Assignment 1: CHCAOD408B and CHCAOD411A
Assignment 1: CHCAOD408B and CHCAOD411A
1. What are you required to discuss with a client prior to an assessment?
Although the exact sequence for preparing a client for an assessment might vary across different organisations, the personal/organisational introduction should always be the first step because it allows us to engage in small talk, establish rapport, and it makes the client feel comfortable. However, in addition to establishing rapport, this phase of the meeting also serves for the purpose of observing the client’s reactions and behaviours. Examples of presenting behaviours in clients with a history of alcohol or other drug (AOD) abuse will include intoxication, suicidal ideation, anger, violence, depression, hyperactivity, nervousness, and distress. It is also important to note the client’s physical presentation, such as smell, appearance, and well-being. Even though some people may be lacking those indicators, I should never discredit them because mentally ill individuals can mask their emotions and intentions. Although some clients are legally obligated to take the assessment and might not understand that they have a problem, I should also ask them why they are seeking help and why they chose my organisation during this phase of the interview.
I must also talk to the client about my organisation and the organisational privacy and confidentiality policies that govern our meetings. That is important because some of the information clients will disclose through speech or through writing in the assessment is sensitive and private. I must assure the client that my organisation has strict privacy policies regarding the disclosure of such information. For example, their private data can be obtained only by authorizes staff or by law enforcements with court orders. That point must be restated whenever I must collect further information from the client, such as immediately before starting the assessment.
Before performing the actual assessment, I am obligated to discuss the purpose of the assessment and the procedure we will use to perform it. The client must confirm that my explanation of the purpose and procedure of the assessment is clear and understandable. I should also monitor the client’s feedback to determine whether the confirmation is voluntary or involuntary.
Finally, before performing the assessment specific for AOD, I should perform the general screening. The general screening is not restricted to learning more about the client’s AOD abuse issues, even though it can include relevant questions. However, the general screening focuses on questions about their sleeping habits, medication use, sadness, eating habits, and similar indicators of emotional and physical well-being. Those questions can indicate the presence of comorbid mood disorders, which should then be included in the assessment process.
2. Alcohol Use Disorder Identification Test (AUDIT) Review
a) Brief description – how and why was it designed?
AUDIT is a screening instrument designed by the World Health Organisation (WHO) to screen clients for excessive drinking problems. The tool was designed so that healthcare practitioners can distinguish between different subtypes of alcohol abuse. Hazardous drinking is a subtype that refers to people who place their well-being and the well-being of others at risk; harmful use refers to clients whose alcohol abuse might contribute to negative physical and mental conditions; alcohol dependence is defined as a condition that develops through persistent use and reflects in the behaviour and cognition of the affected individual (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001).
The development of the AUDIT screening tool took over two decades because the WHO wanted to develop a test that is brief, applicable in different settings, consistent with ICD-10 definitions regarding alcoholism, and applicable in both developed and developing countries. Therefore, to identify the relevant items that could be used in the screening tool, the researchers conducted a cross-national comparative field study in the US, Australia, Norway, Mexico, Bulgaria, and Kenya (Babor et al., 2001). As a result of that research, they were able to identify 10 items that distinguished people without risk of harm and people at risk for harmful alcohol abuse. Those 10 items measured alcohol consumption (items 1-3), drinking behaviour (items 4-6), adverse reactions (items 7-8), and alcohol related problems (items 9-10) (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). The domains addressed by the AUDIT tool can be divided into hazardous alcohol use (items 1-3), dependence symptoms (items 4-6), and harmful alcohol use (items 7-10) (Babor et al., 2001).
When AUDIT was developed, it was tested on known alcoholic patients to determine its validity and cut-off scores. Researchers identified 8 and 10 points as two suitable cut-off scores that ensured sensitivity and specificity (Saunders, et al. 1993). A lower cut-off score of 8 points proved to have higher sensitivity and lower specificity while the higher cut-off score of 10 points had lower sensitivity and higher specificity (Saunders, et al. 1993).
b) How could this tool be used with a client?
Although the instrument was developed as a screening tool in primary healthcare, it can be applied in a variety of contexts when healthcare providers suspect an individual being at risk for alcohol abuse. For example, AUDIT can be used in psychiatric hospitals to determine whether an individual showing suicidal behaviour suffers from alcohol dependence (Babor et al., 2001). It can also be used in prisons to screen offenders who were arrested for violent behaviour or breaking the law under the influence. A study by J. Davey, T. Davey, and Obst (2002) screened Australian university students’ alcohol consumption habits, and they managed to identify the 15% of the sample at risk for alcohol dependency. Therefore, AUDIT is a versatile screening tool that can be used in a variety of settings.
As a general rule, the best way to administer AUDIT to the clients is by adhering to standard screening protocols. That means the healthcare practitioner must inform the client about the purpose of the test, provide information the client needs to successfully complete the test, and reinforce the confidentiality of the client’s information (Babor et al., 2001). The healthcare provider must also address any other concerns or questions a client might have regarding the screening tool, and it is never used while the client is intoxicated or in need of an emergency intervention.
The test is administered in person as a self-reported questionnaire or through an interview. The self-reported questionnaire is faster to complete and can also be administered and scored with a computer, but it might include ambiguous or evasive answers. An interview is a better option for clients who have poor reading skills or evade providing relevant answers.
c) What do you think are some of the benefits and limitations of this tool?
One of the main benefits of the tool is that it is simple and valid. The test takes a short time to complete because it contains only 10 questions. During the development of AUDIT, the tool was tested on known alcoholics to determine its validity. The results for sensitivity and specificity were calculated by comparing AUDIT scores and the participants’ diagnoses. With the cut-off score of 8 points, the overall sensitivity was 92% while overall specificity was 94% (Saunders, et al. 1993). A cut-off score of 10 points increased the overall specificity to 98% while the overall sensitivity decreased to 80% (Saunders, et al. 1993). When the drinking group results were compared to the non-drinking group results, only three participants in the non-drinking group scored 8 points or more while 99% of the drinking group had scores of 8 points or higher (Saunders, et al. 1993). Therefore, AUDIT is both simple and effective in screening clients for alcohol abuse and dependency risks.
The tool is also specific in determining the severity of alcohol abuse. For example, AUDIT scores between 8 and 15 points represent low risk that warrants advice on preventing and reducing hazardous drinking. If the client scores between 15 and 19 points, counselling and monitoring are required. Any score of 20 points and over warrants further diagnostic assessments and evaluations (Babor et al., 2001). Therefore, different scores can help healthcare workers determine further options for diagnostic tests or treatment options.
The only potential limitation of the AUDIT screening tool is the fact that data obtained with it is self-reported, which is a common cause for bias in all questionnaires that rely on self-reported data. However, as long as proper precautions are taken to avoid evasive and biased answers to the questions, AUDIT is a reliable and valid screening tool for alcohol dependence and risk of harm because of alcohol consumption (McCambridge & Day, 2008). Alternatively, if the client is uncooperative, the client can be referred to an organisation that uses physical examinations to determine risk for hazardous drinking (Babor et al., 2001).
3. What areas should be investigated during a screening and assessment process? Think about their AOD use, their environment and their other supports. Provide at least six (6) headings you might use in your documentation.
The goal of the assessment process should be to build a complete profile of the client’s situation. That includes not only information about the client’s AOD issue, but also the client’s background information, such as family history, financial situation, social interactions, and medical history. Six potential heading I could use in my documentation include:
- Background information (e.g. demographics, socioeconomic status, family history)
- Medical information (e.g. medical history, current treatments).
- Mental health (e.g. comorbid disorders, previous treatments or hospital admissions)
- Drug and alcohol abuse (e.g. diagnosis, previous behaviours, available support, previous treatments, current)
- Presenting issues (e.g. anger, violence, suicidal intentions)
- Other issues (e.g. household abuse, protective child custody)
1. Describe how this client is likely to present for her initial assessment. What do you think she might be feeling?
With a six-year history of heroin abuse, Kathy has probably been spending a lot of time and effort to obtain the illicit substance while neglecting her health, education, career, and family. Therefore, her physical appearance will probably indicate poor self-care, and I would also look for substance withdrawal symptoms. Given her position as a victim in her previous relationship and her lack of communication with her family, she will most likely feel depressed, distressed, and nervous.
2. Considering your role as the worker, what would your aims be for this first session?
As a worker, I would proceed with the standard protocol for conducting my first session with Kathy. I would introduce myself and the organisation I work for to establish rapport. During this stage, I would observe her behaviour to determine whether she is under the influence or in an acute crisis because those states would require a different intervention. I would also familiarise her with organisational policies, such as confidentiality and privacy. Because she is seeking help voluntarily, I would ask her to tell me more about her motivations, needs and expectations. Finally, I would perform a general screening for her mental health and a screening specific to her drug abuse. I might also encourage a conversation about her family history to determine whether family therapy is a suitable intervention option at some point during the counselling.
3. What is the range of problems that you and Kathy would be likely to identify?
Because Kathy is addicted to heroin, physiological dependency is probably a critical issue that needs to be resolved. Another problem is her desire to continue using even though she is pregnant and wants to keep the baby, which is a child protection issue. Poor relationships, including both romantic relationships and family relationships, are also a potential reason for her involvement with drugs. Finally, she probably has significant financial issues because she cannot pay the rent and is at a disadvantage in society because of her drug use.
4. What skills and strategies would you use during this assessment with Kathy?
During the assessment, I would primarily focus on using encouraging and reflecting feelings to help her engage in the assessment process. I would also use plain English she can understand and ask her to confirm whether she understands the information and explanations I am providing.
5. What other agencies or professionals would you consider might need to be involved in supporting Kathy? Explain your reasons for their involvement and why particular referrals would be given priority.
The first agency I would consider is a detoxification centre because she needs to overcome her physical withdrawal symptoms. I would also consider referring her to professionals working with behavioural therapy or cognitive-behavioural therapy because she probably has personal issues that require changes in her thought process and life choices. Family therapy might also be required to involve her family and resolve potential issues in that area. Finally, I would consider social skill classes to help her reintegrate with society and form meaningful relationships, but only once she resolves her personal issues.
6. What duty of care issues relate to Kathy and her baby?
As a recovering drug user, Kathy has good chances of keeping her baby if her treatment is successful. However, the damage could have already affected her baby, so Kathy should also be referred to an institution that conducts prenatal screening tests to check the baby’s health. Kathy also wants to continue using, but it is important to help her overcome that desire during the treatment. Otherwise, she will most likely be found guilty for violating the Children and Young Persons (Care and Protection) Act 1998, sections 227 and 228. Section 227 states that any action resulting in physical or emotional harm to the development of the child is an offence while section 228 states that neglect to provide medical care, shelter, or clothing is an offence. If she does not resolve her drug use issue, she will probably be found guilty of both sections and her child will be placed in protective custody.
1. What is the difference between a primary, secondary and tertiary intervention? Give three examples of each.
Primary interventions are aimed at preventing AOD abuse, so the most common strategies in primary care include national drug campaigns, drug education, and community development. For example, the Department of Health in Australia has a program called the National Drugs Campaign (NDC), which created the framework for the National Drug Strategy 2010-2015. The framework determines various objectives to help reduce demand, supply, and harm caused by illicit substances. For example, one of the objectives is to provide support and reintegrate existing users with the community (Commonwealth of Australia, 2011). Another objective is to reduce the supply of illicit substances by improving law enforcement actions aimed at preventing import and manufacturing of illicit substances (Commonwealth of Australia, 2011).
Secondary interventions, also called early interventions, depend on the ability to detect AOD abuse early and utilise interventions that can hinder further dependency development. Crisis interventions are helpful in those instances, but early detection is critical to identify the need for an intervention in the first place. For example, policies at schools or workplaces can require mandatory AOD screening tests. If schools and workplaces do not have such policies in place, noticeable changes in behaviour can be a sign for teachers, parents, employers, friends, and colleagues that a person might be developing AOD dependency.
Tertiary interventions are the final stage of prevention, and they are implemented when a person already develops AOD dependency. The treatment aims to prevent further substance abuse and restore the individual’s health. For example, detoxification programs or pharmacotherapy with substitution drugs may be used to alleviate withdrawal symptoms during the early stage of abstinence while counselling or psychotherapy could be used to develop new behavioural patterns. Physical health should also be considered. For example, a client with alcohol abuse issues might develop liver cirrhosis, so that client would require medical attention specific to that health problem.
2. For three (3) of the following interventions available for individuals, families or the broader community relating to alcohol and other drug issues, please complete the following:
a) Provide a brief description.
Psychotherapy. Psychotherapy is a broad term that encompasses interventions in which a therapist interacts with the client or group of clients. The purpose of psychotherapy is to determine the causes and triggers of certain behaviours and thoughts so that the client and the therapist can find solutions to the problem and set appropriate goals. Some examples of psychotherapy include cognitive-behavioural therapy (CBT), psychoanalysis, and interpersonal psychotherapy.
Detoxification. Detoxification for AOD users is usually conducted in facilities specializing in alleviating physical withdrawal symptoms. The medical staff provides supervision and administers medication for symptom control if necessary. Because drug or alcohol withdrawal symptoms can range from simple sweats and nausea to convulsions and hallucinations, it is critical to monitor patients at all times.
Self-help groups. Self-help groups are run by people with AOD issues and attended by people with similar issues. Meetings are organized at several times throughout the day to ensure all participants can secure a time slot. The purpose of the meetings is to encourage communication among the participants and help themselves provide each other with support in their continuing treatment.
b) List some of their benefits and limitations.
Psychotherapy. Any form of psychotherapy, such as counselling or CBT, is essential for achieving long-term results and preventing relapse. Psychotherapy addresses the causes and triggers of AOD use, so clients can use it to change their behaviours and resolve the causes of their substance abuse issue. However, psychotherapy is only a long-term solution, which means it takes time to identify the causes of the problem, resolve them, and adapt to new behaviours. Short-term interventions might be necessary at early stages of the intervention to ensure adherence to psychotherapy.
Detoxification. The inability to cope with physical withdrawal symptoms is one of the key reasons AOD users relapse into old habits. Alleviating physical symptoms can increase the chances of long-term rehabilitation. Detoxification centres are also equipped with a medical staff and provide a safe environment to their clients with adequate psychosocial support. However, withdrawal time is not the same for all substances, so benzodiazepine users may not find these facilities useful. The centres are also divided by the type of substance abuse they specialize in, so there are fewer centres available to some people, such as methadone users.
Self-help groups. Self-help groups are forgiving to patients who relapse into old habits and take them back by offering support. Meetings are regular and people in the network provide each other with support when necessary, which increases their chances of adherence to abstinence and rehabilitation. However, those centres do not have childcare facilities, which would attract more troubled parents into their meetings. Their emphasis on religion may also turn a lot of potential clients away.
c) Briefly describe at what point/s in a client’s AOD ‘journey’ that this intervention might be useful for a client.
Psychotherapy. Psychotherapy is a good option for clients who understand that they have a problem and are willing to put time and effort into resolving it through cooperation with their therapist. After the initial screening and counselling, clients can be referred to organisations offering psychotherapy services when they are ready to explore the causes for their addiction and are motivated to resolve them.
Detoxification. Because detoxification centres focus on alleviating physical withdrawal symptoms, they are an excellent choice for clients during the early stages of treatments. However, counsellors can refer clients to detoxification centres whenever clients show potential signs of relapse because of their inability to cope with withdrawal symptoms.
Self-help groups. Self-help groups can be joined at any stage of the AOD journey, but the client should ideally work on anger management before joining a self-help group if necessary. That way, it would be possible to ensure that the client does not pose a threat to others and is capable of working in a group setting.
d) Find a local organisation which provides one of the following interventions:
- Case management
- Psychotherapy
- Self-help groups (such as NA or SMART recovery)
- Pharmacotherapy
- Drug education initiatives
- Detoxification
- Residential rehabilitation
Kathleen York House in Glebe NSW is a facility that provides six-month treatment programs to women and their children. The program is divided into individual care and clinical care. The individual care comprises of case management, pregnancy support, and alternative activities (e.g. yoga and meditation). The clinical care comprises of group therapy, assessments, counselling, relapse prevention, drug education, and art therapy.
3. What are the various issues which need to be considered when helping a client to choose an intervention strategy?
Helping a client find a suitable intervention strategy is sometimes a necessary step in the process of counselling when other treatment options need to be considered. However, some issues that need to be addressed are confidentiality, client education, and the client’s needs. For example, a client may want methadone therapy, but the counsellor is also responsible for educating the client about other treatments that might be better options for the client’s situation. Because referring a client to a different organisation may involve sharing their private data, it is important to clarify that issue with the client and obtain written permission before referring the client to another organisation or professional. Finally, referrals should be made only when the counsellor cannot address the client’s problems and needs, rather than making referrals because the client is difficult or uncooperative. In other words, a referral is made because the counsellor cannot help the client anymore with a specific approach, and the client requires a different intervention to continue with the rehabilitation process.
References
Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for use in primary care (2nd ed.). Geneva: World Health Organization. Retrieved from http://whqlibdoc.who.int/hq/2001/ WHO_MSD_MSB_01.6a.pdf
Children and Young Persons (Care and Protection) Act, Sect. 227, 1998.
Children and Young Persons (Care and Protection) Act, Sect. 228, 1998.
Commonwealth of Australia. (2011). National drug strategy 2010-2015. Retrieved from http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/ DB4076D49F13309FCA257854007BAF30/$File/nds2015.pdf
Davey, J., Davey, T., & Obst, P. (2002). Alcohol consumption & drug use. Youth Studies Australia, 21(3), 25-32.
McCambridge, J., & Day, M. (2008). Randomized controlled trial of the effects of completing the Alcohol Use Disorders Identification Test questionnaire on self‐reported hazardous drinking. Addiction, 103(2), 241-248.
Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption‐II. Addiction, 88(6), 791-804.
