Module 6: Assessment practical

Objectives

• To be able to take an integrated history using timeline

• To be able to obtain a current use pattern

• To be able to use cognitive behavioural assessment techniques in assessment

• To be able to formulate problems and strengths and devise a SMART plan

Dual Diagnosis Capabilities• Demonstrate Empathy: To be able to understand the unique

experiences a person with dual diagnosis may have had, and be able to communicate this understanding effectively and empathically to service users, and their carers. Dual Diagnosis Capability 5 level 2

• Interpersonal Skills: To be able to demonstrate effective skills such as active listening, reflection, paraphrasing, summarising, utilising open-ended questions, affirming, elaboration. Dual Diagnosis Capability 7 level 2

• Recognise Needs (Integrated Assessment): In partnership with the service user, perform a triage assessment of mental and physical health, substance use, and social functioning and offending; identifying both needs and strengths. Be able to identify where those needs are best met by local services. Dual Diagnosis 9 level 2

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 activites• Introduce non-drinking social activities• Explore Johns feelings of paranoia• Assess further his mental state• Psychoeducation 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