Day 3 Assessment and Risk

Liz Hughes

Timetable

9. 30 recap from last week, review homework10.00 Assessment10.30 break10.50 confidentiality11.15 history timeline12.00 current use12.30 lunch1.30 Assessment continued2.30 Risk and dual diagnosis3.45 summary and homework4.00 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

• Methamphetamine-48 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 1Substance

(What)

Route

(How taken)

Amount

(How much per session)

Frequency

(How often)

For how long?

Cannabis Smoked £20 per week (2 spliffs a night)

Daily 6 months

Alcohol (5% lager)

Oral 2 pints per session5 units per session20 units per week

4 times a week

2 months

Current Use 2: The 5 “W”’s

What

(what is being used?)

When

(How often is this behaviour occurring?)

Where

(where is this behaviour happening- be 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 exampleWhat is the area to be focused on:

alcohol use• When-most evenings, who with-friends, where-pub, why-

because 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 EVENT- triggers 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 blood-

borne viruses (HIV, hepatitis B and C).• Testing, advice, counselling and treatments for blood-

borne 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 co-morbid 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