Comprehensive Assessment and Intervention Planning

1. Comprehensive
Assessment and
Intervention Planning
ABACUS Counselling, Training and Supervision Ltd

2. Overall Purpose
• Provides a structure for what happens to clients in your care.
• Provides information about wellness needs of clients and
measurable goals; baseline for treatment outcomes.
• Provides ‘map’ showing pathways of their treatment from initial
engagement through to referral & discharge.
• Provides information about clients in a way that anyone should be
able to pick up their file & know the issues & what has been
planned and provided for that person.
• Provides auditable information to demonstrate that contracts for
providing care are being met relevantly, effectively and safely.

3. What does Intervention Include?
• Comprehensive assessment: This section includes personal
information gathered from client and from the case worker’s
observations and knowledge, e.g. all symptoms, medical &
psychiatric history/cultural/spiritual issues, mental state exam.
• ‘Problem’ list: Medical, psychiatric, addiction diagnoses and other
issues affecting treatment, such as whanau/family, social,
employment, financial, legal, cultural, spiritual.
• Planning and interventions (treatment): Details of the specific goals
and instructions for client care that can be followed by any member
of staff are included here.
• Evaluation: Outcome measures e g screens, tests, updated
assessment results, client’s response to treatment, feedback from
referrals, family/whanau; discharge planning.

4. Well-Being (Whanau ora/CEP)
• Need to promote a ‘well-being perspective’ in the care planning
process and make it known & obvious.
• Well-being is personal and involves not only health issues but
social/cultural/spiritual also.
• Problems and disorders are seen as barriers to well-being, and
intervention plans are designed to minimise these barriers, to
improve realistic well-being outcomes (as defined for that
person).
• Need to also identify & enhance their strengths (incl.
relationships), promote hope for recovery and provide for early
successes, to increase motivation.

5. Steps in the Process
• Engagement is essential for empathy, building trust, and belief in
success, and retention in treatment.
• Good assessment is key to gaining accurate, quality information
to inform and guide Intervention Plan.
• Assessment reveals strengths as well as problems and
dysfunction, also motivation level; sets treatment goals &
includes preparation for discharge.
• Treatment delivery targets problem resolution, maintenance of
change, and promotion of well-being.
• Treatment completion based on achievement of goals, evaluation
of response and re-assessment.

6. Assessment Aims
• Engage client, build trust and develop/increase motivation
towards positive change & well-being: a partnership.
• Gather client background, ‘problem’ history and context including
family/whanau, relationships and supports & develop informed
strategies to enhance well-being with their participation &
agreement (intervention plan).
• 3 levels assessment: screening, brief, comprehensive.

7. Screening
• Often done as part of an interview or brief assessment to initially
help identify problems, or in services where case workers don’t
have the specialist skills in that particular problem. Not a
substitute for assessment, but if positive should be followed up
with comprehensive assessment.
• Screening should cover all substances likely to interact with
mental health issues/vice versa.
• Should also ask about quantity, frequency and over time, not just
present use and a few weeks back.

8. Brief Assessment
• Used for finding out if gambling and AOD problems are mild,
moderate or severe, in non-specialist settings, followed by brief
intervention (if mild) – includes feedback, education and harm
reduction ideas
• If there are co-existing mental health problems, comprehensive
assessment is more appropriate, to explore interaction between
MH and addictions/other problems

9. Comprehensive Assessment
Underlying questions (incl. intervention Plan):
• Who are they and their whanau as people?
• Realistically, what is well-being to them?
• What barriers are blocking achievement of this?
• What pathways can enhance the current state?
• What strategies can minimise barriers, enhance current pathways &
develop new ones?
• Who else needs to be involved to support?
• How do we help client/family/whanau implement these strategies?
• Are they appropriate/functional enough for service?

10. (Mini) Mental State Exam
• Cognitive Screening: Orientation - time/place/person year,
season, month, day, date, time.
• Register 4 unrelated objects: e.g. desk, window etc.
• Attention/concentration: 100-7; WORLD backwards.
• Name objects: e.g. watch, strap/bracelet; tell time.
• General Knowledge: P.M. of NZ; Capital city Australia; closest
planet to the sun.
• Interpret a proverb: concrete or abstract, eg “A rolling stone
gathers no moss.”
• Constructional ability: e.g. draw clock face.
• Short-term recall of the 4 unrelated objects above.

11. Mental Health (for CEP)
• Brief mental health assessment will help determine if and how PG
or AOD might be affected by co-existing mental health condition
and vice-versa.
• Identification of MH issues alerts for in-depth assessment.
• Need to be able to screen for/recognise at minimum: Anxiety,
including social anxiety and PTSD; Eating disorders; Mood
disorders including Dysthymia and Bi-Polar Affective disorder;
Suicidality and Homicidality (past as well as present);
schizophrenia/other psychotic disorders; personality disorders
(incl. antisocial and borderline); ADD and ADHD.

12. Key Parts of Ideal Comprehensive Assessment
• Determine level of care.
• Identify cultural and linguistic needs and supports.
• Determine stage of change.
• Suggested management goals and management plan.
• Prognosis (what you think is likely outcome if plan is followed or if
nothing done).
• Feedback to client/negotiate plans.

13. Intervention Considerations
How can we determine how and where to deal with the
following?
• Determine disability and functional impairment.
• Determine severity of co-existing conditions and appropriate
service co-ordination.
• Determine level of care.

14. Referral: Gambling Harm, AOD, MH, or both?
Raistrick 2004
PG/AOD
PG/AOD care
(high PG/AOD; low MH)
PG/AOD or MH
Either care
(low PG/AOD; low MH)
MH + PG/AOD
Shared care
(high PG/AOD; high MH)
Mental Health
MH care
(low PG/AOD; high MH)
MH severity
GamblingHarm/AODseverity

15. Co-occurring MH conditions & addictions
Mental health and addiction issues commonly co-exist,
causing significant impairment or distress:
MH Disorders Addictions
Schizophrenia Cannabis
Bipolar Problem Gambling
Major depression Alcohol
PTSD Cocaine
OCD Benzodiazepines
Complicated grief Amphetamines
Anxiety Methamphetamine
Personality disorders Opiates

16. Treatment Integration: Addictions/MH
• Single co-ordinating point for treatment (overall case
management).
• Use compatible treatment models/concepts.
• Harm minimisation approach.
• Close liaison between all parties.
• Deliver all treatments from one setting.
• Close liaison between therapists, treatment agencies, and
whānau/family.

17. MI Principles for Co-existing Conditions
• Focus on empathy.
• Proceed very slowly to avoid resistance.
• Expose or develop discrepancy very gently.
• Build self-efficacy:
• support self-determination
• encourage early small achievements
Zuckoff & Daley, 2001

18. Intervention Considerations
• Addiction services use the Bio-psycho-social model (plus spiritual
and cultural considerations) in treatment.
• Across these dimensions, there are factors which may cause,
contribute to, trigger off or maintain the problem areas.
• There are also factors which can protect the client from more
severe consequences or make it more easy to recover from
problems.
• Awareness of these interacting factors and relevant interventions
to deal with them contributes to an effective care plan.

19. 5 X 4 Grid (base for plan)
Vulnerability
(Predisposing)
Triggers
(Precipitating)
Maintaining
(Perpetuating)
Strengths
(Protecting)
Biological
Psychological
Social/whanau
Cultural
Spiritual

20. The 4 ‘P’s
Predisposing (vulnerabilities) – long term issues, e.g.:
• Family/whanau history of mental illness/addictions
• Poor socio-economic status
• History of abuse, family violence, bullying
• Co-existing gambling, substance abuse, MH
• Disrupted family/whanau upbringing
• Cultural: identity, autonomy, acculturation

21. Precipitating (triggers) – what initiated current state e.g.:
• Increased gambling, substance use
• Recent bereavement
• Relationship break-up
• Issues with sexual identity
• Loss of employment
• Legal problems/trouble with the police
• Major change in life circumstances
The 4 ‘P’s

22. Perpetuating (maintaining factors) – what things continue the
problems? e.g.:
• Ongoing major life stressors (for example gambling, debt
(chasing), isolation)
• Meaning of events to the individual (negative)
• Mental illnesses (including AOD use)
• Major physical illness; pain
• Feelings of hopelessness, fear for future
• Feeling isolated from family/whanau/culture
The 4 ‘P’s

23. Protecting (strengths) – reward, meaning and sense of purpose to
life, and connections e.g.:
• Others relying on them for ongoing care.
• Sense of ambition, having some successes .
• Having a framework for meaning in life (religious beliefs, need to
care for family, whanau).
• Good self esteem/self confidence.
• Good community supports.
• Close relationships with significant others.
• Employment/stable housing.
The 4 ‘P’s

24. Intervention Planning Goals: Implementation
Phase one (initial intervention):
• Ensuring safety (suicide risk, violence, health).
• Stabilise mental health issues (medication?).
• Stabilise gambling issues/finances/AOD.
• Stabilise lifestyle crisis/problems.
• Complete all assessments.
• Ensure engagement; increase motivation.

25. Phase two (middle treatment):
• Active treatment of mental health issues, gambling problems;
AOD problems.
• Increase focus on enhancing well-being.
• Maintain engagement (retention) and maintain motivation for
positive change.
Intervention Planning Goals: Implementation

26. Phase Three (late treatment):
• Maintain harm reduction or abstinence (if the goal) – relapse
prevention, coping skills, social skills, motivate to “stay with the
programme.”
• Treatment/resolution of MH symptoms.
• Enhance well-being, support back into being part of the
community, build up ongoing recovery and social supports,
improve family/whanau functioning, gain or maintain
employment.
• Increase self-management.
Intervention Planning Goals: Implementation

27. Intervention Planning Practice
• Moana has come in to your service for help. She has played
pokies for 2 years, at times spending $500 per week; she also
buys lotto and scratchies. Her partner was physically violent to
her and the 2 children (now in the care of whanau). She has lost
touch with whanau because of her gambling, ‘crazy’ behaviour,
and controlling relationship, and she wonders now if she might be
bi-polar. Her husband finally threw her out because she
prostituted herself for pokies debt; she currently is on benefit,
has no money, ‘crashes’ at a friend’s place and wants a food
parcel.

28. Intervention Planning Exercise
Brainstorm:
• What do you take care of first?
• What are the issues for assessment?
• What screens and tools could you use?
• How will you approach co-existing issues?
• How could you use the 5X4 grid and 4 ‘P’s to work out some parts
of assessment & intervention plan?
• What do you think well-being might be like for her?
• What about cultural and spiritual considerations?
• What would your care plan look like?