-depth assessment of both disorders should proceed. The information about substance use and mental illness - and how they interact - is needed to develop an effective treatment plan (as described in the next chapter).

IDENTIFYING SUBSTANCE ABUSE
This vignette illustrates four key principles for gathering information about substance use (see Table 1). First, because many clients with severe mental illness have substance use disorders, it is important to ask all clients about substances. This should be done in a matter-of-fact, non-judgmental way. Remember that a substance use disorder is another illness, not bad behavior. Don't forget to ask about over-the-counter and prescribed medications also, as these are often abused.

Second, it is also important to gather information from other sources in addition to the client. Like Marie, many people are reluctant to talk about behaviors that they believe others disapprove of, such as drug use or other illegal activities. Marie denied cocaine use, but cocaine was in her urine drug screen, and her parents and boyfriend confirmed that she was a heavy cocaine user. To get accurate information, multiple sources, such as family, hospital records, and urine drug screens often help. If a client refuses to give a urine drug and alcohol screen, you should probably assume they are using substances.

Third, if information gathered from other sources does not agree with what the client tells you, ask the client to help resolve the discrepancy in a non-threatening and matter-of-fact way. This does not always work (as it didn't with Marie) because clients are worried about being perceived negatively, and about legal or other negative consequences. Nevertheless, asking about substances demonstrates that the clinical team will address substance use in a straightforward way, without judgment and without punishment.

Fourth, because assessments completed soon after meeting a client or in the context of intoxication, withdrawal, or severe psychiatric symptoms are often inaccurate, it is important to continue to gather information over time. The client needs to be mentally stable and to feel safe in order to give accurate information. As the clinician or team gets to know a client and develops a trusting relationship, more information is often revealed about substance use. Thus, assessment is an on-going process that continues during treatment.

To screen for substance abuse in clients with severe mental illness, we recommend the Dartmouth Assessment of Lifestyle (DALI), which was developed for this purpose (see website http://www.dartmouth.edu/~psychrc/alcohol.html). The DALI is an 18-item questionnaire designed for persons with severe mental illness entering mental health treatment settings. A computerized version that clients can self-administer is available.

CHARACTERISTICS OF THE SUBSTANCE USE ASSESSMENT
Although the clinician in the vignette gathered some information on substance use history, it was not structured and organized to permit an accurate psychiatric diagnosis, substance use diagnosis, stage of treatment assessment, and treatment plan. The best model for organizing historical data, called a comprehensive longitudinal assessment, involves collecting information on functional status, mental health, substance use, and interactions between mental illness and substance use in a time line. The time line moves from points in the past to the present, in a step-by-step way (see table 2). You choose the points that seem to make the most sense. At every point on the time line, there are four steps: (1) a description of functioning; (2) mental health symptoms, mental health treatment, and response to that treatment; (3) substance use symptoms, substance abuse treatment, and response to that treatment; and (4) interactions between mental illness, substance use, and treatment. Be sure to ask about points in time when the client was functioning well, possibly before substance use started, or during a period of sobriety. Periods of good function will help you to understand psychiatric symptoms when substance use is stable (and vice versa) and whether treatment has been successful. As in assessing substance use, this information may need to be filled in over time, from multiple sources.

In the case of Marie, we would recommend starting with information regarding her last stable period. The vignette suggests that this occurred a few years ago when she was living with her parents and working at a record store before her substance use escalated. At that time, what medications was she taking, and how well were they helping her symptoms? What substances was she using then, and how did they affect her symptoms and her medication use? What treatment was she receiving for each disorder? Next, we would move forward in time, asking her questions to track how her symptoms progressed leading to her ending her job, closely following the sequence of events right up to the present admission. We would ask questions about her functioning at work, at home, and in relationships to be sure we understood her functioning. This provides a longitudinal assessment that emphasizes functional status and begins to help the client to perceive more accurately the effects of substance use. Below is an example of what we might learn from Marie.

Figure 1. Comprehensive Longitudinal Assessment for Marie

THE CONTEXT OF SUBSTANCE ABUSE
Another important part of the substance assessment is a detailed description of current use patterns, including factors that reinforce use (cause a person to continue to use) and consequences for continued use (which may be viewed positively or negatively by the client). This is called a contextual assessment (see table 3). Some clinicians have learned about a similar type of assessment, called a functional assessment. Because this type of assessment addresses the context of substance use, we call it the contextual assessment. You can get this information from clients by asking open-ended questions about when, where, and with whom substances are used. We try to identify the internal cues or triggers (e.g., anxiety about leaving the house or boredom) and external cues or triggers (e.g., friends smoking pot or smelling cigarette smoke) that lead to substance use. We do this by asking about feelings, thoughts, situations, and environments that precede craving or actual use of substances.

The social pattern of use is particularly important to help us plan how to help a client stop using. Does the person use substances alone, in a small tight-knit group of friends, or in a large social network? Is the person involved with other substance users in high-risk or illegal activity (e.g. trading sex for drugs)? You also need to find out what the person expects from using the substance and how people around them respond when they use. For example, how does he or she feel after using? Does he believe that there are ways in which substance use helps him or her to feel better or cope with stress? What do his friends think of his substance use? His family? Are there positive or negative consequences to using?

The more details the team gathers, the more effective and specific the treatment plan can be. Marie said she found cannabis and alcohol relaxing, and she needed to smoke cannabis to fall asleep. She did not mention any negatives to using, though the vignette suggests that her use of cocaine led to interpersonal problems, unemployment, and homelessness. Sometimes it is useful to have a client like Marie describe a recent day in her life in minute detail, so that you can experience what using substances is like for her and see the pros and cons as she sees them. Note that this approach does not imply that we accept the client's view as totally accurate, since we know that substance abuse and psychiatric symptoms can lead to misperceptions and rationalizations, but rather that we believe it is critical to understand the client's view of her world.

Don't be discouraged if you are unable to obtain this information when you first meet a client. Like Marie, many clients with severe mental illness take weeks or months to trust a clinician enough to tell them about their substance use. When clients are in a crisis like Marie was, it is important to get information about the presence of use from other sources, such as family and urine drug and alcohol screens. However, to get the detailed information for a contextual assessment, a clinician will often have to spend more time with a client getting to know them. Getting this information can occur over time during the engagement and persuasion stages of treatment.

CONTEXTUAL ANALYSIS
The information you gather about the context of substance use is used for the contextual analysis described below. We use the client's expectations, internal cues and external cues (or triggers) for using substances as well as the immediate reinforcers and longer term consequences to diagram, or analyze, the factors that are related to a client's substance use. In Figure 2, you can see an example of how a contextual analysis could be done for Marie. The figure diagrams out how Marie's depressed feelings lead to her thinking that smoking pot will cheer her up(expectancy). She smokes pot, and then feels relaxed (immediate reinforcer) but the next day is upset to realize that she spent all of her money on the pot (long term consequence). This kind of diagram will help you understand your client's substance use, plan interventions to help your client change their behavior, and talk with your clients about their substance use.

MAKING THE DIAGNOSIS
Tables 5 and 6 show the criteria to diagnose a substance use disorder according to the Diagnostic and Statistical Manual (DSM), which is used by all mental health professionals in the United States (these are described in more detail in chapter 2). Getting information to clarify whether a client has symptoms that allow you to make a diagnosis is important. We recommend using the questions contained in the Structured Clinical Interview for DSM-IV as a standardized way of asking about symptoms that form the diagnostic criteria.

Some clients may use substances but do not have a substance use disorder. For example, some clients are able to drink socially without problems for a time, though we know that this rarely lasts. In fact, the overwhelming majority of clients with severe mental illness who use substances either opt for abstinence or develop symptoms of a substance use disorder. It may be important to recognize the category "use without impairment" so that these clients can be offered good information and advice before they develop problems.

Distinguishing between substance abuse and substance dependence is important because abuse implies that the psychological and physiological syndrome of dependence has not yet taken over the client's life. Substance abuse is a behavioral disorder in which a person makes poor choices around substance use, but is still more or less in control of those choices. In contrast, substance dependence is a more serious disorder in which a person loses the ability to control substance use and has powerful impulses to seek intoxication despite past negative consequences. All substance disorder assessments should specifically gather information that pertains to DSM criteria for abuse or dependence to make an accurate substance disorder diagnosis.

In this vignette, Marie's boyfriend and parents gave information that suggested that for years she has used more cocaine than she had planned and continued to use cocaine despite multiple problems. If their information was correct, she could probably be diagnosed with cocaine dependence. Because the vignette did not give enough information about her use of alcohol and cannabis, we would want to get more information about whether she sees herself as in control of her use, or whether she has tried to stop but was unable to do so, and whether she had any subjective withdrawal symptoms. Without more information, we cannot determine for certain whether she has a cannabis or alcohol use disorder.

For clients with dual disorders, there is evidence that both substance abuse, the milder disorder, and substance dependence, the more severe disorder, lead to worsening of mental illness and to other negative outcomes like medical problems, financial problems, family problems, and homelessness over the life span. However, persons with dual disorders may require more intensive or different treatments than persons with single disorders.

STAGE OF CHANGE/STAGE OF TREATMENT
To develop an effective treatment plan, it is important to assess the person's stage of change and stage of treatment (see previous chapters). The stages are a way of describing a person's behavioral readiness for reducing or stopping substance use and their involvement in treatment. Because people often say what they think the clinician wants to hear or what they believe is socially acceptable, many report being more motivated to quit than they really feel. To avoid this problem, clinicians can ask about the client's attitudes regarding substance use and treatment but also observe behavior to understand the client's involvement in treatment, their understanding of the role alcohol and other drugs play in their lives, their current goals, and their current attempts to change substance use, including strategies, supports, and treatments. From these questions, it is possible to determine the stage of treatment and recovery as they are described in Table 3 on page 32.

Effective treatments are different at each stage. What helps in the early engagement phase is very different from what helps in the active treatment phase. In this vignette, the clinicians need to get more information to make an assessment of Marie's stage, but it appears that she is still in the engagement stage. By identifying the stage of treatment, clinicians can match treatments to the client's definition of the problem, her individualized goals, and her current readiness to consider change.

Recommended reading
We recommend Assessment of Addictive Behaviors. Dennis D. Donovan and G. Alan Marlatt (Eds.) New York, Guilford Press, 1988. The introductory chapter on assessment of addictive behaviors is outstanding, and the book also contains many chapters on specific drugs and approaches that are quite good.

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