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Assessment of Addiction and Co-Occurring Disorders

Assessment of Addiction and Co-Occurring Disorders


Brian Stracner
Capella University

Assessment of Addiction and Co-Occurring Disorders

Assessment of Addiction and Co-Occurring Disorders

Assessment of Addiction and Co-occurring Disorders


The assessment of addiction and co-occurring disorders is an important aspect of the initial
session to help fully understand whether or not a dual diagnosis situation is occurring. In the situation
with a culturally diverse client, it is even more important to assure relevant assessment procedures is
being applied. In a recent study the Substance Abuse and Mental Health Services Administration found
that nearly 8.9 million adults have co-occurring mental and substance abuse disorders (SAMHSA,
2015).
The case that will be analyzed will be that of Marifel. Mariel is a Filipino female, who is 19
years old. Marifel was born in her home country, and when she was 2 years old, her and her parents
moved to the United States. Marifels grandparents and other extended family members are still in the
Philippines, but many of her closer relatives are also in the America. Every few years Marifel get to
visit her homeland to spend time with her family.
Last summer Marifel was in a boating accident at a high school graduation party, and her
quality of life was greatly impacted. The driver of the boat could not see a rock under the service of the
water, and the boat smashed into it at high speed. The momentum launched the boat into a nearby pier,
and Marifel suffered multiple severe injuries. However, Marifel was lucky, because one of the people
in the acceded died the night of the traumatic event.
Over the preceding weeks, Marifel would heal physically. Unfortunately, she became reliant on
the prescribed opioids which were intended for the physical discomfort of the injuries. Marifel found
that the opioids helped her become disassociated from the emotional trauma that stemmed from the
tragic nights accident. Marifels doctor discontinued her opioid prescription, but she found a way to
purchase them on the black market instead. Marifel was driven to continue using opioids, because she
could not cope with the memories which arose when she was alone with her thoughts.
Evaluation of Assessment Tools

Assessment of Addiction and Co-Occurring Disorders

In the case of Marifel, it will be important to use a threefold assessment triage due to the
multifaceted dynamic of her situation. Foremost, it will be crucial to assure that the assessment and
approach applied is sensitive to Marifels multicultural background. For this reason, the Cultural
Formulation Interview will be applied (APA, 2013). It is also fairly obvious that Marifel is addicted to
opioids, so the Personal Experience Questionnaire will be examined. Finally, since the stemming
situation was so traumatic, it will be important to assess Marifel to see if she has Post Traumatic Stress
Syndrome (PTSD) from the unfortunate accident. Furthermore, it will be important to assess Marifels
current level of crises, so the PTSD and Suicide Screener will be investigated.
Cultural Formulation Interview
With cultural diversity increasing, it is vital that assessment tools are appropriate for significant
cultural variations. The focus of interpreting assessment findings needs to be the establishment of
cross-cultural validity between Western and Asian groups (Dere, et al, 2015). In Section III of The
DSM-V (APA, 2013), it state that there are four assessment categories which need to be covered which
include the cultural identity of the individual, cultural conceptualizations of distress, psychological
stressors and cultural features of vulnerability and resilience, cultural features of the relationship
between the individual and the clinician, and a summarization of the assessment. One such assessment
tool that is offered by the DSM-V (APA, 2013) is the Cultural Formulation Interview (CFI). The CFI is
most appropriate for this type of case, where there is some demographic information available before
the session (APA, 2013). The CFI is person-centered, so the process focuses on the clients view, and
the views within the clients social network. Even though the CFI can be used in any initial assessment,
it can be especially helpful in situations where the client and councilor do not have similar backgrounds
or common understandings (APA, 2013).
Personal Experience Questionnaire
Another assessment that could be used in this situation. Most people who have a substance abuse

Assessment of Addiction and Co-Occurring Disorders

problem do not understand the depth of their own addiction (Kosten & George, 2002). For this reason it
is important to have an assessment tool which evaluates whether or not the client is faking, as does the
assessment under review in this section. Furthermore, it will be necessary to assure that the assessment
is relevant to the situation and diversity of the client. The Personal Experience Questionnaire (PESQA) is a brief assessment which evaluates whether or not a client needs to be assessed further for
addiction. Once again, this assessment is most efficiently conducted in the initial session. The PESQ-A
is only appropriate for adults over the age of 19, so this just barely meets the age standards needed to
assess Marifel (Kulstad, 2005). One added benefit is that paraprofessionals are able to apply the
assessment, but not do the actual interpretation. However, this added support can easily lend its had to
having someone closer to the clients culture interpret anything that may seem confusing on the test,
since it can also be read. Furthermore, the assessment can be conducted through a recorded audio,
which once again lends its hand to possibilities for interpretation if needed. However, since Marifel has
been in the US since she was 2 years old, there should be no problem in taking the writer test. The
PESQ-A considers sex-specific cutoffs, to make sure the assessment considers gender. Furthermore,
the PESQ-A contains questions that ask for other demographic information as well. However, the
Mental Measurements Yearbook showed that in three samples of diversity problem severity scores
ranged from .87 to .95 (Kulstad, 2005). The overall assessment showed that 94% of the cases who
showed high severity ended up being referred out for further treatment, while 92% were correctly
classified as not needing a referral. This in turn equaled a total of 93% accuracy cross-culturally
(Kulstad, 2005).
PTSD and Suicide Screener
Practically every person alive will eventually be involved in a traumatic experience at some point
in their life (Dibbets & Shulte-Ostermann, 2015). Traumatic memories are common among those who
have experienced a serious threat. Such involuntary experiences occur in several forms including

Assessment of Addiction and Co-Occurring Disorders

visual, sounds, smells, flashbacks, or nightmares. Intrusive memories can negatively impact the daily
functional ability of any individual, which is why it is important to screen people who have
experienced traumatic situation such as in the case of Marifel. One of the benefits of the PTSD and
suicide screener (PSS) is the fact that it screens for indicators for both Post Traumatic Stress Syndrome
and suicidal tendencies (Kulstad, In press). As with the PESQ-A, the PSS can also be administered by
a paraprofessional, and all of the innate benefits in that ability can also apply to the PSS. The PSS was
derived from another assessment called the Detailed Assessment of Post-traumatic Stress (DAPS). If
either components is irrelevant to the person being assessed, they are allowed to skip to the next part of
the assessment, which means if the person answers no to elements within the PTSD assessment, they
can move on to the second part of the test to assess if the client is suicidal or not. One of the major
benefits of the PESQ-A is that during the development of the test multiculturalism was taken in
account, and 2.8% of the measurement was based off of Asian American participants (Kulstad, In
press). Furthermore, the PSS was cross-validated with the DAPS and the clinician-administered gold
standard interview for PTSD.
Choosing the Best Assessment
In this case all of the assessments are relevant and should be applied. However, if one was to
choose which of these assessments is the most relevant to Marifels specific diversity needs, the PSS
would have to come in first. The PSS is the only test out of the bunch that specifically investigates the
trauma which perpetuated all of her other struggles. Furthermore, the PSS is the only test that used
Asian Americans as subjects in the discovery process of the assessment. Furthermore, the PSS also
looks at gender differences, and can be applied by a paraprofessional to help assure the information is
relayed in a culturally sensitive manner. Even so, it is still important to recognize that the case of
Marifel is a duel diagnosis issue, and should be treated with cultural sensitive awareness, while
assessing the level of ned in addiction recovery and PTSD treatment. Furthermore, the PSS goes

Assessment of Addiction and Co-Occurring Disorders

beyond just investigating whether or not a client has PTSD, but it also goes own to assess the clients
level risk in regards to self-harm (Kulstad, In press)). In the case of Marifel, since she has been
showing risk taking behavior by taking illegal drugs, the suicide assessment will be an important
aspect, which further makes the PSS the most relevant assessment in this case.
Results of Assessment
There are many relevant indicators which can be applied to diagnose Marifel. Primarily, it looks
like Marifel will need help overcoming PTSD. According to the DSM-V (309.81, F43.10), this can be
easily seen (APA, 2013). Mariel was exposed to an event which caused serious injury to her, and she
also witnessed the injury of a friend. Later Marifel found out that her friend died after the accident, so
three out of four indicators are prevalent under criteria A for PTSD in the DSM-V (APA, 2013).
Furthermore, four out of five indicators under criteria B which focus on being affected by recurring
thoughts can be related to the information previously gathered from Marifel. The avoidance and
dissociative opioid addiction behavior is also seen under criteria C. However, once criteria D
approaches, it can be seen that more assessment needs to be done to discover if her cognitive abilities
are being affected by PTSD, especially since it has been shown that Asian Americans can somatize
psychosis (Dere, et al, 2015). Criteria E looks into a clients reactivity, which may have been dampened
by Marifels opioid use, so further assessment is needed to investigate this also. It is implied in the case
study that is has been more than a month that Marifel has been trying to cope with the tragedy, so
criteria F is relatable to this case. With further assessment it may be found that the disturbance caused
an impairment on Marifels life skills, but that would need to take place before indicating yes or no
on criteria G. Criteria H may pose a problem if it is found that the opioids are triggering the traumatic
memories, but it it fairly safe to say that this is not the case, since the accident led to the opioid use.
Marifel must also be assessed for opioid addiction. Again applying the DSM-V (APA, 2013) as
the reference it is found that there is also a moderate opioid use disorder (304.00, F11.20). Under

Assessment of Addiction and Co-Occurring Disorders

problematic patters in criteria A, six out of 11 indicators are found that relate to the current information
about Marifel, which specifies her case under moderate severity (APA, 2013).
Description of Client Strengths
Marifel has many strengths to consider. She is determined, has a family who wants to support
her, and she has a caring heart. She has learned how to be strong and how to cope with the trauma that
occurred in her life, even though it is not a healthy coping mechanism. One of Marifel's most important
asset is that she has a close family that loves her (Toner & Velleman, 2014)).
Description of Challenges to Be Addressed
Important facets which need to be investigated in more depth include understanding the family
system deeper through the possible use of a genogram, knowing more about the responsible party in the
accident, and discovering what positive goals she can work towards. The family systems will enable
the clinical to see what kind of family history the client has, which will also help the family become
involved in the treatment plan (Toner & Velleman, 2014). Furthermore, it will be important to discover
who the driver was in the accident, because there many be an underlying feeling of guilt which many
need to be addressed in therapy (Tagney, Stuewig & Hafez, 2011). Having direction is an important
aspect of treatment, and by working towards goals the clients progress will be able to be consistently
evaluated during the process.
Recommended Level of Care
Based upon ASAM criteria it currently seems like Marifel needs to be entered into II-D
ambulatory detoxification with extended on-site monitoring (Lewis, 2014). At Marifels current rate of
use and lack of impulse control it will be important that she gets the support and supervision that she
needs. Lucky she has supportive family members here in America, so she is likely to detox with the
right treatment plan incorporating all of the above mentioned assessment procedures.

Assessment of Addiction and Co-Occurring Disorders

References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Kosten, T. R., & George, T. P. (2002). The Neurobiology of Opioid Dependence: Implications for
Treatment. Science & Practice Perspectives,1(1), 1320.
Kulstad, J. L. (2005). [Test review of Personal Experience Screening Questionnaire for Adults].
In R. A. Spies & B. S. Plake (Eds.), The sixteenth mental measurements yearbook.
Retrieved from http://marketplace.unl.edu/buros/
Kulstad, J. (in press). [Test review of PTSD and Suicide Screener]. In J. F. Carlson, K. F.
Geisinger, & J. L. Jonson (Eds.), The twentieth mental measurements yearbook. Retrieved
from http://marketplace.unl.edu/buros/
Lewis, T.F. (2014). Substance abuse and addiction treatment: Practical application of counseling
theory (5th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
SAMHSA (2015) Substance Abuse and Mental Health Services Administration, Office of
Applied Studies, National Survey on Drug Use and Health, 2008 and 2009
http://media.samhsa.gov/co-occurring/
Tangney, J. P., Stuewig, J., & Hafez, L. (2011). Shame, Guilt and Remorse: Implications for
Offender Populations. The Journal of Forensic Psychiatry & Psychology, 22(5), 706
723. doi.10.1080/14789949.2011.617541
Toner, Paul. Velleman, Richard (2014). Initial reliability and validity of a new measure of
perceived social support for family members of problem substance users. Addiction
research & theory. 22(2 )147-157. doi:10.3109/16066359.2013.779675