Code of Ethics and Scope of Practice laws Assessment and Diagnosis (SACN 2021) Instructor: Madison Hollar, LPCC, LICDC ETHICS APPLY ALL THE TIME 2016 NAADAC CODE OF ETHICS National Association of Alcoholism and Drug Abuse Counselors updated ethics code: ü Includes new principles ü New organization of principles into more useful order as compared to previous versions I. The Counseling Relationship II. Confidentiality/Privileged Communication III. Professional Responsibility and Workplace Standards IV. Working in a Culturally Diverse World V. Assessment, Evaluation, and Interpretation VI. E-Therapy, E-Supervision, and Social Media VII. Supervision and Consultation VIII. Resolving Ethical Issues IX. Research and Publication (NAADAC Code of Ethics) V. ASSESSMENT, EVALUATION, AND INTERPRETATION 1) Assessment 2) Validity-Reliability 3) Validity 4) Explanation 5) Administration V. EVALUATION, ASSESSMENT AND INTERPRETATION STANDARDS 6) Cultural Influences 7) Diagnosing 8) Results 9) Misusing Results 10) Not Normed V. EVALUATION, ASSESSMENT AND INTERPRETATION STANDARDS 11) Referral 12) Security 13) Forensics- consent for evaluation 14) Forensics- provide professional opinions based on data 15) Forensics- avoiding dual relationships Scope of Practice: The ethical and legal limits to which one may engage in a prescribed professional behavior. Often used to distinguish practices of one profession from another. Legal criteria: Established by state (e.g. in Ohio http://ocdp.ohio.gov/pdfs/scope%20of%20practices.pdf) Professional & Ethical Criteria: Established by Certifying and Licensing bodies Nationally: NAADAC Code of Ethics In Ohio, an LCDC III (Licensed Chemical Dependency Counselor III) can: • Diagnose chemical dependency conditions under specific supervision. • Treat chemical dependency conditions; • Perform treatment planning, assessment, crisis intervention, individual and group counseling, case management, and education services as they relate to abuse of and dependency on alcohol and other drugs; and • Refer individuals with nonchemical dependency conditions to appropriate sources of help. • A chemical dependency counselor III may not practice as an individual practitioner. Source: http://ocdp.ohio.gov/pdfs/scope%20of%20practices.pdf Stages of Change and Motivational Interviewing ASSESSMENT AND DIAGNOSIS- SACN 2021 MADISON HOLLAR, LPCC, LICDC Why learn about Stages of Change and MI? — Conventional wisdom about people with substance abuse problems: ¡ Most people who misuse substances use the defense mechanism of denial and are unwilling to admit they have a problem ¡ Only when a person suffers serious consequences (“hits bottom”) will he or she be ready to seek help — Problem with this perspective is that very serious consequences may occur before the individual is ready for treatment Stages of Change — Based on the work of Prochaska & DiClemente (1984) — Describes way to conceptualize how people prepare for, begin, and maintain new behaviors — Dynamic process — In addiction work, clients may cycle through stages, or may move back and forth between stages — Helps clinicians determine motivation for recovery Determining Motivation Level Permanent Exit 6. Relapse 5. Maintenance 1. PreContemplatio n 2. Contemplatio n 4. Action SAMHSA/CSAT TIP 35 3. Preparation Stages of Change, cont. — Precontemplation- not even thinking about change, unaware that problem exists or of need for change — Contemplation- this is ambivalence! Client goes back and forth about idea of change, likely still using, considering reducing or stopping substance use — Preparation- strengthening commitment to change, thinking about ways to stop using, may have tried to cut back, may tell others of plans to stop — Action- ambivalence gone, making changes! — Maintenance- behavior change requires repeated implementation of new life skills; services often withdrawn — Relapse- return to previous behavior; client re-enters cycle at precontemplation, contemplation, or action phases What is Motivation? “Motivation can be understood not as something that one has, but as something that one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy.” — What gets in the way of motivation? • AMBIVALANCE! Ambivalence “I want to change, but I don’t want to change.” — Very few decisions in life are made with 100% certainty — Ambivalence is normal and part of the change process for everyone ¡ Think about a recent change you made… change is difficult! — Motivational Interviewing is the treatment of choice for ambivalence. Motivational Interviewing is… “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002) MI is based on the following assumptions: — Ambivalence about substance use (and change) is normal and constitutes an important motivational obstacle in recovery. — Ambivalence can be resolved by working with your client’s intrinsic motivations and values. — The alliance between you and your client is a collaborative partnership to which you each bring important expertise. — An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.) • SAMHSA TIP 35, CHAPTER 3 Spirit of Motivational Interviewing — Motivations to change are elicited from within the client, not imposed from outside. — It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence. — Direct persuasion is not an effective method for resolving ambivalence. — Readiness to change is not a client trait, but fluctuating product of interpersonal interaction. Spirit of Motivational Interviewing — The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. — Positive atmosphere that is conducive but not coercive for change. — The counselor is directive in helping the client to examine and resolve ambivalence. 5 Principles of MI 1. 2. 3. 4. 5. Express empathy through reflective listening. Develop discrepancy between clients’ goals or values and their current behavior. Avoid argument and direct confrontation. Adjust to client resistance rather than opposing it directly. Support self-efficacy and optimism. Reflective Listening — Empathy “is a specifiable and learnable skill for understanding another’s meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning” (Miller and Rollnick, 1991, p. 20). — Why listen reflectively? ¡ Demonstrates that you have accurately heard and understood the client ¡ Strengthens the empathic relationship ¡ Encourages further exploration of problems and feelings ÷ Avoid the premature-focus trap ¡ Can be used strategically to facilitate change Reflection, cont. — A reflection is two things: ¡ A hypothesis as to what the speaker means ¡ A statement ÷ Statements are less likely than questions to evoke resistance — Simple Reflection – stays close ¡ Repeating ¡ Rephrasing (substitutes synonyms) — Complex Reflection – makes a guess ¡ Paraphrasing – major restatement, infers meaning, “continuing the paragraph’ ¡ Reflection of feeling – deepest Develop Discrepancy — Explore goals and values with which substance use may conflict ü Long term recovery goals ü Values ü Dreams ü Past preferred activities ü Admired people Develop Discrepancy — Client verbalization of negative consequences amplifies discrepancy ¡ Payoff matrix/decisional balance exercise Using Substances Advantages Disadvantages Not Using Substances Avoid Arguments — Arguments elicit resistance — Arguments make clients feel defensive, and more entrenched in not changing — May lead to power struggle — Ultimately… arguments do not enhance motivation for positive change! Adjust to Resistance What is resistance? How is resistance expressed? — Negating ¡ Blaming, disagreeing, excusing, minimizing, unwillingness to change — Ignoring ¡ Inattention, sidetracking, nonanswer — Arguing ¡ Challenging, discounting, hostility — Interrupting Resistance — Counselor behaviors that elicit resistance ¡ Arguing for change (the trap of taking sides) ¡ Assuming the expert role/claiming preeminence ¡ Labeling ¡ Being in a hurry ¡ Criticizing, shaming, or blaming — Product of the interpersonal relationship — We can work to diminish resistance! See strategies in SAMHSA TIP 35, chapter 3. — Resistance is a signal to respond differently, it is valuable feedback Support Self-Efficacy Self-efficacy = extent to which a person feels able to do something • Counselors can elicit hope and optimism! • People cannot be ready to change until they perceive both that they want to and are able to do so • Our own belief in the person’s ability to change becomes a self-fulfilling prophecy • We can support/affirm confidence talk • Responding to Confidence Talk — Elaborating — Reflecting — Summarizing — Affirming — Raising possible problems and challenges Name: Assessment Summary and Diagnosis Final Project Diagnosis (please choose no more than 2 diagnoses, use DSM 5): Additional Questions and explanation: Assessment Summary: Treatment Recommendations: Note: You will need to use more than this one page. This template is just to set up the necessary sections for this assignment, you are not limited to the spaces shown here. gAssessment of Mary Smith Assessment date: (Enter today’s date) Source of information: Client self report Presenting problem: Client is a 19 year old, single Caucasian female who was arrested May 13 after she ran into another car after falling asleep at the wheel. Both she and the driver of the other car were taken to the hospital with minor injuries. Toxicology results from the hospital indicated that client had been using alcohol and opioids at the time of the accident. Client is unsure what her blood alcohol level was at the time; she said she had 2 beers in the hour before she got behind the wheel. Client was charged with operating a vehicle while intoxicated. She has been court ordered for an assessment of his alcohol and drug use. AOD Usage: Alcohol—Began use at age 13. Reports mostly weekend use where she will have 2-6 beers within 1-2 hours. Last use was the day of the accident. She does not report any tolerance or withdrawal symptoms, nor any heavier use or different pattern of use or other symptoms at any other time in her life. She stated she has a pleasant “buzz” when she drinks, and that alcohol helps her not worry about her problems. She does report several arguments with her mother recently (within the past year) about being drunk and not fulfilling obligations to family. Marijuana —Began use at age 17. Smokes 1-2 joints a week. No symptoms reported. Cocaine/crack—Tried crack one time at age 19. “I didn’t like it, it made me edgy.” Amphetamines—N/A Benzodiazepines—N/A Sedatives—N/A Opioids—Began use at age 18 of OxyContin prescribed after a back injury. Client’s physician refused to continue to prescribe the medication so client began buying first OxyContin, then heroin (“it was cheaper”) off the street beginning about 8 months ago. Client uses heroin daily. She currently injects it. Client uses “whatever amount I can get my hands on that I don’t think will kill me.” She initially increased her use, but now tends to use the same amount but gets less of an effect. She continues to use so she does not get “dope sick” –in the past when she has stopped using he has experienced nausea, muscle aches, diarrhea and difficulty sleeping. Last use was the morning of this assessment. Client’s mother has expressed concern about client’s heroin using. Hallucinogens—N/A Inhalants—N/A Nicotine—Began use at age 15. Smokes 1-2 cigarettes a day. Does not desire to smoke any more, no symptoms if she is not able to smoke. Client stated “I only continue to smoke them because it has become a habit I’m used to.” She also believes that smoking helps to control her weight. Caffeine—Began use at age 16. Typically has approx. 2 cups of coffee in morning, and 12 oz. of Diet Coke as part of lunch. Previous alcohol/drug treatment: None reported. Client reports prior attempts to stop heroin use on her own—none of them was successful. Previous psychiatric treatment: None reported. Medical history: Client reports contracting Hepatitis C from IV drug use. She does not have a primary care physician at this time and is unsure of the progression of the disease. When she was first diagnosed with Hepatitis C she was told that continued IV drug use would make the disease worse and that her IV drug use was how she contracted Hepatitis C. Client injured her back at work about a year ago (injury not reported to be alcohol/drug related), but stopped seeing her MD after MD became unwilling to continue pain medications after client had been on them 4 months and the injury had healed. Client does not report any other significant medical history. Client does experience seasonal allergies. She currently does not report any use of prescription medication; she does use OTC (over-thecounter) medications to cope with allergy symptoms when needed. She also takes birth control pills “when I remember” and when she has a current prescription and the funds to pay for the medication. She reports no pregnancies. School/work history: Client is a high school graduate. She describes herself as an “average” student. She does not report alcohol or drug use affecting her school performance. She lost her job as a nursing assistant 2 months ago. Client reported she had been repeatedly working under the influence of heroin, and she was fired as a result. Client occasionally brings in money now through temp employment. Military/legal history: Current charge (OVI- Operating a Vehicle while Impaired) is client’s first charge. No military history. Family: Client grew up in a household headed by her mother. She never knew her father; mother told her that her father died of a drug overdose when client was age 6. Client also has 2 brothers—now ages 15 and 12. Both brothers live with their mother. Client describes a close relationship with her family and says she talks to family members daily. She said his mother is “worried sick” that “I’m going to end up like my dad.” Client currently lives with her boyfriend in a rented apartment in a neighborhood where drugs are frequently sold. Mother gives them both financial support. Mother is “not happy” that client is living with boyfriend, but she is unaware that client’s boyfriend also uses heroin. Interpersonal: Client has no friends currently who do not use alcohol or drugs, and she has given up all her usual social activities in favor of drug use. Currently all of her time is spent in scoring heroin and using. Boyfriend also uses heroin. Risk assessment: Client expresses no suicidal ideation, nor homicidal ideation. She does not have a history of suicide attempts nor history of violence. Client’s father overdosed but this was viewed as an accident and not as suicide. Sexual orientation/history: Client is currently in a relationship with her boyfriend of 1 year, although they both occasionally have sex with other people. She is aware that her IV drug use puts her at risk for contracting infections she could transmit sexually, and that her multiple sexual partners also put her at risk for contracting sexually transmitted infections from them. She practices safer sex “when he’ll wear a condom and when we have one,” but also says that she experiences many occasions when he is not interested in having sex; she attributes this lack of interest to her drug use. Client reports history of sexually transmitted infections (with treatment). She also reports being date-raped once as a teenager (the perpetrator was older and gave her alcohol to drink prior to the rape). Spirituality: Client was raised a Catholic. She is interested in exploring spiritual issues as part of his recovery. Client strengths: motivated for treatment, close relationship with family Client limitations: no pro-social friends, no leisure interests at this time, is not sure of her ability to maintain abstinence, unemployment, current living environment does not support sobriety, boyfriend also uses Mental status exam: Appearance—disheveled but clean, appears older Behavior—cooperative Attitude—cooperative Impulse control—good Posture—slumped Facial expression—worried Speech—soft/subdued Stream of thought—clear and coherent Abnormalities of thought content—none noted Perceptual disturbances—client reports sometimes having visual hallucinations when intoxicated Affect—depressed, anxious Mood—“scared” Suicidal ideation—none noted Orientation—oriented x3 Memory (recent)—intact Memory (remote)—intact Intelligence—average Insight—present Judgment—fair Statement by client about needs/preferences: “I want to get clean real bad, but I’m afraid I won’t make it.” Client wants to get a better job, get married and have children. Assessment completed by Jo Miller LICDC
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