A Captive Audience & SUD Criteria

I’ve been working at a new counseling agency since December 2017, and this is a great one! I actually worked here as Office Manager for three years prior to this, then did my graduate internship for five months, and fortunately for me they were hiring and brought me back on board. I know this agency plays by the rules, and I couldn’t be happier!

Some of our clients seek treatment privately, and some are referred by the local MHA, but the majority of my caseload consists of clients referred by CPS. It goes without saying, then, that many of my clients would rather not be sitting in my office on a weekday morning – they are a captive audience. Or, at least, captive, because I do my best to not just talk at them the way one would to a lecture audience.

Another matter that was upsetting to me at the previous agency was that clients (teens, in that case) constantly seemed to be unaware of their diagnosis, or if they did know it they were unaware of how a diagnosis works. With that in mind, in my new position I have made it a point to always explain to my clients, if they meet criteria, why they meet criteria. It’s only right, after all, since I will be recommending treatment. And, it’s important to me that they know I’m not just some dude who’s exercising a position of power on a whim.

Three things I quickly learned about conducting a SUD screening with a client who is ordered (or voluntold) by an agency with legal authority:

  1. It’s important to use all information available in screening and diagnosis (referring documents, available drug test results, documentation from previous treatment episodes if they happened in your agency or are otherwise available, even reaching out to the referring practitioner or agency);
  2. Try to have your office well lit and pay attention to presentation (not just mental status cues, but physical presentation);
  3. After following items 1 and 2 noted above, and unless certain the client does not meet criteria, it’s probably best to schedule a follow-up appointment for formal assessment.

I conducted a screening on client X in January after they were referred by CPS, and X wasn’t endorsing any drug use during the screening interview and insisted they’d tested positive for heroin because they’re prescribed a medication that’s often provided to people trying to get off heroin. But the puzzle pieces just weren’t fitting when it came to the heroin use. X wouldn’t even admit that they’d used heroin in the past, and couldn’t explain why they were taking that certain medication – the only explanation was that their doctor prescribed it for pain, but they were at a loss to explain what injury precipitated the pain, and they took it because they trust their doctor knows what’s best. Without much to go on in terms of X‘s disclosures, I told them they weren’t meeting criteria for services and sent them home. But I had a nagging feeling something was amiss.

It turns out that X, as I later learned, had been to our agency for treatment not many years before on an opioid diagnosis. That, and X had recently tested positive for heroin while in a delicate state, and soon after for cocaine.

X had left our office without a follow-up appointment because, well, they hadn’t met criteria based on their disclosures, and the original agency’s referral was woefully lacking in any collateral information that could substantiate a substance use disorder. Needless to say, X was upset when our admin called to set a follow-up based on the new information available, and her caseworker was also wondering what was wrong with me when I didn’t diagnose in the screening session.

One of the reasons I was uncertain about whether to cut X loose was because the statements were inconsistent, but also because X‘s arms were covered in what appeared to be bruises. I couldn’t make the marks out too well because I didn’t have the overhead light switched on and my office was dimly lit, but I did note it in the objective part of my note. Later, after learning X had been to our agency for treatment several years before, and had recently tested positive for heroin and cocaine with the referring agency, I was able to make a opiate use disorder diagnosis. And those weren’t bruises on X‘s arms. They were scars from old injection sites.

I’ve since seen X for a few more sessions, but recently they asked for a new counselor because they felt I was “persecuting” them. Now X is MIA. I hope X is alive.

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