CDC Module 3.1

Three-Level Spot Check

• Emergent (severe risk)

• Urgent (high risk)

• Non urgent (moderate/low risk)

Triage Steps

1. Screening/orientation (environment/identifiers, limits/special duty status/screeners)

2. Chief compliant discovery

3. Suicide risk assessment (modifiable/non-modifiable)

4. Patient disposition

[Pain] Actue

• Short duration (less than 3 months) and reversible

[Pain] Chronic

• Persistent and experience for more than 3 months

[Pain] Nociceptive

• Most common type, caused by actual or threatened damaged to body tissue (cut, burn, sprain)

[Pain] Neuropathic

• Caused by damage or dysfunction in the nervous system itself, rather than from tissue damage

[Pain] Inflammation

• Stimulation of nociceptive processes by chemicals released during healing, which make nerve endings more sensitive (causing pain, swelling, redness, and heat)

[Pain] Somatic

• Nociceptive processes activated in skin, bones, joints, connective tissues, and muscles

[Pain] Visceral

• Nociceptive processes activated in organs

6 Domains of Pain

• Physical appearance

• Physical impact

• Pain characteristics

• Emotional/behavioral

• Quality of life

• Past experiences

Mental Health Status Exam (MSE)

• General appearance

• Speech

  • Spontaneity

  • Syntax

  • Rate

  • Volume

• Emotional expression

  • Tone

  • Posture

  • Hand gestures

  • Facial expressions

  • Mood (emotional state)

  • Affect (expression of emotional state)

    • Range (full vs. constricted)

• Thinking and perception

  • Delusions

  • Ideas of reference

  • Obsessions

• Cognitive Functions

  • Level of alertness

  • Attentiveness or concentration

  • Orientation to person, place, and time

  • Immediate, short-term, and long-term memory

  • Insight

  • Judgement

Chronic Suicide Risk Assessment

• High chronic risk

  • History of prior suicide attempts

• Intermediate chronic risk

  • Ability to endure crisis without engaging in self-directed violence

• Low chronic risk

  • Stressors historically/typically endured absent suicidal ideation

Why must MH clinicians be able to synthesize a great deal of information quickly and effectively?

• In order to make sound decision about treatment

[Establish Rapport] Research shows that impactful communication was…

• 7% verbal and 93% non-verbal

  • Non-verbal component was composed of body language (55%) and tone of voice (38%)

[Establish Rapport] Mutuality

• Psychotherapy is a two-way relationship, in which the therapist and client are equal partners

[Establish Rapport] Collaboration

• Working together to define and actualize therapy goals, including the direction the therapy relationship is taking

[Establish Rapport] Flexible

• Counselor’s ability to tailor treatment to pt’s individual characteristics

[Establish Rapport] Responsiveness

• Understanding clients as individuals — being attuned to their personality traits, conflicts, quirks, and motivations

[Establish Rapport] Empathy

• Understanding and sharing someone’s feelings (while sympathy involves feeling sorry or pity for someone)

• Pt will be more inclined to disclose important information

[Establish Rapport] Withdrawal Rupture

• Occurs when pt’s pull away from the therapist or from an aspect of themselves

  • Example

    • When the pt fears the therapist’s criticism or is afraid to delve into a painful topic

[Establish Rapport] Dealing with Emotional Pt

1. Maintain eye contact

2. Open communication

3. Active listening

4. Mirror client

Therapeutic Alliance

• Non-neurotic and non-transferential relational component established between pt and therapist

• Allows pt to follow the therapist and use their interpretations

Therapeutic Alliance Steps

1. Be warm, courteous, and emotionally sensitive to client

   1. Use empathic statements, direct feeling questions, and reflective statements

2. Actively defuse the strangeness of the clinical situation

3. Give your client the opening word

4. Gain your client’s trust by projecting competence

Countertransference

• Sum of a therapist’s emotional and cognitive responses to a pt

• It is the therapist’s responsibility to recognize and manage this to maintain professionalism

Psychological issues include…

• Mental health conditions

• Trauma-related issues

• Cognitive conditions

• Developmental disorders

Psychological vs. Non-Psychological Issues

• Mental health disorder vs. addiction

When screening for psychological issues, consider the following:

1. Take into consideration any psychological issues that might impact treatment

2. Find out the parameters of the psychiatric symptoms

   1. Onset, frequency, precipitating/ameliorating factors, handling, durations, and examples

3. Be aware of how psychological symptoms impair the client’s life

4. Assess the risk of the impairment to determine which treatment facility to send the client to

   1. Dangerousness and lethality

   2. Interference with addiction recovery efforts

   3. Social functioning

   4. Ability to self-care

   5. Course of illness

When screening for psychological issues…

1. Screen for family, religious, or work impairment(s) due to substance use

2. Screen for outside support and resources to help with client’s treatment

3. Find out what the living situation is with the client

What are the two types of withdrawals?

• Acute

• Protracted

What is acute withdrawal?

• Happens immediately after a person stops taking the substance

• Lasts several days and is the first stage of detox

What is protracted withdrawal?

• A continuation of withdrawal symptoms after the body has healed from physical effects of the substance

• AKA post-acute withdrawal syndrome (PAWS)

What is detoxification?

• Process of supporting a person going through withdrawal to help them get the substances out of the body more safely

Heavy Alcohol Use - Common Long Term Problems

• Liver damage (cirrhosis)

• Heart disease (blood clots, high levels of fats and cholesterol)

• Brain and nervous system problems

• Anemia

• Seizures

• Gout (form of arthritis resulting from buildup of uric acid in joints)

• Infections (hampering of immune cells)

• Digestive problems (booze is caustic)

• Underproductive sleep

What is nystagmus?

• Rapid, uncontrolled eye movements

What is tachycardia?

• Rapid heart rate

What is jaundice in skin or eyes?

• Yellowness in skin or eyes due to build up in bilirubin

What are the steps for screening for physiological symptoms?

1. Screen for short and long term medication conditions due to substance use

2. Screen for withdrawal potential

3. Determine if detox is necessary

4. Find a treatment facility to match needs

What are co-existing conditions?

• MH condition + substance use disorder happening together

• 50% of individuals with a substance abuse disorder have a co-occuring MH diagnosis

What are the most common MH conditions/disorders that co-occur with AUD?

• Depression

• Anxiety

• Trauma and stress related (PTSD)

• Other substance use

• Sleep

Four Quadrants Model (aka “quadrants of care)

[Co-occuring Disorder Quadrant Model]

Q1: Less severe mental disorder/less severe SUD

• Primary health care settings (outpatient)

Q2: More severe mental disorder/less severe SUD

• Mental health system (outpatient/inpatient)

Q3: Less severe mental disorder/more severe SUD

• Substance abuse system (DDC or DDE treatment facilities)

Q4: More severe mental disorder/more severe SUD

• State hospitals, jails/prisons, emergency rooms, etc.

12 Core Functions of a Substance Abuse Counselor

1. Screening

2. Intake

3. Orientation

4. Assessment

5. Treatment Planning

6. Counseling

7. Case Management

8. Crisis Intervention

9. Client Education

10. Referral

11. Report and Record Keeping

12. Consultation with Other Professionals

[Commonly Co-Occuring MH Disorders with AUD] Anxiety

• Most prevalent psychiatric disorders in the U.S.

  • Examples:

    • GAD

    • Social Anxiety Disorder

    • Panic Disorder

[Commonly Co-Occuring MH Disorders with AUD] Mood Disorders

• MDD and Bipolar Disorder are common co-occuring disorders

• Evidence suggests genetic links to AUD

[Commonly Co-Occuring MH Disorders with AUD] PTSD

• Shares risk factors with AUD (prior depressive symptoms and significant adverse childhood events)

• May facilitate development of AUD

Steps for Screening for Co-Occuring Symptoms

1. Find out why the client has co-occuring disorders

2. Find out the MH disorder the client has

3. Refer the client to a treatment facility that treats both at the same time

[Lab Tests] BAC

• Detects amount of alcohol currently in bloodstream

  • Recent drinking

  • Quantity can be determined when compared to time since alcohol was consumed

[Lab Tests] Breath Analyzer

• Detects amount of alcohol currently being processed by the body (ethanol in breath)

  • Recent drinking

  • Quantity can be determined when compared to time since alcohol was consumed

[Lab Tests] Aspartate Amino Transferase (AST), Alanine Amino Transferase (ALT)

• Unknown specific quantity, but heavy and lasting for several weeks

  • Primarily reflects liver damage

[Lab Tests] Carb-Deficient Transferrin (CDT)

• At least 5 drinks per day for approx 2 weeks

  • General biomarker for heavy alcohol use

[Lab Tests] Ethyl Glucuronide (EtG), Ethyl Sulfate (EtS)

• As little as a single drink

  • New, but promising biomarkers

  • EtG detects alcohol use within the past 24-48 hours (sometimes up to 72 hours)

[Lab Tests] Gamma Glutamyl Transferase (GGT)

• At least 5 drinks per day for several weeks

  • Primarily reflects liver damage

[Lab Tests] Mean Corpuscular Volume (MCV)

• Unknown specific quantity, but heavy and lasting for several months

  • Poor biomarker for relapse because of sluggish response to drinking

[Lab Tests] Phosphatidyl Ethanol (PEth)

• 3-4 drinks per day for several days

  • Screens for past 28 days indicating binge or daily drinking

  • New, but promising and valuable biomarker, useful when comparing self-reported use vs. actual use