Clinical Evaluation Of Substance Abuse
Approximately 15 million Americans meet diagnostic criteria for alcohol abuse or dependence every year. During an assessment, some individuals give you all of the signs, such as arrests for DUI’s, positive drug screenings, family and employment problems. Others deny use with underreporting and contradiction
An evaluation is broken down into two steps: a screening and an assessment. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines them as:
- Screening is a process for evaluating the possible presence of a particular problem. The outcome is normally a simple yes or no.
- Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.
The screening is a preliminary evaluation that helps the professional to determine if there is a situation present that warrants a more in-depth look. It is an important element of the process because it can allow for preemptive care and support if it does indeed highlight a risk factor, thus helping a person before their substance abuse progresses even further. This is the first step in helping them to see if drug or alcohol abuse may in fact be present.
Here are examples of some of the most commonly used screening tools. They may be either administered online or in person.
- CAGE Questionnaire: This is a widely used method that has four questions which are asked in a brief, yet sensitive manner. One concern is its measure of usefulness in circumstances where a person may be trying to shield the extent of their alcohol abuse.
- Alcohol Use Inventory (AUI): This is a self-administered screening tool used for people who are thought to have an issue with alcohol abuse. It is suitable only for people who are able and willing to be honest about their misuse of alcohol. This inventory is useful because it recognizes that each person has a set of unique perspectives associated with the risks, results, and lifestyle choices associated with their drinking.
- Substance Abuse Subtle Screening Inventory (SASSI): The NIAAA defines SASSI as “a brief self-report, easily administered psychological screening measure that… helps identify individuals who have a high probability of having a substance dependence disorder with an overall empirically tested accuracy of 93 percent.” According to The SASSI Institute, it “identifies high or low probability of substance use disorders and provides clinical insight into level of defensiveness, willingness to acknowledge problems, and the desire for change.” This inventory is useful as it is easy to both administer and score. It also helps the assessor determine if the person’s use extends past social drinking or recreational drug use and what level of seriousness their use implies.
- State Specific Inventories: Your state may have a screening tool that it utilizes in place or in addition to any of the former.
Though some methods of screening can be done by the person themselves or by a family or friend, it is important to remember that in many cases this the first step towards recovery; for that reason it is most advantageous if the screening is either administered or reviewed by a professional who has the appropriate skills and knowledge to correctly ascertain results and provide the person with support and direction.
The assessment of an individual who may have substance abuse problems is more thorough. Its purpose is to find direct evidence that supports either the presence or absence of a condition that can be diagnosable, such as a drug or alcohol addiction. At this point a diagnostic interview is performed whereupon the interviewer will go over the results of the screening and ask more questions to get a better picture of the individual’s drug or alcohol use and abuse. This may be done by one of two ways: either a structured interview or semi-structured interview.
Though the first, by way of set and structured questions, is easier for someone without an intense background in the field to administer, they do not result in as much detail, thus there is not as much information off of which to base a treatment plan. A semi-structured interview allows the professional, who is more skilled within this area, to supplement the structured questions by ones derived from their specific expertise within the field, allowing them to better cross-examine a person’s substance abuse.
information that is obtained by substance abuse and mental health professionals in an initial assessment is the cornerstone from which a comprehensive treatment plan can be developed. The effectiveness of the treatment plan relies heavily on the information gathered such as issues, disorders, obstacles, strengths, willingness and abilities of the client.
There are several types of assessments including, assessments for status, treatment, as well as professional assessments on individuals who have very emotionally challenging careers such as police officers or professionals who have crossed the professional boundaries and have been sanctioned by professional licensing boards, law enforcement or their employer. During this course we will focus primarily on substance abuse and dually diagnosed mental health and addiction assessments.
“Have you ever tried to cut back on your substance use?”
“Do others annoy you by talking to you about your level of use?”
“Have you ever felt guilty about what happened after you used?”
“Have you every needed to use in the morning or before others think it is socially acceptable?”
Assessments are client centered by their very nature and specifically relate to the distress and difficulties that each client must endure. The assessment usually consists of:
-A description of the current problem
-A complete medication history
-Mental status exam
-Alcohol and drug history
-Current living arrangements
The questions asked refer to items such as:
History of Use
- What substance have they used?
- What was their age at first use?
- Who introduced this substance to the client?
- What was their initial level of use, escalation?
- Did their use impact job and family, result in DUI’s or arrests, or cause health problems, what is the status on those issues now?
- Is there a history of sexual or physical abuse, victim or perpetrator?
- Family history of abuse, treatment, relatives used with
- Current use, how much and how often?
- How does the client feel just before using?
- Are there any signs of withdrawal when they don’t use?
- Do they use after fights or disagreements?
- Do they use with others or alone?
- What do they like about using, not like about using?
- Do they have blackouts?
- Do they find it takes more to get “buzzed” or “high” than it used to?
- Do they find themselves using much more than you intended to?
- Be sure to ask about depressive symptoms, and when they began versus when the alcohol abuse began… clinical depression is associated with quicker and more serious relapse after treatment, as well as loner relapse periods, and increased suicide risk after treatment.
Usually a specific form is utilized. This form is not universal, but usually created by the facility or professional. It is the counselors responsibility to gain sufficient information regarding the client and the client’s presenting concerns to establish an effective treatment strategy.
Ask about specific substances individually. When a professional asked the client to describe their use the client will sometimes omit substances that they do not feel are issues such as marijuana.
Many times objective diagnostic measurements are administered as a means of gaining more information about the clinical needs of the client so as to provide strong recommendations to the referral sources. Assessments are best done face to face and in person. This enables body language, tone and affect to be considered. We will explore popular assessments and tools later in the course.
As with the screening there are many tests that can be utilized in the assessment process. Here are two widely used tools within the assessment process.
- Diagnostic Interview Schedule-IV (DIS-IV): This is a fully structured questionnaire that determines the presence of a diagnosis as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Some feel that as a tool this is limited as it only considers the qualifications as set forth in the DSM-IV and may not take into account any new research or theories within the realm of addictions that can lend a greater understanding to a person’s diagnosis or the circumstance that brought them there.
- Addiction Severity Index (ASI): This is a semi-structured interview which assesses seven areas, cited by NIAAA as “medical status, employment and support, drug use, alcohol use, legal status, family/social status, and psychiatric status.” This allows the administer to address questions not only to a person’s use over the past thirty days, but also the implications of the use over the course of their lifetime. It allows an assesor to see conditions that are both persistent and reoccurring which need to be addressed.
The Counselor and the Process
Performing an evaluation involves observation, conversation and exploration. As a professional conducting the assessment it is important to immediately start to perceive signals and make first impressions. When listening to the client avoid stereotypes and consider the context.
The assessment should be geared to the age of the client. There would be different questions and tools used for children, adults or seniors.
A brief introduction with an explanation of what will be happening during the process can improve cooperation and reduce anxiety. The professional can talk about how the assessment will be conducted, through questions, inventories, verbally, written or both.
After the assessment is complete the professional reviews all of the data that they have obtained from the assessment process, including and tests or inventories, if administered, to make a preliminary psychological diagnosis. Frequently, the clinician will refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) for clarification of mental health disorder symptoms and criteria.
Formerly known as dual diagnosis or dual disorder, co-occurring disorders describes the presence of both a mental health and a substance-use disorder.
People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity. In many cases, people receive treatment for one disorder while the other disorder remains untreated. This may occur because both mental and substance use disorders can have biological, psychological, and social components. Other reasons may be inadequate provider training or screening, an overlap of symptoms, or that other health issues need to be addressed first. In any case, the consequences of undiagnosed untreated, or under-treated co-occurring disorders can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.
The symptoms of co-occurring disorders include those associated with the particular substance abuse and mental health conditions a person has. Co-occurring disorders can be difficult to diagnose because the symptoms of substance abuse or dependence can mask the symptoms of a mental illness, and vice versa.
.The Functional Assessment of Mental Health and Addiction Scale (FAMHA) was specifically designed to meet criteria for both mental health issues and addictions.
Clients with co-occurring disorders have multiple service needs in mental health, addiction treatment, and medical interventions. Thus, functional assessments like the FAMHA are the key to not only measuring the outcomes of treatments on a broad scale, but crucial to the clinician’s full understanding of patient’s individual needs.
The FAMHA is not the only scale of this type, but will give the learner an overview of information gathered for the dually diagnosed individual.
Description of the FAMHA:
The scale describes the population types as:
-Mentally Ill Substance Users (MISU)
-Substance Using Mentally Ill (SUMI)
-Medically Compromised – Substance Using Patients (MCSU)
The scale assesses these individuals across a broad range of symptom and functional domains. The 46 items of the scale document functional deficits across all bio-psychosocial functional domains in such a way as to capture the current state of overall functioning, whilst demonstrating specific areas of need. The 46 items subdivided into 6 bio-psychosocial dimensions:
2. SocialCommunity Living
3. SocialInterpersonal Skills
5. Psychological Functioning
6. Physical Functioning.
In addition to the dimensional scales, data as to the patients primary and secondary drug of choice, alcohol consumption, prior mental health and addiction treatment episodes, demographics, and current medical, mental health and addiction diagnoses are also collected to add to the clarity of the diagnostic profile. It is expected that continued statistical analysis, including factor analyses of further trials, will yield more refined, discrete scale dimensions and add to the overall utility of the instrument.
It can be used as both an indicator of current functioning for diagnostic assessment and as a repeated measure to demonstrate the changes that occur to patients throughout the clinical cycle.
Because the term dual diagnosis is somewhat broad and misleading (for example; mental illness and learning disabilities are dual diagnoses). The distinction between MISU, SUMI, and MCMU patients has a significant impact on the selection and use of a variety of intervention techniques and strategies.
Development of the Scale
The FAMHA was developed with a variety of criteria in mind. It was felt that the FAMHA should not only assess the obvious symptom categories of major mental illness and addiction, but should also:
- include functional domains that are deemed important for community based treatment clinics; demonstrate reliability and validity;
- possess sensitivity to treatment-related change; be appropriate and relevant to the dually diagnosed population that it functionally assesses;
- be a useful tool for treatment planning and clinical governance;
- have low administration costs;
- be relatively easy to use by all levels of clinical staff.
The current version of the FAMHA meets all of these criteria and can be administered in as little as 8 minutes by a trained, experienced rater.
The FAMHA uses a seven point, three way anchored Likert-like scale, ranging from extremely dysfunctional symptoms or behaviors (Score 1) to normative levels of these behaviors and symptoms (Score 7).
The scale was designed to quantify patient functional levels more systematically than the Global Assessment of Functioning (GAF)(APA, 1994) and provides for the systematic rating of functional deficits in critical areas of that could not otherwise be assessed in this population. In addition, FAMHA overall scores are designed with a coefficient that readily converts the total score to overall GAF scores. Thus, it refines the diagnostic profile for individual patients that is necessary for appropriate diagnosis within both ICD-10 (WHO-1996) and DSM-IV (APA 1994) diagnostic systems.
An assessment should be done by a qualified, trained professional. The information obtained is crucial to the correct diagnosis and effective treatment planning.
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