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Screening & Assessment

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Presentation on theme: "Screening & Assessment"— Presentation transcript:

1 Screening & Assessment
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Screening Press ENTER for next slide.

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What is the screening? A screening is done as the client seeks services to best determine what the client’s potential problems may be and to determine if a complete assessment is required. The screening asks basic questions about the client’s drug/alcohol use and the severity of that use. The purpose is to determine if there is a probability of a substance related disorder. If it appears that there might be a problem, an assessment then follows. If it does not appear there is a problem, the client is then referred to a social services agency that can best meet his/her needs. In addition to a substance use screening, the client is also screened for high risk behavior that could lead to HIV, STD, TB or Hepatitis transmission. If the client is engaging in these behaviors he or she is referral for testing. Press ENTER for next slide.

4 Screening Instruments
There are several different types of screening tools. Many agencies now use their own specially created tools and there is no one tool that is required. However, the tools used have a mechanism to help make a recommendation for assessment, education, or the client being sent home. The most commonly used tools are: SASSI- BHIPS Screening- Example Attached Agency Devised- Example Attached Press ENTER for next slide.

5 Collateral Information
Often, if a client is not voluntarily seeking services, such as a referral from the criminal justice system or children's protective services, he/she is likely to give little information, offer vague answers, or deny any use at all. It is important that the referral source or a family member be given the opportunity to offer collateral information regarding the client’s behavior. Not what they “think” is occurring, but what behavior they have observed the client engaging in. Press ENTER for next slide.

6 High Risk Behaviors Texas Department of State Health Services (DSHS) wants each participant to be screened for high risk behavior that leads to the transmission of HIV, sexually transmitted diseases, tuberculosis, and hepatitis. This can be done with a short questionnaire. The screener must document ,in a note, that the client was screened and referred for testing.

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ASSESSMENT Press ENTER for next slide.

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What is the assessment? An ASSESSMENT is the gathering of relevant information about the client, their environment, their problem(s), and what they hope to accomplish through the therapeutic intervention. There are many types of assessments used, the most common are: Addiction Severity Index (ASI)- BHIPS Assessment- See Example Attached General Psychosocial Assessment- See Attached Press ENTER for next slide.

9 Assessment Guides Documentation
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10 Goals of the Assessment
The assessment should answer the following questions: Is treatment of any kind required? What are the relative merits of the intervention? What types of treatment approaches might be appropriate? What is the depth of therapy needed? Who should the therapy involve? Have cultural issues been considered? The assessment should enable both the client and Clinician to answer the following questions: Is treatment of any kind required? If treatment is indicated, what are the relative merits of the intervention? What types of treatment approaches might be appropriate? What is the depth of therapy needed? Who should the therapy involve? Have cultural issues been considered? Press ENTER for next slide.

11 Goals of the Assessment
The Assessment should answer these basic questions: Why is the client seeking treatment? How have these problems affected the client’s life? What is maintaining these problems? What does the client hope to gain from treatment? The Assessment should answer these basic Questions: For what problems is the client seeking treatment? How have these problems affected the client’s life? What is maintaining these problems? What does the client hope to gain from treatment? Press ENTER for next slide.

12 Who can conduct an Assessment?
Licensed Counselor (LCDC, LPC, LMSW, Ph.D) Registered Counselor Intern Both are: Knowledgeable to assess the specific needs of the client being served Trained in the use of applicable and appropriate tools Culturally sensitive to the client’s needs Licensed Counselor (LCDC, LPC, LMSW, Ph.D) Registered Counselor Intern Both are: Knowledgeable to assess the specific needs of the client being served Are trained in the use of applicable and appropriate tools Are culturally sensitive to the client’s needs Press ENTER for next slide.

13 Parts of the Assessment
Presenting Problem or Chief Complaint Alcohol and Other Drug Use History (Use) Mental Health History (Mental/Emotional Functioning) Psychiatric and Chemical Dependency Treatment Medical History (HIV, STD, TB, HEP) Relationships with Family Social/Leisure History (Activities) Educational/Vocational Employment Legal History Client Strengths and Limitations Diagnosis and Recommendations Presenting Problem or Chief Complaint Alcohol and Other Drug Use History (use) Family and Social/Leisure History (activities) Educational/Employment History (training) Legal History Mental Health History (mental/emotional functioning) Medical History (HIV, STD, TB, HEP) Client Strengths and Limitations Recommendations Press ENTER for next slide.

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Presenting Problem Asks the client: What brings you here today? Why do you think you need treatment? The answers provide immediate insight into what the client considers the most pressing problem and provides clues as to how distressing these problems are. If the client is entering treatment voluntarily, information relating to how motivated the client is for treatment, and their expectations for treatment can also be obtained. client responses to these questions should be recorded verbatim. Press ENTER for next slide.

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History of the Problem Documentation should include the following: When the client began experiencing the problem Their perception of the cause of the problem Significant events that occurred with or at the time the problem began Precipitants of the problem Thorough knowledge and understanding of the problems history can greatly facilitate its treatment. Your documentation should include the following: When the client began experiencing the problem, Their perception of the cause of the problem, Significant events that occurred at or the time the problem began Precipitants of the problem, What maintains the problems presence, The problem’s course over time, How the problem effects the clients ability to function, What the client has done to try to deal with the problem. Press ENTER for next slide.

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History of the Problem Documentation should include the following: What maintains the problem’s presence The problem’s course over time How the problem affects the client’s ability to function What the client has done to try to deal with the problem Thorough knowledge and understanding of the problems history can greatly facilitate its treatment. Your documentation should include the following: When the client began experiencing the problem, Their perception of the cause of the problem, Significant events that occurred at or the time the problem began Precipitants of the problem, What maintains the problems presence, The problem’s course over time, How the problem effects the clients ability to function, What the client has done to try to deal with the problem. Press ENTER for next slide.

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Alcohol and Drug Use Substances used in the past Substances used recently Frequency/amount/duration Route of administration Year or Age of first use Behavior related to obtaining substances Use or recovering from alcohol or other drugs Previous overdose, withdrawal, or adverse drug or alcohol reactions Attempts to decrease/stop use History of previous substance abuse treatment received Substances used in the past, including prescribed drugs. Substances used recently, especially those used within the last 48 hours. Frequency of use, amount of use, duration of use and route of administration. Year or Age of first use of each substance. Behavior related to obtaining, use or recovering from alcohol or other drugs. Previous occurrences of overdose, withdrawal, or adverse drug or alcohol reactions. Attempts to decrease/stop use any history of previous substance abuse treatment received. Press ENTER for next slide.

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Mental Health History Can shed light on whether the current problem is part of a single or recurrent episode. A progression of behavioral health problems over a period of time. What treatment approaches have or have not worked. Client’s willingness to engage in the treatment process. Gives an idea of current emotional functioning. A previous history of behavioral health problems and treatment is important to know. This should be documented regardless of the level of care. Obtaining this information can shed light on whether the current problem is part of a single or recurrent episode, or a progression of behavioral health problems over a period of time, what treatment approaches have or have not worked in the past, and the client’s willingness to engage in the treatment process. Important to get an idea of current emotional functioning, especially with youth. Press ENTER for next slide.

19 Psychiatric & Chemical Dependency (CD) Treatment
Any previous treatment Dates of Service Type of Service Outcome- did they complete? are they still going to treatment? Aftercare Services Press ENTER for next slide.

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Medical History At a minimum, document these: any significant illnesses hospitalizations past and current physical illnesses or conditions breast or prostate cancer diabetes hypertension injuries or disorders affecting the central nervous system any functional limitations HIV, STD, TB or Hepatitis exposure or contact cursory family history of significant medical problems At a minimum, you should document any significant illnesses, hospitalizations, past and current physical illnesses or conditions (i.e., breast or prostate cancer, diabetes, hypertension), injuries or disorders affecting the central nervous system, any functional limitations. HIV, STD, TB or Hepatitis exposure or contact. You should include a cursory family history of significant medical problems. Press ENTER for next slide.

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Family Relationships The family history should include: Spouse, children information Relationship with spouse and/or children Family expectation of treatment The occupation and education of parents The number of siblings and their birth order The quality of client’s relationship to parents and/or siblings Significant extended family members Substance use in family Child or Domestic Abuse Helps you understand how the client got to this point through a familial context. Important aspects of the family history include: The occupation and education of patents, The number of siblings and their birth order, The quality of clients relationship to parents and or siblings Significant extended family members, Parental approach to child rearing, Familial expectations for the client. Press ENTER for next slide.

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Social & Leisure Components should include: General number of friendships Types of friendships Participation in team sports Involvement in clubs Social activities- main form of socialization and leisure Involvement in religion, political or gang activities Opportunities requiring interpersonal interactions Experiences stemming from being a member of a racial or ethnic minority Helps you understand how the client got to this point through a social context. It may also provide you with information relating to the clients ability to relate well with and take directions from perceived authority figures. Important information includes: the general number of and types of friendships; participation in team sports; involvement in clubs or other social activities; being a leader vs. a follower; involvement in religion, political or gang activities, and other opportunities requiring interpersonal interactions. The client’s experiences stemming from being a member of a racial or ethnic minority, which can have a significant bearing on their current problem and coping styles. Press ENTER for next slide.

23 Educational & Vocational
Educational/Vocational history can give: Rough estimate of the client’s level of intelligence Aspirations, goals, ability to gain from learning experiences Willingness to make a commitment Amount of perseverance Ability to delay gratification Information should include: Highest grade completed Graduation status Feeling regarding education/vocational training Willingness to attend more (school or training) in future This generally provides limited yet potentially important information. The attained level of education can give you an rough estimate of the client’s level of intelligence. It also speaks to the client’s aspirations, goals, ability to gain from learning experiences, their willingness to make a commitment, their amount of perseverance, and their ability to delay gratification. Press ENTER for next slide.

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Employment Employment history can: be useful in developing an effective treatment plan give insight into the client’s ability to get along with others and take direction show client’s ability for assuming the role of a client show compliance with treatment recommendations Employment history should include: Last job held Length of longest employment Job preference Military experience Termination for job reason (if applicable) This can provide you with a wealth of information that can be useful in understanding the client and developing an effective treatment plan. Interactions with supervisors and peers can provide you with insights into the client’s ability to get along with others and take direction. In addition, the client’s ability to assume and meet the expectations of being a hired employee may have implications for assuming the role of a client and complying with treatment recommendations. Press ENTER for next slide.

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Legal History Current legal problems probation parole awaiting trial/sentencing recently released from jail/prison Complications with legal situation positive UA Are legal problems directly related to substance use? Is the client currently experiencing any legal problems (probation, parole, awaiting trial/sentencing, recently released from jail/prison). Complications with legal situation (positive UA) Is legal problems directly related to substance use? Press ENTER for next slide.

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Client Strengths Force clients to consider that their psychological assets can have therapeutic value(s) in themselves. Strength-based assessments can serve as an intervention before formal treatment actually begins. Can help build self-esteem and self-confidence . Reinforce the client’s efforts to seek help. Increase their motivation to return to engage in the work of treatment. It is important to recognize that the benefits of assessing client strengths go beyond their value to the development of the treatment plan. They force clients to consider that their psychological assets can have therapeutic value(s) in themselves. In essence, strength-based assessments can serve as an intervention before formal treatment actually begins. They can help build self-esteem and self-confidence, reinforce the clients’ efforts to seek help, and increase their motivation to return to engage in the work of treatment. Press ENTER for next slide.

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Diagnosis Must be a Five Axial Diagnosis: Must use criteria in DSM-IV-TR Each Axial Diagnosis must be supported in a body of assessment by describing behavior that demonstrates the DSM-IV diagnostic criteria You must determine if the client has a substance-related disorder, if not, they are not eligible for treatment services Press ENTER for next slide.

28 DSM-IV Multi-axial Diagnostic System
Axis I (Clinical Disorders, other conditions that may be a focus of attention) Examples: Substance abuse, substance dependence, anxiety disorders, mood disorders, schizophrenia Axis II (Personality disorders, mental retardation) Examples: Borderline personality disorder, antisocial personality disorder, avoidant personality disorder, mental retardation Axis III (General medical conditions) Examples: Cancer, Hypertension, Diabetes, Migraines, Chronic Pain, Injuries Axis IV (Psychosocial and environmental problems) Examples: Problems with primary support group, occupational problems, problems relating to social environment Axis V (Global assessment of functioning) Example: GAF Score Axis I (Clinical Disorders, other conditions that may be a focus of attention) Examples: Substance abuse, substance dependence, anxiety disorders, mood disorders, schizophrenia An accurate diagnosis can have important implications in the development of an effective course of treatment. Axis II (Personality disorders, mental retardation) Examples: Borderline personality disorder, antisocial personality disorder, avoidant personality disorder, mental retardation Identification of a personality disorder on Axis II with or without an accompanying Axis I disorder would have a bearing on the projected length of treatment. Axis III (General medical conditions) Examples: Cancer, Hypertension, Diabetes, Migraines, Chronic Pain, Injuries Axis IV (Psychosocial and environmental problems) Examples: Problems with primary support group, occupational problems, problems relating to social environment Axis V (Global assessment of functioning) Example: GAF Score Diagnoses are efficient tools for communicating among professionals and organizations. Press ENTER for next slide.

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Recommendations The assessment must include: The clinical recommendations counseling education treatment Recommendation for treatment must indicate the level of care Detox Residential Outpatient What are the recommended: services length of stay intensity of services Diagnostic Justification Summary After your assessment, what are your clinical recommendations. Nothing, other counseling, education, treatment. If recommendation is for treatment what is the level of care (Detox, Residential, Outpatient) What are the recommended services, length of stay and intensity of services. Diagnostic Justification Summary Press ENTER for next slide.

30 Treatment Eligibility
To be eligible for treatment, clients must meet the diagnostic criteria for substance abuse or substance dependence. If they do not meet the diagnostic criteria, as supported and documented in the assessment, you can not admit the client into treatment, they must be referred for education or sent home. Once it is determined that they meet the diagnostic criteria the level of treatment is determined by the Texas Department of Insurance admission placement criteria and if DSHS is to pay for the services, determined by DSHS placement criteria. Press ENTER for next slide.

31 Admission Once the clinician has determined that the client meets the diagnostic, level of care, and financial eligibility criteria for admission, they may begin the admission process. It is important that the admission be justified in writing by acknowledging the diagnostic criteria has been met, the placement criteria has been met, and the financial criteria has been met. The decision to admit should be supported by the assessment, and the assessment is always done before an admission.

32 Other Issues to Consider
Problem Complexity Readiness to Change Social Supports Coping Styles Motivation Press ENTER for next slide.

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Problem Complexity Presenting problems can have an important bearing on the treatment planning process. Problem complexity can be facilitated by historical information about other aspects of the client’s life. Historical information can allow for the revelation of “recurrent patterns or themes arising within objectively different, but symbolically related, relationships”. Whether the client’s presenting problems are high or low with respect to complexity can have an important bearing on the treatment planning process. Ascertaining the level of problem complexity can be facilitated by historical information about other aspects of the clients life. The historical information can allow for the revelation of “recurrent patterns or themes arising within objectively different but symbolically related relationships”. Press ENTER for next slide.

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Non-Complex Problems The following may be exhibited or reported during the assessment: Chronic habits and/or transient responses. Behavior repetition maintained by inadequate knowledge or by ongoing situational rewards. Behaviors having a direct relationship to initiating events. Behaviors that are situation specific. The following may be exhibited or reported during the assessment: Chronic habits and/or transient responses. Behavior repetition maintained by inadequate knowledge or by ongoing situational rewards. Behaviors have a direct relationship to initiating events. Behaviors are situation specific. Press ENTER for next slide.

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Complex Problems The following may be exhibited or reported during the assessment: Behaviors are repeated as themes across unrelated or dissimilar situations. Behaviors are ritualized (yet self-defeating) attempts to resolve dynamic or interpersonal conflicts. Current conflicts are expressions of the client’s past rather than present relationships. Repetitive behaviors results in suffering rather than gratification. Symptoms have a symbolic relationship to initiating events. Problems are enduring, repetitive and symbolic manifestations of characterlogical conflicts. (Patrick, 32) Press ENTER for next slide.

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Readiness to Change Prochaska, DiClemente and colleagues: Five Stages of Change: Pre-Contemplative Contemplative Preparation Action Maintenance The importance of the client’s readiness to change in the therapeutic process comes from the work of Prochaska, DiClemente and their colleagues. They have identified five stages through which individuals go when changing various aspects of their lives. These changes apply not only to change that is sought by behavioral health treatment, but also in non-therapeutic contexts. The five stages are: Pre-Contemplative, Contemplative, Preparation, Action and Maintenance. Press ENTER for next slide.

37 Prochaska’s Stages of Change: Pre-contemplative
Little or no awareness of problems Little or no serious consideration or intent to change Often presents for treatment at the request of/or pressure from another party Change may be exhibited when pressure is applied but the client reverts to previous behavior(s) when pressure is removed. “Resistant to recognizing or changing the problem” is the hallmark of the pre-contemplative stage. Little or no awareness of problems Little or no serious consideration or intent to change Often presents for treatment at the request of/or pressure from another party Change may be exhibited when pressure is applied but the client reverts to previous behavior(s) when pressure is removed. Resistant to recognizing or changing the problem is the hallmark of the pre-contemplative stage. Press ENTER for next slide.

38 Prochaska’s Stages of Change: Contemplative
Awareness of problem and serious thoughts about working on it. No commitment to begin to work on it. Weighing pros and cons of the problem and its solution. “Serious consideration of problem resolution” is the hallmark of the contemplation stage. Awareness of problem and serious thoughts about working on it. No commitment to begin to work on it. Weighing pros and cons of the problem and its solution. Serious consideration of problem resolution is the hallmark of the contemplation stage. Press ENTER for next slide.

39 Prochaska’s Stages of Change: Preparation
Intention to take serious, effective action in the near future (e.g., within a month). Has already made small behavioral changes. “Decision making” is the hallmark of this stage. Intention to take serious, effective action in the near future (e.g., within a month) but has already made small behavioral changes. Decision making is the hallmark of this stage. Press ENTER for next slide.

40 Prochaska’s Stages of Change: Action
Overt modification of behavior, experiences or environment in an effort to overcome the problem. “Modification of problem behavior to an acceptable criterion and serious efforts to change” are the hallmarks of this stage. Overt modification of behavior, experiences or environment in an effort to overcome the problem. Modification of problem behavior to an acceptable criterion and serious efforts to change are the hallmarks of this stage. Press ENTER for next slide.

41 Prochaska’s Stages of Change: Maintenance
Continuation of change to prevent relapse Consolidate the gains made during the action stage. “Stabilizing behavior change and avoiding relapse” are the hallmarks of this stage. Continuation of change to prevent relapse Consolidate the gains made during the action stage. Stabilizing behavior change and avoiding relapse are the hallmarks of this stage. Press ENTER for next slide.

42 Potential Resistance to Therapeutic Influences
Two different types of resistance exists: Resistance a state-like quality in which clients fail to comply with external recommendations or directions. Reactance a more extreme trait-like form of resistance that stems from the client’s feelings that their freedom or sense of control is being challenged by outside forces. This is manifested as active opposition. The potential resistance to therapeutic influences may be an indicator of the clients motivation to engage in treatment. Two different types of resistance exists: Resistance, which may be considered a state-like quality in which clients fail to comply with external recommendations or directions Reactance, a more extreme trait-like form of resistance that stems from the clients feelings that their freedom or sense of control is being challenged by outside forces. This is manifested as active opposition. Press ENTER for next slide.

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Social Supports Objective social supports can be assessed from external evidence of resources available to the client, such as marriage, physical proximity to relatives, network of identified friends, membership in organizations and involvement in religious activities. Also includes the quality of social relationships. Objective social supports can be assessed from external evidence of resources available to the client, such as marriage, physical proximity to relatives, network of identified friends, membership in organizations and involvement in religious activities. Also includes the quality of social relationships. Press ENTER for next slide.

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Coping Styles Coping style is defined as: “an enduring trait that relates to the way one copes with (handles) personal or interpersonal threats”. Two identified coping styles: internalization externalization An important consideration for treatment planning is the identification of the client’s coping style. Coping style is defined as “an enduring trait that relates to the way one copes with personal or interpersonal threats”. There are two identified coping styles: internalization and externalization. Press ENTER for next slide.

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Internalization This style of coping is suggested in clients who tend to: Avoid, deny, repress, or compartmentalize sources of anxiety Be overly introverted, introspective, self-critical, and self-controlled Be emotionally constricted This style of coping is suggested in clients who tend to: Avoid, deny, repress or compartmentalize sources of anxiety Be overly introverted, introspective, self-critical, and self-controlled Be emotionally constricted Press ENTER for next slide.

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Externalization This style of coping is suggested in clients who tend to: Directly avoid, rationalize, project or act-out onto their environment(s). Exhibit a degree of insensitivity to their own and others’ feelings. Be spontaneous, impulsive, extraverted, and sometimes manipulative. This style of coping is suggested in clients who tend to: Directly avoid, rationalize, project or act-out onto their environment(s); Exhibit a degree of insensitivity to their own and others’ feelings; Be spontaneous, impulsive, extraverted, and sometimes manipulative. Press ENTER for next slide.

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Motivation to Change How to determine the client’s level of motivation to change: Is the client seeking treatment from their own desire for help or from the request/demand of another? What is the client’s stated willingness to be actively involved in the treatment process? What is the client’s subjective distress and reactance? What is the client’s readiness for, or stage of, change? An important factor to assess for treatment planning is the client’s motivation to change. How to arrive at a good estimate of the clients level of motivation to change: Is the client seeking treatment from their own desire for help or from the request/demand of another? What is the client’s stated willingness to be actively involved in the treatment process? What is the client’s subjective distress and reactance? What is the client’s readiness for, or stage of change? Press ENTER for next slide.

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Motivation to Change Factors that should be considered in the evaluation of motivation to engage in treatment: A willingness to participate in the diagnostic evaluation. Honesty in reporting about oneself and one’s difficulties. Ability to recognize that the symptoms experienced are psychological in nature. Introspectiveness and curiosity about one’s own behavior and motives. Openness to new ideas, with a willingness to consider different attitudes. Realistic expectations for the results of treatment. Willingness to make a reasonable sacrifice in order to achieve a successful outcome. Seven factors have been identified that should be considered in the evaluation of motivation to engage in treatment: A willingness to participate in the diagnostic evaluation. Honesty in reporting about oneself and one’s difficulties. Ability to recognize that the symptoms experienced are psychological in nature. Introspectiveness and curiosity about one’s own behavior and motives. Openness to new ideas, with a willingness to consider different attitudes. Realistic expectations for the results of treatment. Willingness to make a reasonable sacrifice in order to achieve a successful outcome. Press ENTER for next slide.

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Involving Others The client's family is an important factor in the client's involvement in, and treatment for, substance use disorders. Therefore, it is critical to form a therapeutic alliance with the family to the fullest extent possible, and to involve the family in the assessment process. If there is evidence that the client is being abused at home, the family should still be questioned about the matter. It is important to pursue what is known about possible abuse from the parents, even the abusing parent, as well as other family members (e.g., siblings). Press ENTER for next slide.

50 Involving Others-Continued
The assessment should not be considered complete until there has been time to assess the traditionally defined family and others identified by the court as legal custodians who can speak for the best interests of the client, as well as the family that is defined by the young person. Press ENTER for next slide.

51 Involving Others-Continued
If other people, such as the client's family, are involved in the assessment process, the assessor should determine the order of the interviewing process. For example, it may be advisable to first interview the young person in private, then the parent(s) in private, then with the group as a whole, being sure to tell each person that no information given in confidence will be shared with the entire group unless prior permission is granted. This strategy will maximize comfort and confidentiality. Press ENTER for next slide.

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Setting The assessment should be conducted in an office or other site where confidentiality can be ensured and where the client can feel comfortable, private, and secure. The validity of information provided by the client may depend on the setting (especially if the setting is seen by the client as adversarial or threatening), the level of trust between the client and the assessor, and the client's understanding of the potential use and audience for the information he is about to divulge. If the client feels that he will be overheard by others in the assessor's office, or that providing information will result in punishment, he is unlikely to tell the full truth. If an interview is conducted in a detention center, the juvenile should be assured that no one in authority at the center can overhear the interview. Press ENTER for next slide.


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