Day 3 Assessment and Risk
Liz Hughes
Timetable
9. 30 recap from last week, review homework
10.00 Assessment
10.30 break
10.50 confidentiality
11.15 history timeline
12.00 current use
12.30 lunch
1.30 Assessment continued
2.30 Risk and dual diagnosis
3.45 summary and homework
4.00 end
Objectives
• Develop a rationale for assessment
• Be able to identify attitudes and key skills for dual
diagnosis assessment
• Be aware of confidentiality issues within your workplace
regarding discussion of substance use and other illicit
behaviours
• Be able to take a history using parallel timeline, and be
able to assess current use in context of mental health and
other problems
• Be aware of risks related to dual diagnosis and be able to
develop a risk management plan
Purpose of Assessment
• To gather baseline information about the types of difficulties that a
person is experiencing (i.e. what is the problem?).
• the impact of those difficulties on their life.
• an understanding of how they developed.
• What factors maintain the difficulties, and what factors moderate
them.
• Motivation to change, or intention.
• Future goals and roadblocks to achieving those goals.
• Assessment of strengths and changes already achieved
Assessment
Levels:• Brief 10 minutes informal chat
• Semi-structured interviewing/ questioning
• Use of structured exercises
• Use of validated tools
• Physical tests:- liver enzymes, urine and blood tox. Screens
• Corroborative information- past notes, family, other professionals
Maximum detection times for drugs
in urine
• Amphetamine- 2-3 days
• Ecstasy- 30-48 hours
• Cannabis:
–
–
–
–
Single use- 3 days
Moderate use- 4 days
Heavy use- 10 days
Chronic heavy use- 36 days
• Methamphetamine48 hours
• Cocaine- 6-8 hours
• Methadone- 7-9 days
• Codeine- 24 hours
• Heroin- 1-2 days
Essential Skills
• Attitudes and values
• Collaboration/ working in partnership with
service users and carers
• Structuring session and use of agenda
• Open and closed questioning
• Reflection and summarising
Exercise:
Confidentiality: Take 10 minutes to consider:
• What are the boundaries of confidentiality within your role
around the disclosure of substance use?
• At what point would you breach confidentiality, and how
would this be communicated to the service user?
Confidentiality
• Doesn’t mean secret!
• Be up front about who gets access to information and why.
• Illegal activities may have to be reported to the police (dealing
drugs, threats of violence, serious crimes)
• Child protection issues will need to be reported.
• Respect peoples’ right to privacy within limits.
• Carers want and need information, and this should be shared
only with full consent of the service user unless there are
safety/legal issues.
• Carers may have important information for the care of the
person
• Balance needs of individual against safety of others
• Fully explain why confidentiality may be breached.
• May have to re-engage person at a later stage.
Parallel Timeline
• Gather information about the development
of current problems
• May be painful process
• Doesn’t have to be perfectly accurate- its
about getting the person’s own perspective
• Identify patterns of substance use and
mental health problems that may be useful
for futher work (e.g. relapse prevention)
Current Use 1
Substance
(What)
Route
(How taken)
Amount
(How much per
session)
Cannabis
Smoked
£20 per week
Daily
(2 spliffs a night)
6
months
2 pints per
4 times a
session
week
5 units per
session
20 units per week
2
months
Alcohol (5% Oral
lager)
Frequency For
(How often) how
long?
Current Use 2: The 5 “W”’s
What
When
(what is being (How often is
used?)
this
behaviour
occurring?)
Where
(where is this
behaviour
happeningbe specific)
Who with
(Alone, or
with
others?)
Why?
What reasons are
there for using
substances at
that time?)
Cannabis
Every
evening
In bedroom
at home
alone
voices bad, felt
uptight, needed
to relax
Alcohol
4 x per week In pub
With
friends
To be sociable,
like it, helps me
to talk to
people, to have
a laugh
Cognitive Behavioural Assessment
• Gain an understanding about what triggers and maintains
their substance use (and other problems)
• Generate problem statements that can be turned into goals.
• Assess what happens in 6 domains/areas:
– Cognitive (what are you thinking? What goes through your mind
when…) by this we are trying to elicit the thought processes and
decision-making.
– Physical (what sensations do you notice in your body?)
– Affective (how do you feel when…..)
– Behavioural (what do you do as a result of…)
– Interpersonal (who are you with and how do they affect you),
– Situational (where are you? in what setting does this seem to
happen?)
An example
What is the area to be focused on:
alcohol use
• When-most evenings, who with-friends, where-pub, whybecause I feel miserable and it cheers me up
• Domains: affect-it makes me feel happy initially, then I get
angry, physiological-I feel relaxed, interpersonal-I am
more sociable but I do have more rows when I am drunk.
Psychological- feel paranoid by end of evening.
• Frequency-daily, intensity- 5 pints, duration- 7pm till
11pm, onset-mate calls for me at 6.30 in the hostel
Problem statement
• John spends the day alone in the hostel. He looks
forward to going to the pub with his mates in the
evening. He drinks an average of 5 pints (5%)
lager. Initially he feels happy, relaxed and
sociable, but as he drinks more he starts to think
that other people in the pub are talking and
laughing at him. Because he is drunk, he ends up
shouting at people and then is asked to leave.
Possible areas of intervention
•
•
•
•
•
Improve daily activities
Introduce non-drinking social activities
Explore Johns feelings of paranoia
Assess further his mental state
Psycho-education re alcohol-effects on
psychological and physical health
• Assess for alcohol dependence
• Assess motivation to reduce alcohol
Working with Beliefs
• Identify beliefs about substances
• Ask person to consider the evidence for and against the
beliefs (e.g. does cannabis always calm you down?
• Assist the person to generate some alternative beliefs or
thoughts that may be more helpful (e.g. I want to smoke
cannabis as I am stressed but it just makes things worse in
the long run)
• This in turn may help change the consequences (decides
not to smoke cannabis)
ABC for Specific Beliefs
• ANTECEDENTS/ACTIVATING EVENTtriggers and cues including auditory
hallucinations, physical sensations, interpersonal
conflict, stressful events, and specific
environments or people
• BELIEFS/INFERENCES- what the person
considers is the meaning or explanation of the
above events
• CONSEQUENCES- this is what the person does
in response to their beliefs or inferences.
An example of applying ABC
• Antecedents:
– Felt stressed as large housing benefit bill arrived, and can’t pay it
– Friend arrives with some cannabis later that day
• Beliefs:
– “I’m so stressed, cannabis will calm me down”
– “I can forget about my worries for a while”
– “I deserve some fun”
• Consequences:
–
–
–
–
Initially felt better
Voices got worse after a while
Felt really stressed out
Had argument with friend
Harm Minimisation
• This is an approach to treatment that advocates
interventions that seek to reduce or minimise the
adverse health consequences of substance use.
• It acknowledges that not everyone who comes for
help wants to stop using substances completely at
that point in time.
• The main aim is to prevent harm as a result of
disease, overdose, or drug-related deaths.
• This also incorporates the mental health risks
associated with some drugs and alcohol
consumption
Harm Minimisation Interventions
• Needle exchanges.
• Advice about safer injecting and safer drug use.
• Advice about the prevention of infection with bloodborne viruses (HIV, hepatitis B and C).
• Testing, advice, counselling and treatments for bloodborne viruses.
• Advice about preventing overdose and drug-related
deaths.
• Education about the effects of illicit substances on
mental health, and interactions with prescribed
medicatons.
Physical Health Issues for Dual
Diagnosis
• People with mental health and substance use generally suffer from
poor physical health.
– People with schizophrenia are at risk of developing type II diabetes
(possibly in connection with obesity),
– heart problems (extended Q wave interval),
– smoking related illnesses such as cancer.
• People who use substances:
–
–
–
–
–
–
Cardiac problems,
Circulatory problems,
Malnutrition
Poor dental hygiene
Injecting drugs then this comes with an array of associated problems.
Heavy alcohol consumption is associated with a significant number of
health problems.
Injecting and Sexual Health
Assessment
•
•
•
•
All service users with dual diagnosis should be asked about injecting
behaviour- they may have tried it in the past
Give a clear rationale questions about injecting and sexual behaviour and
advise that they may feel embarrassed
The worker should be in a position to answer questions, offer reassurance and
be able to refer to appropriate services that can offer more detailed assessment
and interventions.
Requires a basic knowledge of:
–
–
–
–
•
•
blood borne viruses and testing facilities
sexual health clinics and advisors
needle exchanges in the community,
safer injecting practices and safer sex.
Therefore it is important to find out about local services, and have literature
available.
Information should be presented in a rational and balanced way.
Examples of Key Questions
•
•
•
•
•
•
•
•
•
•
Have you ever injected? (People with dual diagnosis are less frequent injectors
but even once before warrants further exploration as to how safe their practice was)
If so, where did you obtain your injecting equipment? (This is to check if sterile
equipment was used, or whether equipment that had been used before)
Where do (did) you inject?
May I see where you inject (check for abscesses, ulcers, and general quality of the
injecting area)
What is your current form of contraception? (Do they use condoms? If not have
a discussion about the importance of using condoms to prevent transmission of
sexually transmitted diseases and where condoms can be obtained)
Have you ever had any sexually transmitted diseases? (The risk of HIV is higher
in those who have had STD’s. It’s also an indicator of unsafe sex)
What is your appetite like in the last 4 weeks?
What is your typical diet like?
Have you any health concerns at the moment?
When was the last time you saw your G.P. (check if they have a G.P.!)-
Exercise 1: Risks associated with
dual diagnosis
• Thinking about your work experience, what
are the risks associated with people with comorbid mental health and substance use
problems?
• Discuss in pairs, and make a list. (10
minutes)
Risks
• People with dual diagnosis are far more likely than people
with single diagnoses to be at risk of harm either to
themselves or others.
• Risks include:
–
–
–
–
–
–
violence
suicide
self-harm
accidental overdose from alcohol and/or illicit drugs,
self-neglect and malnutrition.
physical health problems (such as blood borne viruses and
injecting related problems)
– victimisation (bullying).
Risk Management
•
•
•
•
•
Requires effective interpersonal and engagement skills, good communication
between service user and all the services involved in their care, good support,
and monitoring.
It is almost impossible to prevent every untoward incident from occurring, but
a lot can be done to minimize the risk and reduce the likelihood of it occurring.
The service user should be placed at the centre of any risk management plan,
and their needs should be addressed as far as possible.
However there will be times in which the needs of the individual cannot be
met as this poses a threat to others.
This dilemma needs to be managed with as little confrontation as possible and
with as much dignity as possible for the service user.
– For example, if you are aware that the person is likely to harm a relative then
immediate action should be taken in order to prevent this. This may involve
informing the relative of the threat posed, or preventing the service user from
access to that person until the threat has subsided or if the safety of that person can
be protected (supervised contact for example).
Recommendations From “Avoidable Deaths”
(National Confidential Enquiry into Homicides and Suicides by those with Mental
Illness 2006)
• Reduce levels of absconding as deaths occurred after absconding from
inpatient wards
• Transition from ward to community- ensure a safe transition from ward to
home.
• Use of CPA and management of risk- comprehensive risk assessment and
high risk service users subject to enhanced CPA (including substance
users).
• Responding quickly when a care plan breaks down
• Improve observation on inpatient wards.
• Change attitude of “inevitability” towards suicides by people with mental
illness
• Improve services for dual diagnosis
Exercise 2 : Risk identification and
Management
• In small groups, read scenario then consider:
• What are the main concerns you would have about this man?
• From the case history, make a list of the risk factors and explain why
they are significant
• What kind of risk management plan would you want to implement?
• Who would be involved in this plan?
• What part of your plan ‘promotes safety’?
• Who helps determine the management plan? What role has the Service
User in determining this risk management plan