No wrong door

“No wrong door” refers to formal recognition by a service system that individuals with COD may enter a range of community service sites; that they are a high priority for engagement in treatment; and that proactive efforts are necessary to welcome them into treatment and prevent them from falling through the cracks. Substance abuse and mental health counselors are encouraged to identify individuals with COD, welcome them into the service system, and initiate proactive efforts to help them access appropriate treatment in the system, regardless of their initial site of presentation. The recommended attitude is as follows: The purpose of this assessment is not just to determine whether the client fits in my program, but to help the client figure out where he or she fits in the system of care, and to help him or her get there.

Empathic detachment

Empathic detachment requires the assessing clinician to

• Acknowledge that the clinician and client are working together to make decisions to support the client's best interest
• Recognize that the clinician cannot transform the client into a different person, but can only support change that he or she is already making
• Maintain empathic connection even if the client does not seem to fit into the clinician's expectations, treatment categories, or preferred methods of working

In the past, the attitude was that the client with COD was the exception. Today, clinicians should be prepared to demonstrate responsiveness to the requirements clients with COD present. Counselors should be careful not to label mental health symptoms immediately as caused by addiction, but instead should be comfortable with the strong possibility that a mental-health condition may be present independently and encourage disclosure of information that will help clarify the meaning of any COD for that client.

Person-centered assessment

Person-centered assessment emphasizes that the focus of initial contact is not on filling out a form or answering several questions or on establishing program fit, but rather on finding out what the client wants, in terms of his or her perception of the problem, what he or she wants to change, and how he or she thinks that change will occur. Mee-Lee (1998) has developed a useful guide that illustrates the types of questions that might be asked in a person-centered assessment in an addiction setting (see Figure 4-1). (It should be noted, however, that this is not a validated tool.) While each step in this decision tree leads to the next, the final step can lead back to a previous step, depending on the client's progress in treatment.

Answers to some of these important questions inevitably will change over time. As the answers change, adjustments in treatment strategies may be appropriate to help the client continue to engage in the treatment process.

Sensitivity to culture, gender, and sexual orientation

An important component of a person-centered assessment is the continual recognition that culture plays a significant role in determining the client's view of the problem and the treatment. (For a comprehensive discussion of culturally sensitive assessment strategies in addiction settings, see the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [CSAT in development a]). With regard to COD, clinicians must remember that ethnic cultures may differ significantly in their approach to substance use disorders and mental disorders, and that this may affect how the client presents. In addition, clients may participate in treatment cultures (12-Step recovery, Dual Recovery Self-Help, psychiatric rehabilitation) that also may affect how they view treatment. Cultural sensitivity also requires recognition of one's own cultural perspective and a genuine spirit of inquiry into how cultural factors influence the client's request for help. (See also chapter 2 for a discussion of culturally competent treatment.)

During the assessment process, it is important to ascertain the individual's sexual orientation as part of the counselor's appreciation for the client's personal identity, living situation, and relationships. Counselors also should be aware that women often have family-related and other concerns that must be addressed to engage them in treatment, such as the need for child care. See chapter 7 of this TIP for a more extended consideration of women with COD as a population with specific needs. More information about women's issues is provided in the forthcoming TIP Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in development b).

Trauma sensitivity

The high prevalence of trauma in individuals with COD requires that the clinician consider the possibility of a trauma history even before the assessment begins. Trauma may include early childhood physical, sexual, or emotional abuse; experiences of rape or interpersonal violence as an adult; and traumatic experiences associated with political oppression, as might be the case in refugee or other immigrant populations. This pre-interview consideration means that the approach to the client must be sensitive to the possibility that the client has suffered previous traumatic experiences that may interfere with his or her ability to be trusting of the counselor. Clinicians who observe guardedness on the part of the client should consider the possibility of trauma and try to promote safety in the interview through providing support and gentleness, rather than trying to “break through” evasiveness that erroneously might look like resistance or denial. All questioning should avoid “retraumatizing” the client—see section on trauma screening later in this chapter and, for additional details, see the forthcoming TIP Substance Abuse Treatment and Trauma (CSAT in development d).

Safety screening

Safety screening requires that early in the interview the clinician specifically ask the client if he or she has any immediate impulse to engage in violent or self-injurious behavior, or if the client is in any immediate danger from others. These questions should be asked directly of the client and of anyone else who is providing information. If the answer is yes, the clinician should obtain more detailed information about the nature and severity of the danger, the client's ability to avoid the danger, the immediacy of the danger, what the client needs to do to be safe and feel safe, and any other information relevant to safety. Additional information can be gathered depending on the counselor/staff training for crisis/emergency situations and the interventions appropriate to the treatment provider's particular setting and circumstances. Once this information is gathered, if it appears that the client is at some immediate risk, the clinician should arrange for a more in-depth risk assessment by a mental-health-trained clinician, and the client should not be left alone or unsupervised.

A variety of tools are available for use in safety screening:

• ASAM PPC-2R identifies considerations for immediate risk assessment and recommends follow up procedures (ASAM 2001).
• ASI (McLellan et al. 1992) and Global Appraisal of Individual Needs (GAIN) (Dennis 1998) also include some safety screening questions.
• Some systems use LOCUS (American Association of Community Psychiatrists [AACP] 2000a ) as the tool to determine level of care for both mental disorders and addiction. One dimension of LOCUS specifically provides guides for scoring severity of risk of harm. See Potential Risk of Harm below.

Potential Risk of Harm

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• Risk of Harm: This dimension of the assessment considers a person's potential to cause significant harm to self or others. While this may most frequently be due to suicidal or homicidal thoughts or intentions, in many cases unintentional harm may result from misinterpretations of reality, from inability to care adequately for oneself, or from altered states of consciousness due to use of intoxicating substances. For the purpose of evaluation in this parameter, deficits in ability to care for oneself are considered only in the context of their potential to cause harm. Likewise, only behaviors associated with substance use are used to rate risk of harm, not the substance use itself. In addition to direct evidence of potentially dangerous behavior from interview and observation, other factors may be considered in determining the likelihood of such behavior such as past history of dangerous behaviors, ability to contract for safety, and availability of means. When considering historical information, recent patterns of behavior should take precedence over patterns reported from the remote past. Risk of harm may be rated according to the following criteria:

• Minimal risk of harm:

(a) No indication of suicidal or homicidal thoughts or impulses, no history of suicidal or homicidal ideation, and no indication of significant distress.

(b) Clear ability to care for self now and in the past.

• Low risk of harm:

• No current suicidal or homicidal ideation, plan, intentions or serious distress, but may have had transient or passive thoughts recently or in the past.

• Substance use without significant episodes of potentially harmful behaviors.

• Periods in the past of self-neglect without current evidence of such behavior.

• Moderate risk of harm:

(a) Significant current suicidal or homicidal ideation without intent or conscious plan and without past history.

(b) No active suicidal/homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior exists.

(c) History of chronic impulsive suicidal/homicidal behavior or threats and current expressions do not represent significant change from baseline.

(d) Binge or excessive use of substances resulting in potentially harmful behaviors without current involvement in such behavior.

(e) Some evidence of self neglect and/or compromise in ability to care for oneself in current environment.

• Serious risk of harm:

• Current suicidal or homicidal ideation with expressed intentions and/or past history of carrying out such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so, or with ability to contract for safety.

• History of chronic impulsive suicidal/homicidal behavior or threats with current expressions or behavior representing a significant elevation from baseline.

• Recent pattern of excessive substance use resulting in disinhibition and clearly harmful behaviors with no demonstrated ability to abstain from use.

• Clear compromise of ability to care adequately for oneself or to be aware adequately of environment.

• Extreme risk of harm:

• Current suicidal or homicidal behavior or such intentions with a plan and available means to carry out this behavior without expressed ambivalence or significant barriers to doing so; or with a history of serious past attempts which are not of a chronic, impulsive, or consistent nature; or in presence of command hallucinations or delusions which threaten to override usual impulse control.

• Repeated episodes of violence toward self or others, or other behaviors resulting in harm while under the influence of intoxicating substances with pattern of nearly continuous and uncontrolled use.

• Extreme compromise of ability to care for oneself or to monitor adequately the environment with evidence of deterioration in physical condition or injury related to these deficits.

Source: AACP 2000a .

None of these tools is definitive for safety screening. Clinicians and programs should use one of these tools only as a starting point, and then elaborate more detailed questions to get all relevant information.

Clinicians should not underestimate risk because the client is using substances actively. For example, although people who are intoxicated might only seem to be making threats of self-harm (e.g., “I'm just going to go home and blow my head off if nobody around here can help me”), all statements about harming oneself or others must be taken seriously. Individuals who have suicidal or aggressive impulses when intoxicated may act on those impulses; remember, alcohol and drug abuse are among the highest predictors of dangerousness to self or others—even without any co-occurring mental disorder. Determining which intoxicated suicidal client is “serious” and which one is not requires a skilled mental health assessment, plus information from collaterals who know the client best. (See chapter 8 and appendix D of this TIP for a more detailed discussion of suicidality.) In addition, it is important to remember that the vast majority of people who are abusing or dependent on substances will experience at least transient symptoms of depression, anxiety, and other mental symptoms. Moreover, it may not be possible, even with a skilled clinician, to determine whether an intoxicated suicidal patient is making a serious threat of self harm; however, safety is a critical and paramount concern. A more detailed discussion of each symptom subgroup is provided in appendix D. Safety screening conducted in mental health settings is highlighted in the text box below.

Safety Screening in Mental Health Settings

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Evaluating safety considerations in mental health settings involves direct questioning of client and collaterals regarding current substance use and/or recent discontinuation of heavy use, along with past and present experiences of withdrawal. If clients obviously are intoxicated, they need to be treated with empathy and firmness, and provision needs to be made for their physical safety. If clients report that they are experiencing withdrawal, or appear to be exhibiting signs of withdrawal, use of formal withdrawal scales can help even inexperienced clinicians to gather information from which medically trained personnel can determine whether medical intervention is required. Such tools include the Clinical Institute Withdrawal Assessment (CIWA-Ar) (Sullivan et al. 1989) for alcohol withdrawal and the Clinical Institute Narcotic Assessment (CINA) (Zilm and Sellers 1978) for opioid withdrawal.

Mental health clinicians need to be aware that not all drugs have a physiological withdrawal associated with them, and it should not be assumed that withdrawal from any drug of abuse will require medical intervention. Only in the case of alcohol, opioids, sedative-hypnotics, or benzodiazepines is medical intervention likely to be required due to the pharmacological properties of the substance.

Screening for past and present mental disorders

Screening for past and present mental disorders has three goals:

1. To understand a client's history and, if the history is positive for a mental disorder, to alert the counselor and treatment team to the types of symptoms that might reappear so that the counselor, client, and staff can be vigilant about the emergence of any such symptoms.
2. To identify clients who might have a current mental disorder and need both an assessment to determine the nature of the disorder and an evaluation to plan for its treatment.
3. For clients with a current COD, to determine the nature of the symptoms that might wax and wane to help the client monitor the symptoms, especially how the symptoms improve or worsen in response to medications, “slips” (i.e., substance use), and treatment interventions. For example, clients often need help seeing that the treatment goal of avoiding isolation improves their mood—that when they call their sponsor and go to a meeting they break the vicious cycle of depressed mood, seclusion, dwelling on oneself and one's mood, increased depression, greater isolation, and so on.

A number of screening, assessment, and treatment planning tools are available to assist the substance abuse treatment team. For assessment of specific disorders and/or for differential diagnosis and treatment planning, there are literally hundreds of assessment and treatment planning tools. NIAAA operates a web-based service that provides quick information about alcoholism treatment assessment instruments and immediate online access to most of them, and the service is updated continually with new information and assessment instruments (www.niaaa.nih.gov/publications/Assesing%20Alcohol/index.pdf). NIDA has a publication from a decade ago (Rounsaville et al. 1993) that provides broad background information on assessment issues pertinent to COD and specific information about numerous mental health, treatment planning, and substance abuse tools. Of course, NIDA continues to explore issues related to screening and assessment (e.g., see www.drugabuse.gov/DirReports/DirRep203/DirectorReport6.html and www.drugabuse.gov/Meetings/Childhood/Agenda/agenda.html). The mental health field contains a vast array of screening and assessment devices, as well as subfields devoted primarily to the study and development of evaluative methods. Almost all Substance Abuse and Mental Health Services Administration TIPs, which are available online (www.kap.samhsa.gov), have a section on assessment, many have appendices with wholly reproduced assessment tools or information about locating such tools, and TIPs 31, 16, 13, 11, 10, 9, 7, and 6 are centered specifically on assessment issues.

Advanced assessment techniques include assessment instruments for general and specific purposes and advanced guides to differential diagnosis. Most high-power assessment techniques center on a specific type of problem or set of symptoms, such as the BDI-II (Beck et al. 1996), the Beck Anxiety Inventory (BAI) (Beck et al. 1988), or the Hamilton Anxiety Scale (Hamilton 1959) or the Hamilton Rating Scale for Depression (Hedlung and Vieweg 1979). There are high-power broad assessment measures such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (Butcher et al. 2001). However, such assessment devices typically are lengthy (the MMPI is more than 500 items), often require specific doctoral training to use, and can be difficult to adapt properly for some substance abuse treatment settings.

For both clinical and research activities, there are a number of well-known and widely used guides to the differential diagnostic process in the mental health field, such as the Structured Clinical Interview for Diagnosis (SCID). Again, the SCIDs involve considerable time and training, with a separate SCID for Axis I, Axis II, and dissociative disorders. Other broad high-power diagnostic tools are the Diagnostic Interview Schedule (DIS) and the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), but these methods can require 1 to 3 hours and extensive training. These tools generally provide information beyond the requirements of most substance abuse treatment programs.

When using any of the wide array of tools that detect symptoms of mental disorders, counselors should bear in mind that symptoms of mental disorder can be mimicked by substances. For example, hallucinogens may produce symptoms that resemble psychosis, and depression commonly occurs during withdrawal from many substances. Even with well-tested tools, it can be difficult to distinguish between a mental disorder and a substance-related disorder without additional information such as the history and chronology of symptoms. In addition to interpreting the results of such instruments in the broader context of what is known about the client's history, counselors also are reminded that retesting often is important, particularly to confirm diagnostic conclusions for clients who have used substances.

The section below briefly highlights some available instruments available for mental health screening.

Mental Health Screening Form-III

The Mental Health Screening Form-III (MHSF-III) has only 18 simple questions and is designed to screen for present or past symptoms of most of the main mental disorders (Carroll and McGinley 2001). It is available to the public at no charge from the Project Return Foundation, Inc. and it is reproduced in its entirety in appendix H, along with instructions for its use and contact information (a Spanish form and instructions can be downloaded). The MHSF-III was developed within a substance abuse treatment setting and it has face validity—that is, if a knowledgeable diagnostician reads each item, it seems clear that a “yes” answer to that item would warrant further evaluation of the client for the mental disorder for which the item represents typical symptomatology.

On the other hand, the MHSF-III is only a screening device as it asks only one question for each disorder for which it attempts to screen. If a client answers “no” because of a misunderstanding of the question or a momentary lapse in memory or test-taking attitude, the screen would produce a “false-negative,” where the client might have the mental disorder but the screen falsely indicates that the person probably does not have the disorder. In a journal article the MHSF-III is referred to as a “rough screening device” (Carroll and McGinley 2001, p. 35), and the authors make suggestions about its use, comments about its limitations, and review favorable validity and reliability data.

Mini-International Neuropsychiatric Interview

For a more complete screening instrument, the Mini-International Neuropsychiatric Interview (M.I.N.I.) is a simple 15- to 30-minute device that covers 20 mental disorders, including substance use disorders. Considerable validation research has accumulated on the M.I.N.I. (Sheehan et al. 1998).

For each disorder the M.I.N.I. has an ordered series of about 6 to 12 questions, and it has a simple and immediate scoring procedure. For example, in terms of suicidality the M.I.N.I. contains questions about whether in the past month the client has

1. Thought about being better off dead or wishing to be dead (1 point)

2. Wanted to harm himself/herself (2 points)

3. Thought about suicide (6 points)

4. Attempted suicide (10 points)

5. Developed a suicide plan (10 points)

M.I.N.I. contains a sixth question asking if the client has ever attempted suicide (4 points). Scoring rates low current suicide risk as 1 to 5 points, moderate as 6 to 9 points, and high as 10 or more points.

The M.I.N.I. family consists of

• The M.I.N.I. (a low-power, broad screening device to see if the client requires further assessment)

• A two-page M.I.N.I. screen for research purposes or when time is limited

• The M.I.N.I. Plus (an expanded version of the M.I.N.I. designed specifically to determine whether symptoms were associated with alcohol and other drug use and/or periods of abstinence)

• The M.I.N.I. Tracking (a 17-page document that provides symptom descriptors that can be used to monitor a client's progress in treatment, monitor how a client's symptoms are affected by treatment interventions or medications or other factors, and help with documenting where, when, and why changes occur)

Brief Symptom Inventory-18

Another proprietary instrument that can be used to track clients from session to session or over longer periods of time is the Brief Symptom Inventory-18 (BSI-18). The BSI-18 questionnaire contains 18 items and asks clients to rate each question on a five-point scale. In addition to a Global Severity Index score, there are separate scores for anxiety, depression, and somatization subscales. The BSI-18 was derived from the 53-item Brief Symptom Inventory, which was derived from the Symptom Checklist-90-Revised (SCL-90-R) (Derogatis 1975), and the 15-item SDS (McCorkle and Young 1978) also was a derivative of the BSI that has been superceded by the relatively new BSI-18.

ASI

The ASI (McLellan et al. 1992) does not screen for mental disorders and provides only a low-power screen for generic mental health problems. Use of the ASI ranges widely, with some substance abuse treatment programs using a scaled-down approach to gather basic information about a client's alcohol use, drug use, legal status, employment, family/social, medical, and psychiatric status, to an in-depth assessment and treatment planning instrument to be administered by a trained interviewer who makes complex judgments about the client's presentation and ASI-taking attitudes. Counselors can be trained to make clinical judgments about how the client comes across, how genuine and legitimate the client's way of responding seems, whether there are any safety or self-harm concerns requiring further investigation, and where the client falls on a nine-point scale for each dimension. With about 200 items, the ASI is a low-power instrument but with a very broad range, covering the seven areas mentioned above and requiring about 1 hour for the interview. Development of and research into the ASI continues, including training programs, computerization, and critical analyses. It is a public domain document that has been used widely for 2 decades. It is reproduced in TIP 38 as appendix D (CSAT 2000c , pp. 193–204), and information about obtaining the manual for the ASI and up-to-date information is in appendix G. Over the past several years, NIDA's Clinical Trials Network (CTN) has been researching both the use of and the training for the ASI (www.drugabuse.gov/CTN/asi_team.html).

Screening for past and present substance use disorder

This section is intended primarily for counselors working in mental health service settings. It suggests ways to screen clients for substance abuse problems.

Screening begins with inquiry about past and present substance use and substance-related problems and disorders. If the client answers yes to having problems and/or a disorder, further assessment is warranted. It is important to remember that if the client acknowledges a past substance problem but states that it is now resolved, assessment is still required. Careful exploration of what current strategies the individual is using to prevent relapse is warranted. Such information can help ensure that those strategies continue while the individual is focusing on mental health treatment.

Screening for the presence of substance abuse symptoms and problems involves four components:

• Substance abuse symptom checklists
• Substance abuse severity checklists
• Formal screening tools that work around denial
• Screening of urine, saliva, or hair samples

Symptom checklists: These include checklists of common categories of substances, history of associated problems with use, and a history of meeting criteria for substance dependence for that substance. It is not helpful to develop checklists that are overly detailed, because they begin to lose value as simple screening tools. It is helpful to remember to include abuse of over-the-counter medication (e.g., cold pills), abuse of prescribed medication, and gambling behavior in the checklist. It also is reasonable to screen for compulsive sexual behavior, Internet addiction, and compulsive spending.

Severity checklists: It is useful to monitor the severity of substance use disorder (if present) and to determine the possible presence of dependence. This process can begin with simple questions about past or present diagnosis of substance dependence, and the client's experience of associated difficulties. Some programs may use formal substance use disorder diagnostic tools; others use the ASI (McLellan et al. 1992) or similar instrument, even in the mental health setting. The New Hampshire Dartmouth Psychiatric Research Center has developed clinician-rated alcohol- and drug-use scales for monitoring substance abuse severity in individuals with mental disorders: the Alcohol Use Scale (AUS) and Drug Use Scale (DUS) (Drake et al. 1996b ) and others (www.dartmouth.edu/~psychrc/instru.html).

Screening tools: Most common substance abuse screening tools have been used with individuals with COD. These include the CAGE (Mayfield et al. 1974), the Michigan Alcoholism Screen Test (MAST) (Selzer 1971), the Drug Abuse Screening Test (DAST) (Skinner 1982), and the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al. 1992). The Dartmouth Assessment of Lifestyle Inventory (DALI) is used routinely as a screening tool in some research settings working with individuals with serious mental disorders (Rosenberg et al. 1998).

The SSI-SA was developed by the consensus panel of TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (CSAT 1994c ). The SSI-SA is reproduced in its entirety in appendix H. It is a 16-item scale, although only 14 items are scored so that scores can range from 0 to 14. These 14 items were selected by the TIP 11 consensus panelists from existing alcohol and drug abuse screening tools. A score of 4 or greater has become the established cut-off point for warranting a referral for a full assessment. Since its publication in 1994 the SSI-SA has been widely used and its reliability and validity investigated. For example, Peters and colleagues (2004) reported on a national survey of correctional treatment for COD. Reviewing 20 COD treatment programs in correctional settings from 13 States, the SSI-SA was identified as among the most common screening instruments used. For more information, see appendix H.

Toxicology screening: Given the high prevalence of substance use disorders in patients with mental health problems, the routine use of urine or other screening is indicated for all new mental health clients. It especially is suggested in settings in which the likelihood of clients regularly presenting unreliable information is particularly great; for example, in adolescent and/or criminal justice settings. Use of urine screening is highly recommended whenever the clinical presentation does not seem to fit the client's story, or where there appear to be unusual mental status symptoms or changes not explained adequately. Saliva testing may be less intrusive than hair or urine testing in patients who are shy or who are extremely paranoid.

Trauma screening

Research projects focusing on the needs of people with COD who are victims of trauma have led to the development of specific screening tools to identify trauma in treatment populations. To screen for posttraumatic stress disorder (PTSD), assuming the client has a trauma, the Modified PTSD Symptom Scale: Self-Report Version would be a good choice (this instrument can be found in TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues [CSAT 2000d , p. 170]). This scale also is useful for monitoring and tracking PTSD symptoms over time. The PTSD Checklist (Blanchard et al. 1996) is a validated instrument that substance abuse treatment agencies also may find useful in trauma screening.

It is important to emphasize that in screening for a history of trauma or in obtaining a preliminary diagnosis of PTSD, it can be damaging to ask the client to describe traumatic events in detail. To screen, it is important to limit questioning to very brief and general questions, such as “Have you ever experienced childhood physical abuse? Sexual abuse? A serious accident? Violence or the threat of it? Have there been experiences in your life that were so traumatic they left you unable to cope with day-to-day life?” See the discussion of screening and assessment for PTSD in appendix D for more complete information.

Determination of serious mental illness (SMI) status

Every State mental health system has developed a set of specific criteria for determining who can be considered seriously mentally ill (and therefore eligible to be considered a mental health priority client). These criteria are based on combinations of specific diagnoses, severity of disability, and duration of disability (usually 6 months to 1 year). Some require that the condition be independent of a substance use disorder. These criteria are different for every State. It would be helpful for substance abuse treatment providers to obtain copies of the criteria for their own States, as well as copies of the specific procedures by which eligibility is established by their States' mental health systems. By determining that a client might be eligible for consideration as a mental health priority client, the substance abuse treatment counselor can assist the client in accessing a range of services and/or benefits that the client may not know is open to her or him.

Determining SMI status begins with finding out if the client already is receiving mental health priority services (e.g., Do you have a mental health case manager? Are you a Department of Mental Health client?).

• If the client already is a mental health client, then he or she will be assigned to quadrant II or IV. Contact needs to be made with the mental health case manager and a means of collaboration established to promote case management.
• If the client is not already a mental health client, but appears to be eligible and the client and family are willing, referral for eligibility determination should be arranged.
• Clients who present in addiction treatment settings who look as if they might be SMI, but have not been so determined, should be considered to belong to quadrant IV.

For assistance in determination of the severity of symptoms and disability, the substance abuse treatment clinician can use the Dimension 3 (Emotional/Behavioral) subscales in the ASAM PPC-2R or LOCUS, especially the levels of severity of comorbidity and impairment/functionality.

Determination of severity of substance use disorders

Presence of active or unstable substance dependence or serious substance abuse (e.g., recurrent substance-induced psychosis without meeting other criteria for dependence) would identify the individual as being in quadrant III or IV. Less serious substance use disorder (mild to moderate substance abuse; substance dependence in full or partial remission) identifies the individual as being in quadrant I or II.

If the client is determined to have SMI with serious substance use disorder, he falls in quadrant IV; those with SMI and mild substance use disorder fall in quadrant II. A client with serious substance use disorder who has mental health symptoms that do not constitute SMI falls into quadrant III. A client with mild to moderate mental health symptoms and less serious substance use disorder falls into quadrant I.

Clients in quadrant III who present in substance abuse treatment settings are often best managed by receiving care in the addiction treatment setting, with collaborative or consultative support from mental health providers. Individuals in quadrant IV usually require intensive intervention to stabilize and determination of eligibility for mental health services and appropriate locus of continuing care. If they do not meet criteria for SMI, once their more serious mental symptoms have stabilized and substance use is controlled initially, they begin to look like individuals in quadrant III, and can respond to similar services.

Note, however, that this discussion of quadrant determination is not validated by clinical research. It is merely a practical approach to adapting an existing framework for clinical use, in advance of more formal processes being developed, tested, and disseminated.

Assessment Step 4—Application to Case Examples

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Cases 1 and 2. Both Maria M. and George T. are examples of clients with serious addiction who also have serious mental disorders, but do not appear to be seriously disabled. They would therefore meet criteria for quadrant III and should be placed in programs for people who have less serious mental disorders and more serious substance use disorders. Note that though the diagnosis of bipolar disorder is typically considered a serious mental illness, the quadrant system emphasizes the acute level of disability/severity of the mental and substance use disorders of the individual, rather than relying solely on diagnostic classification.

Case 3. Jane B., the homeless woman with paranoid schizophrenia, generally would meet criteria for serious and persistent mental illness in almost every State, based on the severity of the diagnosis and disability, combined with the persistence of the disorder. Jane B. also has serious addiction. In the quadrant model, if she already has been identified as a mental health priority client (e.g., has a mental health case manager), she would be considered quadrant IV, and referral for mental health case management services would be important.

In many systems, the process of assessment stops largely after assessment step 4 with the determination of placement. Some information from subsequent steps (especially step 7) may be included in this initial process, but usually more in-depth or detailed consideration of treatment needs may not occur until after “placement” in an actual treatment setting.

The importance of client history

• Principle #1: Diagnosis is established more by history than by current symptom presentation. This applies to both mental and substance use disorders.

The first step in determining the diagnosis is to determine whether the client has an established diagnosis and/or is receiving ongoing treatment for an established disorder. This information can be obtained by the counselor as part of the routine intake process. If there is evidence of a disorder but the diagnosis and/or treatment recommendations are unclear, the counselor immediately should begin the process of obtaining this information from collaterals. If there is a valid history of a mental disorder diagnosis at admission to substance abuse treatment, that diagnosis should be considered presumptively valid for initial treatment planning, and any existing stabilizing treatment should be maintained. In addition to confirming an established diagnosis, the client's history can provide insight into patterns that may emerge and add depth to knowledge of the client.

For example, if a client comes into the clinician's office under the influence of alcohol, it is reasonable to suspect alcohol dependence, but the only diagnosis that can be made based on that datum is “alcohol intoxication.” It is important to note that this warrants further investigation; on the one hand, false positives can occur, while on the other, detoxification may be needed. Conversely, if a client comes into the clinician's office and has not had a drink in 10 years, attends Alcoholics Anonymous (AA) meetings three times per week, and had four previous detoxification admissions, the clinician can make a diagnosis of alcohol dependence (in remission at present). Moreover, the clinician can predict that 20 years from now that client will still have the diagnosis of alcohol dependence since the history of alcohol dependence and treatment sustains a lifetime diagnosis of alcohol dependence.

Similarly, if a client comes into the clinician's office and says she hears voices (whether or not the client is sober currently), no diagnosis should be made on that basis alone. There are many reasons people hear voices. They may be related to substance-related syndromes (e.g., substance-induced psychosis or hallucinosis, which is the experience of hearing voices that the client knows are not real, and that may say things that are distressing or attacking—particularly when there is a trauma history—but are not bizarre). With COD, most causes will be independent of substance use (e.g., schizophrenia, schizoaffective disorder, affective disorder with psychosis or dissociative hallucinosis related to PTSD). Psychosis usually involves loss of ability to tell that the voices are not real, and increased likelihood that they are bizarre in content. Methamphetamine psychosis is particularly confounding because it can mimic schizophrenia. Many individuals with psychotic disorders will still hear voices when on medication, but the medication makes the voices less bizarre and helps the client know they are not real.

If the client states he has heard voices, though not as much as he used to, that he has been clean and sober for 4 years, that he remembers to take his medication most days though every now and then he forgets, and that he had multiple psychiatric hospitalizations for psychosis 10 years ago but none since, then the client clearly has a diagnosis of psychotic illness (probably schizophrenia or schizoaffective disorder). Given the client's continuing symptoms while clean and sober and on medication, it is quite possible that the diagnosis will persist.

Assessment Step 6—Application to Case Examples

Case 2. George T. has cocaine dependence and bipolar disorder stabilized with lithium. He reports that when he uses cocaine he has mood swings, but that these go away when he stops using for a while, as long as he takes his medication. At the initial visit, George T. states he has not used for a week and has been taking his medication regularly. He displays no significant symptoms of mania or depression and appears reasonably calm. The counselor should not conclude that because George T. has no current symptoms the diagnosis of bipolar disorder is incorrect, or that all the mood swings are due to cocaine dependence. At initial contact, the presumption should be that the diagnosis of bipolar disorder is accurate, and lithium needs to be maintained.

Documenting prior diagnoses

• Principle #2: It is important to document prior diagnoses and gather information related to current diagnoses, even though substance abuse treatment counselors may not be licensed to make a mental disorder diagnosis.

Diagnoses established by history should not be changed at the point of initial assessment. If the clinician has a suspicion that a long-established diagnosis may be invalid, it is important that he or she takes time to gather additional information, consult with collaterals, get more careful and detailed history (see below), and develop a better relationship with the client before recommending diagnostic re-evaluation. It is important for the counselor to raise issues related to diagnosis with the clinical supervisor or at a team meeting.

In many instances, of course, no well-established mental disorder diagnosis exists, or multiple diagnoses give a confusing picture. Even when there is an established diagnosis, it is helpful to gather information to confirm that diagnosis. During the initial assessment process, substance abuse treatment counselors can gather data that can assist in the diagnostic process, either by supporting the findings of the existing mental health assessment, or providing useful background information in the event a new mental health assessment is conducted. The key to doing this is not merely to gather lists of past and present symptoms, but to connect those symptoms to key time periods in the client's life that are helpful in the diagnostic process—namely, before the onset of a substance use disorder and during periods of abstinence (or during periods of very limited use) or those that occur after the onset of the substance use disorder and persist for more than 30 days.

The clinician also must seek to determine whether mental symptoms occur only when the client is using substances actively. Therefore, it is important to determine the nature and severity of the symptoms of the mental disorder when the substance disorder is stabilized.

Linking mental symptoms to specific periods

• Principle #3: For diagnostic purposes, it is almost always necessary to tie mental symptoms to specific periods of time in the client's history, in particular those times when active substance use disorder was not present.

Unfortunately, most substance abuse assessment tools are not structured to require connection of mental symptoms to such periods of use or abstinence. For this reason, mental disorder symptom information obtained from such tools can be confusing and often contributes to counselors feeling the whole process is not worth the effort. In fact, it is striking that when clinicians seek information about mental symptoms during periods of abstinence, such information is almost never part of traditional assessment forms. The mental history and substance use history have in the past been collected separately and independently. As a result, the opportunity to evaluate interaction, which is the most important diagnostic information beyond the history, has been routinely lost. Newer and more detailed assessment tools overcome these historical, unnecessary divisions.

One instrument that may be helpful in this regard is the M.I.N.I. Plus (described above), which has a structure to connect any identified symptoms to periods of abstinence. Clinicians can use this information to distinguish substance-induced mental disorders from independent mental disorders. Drake and others in their work on mental disorder treatment teams in New Hampshire have adapted the Timeline Follow Back Method (www.dartmouth.edu/~psychrc/instru.html), developed by Sobell and Mueser (Mueser et al. 1995b ; Sobell et al. 1979), that can be used with individuals who have serious mental disorders and substance use disorders. More detailed mental health research diagnostic tools (e.g., the SCID) encourage a similar process.

Consequently, the substance abuse treatment counselor can proceed in two ways:

1. Inquire whether any mental symptoms or treatments identified in the screening process were present during periods of 30 days of abstinence or longer, or were present before onset of substance use. (“Did this symptom or episode occur during a period when you were clean and sober for at least 30 days?”)
2. Define with the client specific time periods where substance use disorder was in remission, and then get detailed information about mental symptoms, diagnoses, impairments, and treatments during those periods of time. (“Can you recall a specific period when you were not using? Did these symptoms [or whatever the client has reported] occur during that period?”) This approach may yield more reliable information.

During this latter process, the counselor can use one of the medium-power symptom screening tools as a guide. Alternatively, the counselor can use the handy outlines of the DSM-IV criteria for common disorders and inquire whether those criteria symptoms were met, whether they were diagnosed and treated, and if so, with what methods and how successfully. This information can suggest or support the accuracy of diagnoses. Documentation also can facilitate later diagnostic assessment by a mental-health-trained clinician.

Assessment Step 6—Application to Case Example

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Case 1. Maria M., the 38-year-old Hispanic/Latina female with cocaine and opioid dependence, initially was receiving methadone maintenance treatment only. She also used antidepressants prescribed by her outside primary care physician. She presented to methadone maintenance program staff with complaints of depression. Maria M. reported that since treatment with methadone (1 year) she had not used illicit opioids. However, she stated that when she does not use cocaine, she often feels depressed “for no reason.” Nevertheless, she has many stressors involving her children, who also have drug problems. She reports that depression is associated with impulses to use cocaine, and consequently she has recurrent cocaine binges. These last a few days and are followed by persistent depression.

What is the mental diagnosis? To answer this question it is important to obtain a mental disorder history that relates mental symptoms to particular time periods and patterns of substance use and abuse.

The client's history reveals that although she grew up with an abusive father with an alcohol problem, she herself was not abused physically or sexually. Although hampered by poor reading ability, she stayed in school with no substance abuse until she became pregnant at age 16 and dropped out of high school. Despite becoming a single mother at such a young age, she worked three jobs and functioned well, while her mother helped raise the baby. At age 23, she began a 9-year relationship with an abusive person with an alcohol and illicit drug problem, during which time she was exposed to a period of severe trauma and abuse. She is able to recall that during this relationship, she began to lose her self-esteem and experience persistent depression and anxiety.

She began using cocaine at age 27, initially to relieve those symptoms. Later, she lost control and became addicted. Four years ago, she was first diagnosed as having major depression, and was prescribed antidepressant medication, which she found helpful. Two years ago, she began using opioids, became addicted, and then entered methadone treatment. She receives no specific treatment for cocaine dependence. She has noticed that her depression persists during periods of cocaine and opioid abstinence lasting more than 30 days. On one occasion, during one of these periods, her medication ran out, and she noticed her depression became much worse. Even at her baseline, she remains troubled by lack of self-confidence and fearfulness, as well as depressed mood.

Her depression persists during periods of more than 30 days of abstinence and responds to some degree to antidepressants. The fact that her depression persists even when she is abstinent and responds to antidepressants suggests strongly a co-occurring affective disorder. There are also indications of the persistent effects of trauma, possibly posttraumatic stress disorder. Trauma issues have never been addressed. Her opioid dependence has been stabilized with methadone. She has resisted recommendations to obtain more specific treatment for cocaine dependence.

Assessing functional capability

Current level of impairment is determined by assessing functional capabilities and deficits in each of the areas listed below. Similarly, baseline level of impairment is determined by identifying periods of extended abstinence and mental health stability (greater than 30 days) according to the methods described in the previous assessment step. The clinician determines:

• Is the client capable of living independently (in terms of independent living skills, not in terms of maintaining abstinence)? If not, what types of support are needed?
• Is the client capable of supporting himself financially? If so, through what means? If not, is the client disabled, or dependent on others for financial support?
• Can the client engage in reasonable social relationships? Are there good social supports? If not, what interferes with this ability, and what supports would the client need?
• What is the client's level of intelligence? Is there a developmental or learning disability? Are there cognitive or memory impairments that impede learning? Is the client limited in ability to read, write, or understand? Are there difficulties with focusing, concentrating, and completing tasks?

The ASI (McLellan et al. 1992) and the GAIN (Dennis 1998) provide some information about level of functioning for individuals with substance use disorders. They are valuable when supplemented by interview information in the above areas. (Note that the ASI also exists in an expanded version specifically for women [ASI-F, CSAT 1997c ].) The counselor also should inquire about any current or past difficulties the client has had in learning or using relapse prevention skills, participating in self-help recovery programs, or obtaining medication or following medication regimens. In the same vein, the clinician may inquire about use of transportation, budgeting, self-care, and other related skills, and their effect on life functioning and treatment participation.

For individuals with COD, the impairment may be related to intellectual/cognitive ability or the mental disability. These disorders may exist in addition to the substance use disorder. The clinician should try to establish both level of intellectual/cognitive functioning in childhood and whether any impairment persists, and if so, at what level, during the periods when substance use is in full or partial remission, just as in the above discussion of diagnosis.

Assessment Step 7—Application to Case Example

Case 1. Assessment of Maria M.'s functional capacity at baseline indicated that she could read only at a second grade level. Consequently, educational materials presented in written form needed to be presented in alternative formats. These included audiotapes and videos to teach her about addiction, depression, trauma, and recovery from these conditions. In addition, Maria M.'s history of trauma (previously discussed) led her to experience anxiety in large group situations, particularly where men were present. This led her counselor to recommend attending 12-Step meetings that were smaller and/or women only. The counselor also suggested that she attend in the company of female peers. Further, the clinician referred her to trauma-specific counseling.

Determining the need for “Capable” or “Enhanced” level services

A specific tool to assess the need for “Capable” or “Enhanced” level services for persons with COD currently is not available. The consensus panel recommends a process of “practical assessment” that seeks to match the client's assessment (mental health, substance abuse, level of impairment) to the type of services needed. The individual may even be given trial tasks or assignments to determine in concert with the counselor if her performance meets the requirements of the program being considered.

Assessment Step 7—Application to Case Example

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Case 3. Once Jane B. had begun to stabilize on medication and expressed interest in residential addiction treatment, it became necessary to assess her ability to participate in standard dual diagnosis capable (DDC) treatment versus her need for more dual diagnosis enhanced (DDE) treatment. Jane B. was still living in a shelter, but was able to maintain her personal hygiene and dress appropriately now that she was on medication. She looked somewhat suspicious and guarded, but could answer questions appropriately and denied having hallucinations.

To determine her ability to succeed in standard residential substance abuse treatment, her counselor asked her to attend an AA meeting. The clinician also asked her to complete an assignment to read some substance abuse literature and write down what she had learned. The client reported that she was nervous at the meeting but was able to stay the whole time. She said that she related well to what one of the speakers was saying. She also completed the written assignment quite well; it turned out she was very bright and had completed 1 year of college. Noting that she was complying with medication and her mental status was stable, the counselor felt comfortable referring her to the DDC program.

Had this client been unable to attend AA without individual support, or if she experienced obvious difficulty with the assignment, it would have been clearer that a program with an enhanced capacity to treat persons with COD would be indicated. If such a program were not available, she would have needed to continue to build skills slowly to address her substance use with the assistance of her outpatient case management program.

Not fitting into the treatment culture

To a certain degree, individuals with COD and SMI tend not to fit into existing treatment cultures. Most of these clients are aware of a variety of different attitudes and suggestions toward their disorders that can affect relationships with others. Traditional culture carriers (parents, grandparents) may have different views of their problems and the most appropriate treatment compared to peers. Individual clients may have positive or negative allegiance to a variety of peer or treatment cultures (e.g., mental health consumer movement, having mild or moderate severity mental disorders versus severe and persistent mental illness [SPMI], 12-Step or dual recovery self-help, etc.) based on past experience or on fears and concerns related to the mental disorder. Specific considerations to explore with the client include

• How are your substance abuse and mental health problems defined by your parents? Peers? Other clients?
• What do they think you should be doing to remedy these problems?
• How do you decide which suggestions to follow?
• In what kinds of treatment settings do you feel most comfortable?
• What do you think I (the counselor) should be doing to help you improve your situation?

Assessment Step 9—Application to Case Example

Case 2. George T. originally was referred to Cocaine Anonymous (CA) by his counselor because the counselor knew of several local meetings with a large membership of African-American men. When George T. went, however, he reported back to the counselor that he did not feel comfortable there. First, he felt that as a family man with a responsible job he had pulled himself out of the “street culture” that was prevalent at the meeting. Second, unlike many people with COD who feel more ashamed of mental disorders than addiction, he felt more ashamed at the CA meeting than at his support group for persons with mental disorders. Therefore, for George, it was more “culturally appropriate” to refer him to 12-Step meetings attended by other middle class individuals (regardless of race) and to continue to encourage him to attend his MDDA support group for his mental disorder.

Cultural and linguistic service barriers

Access to COD treatment is compounded by cultural or linguistic barriers. The assessment process must address specifically whether these barriers prevent access to care (e.g., the client reads or speaks only Spanish, or does not read any language) and if so, determine some possibilities for providing more individualized intervention or for integrating intervention into naturalistic culturally and linguistically appropriate human service settings.

Assessment Step 9—Application to Case Example

Case 1. Maria M. initially had difficulty identifying herself as being a victim of trauma both because she had normalized her perception of her early family experience with her abusive father and because she had received cultural reinforcement in the past that condoned the behavior of her abusive boyfriend as “normal machismo.” Referral to a group that included other Hispanic women who also had suffered abuse was very helpful to her. With the help of the group, she began to recognize the reality of the impact that trauma had had in her life.

Considerations in Treatment Matching

Previous chapters introduced a variety of concepts for categorizing individuals with COD and the clinicians, programs, and systems responsible for serving those individuals. The consensus panel has identified critical factors that have been determined, either by research evidence or by consensus clinical practice, to be relevant to the process of matching individual clients to available treatment. These considerations are shown in Figure 4-3.