Level of Care Utilization System (LOCUS)


The Level of Care Utilization System or LOCUS tool has been designed by the American Association of Community Psychiatrists (2009) to allow staff who work on inpatient hospital environments with patients with psychiatric problems (such as emergency departments, psychiatric sections of general hospitals or in psychiatric hospitals) to determine the level of care that an individual should receive.

The LOCUS provides for six levels, ranging from the least intense (recovery maintenance, such as seeing a case manager once a month and having access to a 24-hour crisis line if needed) to the most intense (medically managed residential services such as being a hospital inpatient.)


The LOCUS is based on a set of parameters that an individual is scored along. The level of care is determined based on the mix of parameters that each client has. These parameters are:

  1. Risk of Harm
  2. Functional Status
  3. Medical, Addictive and Psychiatric Co-morbidity
  4. Recovery Environment
  5. Treatment and Recovery History
  6. Engagement and Recovery Status

In most of these domains there are a number of states that are used to code the domain. For instance, “Risk of Harm” has five potential states from Minimal Risk of Harm to Extreme Risk of Harm. The exception is 4. Recovery Environment which has two subcomponents, Level of Stress and Level of Support.

The LOCUS manual provides detailed coding instructions to allow an individual to be assessed in a reliable, repeatable way.

Levels of Care

For each Level of Care, the manual provides for four categories, Care Environment, Clinical Services, Supportive Systems, and Crisis Stabilization and Prevention Services.

Care Environment describes where services are delivered and what facilities might need to be available. Clinical Services describes the type and number of clinical employees (nurses, etc.) and the types of therapies or treatments available. Supportive Services includes client access to things like case management, outreach and financial support, while Prevention Services include mobile crisis, crisis lines, and other access to services.


Each of the levels includes specific individual scores required for a level, and also a composite score. The Composite Score overrides the individual scores to determine which level an individual is placed at if the Composite Score results in a more intense level of care.

Composite Scores

  • Level 1 – 10-13
  • Level 2 – 14-16
  • Level 3 – 17-19
  • Level 4 – 20-22
  • Level 5 – 23 – 27
  • Level 6 – 28+

Level 1 – Recovery Maintenance and Health Management

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 4
  • Level of Support: Sum of Stress and Support less than 4
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 2 – Low Intensity Community Based Services

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 3 – High Intensity Community Based Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 3 or less
  • Engagement & Recovery Status: 3 or less

Level 4 – Medically Monitored Non-Residential Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: 3 or 4
  • Level of Support: 3 or less
  • Treatment & Recovery History: 3 or 4
  • Engagement & Recovery Status: 3 or 4

Level 5 – Medically Monitored Residential Services

  • Risk of Harm: If the score is 4 or higher – the client is automatically Level 5
  • Functional Status: If the score is 4 or higher – most clients are automatically Level 5
  • Co-morbidity: If the score is 4 or higher – most clients are automatically Level 5
  • Level of Stress: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Level of Support: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Treatment & Recovery History: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Engagement & Recovery Status: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity

Level 6 – Medically Managed Residential Services

  • Risk of Harm: If the score is 5 or higher – the client is automatically Level 6
  • Functional Status: If the score is 5 or higher – the client is automatically Level 6
  • Co-morbidity: If the score is 5 or higher the client is automatically Level 6
  • Level of Stress: 4 or more
  • Level of Support: 4 or more
  • Treatment & Recovery History: 4 or more
  • Engagement & Recovery Status: 4 or more

Given that there are a number of nuances in the exact scoring it’s recommended that an individual read or receive structured training in administration of the LOCUS. The LOCUS manual also provides a decision tree (not shown) to assist in making your determinations and a determination grid (shown below.)

Level of Care Determination Grid

LOCUS Level of Care Determination Grid


Although the LOCUS is widely used, research is surprisingly limited.

The initial study validating the LOCUS was Sowers, George & Thomson (1999). Their study examined scores on the LOCUS and correlated them to expert decisions to see if the LOCUS matched that decision-making; their results indicated that it performed well in this function.

Kimura, Yagi & Toshizumi (2013) reviewed the LOCUS by comparing scores on it to the Global Assessment Scale (GAS) scores, a similar tool and examining the change of scores from admission to discharge. They found it a sensitive and effective tool for clinical use in Japan.

Ontario Shores, a large mental hospital in Whitby, ON implements the LOCUS along with the RAI tools as well.


American Association of Community Psychiatrists. (2009) LOCUS Level of Care Utilization System for Psychiatric and Addictions Services, Adult Version 2010. Retrieved on January 18, 2017 from http://cchealth.org/mentalhealth/pdf/LOCUS.pdf

Kimura, T., Yagi, F., & Yoshizumi, A. (2013). Application of Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) to Psychiatric Practice in Japan: A Preliminary Assessment of Validity and Sensitivity to Change. Community Mental Health Journal, 49(4), 477-491. doi:10.1007/s10597-012-9562-6

Sowers, W., George, C., & Thomson, K. R. (1999). Level of care utilization system for psychiatric and addiction services (LOCUS): a preliminary assessment of reliability and validity. Community Mental Health Journal, (6), 545.

Cite this article as: MacDonald, D.K., (2017), "Level of Care Utilization System (LOCUS)," retrieved on October 22, 2018 from http://dustinkmacdonald.com/level-care-utilization-system-locus/.
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Language Learning for Social Service Workers


An important part of cultural competency for social workers is the ability to speak a language understood by their clients. In the US and Canada there are significant populations of Spanish, French, and South Asian language speakers, and their ability to access social work support may be impaired by the lack of speakers of those languages.

The good news is that it’s not an insurmountable goal to learn a language, especially with new technologies. Many resources exist for free that help an individual learn their language of choice. Some people wonder about the time commitment, but luckily the US State Department has already answered this question.

The State Department operates the Foreign Service Institute (FSI), a language school for US Diplomats. Based on their extensive research and experience actually training complete beginners to speak a variety of languages, they’ve separated them into four categories. Each of these categories are listed below with some of the languages that fit into them:

Category I Language (languages closely related to English)

  • Danish
  • Dutch
  • French
  • Italian
  • Norwegian
  • Portuguese
  • Romanian
  • Spanish
  • Swedish

Category II Languages (languages similar to English)

  • German
  • Indonesian
  • Malay
  • Swahili

Category III Languages (languages moderately different from English)

  • Albanian
  • Amharic
  • Armenian
  • Azerbaijani
  • Bengali
  • Bulgarian
  • Burmese
  • Czech
  • Dari
  • Estonian
  • Farsi
  • Finnish
  • Georgian
  • Greek
  • Gujarati
  • Hausa
  • Hebrew
  • Hindi
  • Hungarian
  • Icelandic
  • Kazakh
  • Khmer
  • Kurdish
  • Lao
  • Latvian
  • Lithuanian
  • Macedonian
  • Mongolian
  • Nepali
  • Pashto
  • Polish
  • Russian
  • Serbo-Croatian
  • Sinhala
  • Slovak
  • Slovenian
  • Somali
  • Tagalog
  • Tajiki
  • Tamil
  • Telugu
  • Thai
  • Tibetan
  • Turkish
  • Ukrainian
  • Urdu
  • Uzbek
  • Vietnamese

Category IV Languages (languages significantly different from English)

  • Arabic
  • Chinese (Mandarin)
  • Japanese
  • Korean

For each of these categories the State Department prescribes how much time it will take for an English learner to reach a useful level of language knowledge. For Category I languages you must study for 600 hours, for Category II 750 hours, for Category III 900 hours and for Category IV 1100 hours. Of course, this may be an under-estimation because these individuals are in class for 30 hours a week, but it gives you a good idea.

Choose a Language

Choosing a language is a very personal choice, but there are a few things that might be able to help you decide: number of speakers (or number of speakers in your area), ease of accessing language material, career usefulness and closeness to your native language.

For individuals who choose a language based on number of speakers, here are the top 5:

  1. Chinese (Mandarin)
  2. Hindi
  3. Spanish
  4. English
  5. Arabic

Ease of accessing language material is hard to quantify but there are certainly many products available for the Romance languages (French, Spanish, Italian, etc.) as opposed to others.

Career usefulness can be looked at in terms of languages critical to US interests (just a few of the 60 languages listed:

  1. Arabic
  2. Chinese (Cantonese and Mandarin)
  3. Hindi
  4. Indonesian
  5. Korean
  6. Russian
  7. Turkish

For those interested in using their language in their Social Work career, knowing the number of US speakers may be important:

  1. English
  2. Spanish
  3. Chinese (Cantonese and Mandarin)
  4. French
  5. Tagalog

Measuring Fluency

If you had attended an FSI or DLI (Defense Language Institute – the military’s language school) course, you would be considered at a level useful enough to understand the language as spoken and to produce it yourself. But how do you know what that actually means, especially when compared to another individual? That’s where various proficiency tests and assessments come in.

Although I won’t go into detail about specific language-related tests (like the DELF tests for French), I will discuss two common standards, the Common European Framework of Reference for Languages and the Defense Language Proficiency Test.

Common European Framework of Reference for Languages (CEFR)

The CEFR is the worldwide standard for proficiency. It is grouped into 6 categories, A1, A2, B1, B2 and C1 and C2. A1 and A2 are beginner and low-intermediate levels of proficiency. B1 and B2 are considered intermediate users of the language who are independent, while C1 and C2 are advanced language learners. For each language you wish to take, there are CEFR assessments that match.

An FSI language course would place a learner at B1 at completion, enough to use the language independently, engage in conversations and understand the world around them.

Defense Language Proficiency Test (DLPT)

The DLPT is another proficiency test for languages. The reason that I list it, is that there are a lot of people using DLI language learning materials who might want to understand this test. After completing the DLPT, a learner is assessed a scale from 0-3, with 2/2 generally corresponding to B1, and 3/3 corresponding to C1. In each category, there are plus (+) options available to indicate a level of proficiency higher than the number.

Language Learning Resources

Language learning resources differ based on what language an individual is learning. Below are a few resources I’m familiar with a heavy influence towards French (the language I’m learning now), Spanish (a language I spent 3 years learning in high school) and Arabic (the next challenge I want to tackle.)


Available Languages: Spanish, French, German, Italian, Portuguese, Russian, Dutch, Swedish, Irish, Turkish, Danish, Norwegian, Polish, Esperanto, Hebrew, Ukranian, Vietnamese, Welsh (In Beta): Hungarian, Greek, Romanian (In Progress): Swahili, Czech, Hindi, Korean, Klingon, Indonesian

Price: Free

Description: Duolingo offers you a skills tree with all the information you need to reach approximately A2 (some people say B1) of your language, and learn about 2000 words in the process. It’s very intuitive and by working through the course you learn to translate between your native language and English while developing knowledge of vocabulary.

Pros: It’s simple and very fun. You get to see your progress and work your way to the end. You get a trophy when you finish!

Cons: The grammar instruction can be light in some areas which can be very confusing


Available Languages: (Made by Memrise Team): English, Japanese, French, Spanish, German, Chinese, Korean, Italian, Russian

Price: Free

Description:  Memrise is like a flashcards program on steroids, but organized into courses. You do a lot of filling in the blanks or other exercises that teach you words and helps build your vocab.

Pros: Great audio narration accompanies the cards. There are courses for the most common languages that correspond to the CEFR Levels. For instance, French has 7 courses. French 1-3 correspond to A1, French 4-6 correspond to A2, and French 7 corresponds to B1.

Cons: There’s zero grammar instruction which means Memrise is not useable on its own. There’s also no indication on the number of words, and many of the smaller courses (not created by the Memrise team) are of varying quality.


Available Languages: French, German, Russian, Spanish

Price: Free

Description: Lingvist is a deceptively simple but very powerful program designed to build your vocabulary up to 5000 words. It uses an endless card interface that presents you with a “fill in the blank.” You can double click on the sentence or any word to get a translation to help you, and if you get it wrong you’ll get an opportunity to fill in the correct answer.

Pros: Never-ending interface allows you to go much longer before you get bored or tired. Beautiful interface. 5000 words beats Memrise and Duolingo

Cons: No grammar instruction similar to Memrise

GLOSS (Global Language Online Support System)

Available Languages: Albanian, Arabic (Egyptian, Gulf, Iraqi, Levantine, MSA, Sudanese, Yemeni), Azerbaijani, Balochi, Chinese (Mandarin), Croatian, Dari, Farsi, French,German, Greek, Hausa, Hebrew, Hindi, Indonesian, Japanese, Korean (North and South), Kurmanji, Pashto, Portuguese (Brazilian and European), Punjabi, Russian, Serbian, Somali, Sorani, Spanish, Swahili, Tagalog, Thai, Turkish, Turkmen

Price: Free

Description: Created by the US military, GLOSS exercises are sorted into the 3/3 DLPT proficency areas and allow you to view real material in those languages and answer questions or complete exercises.

Pros: Lots of exercises available for lots of languages, native material means it’s very high quality

Cons: Not a language course per se


Available Languages: Amharic, Arabic (Egyptian, Iraqi, Levantine, MSA, Moroccan) Baluchi, Cebuano, Chavacano, Chinese (Mandarin), Dari, French, German, Hausi, Hindi, Indonesian, Italian, Japanese, Korean, Kurmanji, Malay, Pashto, Persian-Farsi, Portguese (Brazilian, European), Russian, Somali, Spanish, Swahili, Tagalog, Tausug, Thai, Turkish, Turkmen, Urdu, Uzbek, Yemeni

Price: Free

Description: Brought to you by the Defense Language Institute, Headstart2 provides you with approximately 750 words, and basic grammar with the goal of getting you to 0+ (memorized proficiency) on the DLPT.

Pros: For languages like Hindi, Arabic and Pashto that don’t use the Latin alphabet, Headstart2 is a great teaching resource

Cons: Vocabulary is very military-focused (if you consider that a con.) Will need to move on to other courses quickly.

Peace Corps

Available Languages: Albanian, Arabic, Armenian, Azerbaijani, Bambara, Bengali, Bulgarian, Chinese, French, Georgian, Hausa, Kyrgyz, Macedonian, Malagasy, Mongolian, Romanian, Moldovan, Russian, Siswati, Thai, Tswana, Turkmen, Ukrainian, Wolof

Price: Free

Description: The Peace Corps requires all individuals who deploy as volunteers to reach a certain level of language training. Although the Peace Corps uses a simple proficiency scale (Beginner, Intermediate, Advanced, with Low, Intermediate, High for each level.) Part of these training resources are available online.

Pros: Very audio-focused, with lots of survival phrases

Cons: Some languages have limited material; the accents can be challenging

Special Operations Language Training (SOLT)

Available Languages: IndonesianRussian, SerbianSpanishThai, many others (if active-duty military)

Price: Free

Description: Similar to the Peace Corps, members of the US Special Forces are required to reach a certain level of language proficiency (in their case 1/1 on the DLPT scale.) When completed in person, this 18 weeks (for Pashto) or 24 weeks (for Arabic); other languages are shorter.

Pros: Not a lot of “fluff”, courses get down to business quickly

Cons: Only a few courses are available online

Cite this article as: MacDonald, D.K., (2017), "Language Learning for Social Service Workers," retrieved on October 22, 2018 from http://dustinkmacdonald.com/language-learning-social-service-workers/.
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PREPaRE Model for School Crisis Intervention


When we normally think of crisis intervention, we think of adults responding to events in their personal life. Of course, people young and old can require crisis intervention, and not just from events in their personal life. School violence, natural disasters and other elements can require crisis intervention.

Werner (2015) noted that the tow most important activities school counsellors can do to prepare for crisis events are to develop a comprehensive crisis plan and to practice it regularly. The goal of the PREPaRE Curriculum is to train mental health worker, school psychologists and other administrators, educators and clinicians to develop such a crisis plan, to build a crisis team to execute that plan and to understand the tasks of crisis intervention in the aftermath of a crisis.

School Crisis Intervention

Most school counsellors receive little or no crisis intervention training and therefore enter the field feeling unprepared to handle tasks that become assigned to them in the aftermath of a crisis. (Allen, et. al., 2002) Training like the PREPaRE Model and other programs can help bridge this gap.

Knox & Roberts (2005) performed a comprehensive literature review on school crisis intervention and specifically crisis intervention teams. They found that there was a need for well-thought out crisis intervention programs and plans before crises occur, and that there were similarities in the literature about how experts believed response to a crisis should be structured.

They recommended school crisis intervention be split into three phases:

Primary Interventions

Primary prevention activities are those that are provided to all students in order to promote safety and health. These could be “conflict resolution, gun safety and safe driving courses, alcohol and drug awareness programs, teenage parenting resources, and suicide prevention programs.” (Knox & Roberts, 2005; p.94)

Secondary Interventions

Secondary prevention activities focus on individuals in the aftermath of a crisis in order to limit its impact. This can include physical measures like moving students, debriefing and immediate crisis intervention in the aftermath, and notifying parents and the media.

Tertiary Interventions

Tertiary interventions include long-term counselling and psychotherapy that extends after the crisis period ends and the school environment returns to normal.

PREPaRE Framework

  • Prevent and Prepare for psychological trauma
  • Reaffirm physical health, perceptions of security and safety
  • Evaluate psychological trauma risk
  • Provide interventions and Respond to psychological needs
  • Examine the effectiveness of crisis prevention and intervention

The PREPare Model is structured around two workshops. The first (1-day) workshop is provided for all school staff to teach them how the crisis team and crisis intervention works, while the second (2-day) workshop is designed specifically for crisis team members.

PREPaRE Curriculum

The following information comes from Nickerson et. al. (2014):

Crisis Prevention and Preparedness (1-day workshop for all staff)

  • Identify four characteristics of a crisis event.
  • Identify the key concepts associated with the PREPaRE acronym.
  • Describe the four activities of the school crisis team.
  • Understand the importance of hierarchical crisis team structure and response.
  • Identify the five major functions of the Incident Command System (ICS).
  • Identify strategies for communicating with school boards creating or sustaining teams.
  • Identify three concepts related to crime prevention through environmental design.
  • Identify guiding principles in crisis plan development.
  • Identify essential components of crisis plans.
  • Identify key concepts from the workshop that their crisis team needs to learn or address to be adequately prepared for crisis situations

Crisis Intervention and Recovery (2-day workshop for crisis intervention staff)

  • Report improved attitudes toward, and readiness to provide, school crisis intervention.
  • Identify the variables that determine the traumatizing potential of a crisis event.
  • Identify the range of school crisis interventions indicated by the PREPaRE acronym.
  • Indicate how school crisis interventions fit into the larger school crisis response.
  • Specify the critical factors in evaluating psychological trauma risk after a crisis event.
  • Match psychological trauma risk to a range of appropriate school crisis interventions.

Elements of a Crisis Team

A crisis team should be in place before a crisis occurs so that they can immediately get to work after a crisis occurs. Knox & Roberts (2005) recommend that the team be comprised of 4-8 multidisciplinary members (e.g. Principal, counsellor, nurse, etc.)

Responding to a Crisis

Brock (2006) indicates a variety of responses for each level of the framework that are available to the mental health professional facilitating a crisis intervention. These items assume that a crisis has already occurred.

Reaffirm physical health, perceptions of security and safety

  • Meet physical needs like shelter and water
  • Provide a sense of safety by removing individuals from the site of a crisis
  • Remove or restrict access to dangerous objects or crisis site (remove sharps, put up barriers, etc.)

Evaluate psychological trauma risk

  • Evaluate exposure to crisis and note reactions (physical, behavioural, cognitive)
  • Examine internal and external resources (within the school and local community agencies)
  • Refer clients to psychotherapy where possible

Provide interventions and Respond to psychological needs

  • Re-establish social support systems. This can involve
  • Provide psycho-education: Empower survivors and their caregivers
  • Provide immediate crisis intervention
  • Provide/Refer for longer term crisis intervention

Evaluation of the PREPaRE Curriculum

Brock et. al. (2011) performed the initial evaluation of the program and found that participants significantly improved on their skills related to crisis prevention, crisis intervention and displayed high general satisfaction with the workshops. When Nickerson et. al. (2014) evaluated the PREPaRE after making changes they found that these benefits continued to be demonstrated in follow-ups, proving the efficacy of the program.

Training in the PREPaRE Model

Brock (2006) publishes the content of the PREPaRE workshop online, where they can be accessed in order to help individuals build their crisis intervention skills. Additionally, workshops can be accessed through the National Association for School Psychologists (NASP).


Allen, M., Burt, K., Bryan, E., Carter, D., Orsi, R, & Durkan, L.(2002). School counselors’ preparation for and participation in crisis intervention. Professional School Counseling, 6, 96-102

Brock, S.E. (2006) “Crisis Intervention Training”, Workshop PDF. Accessed on November 19, 2016 from www.csus.edu/indiv/b/brocks/workshops/district/smfcsd.12.06.pdf

Brock, S. E., Nickerson, A. B., Reeves, M. A., Savage, T. A., & Woitaszewski, S. A. (2011). Development, Evaluation, and Future Directions of the PREPaRE School Crisis Prevention and Intervention Training Curriculum. Journal Of School Violence10(1), 34-52. doi:10.1080/15388220.2010.519268

Knox, K., & Roberts, A. (2005). Crisis intervention and crisis team models in schools. Children & Schools27(2), 93-100.

Nickerson, A. B., Serwacki, M. L., Brock, S. E., Savage, T. A., Woitaszewski, S. A., & Louvar Reeves, M. A. (2014). PROGRAM EVALUATION OF THE PREPaRE SCHOOL CRISIS PREVENTION AND INTERVENTION TRAINING CURRICULUM. Psychology In The Schools51(5), 466-479. doi:10.1002/pits.21757

Cite this article as: MacDonald, D.K., (2016), "PREPaRE Model for School Crisis Intervention," retrieved on October 22, 2018 from http://dustinkmacdonald.com/prepare-model-school-crisis-intervention/.
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Quit Smoking Counselling


Counselling clients to quit smoking may be a part of your practice no matter what kind of therapy you do. While many clinicians may wish to refer clients to others for this work, learning the skills to handle smoking cessation may be a valuable addition to your work with clients in other areas and so is worth the time.

In Canada, about 1 in 5 individuals smoke (Statistics Canada, 2014) and this level has been going down, as it has in most western countries, for many years. Tobacco smoking often begins in the teen years (U.S. Department of Health and Human Services, 2012) with the Surgeon General noting that “vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.”

Smoking often affects the poor, mentally ill and other marginalized groups. (Passey & Bonevski, 2014) The mortality rate of both male and female smokers is three times higher than non-smokers and the rate of heart attack in middle aged men is four times higher. (CDC, n.d.)

Most individuals who attempt to quit smoking will require multiple attempts to quit, with sources citing between 5 and 30 (Chaiton, et. al., 2016).

Benefits of Quitting Smoking

The following list of health benefits comes from the World Health Organization (n.d.), and may help convince a smoker who believes that there is no point in quitting, to attempt to do so:

Within 20 minutes of your last cigarette, your heart rate and blood pressure drop.

Within 12 hours, the carbon monoxide level in your blood drops to normal.

2-12 weeks, your circulation improves and your lung function increases.

1-9 months, coughing and shortness of breath decrease.

1 year, your risk of coronary heart disease is about half that of a smoker’s.

5 years, your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.

10 years, your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decreases.

15 years, the risk of coronary heart disease is that of a nonsmoker’s.

The benefits are clear! But that doesn’t mean quitting smoking is easy.

Nicotine Withdrawal

When a client stops their regular smoking, they begin to experience withdrawal symptoms within about 2 hours (Medline, 2015) as the nicotine begins to leave their bloodstream. The Mood and Physical Symptoms Scale (West & Hajek, 2004) is a tool for measuring withdrawal symptoms. These symptoms can include depression, anxiety, irritability, restlessness, hunger, inability to concentrate, poor sleep and more.

Assessment of Smoking Behaviours

The Fagerstrom Test for Nicotine Dependence is a common measure of smoking-related behaviour. It asks six questions:

  1. How soon after waking do you smoke your first cigarette?
  2. Do you find it difficult to refrain from smoking in places where it is forbidden? E.g. Church, library
  3. Which cigarette would you hate to give up?
  4. How many cigarettes in a day do you smoke?
  5. Do you smoke more frequently in the morning?
  6. Do you smoke even if you are sick in bed most of the time?

See my article on assessments for substance use disorders for more information on the Fagerstrom Test.

Interventions to Quit Smoking

Nicotine Replacement Therapy (NRT)

Nicotine replacement therapy (NRT) includes products like patches, gum, inhalers and lozenges. Use of nicotine replacement therapy nearly doubled a client’s ability to quit smoking in a Cochrane review (Silagy, et. al., 2012) NRT is contraindicated  in the following groups (Department of Health, Western Australia, 2012):

  • Lactating women
  • Smokers under 12 years of age

As well, those:

  • Between 13 and 18
  • With severe heart problems

Should receive NRT under physician supervision. Additional recommendations (e.g. for people with diabetes, mental health issues or from specific cultural groups) are found in the Clinical Guidelines in the References. In general, clients should receive medical support from a GP who can properly monitor them when taking any medications, including NRT.

Motivational Interviewing

Motivational interviewing (MI) is a brief intervention that aims to highlight and amplify intrinsic motivation and intent to quit smoking that already exists in clients. (Rollnick & Allison, 2001) Some elements of motivational interviewing include (Sciacca, 2009):

  • Change and sustain talk, messages from the client that indicate either a willingness to change or a desire to keep things the way they are
  • Rolling with resistance, and recognizing a client’s desire not to change may be the result of the clinician’s approach, the client’s unreadiness or both
  • Ensuring empathy to build a strong relationship
  • Identifying discrepancies, for instance where a client’s values (“I want to be there for my children”) conflict with their behaviours (“My daughter had to wait in the rain so I could have a smoke”)

There is a large body of research (e.g. the metareview by Lundahl & Burke, 2009) supporting the effectiveness of motivational interviewing in helping clients to quit smoking or using other substances.

The 5 A’s of Quitting Smoking

The 5 A’s describe simple set of steps for a brief tobacco intervention, they come from MDQuit (2012).

  1. Ask – It’s important to ask the patient about their smoking. Do they smoke at all?
  2. Assess – If they do smoke, how much do they smoke. You may wish to use the Fagerstrom criteria for this (see above, Assessment for Substance Use Disorders)
  3. Assist – Help the client make an informed decision about their smoking behaviour if they wish to cut down.
  4. Advice – Provide information on the risks of continuing and the benefits of quitting.
  5. Arrange – Finally, arrange some form of followup if possible to check on their progress.

Quit Smoking Training

The Government of Western Australia has produced the Brief Tobacco Intervention Training Program designed to teach basic cessation skills to clinicians (nurses and doctors) in advising clients on how to quit smoking. It is available freely online and takes about 2 hours to complete.

The California Smokers Helpline provides a number of free courses and online webinars covering a variety of smoking cessation-related topics that may be eligible for Continuing Education (CE) credits.

In Canada, the Centre for Addiction and Mental Health provides the Training Enhancement in Applied Cessation Counselling and Health (TEACH) program, comprised of online and in-person workshops to teach clinicians skills in smoking cessation.


Centers for Disease Control and Prevention. (n.d.) “CDC – Fact Sheet – Tobacco-Related Mortality – Smoking & Tobacco Use”. Retrieved on August 11, 2016 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/

Chaiton, M., Diemert, L., Cohen, J., Bondy, S., Selby, P., Philipneri, A., & Schwartz, R. (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open, 6(6), doi:10.1136/bmjopen-2016-011045

Department of Health, Western Australia. (2011) Clinical guidelines and procedures for the management of nicotine dependent inpatients. Perth: Smoke Free WA Health Working Party, Health Networks Branch, Department of Health, Western Australia; Retrieved on August 11, 2016 from http://www.health.wa.gov.au/smokefree/docs/Clinical_guidelines.pdf

Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. Journal Of Clinical Psychology, 65(11), 1232-1245. doi:10.1002/jclp.20638

Medline. (2015). Martin, L.J. “Nicotine and tobacco” Retrieved on August 11, 2016 from https://medlineplus.gov/ency/article/000953.htm

MDQuit. (2012) “Brief Interventions & 5 A’s | MDQuit.org” Retrieved on August 11, 2016 from http://mdquit.org/cessation-programs/brief-interventions-5

Passey, M., & Bonevski, B. (2014). The importance of tobacco research focusing on marginalized groups. Addiction, 109(7), 1049-1051. doi:10.1111/add.12548

Rollnick S., & Allison J. (2001) Motivational interviewing. In: Heather, N., Peters, T.J, & Stockwell T. International handbook of alcohol dependence and problems. New York, NY: Wiley; pp. 593-603.

Sciacca, K. (2009) “MOTIVATIONAL INTERVIEWING –MI, GLOSSARY & FACT SHEET” Retrieved on August 11, 2016 from http://www.motivationalinterview.net/miglossary.pdf

Silagy, C., Lancaster, T., Stead, L., Mant, D. & Fowler, G. (2007) Nicotine replacement therapy for smoking cessation (Review). The Cochrane Library. (3)

Statistics Canada. (2014) “Smoking, 2014”, Retrieved on August 11, 2016 from http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14190-eng.htm

U.S. Department of Health and Human Services. (2012) Preventing Tobacco Use Among
Youth and Young Adults: A Report of the Surgeon General. Retrieved on August 11, 2016 from http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf

West, R. & Hajek, P. (2004). Evaluation of the mood and physical symptoms scale (MPSS) to assess cigarette withdrawal Psychopharmacology, 177, 195-199.

Cite this article as: MacDonald, D.K., (2016), "Quit Smoking Counselling," retrieved on October 22, 2018 from http://dustinkmacdonald.com/quit-smoking-counselling/.
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Spousal Assault Risk Assessment (SARA)

Introduction to Spousal Assault Risk Assessment

The Spousal Assault Risk Assessment (SARA) by Kropp, Hart, Webster & Eaves (1995) is used to assess the risk of intimate partner violence. Their tool recognizes that intimate partner violence may occur without regard to gender (male on female, female on male, female on female, male on male, and any other combination including trans and non-binary individuals), marital status (married and commonlaw individuals may engage in intimate partner violence), and does not necessarily require physical injury.

What follows is a brief summary of how to administer and score the SARA. More comprehensive information can be found in the manual itself. The SARA may be administered by minimally trained individuals up to Forensic Psychologists and Psychiatrists.

The SARA is comprised of 20 items that to provide a framework of historic, static and dynamic risk factors that have been shown to increase risk.

Information Required Prior to Assessment

All available sources of information should be consulted before completing the SARA.  This should include:

  • Interviews with both the accused/perpetrator and the victim/survivor(s) with a goal of collecting the SARA items
  • Standard measures for substance abuse (drugs and alcohol), personality, and IQ if available; the SARA manual recommends the Michigan Alcoholism Screening Test (MAST) by Seltzer (1971) for alcohol, and the Drug Abuse Screening Test (Skinner, 1982) for drugs, and the Personality Assessment Inventory by Morey (1991) for personality
  • Police reports, court documents, criminal records, etc.
  • Interviews with relatives or children who may have been exposed to abuse
  • Interview with probation officers


All items in the SARA are scored based on a 3-point scale:

  • 0 = Absent
  • 1 = Subthreshold
  • 2 = Present

If there is not enough to code an item, it should be excluded, not coded as absent. For instance, if there is no information to confirm or deny a current substance abuse issue, this should be left blank and noted, not assumed to be absent.

Critical Items

Some items are considered critical items – if these are present then it is enough to assume that potential/actual victims are at risk. These items are coded on a 2-point scale:

  • 0 = Absent
  • 1 = Present

These items are chosen as critical items based on the evaluator’s judgement.

Summarizing Risk

The result of a risk assessment will usually address two issues:

  1. Is there risk to the partner?
  2. Is there risk to children/non-spouse/others?

This summary is coded on a 3-point scale,

  • 1 = Low
  • 2 = Moderate
  • 3 = High

Communicating Risk

Writing a risk assessment is outside the scope of this article but you may see the original guide for more detailed information or my blog post about documenting suicide risk assessments for more information.

Assessment Items and Risk Management

For more detailed rating criteria please consult the original guide. The coding has been omitted from this table in appreciation for the original author’s copyright.

Item Name Coding Risk Management Strategies
1 – Past Assault of Family Members Intensive supervision or monitoring
2 – Past Assault of Strangers or Acquaintances Intensive supervision or monitoring
3 – Past Violation of Conditional Release or Community Supervision Intensive supervision or monitoring
4 – Recent Relationship Problems Interpersonal treatment (individual or group)

Legal advice or dispute resolution

Vocational counselling

5 – Recent Employment Problems Interpersonal treatment (individual or group)

Vocational counselling

6 – Victim of and/or Witness to Family Violence as a Child or Adolescent None given in guide;Interpersonal treatment (individual or group)
7 – Recent Substance Abuse/Dependence  Court-ordered abstinence, drug testing

Alcohol/drug treatment

8 – Recent Suicidal or Homicidal Ideation/Intent Crisis counselling


Psychotropic medication

Court-ordered weapons restrictions

9 – Recent Psychotic or Manic Symptoms Crisis counselling


Psychotropic medication

Court-ordered weapons restrictions

10 – Personality Disorder with Anger, Impulsivity or Behavioural Instability Intensive supervision

Long-term individual therapy

Group treatment


11 – Past Physical Assault None given in guide;

Intensive supervision or monitoring

12 – Past Sexual Assaut/Sexual Jealousy None given in guide;

Intensive supervision or monitoring

Long-term individual therapy

13 – Past Use of Weapons and/or Credible Threats of Death None given in guide;

Court-ordered weapons restrictions

14 – Recent Escalation in Frequency or Severity of Assault None given in guide;
15 – Past Violations of “No Contact” Orders Intensive supervision or monitoring
16 – Extreme Minimization or Denial of Spousal Assault History Intensive supervision

Long-term individual therapy

Group treatment


17 – Attitudes That Condone or Support Spousal Assault Intensive supervision

Long-term individual therapy

Group treatment


18 – Severe and/or Sexual Assault None given in guide; long-term individual therapy
19 – Use of Weapons and/or Credible Threats of Death None given in guide; long-term individual therapy

Court-ordered weapons restrictions


20 – Violation of “No Contact” order Intensive supervision or monitoring

Other Considerations

The SARA manual indicates a number of other risk factors which may be factored into the assessment at the expert judgement of the evaluator. Examples of these include:

  • Current emotional crisis
  • History of torturing or disfiguring intimate partners
  • Victim or witness of political persecution, torture, or violence
  • Sexual sadism
  • Easy access to firearms
  • Stalking
  • Recent loss of social support network


Kropp, PR., Hart, S.D., Webster, C.D. & Eaves, D. (1995) Manual for the Spousal Assault Risk Assessment Guide, 2nd ed., The British Columbia Institute Against Family Violence.

Morey, L.C. (1991) Personality Assessment Inventory Professional Manual. Odessa, FL: Psychological Assessment Resources, Inc.

Selzer, M. (1971) The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 127. 1653-1658.

Skinner, H.A. (1982) The Drug Abuse Screening Test. Addictive Behaviour. 7, 363-371.

Cite this article as: MacDonald, D.K., (2016), "Spousal Assault Risk Assessment (SARA)," retrieved on October 22, 2018 from http://dustinkmacdonald.com/spousal-assault-risk-assessment-sara-guide/.

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