5 Assessment

What is assessment?

Although all the core functions substance abuse counselors carry out are important, assessment is particularly significant.  Assessment is the procedure by which a counselor/program identifies and evaluates an individual’s strengths, weaknesses, problems, and needs for the development of a treatment plan.  Global criteria for assessment include:

• Gather relevant history from client, including, but not limited to, alcohol and other drug abuse, using appropriate interview techniques.
• Identify methods and procedures for obtaining corroborative information from significant secondary sources regarding client’s alcohol and other drug abuse and psychosocial history.
• Identify appropriate assessment tools.
• Explain to the client the rationale for the use of assessment techniques in order to facilitate understanding.
• Develop a diagnostic evaluation of the client’s substance abuse and any coexisting conditions based on the results of all assessments in order to provide an integrated approach to treatment planning based on the client’s strengths, weaknesses, and identified problems and needs.

The initial assessment occurs at the beginning of the client’s treatment journey and it usually takes place during the initial visit.  However, it’s important to note that assessment is an ongoing process that helps us in evaluating client progress.  During the initial assessment, the counselor gathers a thorough client history that includes, but is not limited to:

• Current status of and history related to alcohol and drug use, including any previous treatment
• Current status of and history related to physical health, including any hospitalizations
• Current status of and history related to mental health, including any previous treatment
• Family relationships, including possible issues
• Employment history and career issues
• Current legal status and history of involvement with the legal system
• Emotional and behavioral issues
• Spiritual beliefs, practices, and concerns of the client
• Education and basic life skills
• Strengths the client possesses
• Access to and use of familial and social support
• Access to and use of community resources
• Treatment readiness
• Level of cognitive and behavioral functioning

Resource: Treatment improvement protocol (tIp) 24: A Guide to Substance Abuse Services for Primary Care Clinicians

Information gained through an assessment will clarify the type and extent of the problem and will help determine the appropriate treatment response. Assessment:

• Examines problems related to use (e.g., medical, behavioral, social, and financial)
• Provides data for a formal diagnosis of a possible problem
• Establishes the severity of an identified problem (i.e., mild, moderate, intermediate, or severe stage)
• Helps to determine appropriate level of care
• Guides treatment planning (e.g., whether specialized care is needed, components of an appropriate referral, and eligibility for services)
• Defines a baseline of the patient’s status to which future conditions can be compared (National Institute on Alcohol Abuse and Alcoholism, 1995a)

If one thinks of screening as triage, then assessment is acquiring the information needed to direct a patient to appropriate treatment. At a minimum, patients must be assessed for:

1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional/behavioral conditions (e.g., psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origin, poor impulse control, changes in mental status, or transient neuropsychiatric complications)
4. Treatment acceptance or resistance
5. Relapse potential or continued use potential
6. Recovery/living environment (American Society of Addiction Medicine, 1996, p. 6)

Assessing along these dimensions helps the assessor confirm that a substance abuse problem exists and recommend an appropriate level of care.

Through a combination of clinical interview, personal history-taking, and self-reports, supplemented by laboratory testing and collateral reports as appropriate, the assessment process identifies patients’ health problems, interest in and readiness for treatment, and feasible treatment options. It also provides information on a patient’s familial, educational, social, and vocational supports and deficits.

Understanding the Impact of Culture and Gender

Clinicians performing in-depth assessments should also understand how patients’ gender and cultural background bear on the characteristics and severity of the disease (Spector, 1996). For example, more males than females abuse alcohol and drugs, and older women are more likely than older men to abuse prescription drugs. Culture and gender also may influence patients’ recognition of their problems (e.g., local cultural norms may condone or accept male drunkenness) and their reaction to the assessment process and recommended treatment interventions (e.g., substantial stigma may be associated with substance abuse treatment, especially for women and older patients of either sex).

Assessors also should be aware of the influence of their own gender and cultural background on their response to patients with suspected substance abuse problems and on their interpretation of the information provided through the assessment process. While an understanding of “typical” patterns is useful in anticipating problem areas, experienced assessors resist the temptation to stereotype patients and subsume them within broad categories based on language, ethnicity, age, education, and appearance. An oft-repeated anecdote illustrating the dangers of stereotyping concerns a well-dressed, middle-aged woman and her disheveled teenage son seen in an emergency room following a car accident. The young man was screened for substance abuse; the mother was not. Several hours after admission, the woman went into alcohol withdrawal.

When referring patients for assessment, primary care clinicians should consider whether a particular patient will relate more readily to a male or female assessor of similar cultural background or if a patient who speaks English as a second language will respond more easily to questions posed in his native tongue (Spector, 1996).

Knowledge of Comorbid Mental Disorders

The relationship between mental disorders and substance use disorders is variable and complicated. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that, in the general population, 4.7 to 13.7 percent of individuals between the ages of 15 and 54 may have both a mental disorder and a substance abuse or dependence problem (Substance Abuse and Mental Health Services Administration, 1995). Intoxication with a drug can produce psychiatric symptoms that subside with abstinence, but for those with a mental illness, substance use may mask, exacerbate, or be used to ameliorate psychiatric symptoms; precipitate psychological decompensation; or increase the frequency with which individuals require hospitalization. Because substance abuse disorders often manifest symptoms similar to those of mental health disorders, misdiagnosis may occur.

Inadvertent bias may affect the assessment process when performed by addiction specialists who do not recognize or accept the role of mental disorders in prompting or sustaining substance use or who have no experience with dually diagnosed patients. Conversely, some mental health practitioners dismiss substance abuse as merely symptomatic of underlying mental health disorders and do not acknowledge it as a problem requiring specific attention. While screening results, per se, do little to illuminate comorbid mental health disorders, information gleaned through a patient’s history or inability to respond to brief intervention may suggest a mental health problem. If possible, primary care clinicians should refer patients to assessors who understand and are trained in mental health as well as substance abuse assessment, and who are willing and able to expand the assessment process as needed to identify the multiple dimensions that may be contributing to a patient’s problems (Institute of Medicine, 1990).

Whether referring for or conducting intensive assessments themselves, primary care clinicians also should be alert to the possibility of conflict of interest when assessors are linked to a program or practice providing substance abuse services. There may be financial incentives (e.g., fee-for-service arrangements) or ideological pressure to interpret assessment results in such a way as to steer patients to a particular program or treatment provider (Institute of Medicine, 1990). Aside from insisting on an independent assessment source, which may be impractical, clinicians have few options for ensuring objective assessments (Institute of Medicine, 1990). However, primary care providers who understand the purposes of assessment and are familiar with its components will be in a better position to identify and subsequently avoid biased assessors.

The Assessment Setting

Like screening, assessments must be conducted in private, and patients must be assured that the information they provide is confidential.  Patients often will not reveal information about drug or alcohol use because they fear that information will be shared with their family members or employers or be used against them by law enforcement agencies or health insurance organizations. Prior to conducting an assessment, assessors should review current legal protections with the patient and discuss the limitations that apply to sharing information.

Assessment Components

Assessment comprises a medical and psychological history along with family, social, sexual, and drug use histories.  In its 1990 report, Broadening the Base of Treatment for Alcohol Problems, the Institute of Medicine recommended conducting “sequential” and “multidimensional” assessments for alcohol problems (Institute of Medicine, 1990). The Consensus Panel recommends the same approach when assessing for other drug-related problems. Essentially, sequential assessment entails separating “the process of assessment into a series of stages, each of which may or may not lead into the next stage” (Institute of Medicine, 1990, p. 249; Skinner, 1981) depending on the information obtained previously. In this model, a broad-based assessment is conducted first. If the information compiled suggests that other problems may be present, such as a psychiatric disorder, then a series of progressively more intense procedures would be initiated to confirm and characterize that finding. This approach not only provides information needed for treatment planning, it saves both patient and assessor time. Moreover, by ensuring that “further information is necessary [it also] justifies its increased cost” (adapted from Skinner, 1981, in Institute of Medicine, 1990, p. 250).

A multidimensional approach to assessment ensures that the variety of factors that impinge on an individual’s substance abuse (level, pattern, and history of use; signs and symptoms of use; and consequences of use) are considered when evaluating individual patient problems and recommending treatment (Institute of Medicine, 1990). Detailed characterization not only helps assessors match patients to appropriate available services, it also provides information useful in anticipating relapse triggers and planning for relapse management.  A number of assessment instruments elicit similar information, and specialized substance abuse treatment assessors may use one or more with patients.

Administering an assessment can take from 90 minutes to 2 hours, depending on the instrument(s) being used. Training is frequently required, and costs for purchase and required staff time can be substantial.  Based on members’ clinical experience, the Consensus Panel recommends that an assessment include at least the components presented in the chart Key Elements in Assessment.  The chart also includes additional questions on certain sensitive topics for situations in which primary care clinicians cannot refer for specialized assessment and require additional information in order to make a reasonable decision about the need for formal substance abuse treatment. In addition to the elements listed under the Mental Health History component, primary care clinicians contemplating a possible referral for treatment should evaluate level of cognition because it is such an important measure of a patient’s ability to participate in treatment. Results of a mental status examination can support diagnoses of intoxication, withdrawal, depression, and suicidal tendencies and signal the possibility of psychosis and organic states such as dementia.

Assessment Instruments

Assessment instruments assist in gathering consistent information, clarifying and elaborating on information obtained through the patient history and physical examination, and establishing a baseline against which patient progress can be monitored. Instruments are not a substitute for clinical judgment, but the uniformity they introduce to the assessment process helps to ensure that key areas are not overlooked (Institute of Medicine, 1990).

Standardized tools have already been tested for reliability and validity and offer assessors ready-made and carefully sequenced questions that are easy to use in patient interviews and relatively simple to score (National Institute on Drug Abuse, 1994). Some instruments can be self-administered, are available in multiple languages, are computerized, and are in the public domain. However, many require that those administering them be trained in their use.

Collateral reports and laboratory tests are tools used to supplement and, in some cases, augment the information obtained during the intensive assessment.

Collateral reporting (information supplied by family and friends) can help a clinician validate substance use because patients do not always reply honestly to assessment questions, especially those concerning illicit drug use. In addition, some patients cannot recall information accurately because of cognitive impairments. Collateral reports can be useful in determining or confirming the following:

• Which substances a patient used
• Age at first use
• Frequency of use
• Quantities used per occasion
• Duration of periods of abstinence
• Concurrent or sequential choice of substances
• Dysfunctional or inappropriate use of alcohol or prescription drugs (e.g., using anxiolytics or alcohol to induce sleep or sedatives to reduce anxiety)

However, before a clinician can obtain information from family members and significant others, the patient must give consent. In some cases, permission may be denied or family members will refuse to cooperate or cannot be contacted. While less than ideal, assessors in this situation may ask the patient, “Has anybody told you that you’re doing this too often?” or “Has anybody complained about your behavior when you use?” Because people with substance use disorders are often “in denial,” responses that provide a perspective that differs from the patient’s account of his use and its consequences frequently suggest a problem. Sometimes, patients’ explanations for why their interpretation conflicts with those of family and friends also can be useful in gauging a patient’s understanding of his situation and readiness to change: “My wife is so rigid, drinking just loosens me up. When I’m uninhibited, she gets nervous.” Or, “I just smoke pot to relax. What my mom really doesn’t like are my friends.”

Supporting Laboratory Tests

Common laboratory tests for direct measures of recent alcohol use include blood alcohol content (BAC) levels, urine, Breathalyzers^™, and recheck Breathalyzers^™. These tests measure current use and are used for the most part by law enforcement and hospital emergency room personnel (National Institute on Alcohol Abuse and Alcoholism, 1993). Drug tests include analysis of urine, hair, and saliva, though the latter two are not commonly used. Because of the limitations of self-reporting and of under-reporting due to the stigma associated with problem drinking, many assessors use laboratory testing to:

• Confirm recent use (prior to recommending methadone, for example)
• Validate suspicions about recent use
• Support findings from the assessment pointing to chronic use
• Provide information about alcohol- and other drug-related physical problems (e.g., liver damage)

Making the Diagnosis

The categorical classification of “Substance Use Disorders” in the DSM-5-TR provides the standard against which a formal diagnosis is made. Once an assessor has made a diagnosis, the next critical step is to work with the patient in determining the level and type of services that the patient needs. Over the past several years, the substance abuse treatment field, led by the American Society of Addiction Medicine (ASAM), has been grappling with the concept and implementation of patient placement criteria that identify both major problem areas that should be considered in designing an individual treatment plan, and the array of services most likely to address those problems. ASAM’s Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM PPC-2), offers guidelines that are consistent with the DSM-IV to help assessors and other clinicians evaluate the “severity and intensity of service required” (American Society of Addiction Medicine, 1996, p. 14). See TIP 13, The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders, for more on patient placement criteria (CSAT, 1995a).

Central to this evolving model of patient placement is that level of care and service mix may change as patient needs dictate. When selecting the level of care, the goal should be the least restrictive treatment that is effective. ASAM’s criteria help focus attention on an individual’s needs (American Society of Addiction Medicine, 1996). Rather than forcing a fit between a patient and a single program, those criteria provide information that frees assessors and patients to critically evaluate assessment results, investigate various options in the community, and construct a plan that incorporates needed services from a variety of resources. The realities of service availability and insurance coverage, however, ultimately affect both the level and type of service a patient receives.

Substance Abuse and Mental Health Services Administration. (1997). Treatment Improvement Protocol (TIP) Series 24: A Guide to Substance Abuse Services for Primary Care Clinicians (DHHS Publication No. (SMA) 08-4075. Rockville, MD

Assessing for Stage of Change

Looking back to Unit 1, we discussed the American Society of Addiction Medicine (ASAM) patient placement criteria. Dimension 4 helps identify a client’s readiness to change. Questions to consider for dimension 4 include, but are not limited to:

• Is the client seeking treatment on their own or are they being “mandated” by an external source (e.g., spouse, child, employer, legal system, etc.)?
• Does the client believe their behavior (use) is a problem?
• How ready or committed is the client to change?
• Has the client already taken steps toward change?
• What stage of change do you believe the client is in?

To understand what is meant by “stage of change,” it’s important for us to look at the Transtheoretical Model of Stages of Change (often referred to as the Stages of Change Model) of health behavior change developed by James Prochaska and Roberto DiClemente. While working with individuals who were at various stages in their attempts at smoking cessation, Prochaska and DiClemente posited there are 6 identifiable stages an individual works through when attempting to achieve behavior change.  These stages of change are:

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse

The precontemplation stage of change is one in which an individual doesn’t recognize their behavior is problematic. You may have heard the phrase “He’s/she’s in denial!” Most people interpret this to mean the individual is oblivious for the need to change their behavior. It’s important to note that many professionals in the addictions field are steering away from using the term “denial” due to its judgmental connotation and agree that sometimes people simply aren’t ready for change.

The second stage of change is contemplation. In the contemplation stage of change, the individual feels two ways about the need for change. In other words, they are ambivalent about change. On one hand, they can see that perhaps their behavior does yield some consequences, but they’re not quite sure if they are ready to change, may not feel their behavior is “that bad,” and/or still justify and defend their problematic behavior.

While in the preparation stage of change, the individual starts to take steps toward behavior change. The smoker buys nicotine patches, but doesn’t set a quit date. The dieter starts looking up healthier recipes, but doesn’t start to make them. In other words, the person starts to prepare for behavior change, even though they may not yet be ready to totally commit.

In the action stage of change, there is a commitment to change, and the individual starts to engage in the new desired behavior and eliminate the old, ineffective one. For someone with a substance use disorder, action can take many forms.  Some will commit to total abstinence. Others may decide to limit their use as opposed to stopping altogether. What is important to note is that is that each individual has the autonomy to choose their own goal, and meeting clients where they’re at tends to strengthen the therapeutic relationship and increase the chances of better outcomes for treatment.

In the maintenance stage of change, individuals are maintaining their change. They engage in activities and use supports and other tools to help them maintain their new behavior. For those recovering from addiction, that may include things such as participating in community-based self-help meetings and other recovery support groups; avoiding people, places, and things that trigger urges and cravings and a possible return to old behavior; the use of medication (e.g., Antabuse, Suboxone, etc.); and continued treatment.

The final stage of change Prochaska and DiClemente proposed was relapse. Relapse is a return to problematic behavior after a period of improvement. Relapse has a negative connotation, which is understandable, particularly with addiction. It’s difficult to see someone return to a problematic pattern of use and encounter unpleasant consequences. It’s also concerning given the risk for overdose with certain substances. However, if we can normalize relapse as something that doesn’t have to happen, but more often than not does, we can use it as a path to identify what needs to change and what to do differently the next time. Think of your own journey while attempting a behavior change. Perhaps you tried to eat healthier. Or maybe you tried to or successfully quit smoking. Most people who attempt to change a behavior will experience a return to the behavior they are trying to change. Thus, relapse doesn’t equate to failure. Instead, it can be a learning experience.