Kenneth Minkoff, MD

CO-OCCURRING DISORDER ASSESSMENT FORMAT

December, 2001

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A. INTEGRATED LONGITUDINAL STRENGTH-BASED ASSESSMENT (ILSA)

1. Identification and stabilization of ACUTE risk.

a. Safety: Violence, self-harm, basic self-care

b. Symptoms: Severe depression/panic; intense mania, disorganizing

psychosis

c. Substance Use: Need for acute detoxification

d. Social Safety: abuse, victimization, trauma

e. Somatic; Acute medical problems

2. Elements of Treatment Matching (according to CCISC Principles)

a. Subtype of Dual Disorder (Four Quadrants)

b. Diagnoses

c. Level of Functioning at Baseline (self-care, social, vocational, parenting)

d. External Problem Areas (ASI domains): Legal, Medical, Social, Family, Economic, Child Protective, Housing, Trauma/Abuse, plus associated contingencies in each area. External Supports: Family, Income, PCP, etc...

e. Existing Treatment Relationships (Integrated continuity present?) and Treatment Program for each problem, plus adherence with recommendations

f. Phase of Recovery for each diagnosis; Stage of Change regarding definition of problem, willingness to change, willingness to enter treatment, and adherence to treatment recommendations

g. Current Skills in managing MI and/or substance use.

h. Level of Care for continuing rx (ASAM 2R, LOCUS)

3. Assessment Process

a. Detachment: Establish empathy, empathic detachment and hope;

Identify initial treatment goals, create hopeful vision

b. Detection: Screening for co-occurring disorders (Screening Tools)

c. Diagnosis and Disability: Integrated, longitudinal, strength based history, with detailed description of most recent baseline, and emphasis on describing baseline functioning, and identification of symptoms of each disorder during stability from the other.

d. Detailed description of current situation: life circumstance, functioning, symptoms, supports, motivators to change, barriers to change, existing treatment and adherence, perception of what's working, etc.. Include addressing cultural context and conflict.

e. Determination of treatment needs: motivational enhancement assessment (MAGIC)

4. Integrated Longitudinal Strength-Based History: Structure

a. Identify and describe most recent baseline, using the following outline:

1. Level of functioning: housing, relationships, income, and daily activity

2. Identify mental health symptoms, diagnosis (if any), treatment (if any), and response to treatment.

3. Identify substance use, associated problems, diagnosis (if any), treatment (if any), and response to treatment.

4. Describe interactions between mental health symptoms, functioning, treatment, and substance use symptoms and treatment.

b. If patient not currently at baseline, follow longitudinal sequence to get to current situation.

c. Then, go back to childhood, and use the above outline to define history during childhood. Put significant life events in chronological sequence (divorce, death of parent, etc..) and assess impact on other variables.

d. Then, develop timeline of significant periods: high school, first marriage, long term job, period in prison, etc., and use outline for each period.

e. Link together the timeline chronologically. Focus on periods of GOOD functioning, and identify baseline symptoms, treatments, and strengths during those periods. For use in identification of both diagnosis and in terms of predicting what will work in future treatment.

B. CO-OCCURRING DISORDERS TREATMENT PLANNING FORMAT

1. Considerations for Determining Treatment Interventions

a. Subtype: Define locus of responsibility per quadrant

b. Diagnosis: Specific treatment intervention for each diagnosis - provides best treatment, add ancillary RX, ensure adequacy of "dosage"

c. Level of Functioning: Case management support in areas of incapacity; promote areas of strength

d. External Problem Areas: Specific problem solving, assistance, collaboration in each area. Development of contingency contracting using external constraint.

e. Treatment Relationships: Establish relationship if none present; collaborate with existing treaters; review adequacy of existing supports

f. Phase of Recovery/Stage of Change: Phase or stage-specific interventions: acute stabilization, motivational enhancement, active treatment, relapse prevention, rehabilitation

g. Current Skills: Skills training in disease management or daily living

h. Level of Care: Determine matrix of service intensities in dimensions of residential support, case management, treatment content/frequency medical/psychiatric/nursing supervision

2. Treatment Planning Outcomes (e.g.. 3 month goals)

a. Subtype: N/A

b. Diagnosis: Reduction in MI symptoms or disability; reduction in substance use

Ex. Reduce cocaine use from 2x/wk to lx/wk

c. Level of functioning: Improvement in one specific area. Ex: Rent paid on time through payee ship; pt. learns to write checks each month with help

d. External Problem Areas: Improvement in one or more specific domains.

Ex. Complaints from landlord reduced because pt uses ETOH indoors instead of on front steps

e. Treatment Relationships: More consistent support from treaters and other supports

Ex. Pt meets with case manager 75% of scheduled visits, to discuss both disorders

f. Phase of Treatment: Improvement in stage of change, or movement through RX phases

Ex. Pt becomes willing to admit that he might have a problem with substances OR might have a problem with mood swings that would be helped by meds.

g. Skills: Development of one or more specific skills.

Ex. Pt develops skill for what to say if asked about meds at AA meeting

h. Level of Care: Attains specific ability to manage treatment at next lower level of care

Ex. Pt in addiction residential rx develops skill to ask for help with overnight cravings and agrees to attend day treatment