Project Analysis

Chapter 5 Screening, Diagnosis, Assessment, and Referral

This chapter presents a systems or biopsychosocial approach to determining whether an individual has a chemical abuse or dependency problem. The first steps in this approach are screening and diagnosis. The chapter also considers the extension of this process, called assessment, to examine the client’s needs further. A thorough assessment is generally needed to develop a treatment plan and to make referrals to appropriate resources.

Some individuals with alcohol and drug problems experience medical emergencies (intentional overdoses, accidental alcohol or drug poisoning, pancreatitis, delirium tremens, seizures, etc.) that require immediate attention. Social workers, psychologists, and other human service professionals should know what these emergencies are, but these problems can be diagnosed and treated only by qualified medical personnel. This chapter focuses primarily on the work of helping professionals once such medical crises have been resolved or when a client is seen by a helping professional before these medical complications arise.

We begin by discussing screening, which may be defined as the use of rapid assessment instruments and other tools to determine the likelihood that an individual has a chemical abuse or chemical dependency problem. In practice, much screening is informal and is not done with structured or standardized instruments. For example, after reviewing a parolee’s “rap sheet” containing repeated alcohol- or drug-related arrests, a parole officer may feel that is all the screening necessary for referring the client to a chemical dependency treatment program or insisting on participation in a mutual-help group as a condition of parole.

Diagnosis is the confirmation of a chemical abuse or dependency problem based on established clinical criteria. The diagnostic process generally involves an interview with the patient or client and often includes information from other sources such as a medical examination, including laboratory tests, and previous medical, psychological or psychiatric, criminal, school, and other records. Consultation with other professionals might also be used as is information from collaterals (e.g., family) who know the patient or client well.

The term assessment is sometimes used synonymously with the term diagnosis, but we use it to mean an in-depth consideration of the client’s chemical abuse or dependency problems as they have affected his or her psychological well-being, social circumstances (including interpersonal relationships), financial status, employment or education, health, and so forth. This process also includes consideration of the individual’s strengths and resources that may be assets in treatment and recovery. Going beyond a confirmatory diagnosis, this type of multidimensional or biopsychosocial assessment provides the basis for treatment planning.

The cornerstones of screening, diagnosis, and assessment are knowledge of substance use disorders and good interviewing skills, including the ability to establish some level of rapport with clients in a relatively brief period. Denial is a pervasive issue in work with clients who have alcohol and drug problems. Helping professionals must frequently work with clients and their significant others to reduce defensiveness and resistance; thus, this chapter addresses these topics. The assurance of confidentiality in treatment and research settings can increase the validity of clients’ reports of their alcohol and drug problem (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1990), but the extent to which confidentiality can be guaranteed varies and should be represented fairly to the client. Confidentiality, as well as other aspects of ethical or professional conduct, also warrants attention in this chapter.

In addition to chemical dependency treatment, clients often need the services of other agencies. The final section of this chapter discusses the process of referring clients to other services, including mutual-help groups.

Screening

Screening for alcohol and drug problems is done in many types of settings in addition to chemical dependency programs, such as in health care facilities, mental health programs, and correctional facilities.

Although much work is being done, there is currently no biological testing procedure that most human service professionals can easily use to identify people with substance use disorders or those who have the potential to develop these problems (see Allen, Sillanaukee, Strid, & Litten, 2003; Substance Abuse and Mental Health Services Administration, 2006). Instead, human service professionals generally inquire about family history of alcohol and drug problems, the quantity and frequency of the individual’s own drinking or drug use, and especially the individual’s alcohol-and drug-related problems. To do this, they often use one of a number of the paper-and-pencil or verbally administered tests specifically designed to screen for chemical abuse or dependence problems. Some of the many screening instruments available are the CAGE (defined shortly), the Michigan Alcoholism Screening Test (MAST), the Alcohol Use Disorders Identification Test (AUDIT), the Drug Abuse Screening Test (DAST), the Problem Oriented Screening Instrument for Teenagers (POSIT), and the Substance Abuse Subtle Screening Inventory (SASSI). Before these instruments are administered, there should be some interaction between the client and the treatment professional in order to explain the purpose of the screening, to put the client at ease, to encourage honest responses, and to answer questions the client might have about the procedure.

CAGE

Screening devices as short as one or two items have been tested for use in busy medical practices (Brown, Leonard, Saunders, & Papasouliotis, 2001; Smith, Schmidt, Allensworth-Davies, & Saitz, 2009), but the CAGE, developed by John Ewing and Beatrice Rouse, is the briefest of the most widely used screening instruments (see Ewing, 1984; Mayfield, McLeod, & Hall, 1974). The CAGE consists of four questions asked directly to the patient:

Have you ever felt you should Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?

The letters in bold type in each question makeup the acronym that serves as the instrument’s name; the letters also serve as a mnemonic device so that the instrument is easily committed to memory. A positive response to one or more of the questions indicates the need to explore problems the patient or client may be experiencing with the use of alcohol. Two or more positive responses generally indicate a positive test (Buchsbaum, 1995; Liskow, Campbell, Nickel, & Powell, 1995). This tool is easily used in many types of clinical settings. The CAGE is generally reported to be effective in identifying adults with alcohol problems (Bush, Shaw, Cleary, Delbanco, & Aronson, 1987; Liskow et al., 1995). Since the CAGE inquires only about alcohol, the CAGE Adapted to Include Drugs (CAGE-AID) may be used with instructions to the patient or client that “when thinking about drug use, include illegal drug use and the use of prescription drugs other than as prescribed” (Brown, Leonard, Saunders, & Papasouliotis, 1998, p. 102; also see Lanier & Ko, 2008). These instructions are useful in screening individuals who are taking pain medication and those who have been prescribed medications for psychiatric disorders and are using them inappropriately.

Michigan Alcoholism Screening Test (MAST)

Another widely used screening instrument for alcohol problems is the Michigan Alcoholism Screening Test (MAST) (Selzer, 1971). It has been shown to have good validity and reliability (Lettieri, Nelson, & Sayers, 1985; Skinner, 1979). The original MAST contains 25 items and is usually self-administered (i.e., the client is asked to read and complete it). As with most screening instruments, clarifying clients’ responses can be helpful. For example, question 3 on the MAST is “Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?” Drinkers married to teetotalers may respond positively to this question even if their drinking is not problematic, or an individual with ties to a religious group that prohibits drinking may respond positively to question 5 (“Do you ever feel guilty about your drinking?”) regardless of how much he or she drinks.

Shorter versions of the MAST are also available (see Connors & Volk, 2003). One, called the Short MAST or the SMAST, contains 13 questions (Selzer, Vinokur, & van Rooijen, 1975). Another is the Brief MAST (B-MAST), which contains ten questions (Pokorny, Miller, & Kaplan, 1972). The shorter versions are often used with slower readers. These instruments may also be tape-recorded or read to the client or patient by the person administering the test. The MAST has been used as a screening tool in many settings, such as in programs for those convicted of driving under the influence (DUI).

Alcohol Use Disorders Identification Test (AUDIT)

The World Health Organization (WHO) developed the Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument for use by primary health care providers (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). Social service providers can also use it. As Figure 5.1 shows, the AUDIT contains ten items. Items 1 through 3 concern hazardous drinking (frequency and quantity), items 4 through 6 concern alcohol dependence, and items 7 through 10 refer to harmful alcohol use (alcohol-related problems). The AUDIT can be administered as a self-report questionnaire or as an interview. Clinical screening procedures (a physical exam and laboratory tests), which can only be administered by qualified health care providers, are also recommended, especially when an individual may not be candid about alcohol use or cannot provide answers to questions or when additional information is needed. The clinical indicators include blood vessels appearing in the face, hand and tongue tremor, changes in mucous membranes and mouth, and elevated liver enzymes observed through tests such as the serum gamma-glutamyl transferase (GGT). The AUDIT is available in a number of languages. Since drinking preferences and customs vary among cultures, these factors must be taken into account when administering the AUDIT. For example, the number of drinks specified in items 2 and 3 may require adjusting, since serving size and alcohol strength vary among countries. As Figure 5.1 also shows, the patient’s score indicates the type of intervention needed.

FIGURE 5.1 The Alcohol Use Disorders Identification Test (AUDIT): Interview Version

Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask you some questions about your use of alcoholic beverages during this past year.” Explain what is meant by “alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks.” Place the correct answer number in the box at the right.

How often do you have a drink containing alcohol?

(0) Never (Skip to Questions 9-10)

(1) Monthly or less

(2) 2 to 4 times a month

(3) 2 to 3 times a week

(4) 4 or more times a week

How many drinks containing alcohol do you have on a typical day when you are drinking?

(0) 1 or 2

(1) 3 or 4

(2) 5 or 6

(3) 7, 8, or 9

(4) 10 or more

How often do you have six or more drinks on one occasion?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily

Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0

How often during the last year have you found that you were not able to stop drinking once you had started?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

Have you or someone else been injured as a result of your drinking?

(0) No

(2) Yes, but not in the last year

(4) Yes, during the last year

Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?

(0) No

(2) Yes, but not in the last year

(4) Yes, during the last year

Record total of specific items here

Risk Level Intervention AUDIT Score*

*The AUDIT cut-off score may vary slightly depending on the country’s drinking patterns, the alcohol content of standard drinks, and the nature of the screening program. Clinical judgment should be exercised in cases where the patient’s score is not consistent with other evidence, or if the patient has a prior history of alcohol dependence. It may also be instructive to review the patient’s responses to individual questions dealing with dependence symptoms (see Questions 4, 5, and 6) and alcohol-related problems (see Questions 9 and 10). Provide the next highest level of interventation to patients who score 2 or more on Questions 4, 5, and 6, or 4 on Questions 9 or 10.

Zone I Alcohol Education 0–7

Zone II Simple Advice 8–15

Zone III Simple Advice plus Brief Counseling and Continued Monitoring 16–19

Zone IV Referral to Specialist for Diagnostic Evaluation and Treatment 20–40

Source: T. F. Babor, J. C. Higgins, J. B. Saunders, & M. G. Monteiro, AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care, 2nd ed. (Geneva, Switzerland: World Health Organization, 2001), Reprinted with permission of the World Health Organization.

Drug Abuse Screening Test (DAST)

Some instruments, such as the Drug Abuse Screening Test, are used to screen for drug problems other than alcohol (Skinner, 1982; also see Lanier & Ko, 2008). The DAST was patterned after the MAST. Like the CAGE, MAST, and ten-item AUDIT, the DAST relies on the client or patient’s responses to questions. The 10-, 20-, and 28-item versions of the DAST are reported to have good psychometric properties (Yudko, Lozhkina, & Fouts, 2007).Figure 5.2 contains the 20-item version.

Problem Oriented Screening Instrument for Teenagers (POSIT)

An instrument often used with adolescents is the Problem Oriented Screening Instrument for Teenagers (POSIT) (Winters, 1999, 2003; also see Knight, Sherritt, Harris, Gates, & Chang, 2003). POSIT is a screening tool for substance use problems and social, behavioral, and learning problems. The 139-item POSIT is longer than other tools described thus far and takes 20 to 30 minutes to complete. It is self-administered, requiring a fifth-grade reading level, and is available in English and Spanish.

Substance Abuse Subtle Screening Inventory (SASSI)

The Substance Abuse Subtle Screening Inventory (SASSI) is another instrument the client completes (Lazowski, Miller, Boye, & Miller 1998; Miller & Lazowski, 1999, 2001, 2005). There is a version for adults and one for adolescents. The SASSI differs from many instruments available in the field because most of the true/false items on one side of the form do not inquire directly about alcohol or drug use. The reverse side of the SASSI form contains another set of questions (formerly called the Risk Prediction Scales) (Morton,1978) that do inquire directly about alcohol and other drug abuse. The SASSI therefore contains both face-valid items and subtle items that are empirically derived. Administration of the subtle true/false items before the more obvious alcohol- and drug-related questions may help minimize client defensiveness. Since the denial or defensiveness common among many persons with chemical dependency problems may result in failure to provide accurate information on face-valid, self-report measures, there has been interest in less obtrusive measures of substance use disorders such as the SASSI.

FIGURE 5.2 Drug Abuse Screening Test (DAST-20)

The following questions concern information about your potential involvement with drugs not including alcoholic beverages during the past 12 months. Carefully read each statement and decide if your answer is “Yes” or “No.” Then, circle the appropriate response beside the question. In the statements “drug abuse” refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions and (2) any non-medical use of drugs. The various classes of drugs may include: cannabis (e.g., marijuana, hash), solvents, tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages. Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.

These questions refer to the past 12 months. Circle your response.

1. Have you used drugs other than those required for medical reasons? Yes No

2. Have you abused prescription drugs? Yes No

3. Do you abuse more than one drug at a time? Yes No

4. Can you get through the week without using drugs? Yes No

5. Are you always able to stop using drugs when you want to? Yes No

6. Have you had “blackouts” or “flashbacks” as a result of drug use? Yes No

7. Do you ever feel bad or guilty about your drug use? Yes No

8. Does your spouse (or parents) ever complain about your involvement with drugs? Yes No

9. Has drug abuse created problems between you and your spouse or your parents? Yes No

10. Have you lost friends because of your use of drugs? Yes No

11. Have you neglected your family because of your use of drugs? Yes No

12. Have you been in trouble at work because of drug abuse? Yes No

13. Have you lost a job because of drug abuse? Yes No

14. Have you gotten into fights when under the influence of drugs? Yes No

15. Have you engaged in illegal activities in order to obtain drugs? Yes No

16. Have you been arrested for possession of illegal drugs? Yes No

17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? Yes No

18. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? Yes No

19. Have you gone to anyone for help for a drug problem? Yes No

20. Have you been involved in a treatment program specifically related to drug use? Yes No

Source: Drug Abuse Screening Test (DAST-20) is reprinted by permission of the Centre for Addiction and Mental Health, Toronto, ON, Canada. Copyright © 1982.

The SASSI includes a set of decision rules to determine if the respondent fits the profile of a chemically dependent individual. Additional guidelines can be helpful in identifying some substance abusers who are not dependent. Separate profiles are used to score results for men and women. In addition to its basic function as a substance abuse and dependence screening instrument, the SASSI may provide other useful information. Clinical experience indicates that elevations on specific scales that comprise the SASSI reflect such things as defensiveness, willingness to acknowledge problematic behavior, depressed affect, focus on others, and relative likelihood of legal problems. The SASSI can be administered as a paper-and-pencil test or on a computer.

MacAndrew Alcoholism Scale

Another device included under the category of screening tools is the MacAndrew Alcoholism Scale (MacAndrew, 1965). It is a subscale of the well-known Minnesota Multiphasic Personality Inventory (MMPI), which psychologists often use to detect a wide range of mental disorders. The items are unobtrusive and have been used for more than four decades. Special training and approval are required to interpret the MMPI.

Utility of Screening Instruments

The screening instruments discussed thus far are generally reported to have good validity and reliability by their authors, and for the most part, other researchers have provided evidence of their utility. Other factors to recommend them are that most are easy to administer, and they generally take from about 1 to 20 minutes to complete (depending on the instrument). Except for the MMPI and the AUDIT’s clinical screening procedures, they can be administered and scored by most human service professionals who need relatively minimal special training in their use.

We have discussed just a few of the instruments that may be useful to human service professionals in screening for substance abuse and dependence. Allen and Wilson (2003) and several volumes in the Substance Abuse and Mental Health Services Administration’s Treatment Improvement Protocol Series provide additional discussion of screening devices and screening methods. In conducting screenings and assessments for alcohol and drug problems, treatment providers often use instruments to detect other problems the client may be experiencing, such as depression, suicidal ideation, or other psychiatric problems.

Can People with Alcohol and Drug Problems Be Believed?

In our section on screening, we mentioned the terms validity and reliability (see, for example, Allen, 2003; Connors & Volk, 2003). These are basic social science concepts. An instrument is reliable if it produces the same results with the same person at different times and under different circumstances. For example, if the MAST or the SASSI were administered to a client today during a visit to an outpatient clinic, one would expect the same or very similar results if it were administered to the client next week at his or her home. If an instrument does not consistently produce the same results, it is not very reliable.

Validity refers to whether an instrument measures what one wants it to measure. In this case, human service professionals want to be sure they are using an instrument that will detect alcohol or drug problems, not some other concept such as bipolar disorder or antisocial personality disorder. Professionals may also be interested in these problems, but they clearly want to know which instruments should be used to screen for each of these problems.

An instrument can be reliable but not valid. For example, an instrument may consistently or reliably measure the same concept over and over, but it may not be the concept in which one is interested. To be valid, however, an instrument must be reliable. If an instrument fails to measure consistently the same concept, it is not valid, because one cannot be sure it is measuring what one wants it to measure.

Also of concern is that the instrument has good sensitivity and specificity (Connors & Volk, 2003). Sensitivity refers to the instrument’s ability to identify correctly someone with an alcohol or drug problem (called true positives). Clinicians want to avoid instruments that are likely to classify an individual as having a substance use disorder when he or she does not have such a problem (false positives). The professional also tries to select instruments that have high specificity. They maximize the likelihood that people who do not have alcohol or drug problems will be correctly classified (true negatives), and they minimize the likelihood that people who have alcohol or drug problems will be misclassified as not having such a problem (false negatives).

Unfortunately, as sensitivity increases, specificity is likely to decrease and vice versa. One key to selecting appropriate instruments is in knowing the prevalence of the problem in the population. For example, sensitivity is greater when there is a greater likelihood of a problem occurring in a given population group (see Lanier & Ko, 2008). In a study using the Brief MAST to detect alcoholism in three groups (a general population sample, general medical patients, and people in inpatient alcoholism treatment), Chan and colleagues (1994) found that sensitivity was lowest for the general population sample, “probably because most of the B-MAST questions deal with severe alcohol problems, and they are not sufficiently sensitive to detect those who drank heavily but who had not yet developed these alcohol problems” (p. 695). Similarly, Heck and Williams (1995) found that the CAGE may not be as sensitive in identifying problem drinking among college students, especially women, as it generally is with adults.

To improve sensitivity and specificity of instruments with various populations, changes may be required in cutoff scores or in how items are weighted (Fleming & Barry, 1989, 1991). Wording changes may also provide more valid responses. Research helps to clarify whether modifications are useful. It may also be that another instrument is better suited to the population of interest. Various studies have compared the utility of the commonly used screening instruments, and some are more easily administered or more accurate with various types of clients in particular types of setting than others (see Connors & Volk, 2003). Staff, however, may be unaware of the psychometric properties of the instruments they routinely use. In selecting appropriate instruments, clinicians are advised to consult the available literature and to be mindful of the caveats discussed in this chapter.

Clinicians are concerned about selecting instruments with good psychometric properties, not only in screening and assessment but also in other situations such as measuring the client’s progress during and after treatment and in evaluating the effectiveness of chemical dependency treatment programs. Factors such as the client’s ability to recall past behaviors or events can affect accurate reporting. Questions that are ambiguous or poorly worded also present a problem.

Professionals also want to know if an instrument has been validated on the populations of interest to them. Many instruments have been validated on men. Some work has been done to develop instruments that are more sensitive to detecting alcohol problems in women. For example, Russell (1994) developed the TWEAK by using some items from other instruments, eliminating others, and making wording changes that better reflect the situation of women. For example, asking women whether they have had fistfights may not accurately reflect the drinking-related behavior they tend to exhibit. The TWEAK was developed to screen for problem drinking during pregnancy, but it may also be useful with women in other situations (Chan, Pristach, Welte, & Russell, 1993).

Another issue is whether the instrument has been tested with members of various ethnic and cultural groups. Language may be a particular concern. Terms commonly used by one ethnic group may have no meaning or a different meaning for other ethnic groups. Some efforts have been made to develop instruments that are sensitive to specific cultural groups (see, for example, Carise & McLellan, 1999), but instruments that are valid across ethnic groups are particularly useful. Language can also be a problem when an instrument is used with individuals from different age cohorts, since words can take on different meanings over time. Some instruments are designed specifically for use with adolescents and others with adults. Items should be relevant to the client’s age group. For example, an adult may be asked about job and family responsibilities, whereas a child or adolescent may be asked about school.

Many of the instruments discussed so far rely on the client’s self-report. Many of them are also face valid, because they clearly ask clients about their alcohol or drug use. When using a face-valid instrument, what confidence does one have that clients are telling the truth about their behavior? When asked about the amount of alcohol or drugs they consume or whether they have had an alcohol-related blackout or lost a job due to drug use, clients can easily lie, but are they likely to do this?

Based on research to determine the reliability and validity of clients’ self-reports, many think that clinicians can have confidence in them (Fuller, 1988; Hesselbrock, Babor, Hesselbrock, Meyer, & Workman, 1983; NIAAA, 1990). Some also believe that direct questions about substance use “provide the logical basis for one to evaluate with the assessed person their alcohol and drug consumption and its consequences” (Svanum & McGrew, 1995, p. 212). Some researchers have correlated clients’ self-reports with information from other sources, such as collateral contacts and laboratory (medical) tests, and have found good agreement among them. Fuller (1988) agrees that the balance of evidence favors their usefulness. He also notes that some studies raise serious enough questions that self-reports should be used in combination with other evidence to gain the most accurate picture of the client’s problems and functioning. Skinner (1984) describes the situations or conditions that influence the validity of clients’ self-reports. These factors include whether the client is detoxified and psychologically stable at the time of the assessment, the rapport established by the interviewer with the interviewee, the clarity of the questions asked, whether the client knows that his or her responses will be corroborated with other sources of information (particularly laboratory tests [NIAAA, 1993]), and the degree of confidentiality that can be promised to the individual.

Hesselbrock and colleagues (1983) also suggest that the “demand characteristics of the situation” affect the accuracy of client self-reports. For example, individuals who have little to lose from reporting problem behaviors accurately are more likely to do so. In many situations in which alcohol- and drug-dependent individuals are found, such as criminal justice or child welfare settings, this is not the case. A diagnosis of chemical abuse or dependence may have serious consequences for them. In these cases, it may be particularly important for the clinician to utilize additional sources of information to obtain a complete picture of individuals’ alcohol and drug use and any related problems in order to serve them appropriately.

There has been an interest in the use of less obtrusive (i.e., nonface-valid) instruments, such as the MacAndrew scale and the SASSI, in situations where demand characteristics might inhibit clients from giving accurate responses to face-valid questions. Even when less obtrusive measures are used, ethical, professional conduct generally requires that clients be told the purpose of the screening or assessment in which they are participating.

Diagnosis

For those individuals who screen positive, the next step is often to determine if there is sufficient evidence to confirm a diagnosis of a substance use disorder. Ideally, diagnosis is accompanied by a multidimensional, biopsychosocial assessment, which includes not only an in-depth understanding of clients’ alcohol- and drug-related problems but also their strengths, support systems, and other factors that may help promote recovery.

Various authors have recounted the history of attempts to reach agreement on the criteria needed to define and diagnose alcohol and drug problems (see, for example, Alcohol Health & Research World 15[4], 1991; 20[1], 1996). In the last few decades, considerable progress has been made in helping clinicians and researchers grapple with these issues. An important step was the work of the Criteria Committee of the National Council on Alcoholism (NCA), now the National Council on Alcoholism and Drug Dependence (NCADD). In 1972, it simultaneously published “Criteria for the Diagnosis and Treatment of Alcoholism” in the American Journal of Psychiatry and Annals of International Medicine.

Today, the criteria of the American Psychiatric Association (APA, 2000) and the World Health Organization (WHO, 1992) are the most widely used diagnostic tools in the field. Edwards and Gross’s work (1976) played an important role in the APA and WHO’s efforts to define alcohol dependence. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) delineates the current APA criteria for diagnosing substance (alcohol and other drug) use disorders. The WHO’s tenth edition of the International Classification of Diseases (ICD-10) contains its current criteria for alcohol and drug disorders. Table 5.1 compares the APA’s criteria for alcohol dependence and abuse with the WHO’s criteria for alcohol dependence and harmful use of alcohol, respectively. In the United States, the DSM-IV-TR is widely used to diagnose substance use disorders and other mental disorders. Over the years, substantial changes have been made in DSM criteria for substance use disorders. For example, tolerance or withdrawal symptoms are no longer required for a diagnosis of dependence.

As another example from the DSM-IV-TR, Figure 5.3 contains its descriptions of cocaine abuse and dependence. The DSM-IV-TR also contains descriptions and diagnostic criteria for other types of substance use disorders (amphetamines, cannabis, opioids, etc.) and for substance-induced disorders (e.g., intoxication, withdrawal, psychosis, sleep, mood, anxiety, sexual dysfunction, etc.).

Professionals in the United States are often required to use DSM diagnoses to request third-party (insurance) payments for treating mental health problems, including substance use and dependence. Interview protocols (First, Spitzer, Gibbon, & Williams, 1997) and study guides(Fauman, 2002) are available to assist in applying the DSM diagnostic criteria.

A fifth edition of the DSM is being developed. Though not yet finalized, the proposed criteria are based on clinical experience and research and may differ in many ways from the current criteria. For example, given that research indicated that the reliability of the abuse diagnosis was much weaker than the dependence diagnosis, the recommendation is to replace dependence and abuse with a single diagnosis of substance use disorder. The diagnosis of substance use disorder would be specified as either moderate or severe depending on whether two to three or four or more criteria are met, respectively. The idea that alcohol and other drug problems fall along a continuum has been suggested for some time. Another significant proposed change is to add a new criterion described as “craving,” given that it is a common clinical symptom or indicator of a substance use problem that is often categorized as severe(American Psychiatric Association, 2010).

TABLE 5.1 Comparison of the Diagnostic Criteria for Alcohol Dependence and Alcohol Abuse or Harmful Use in Two Diagnostic Schemes: The ICD-10a and the DSM-IV-TRb

ICD-10 DSM-IV-TR

Comparison of Criteria for Alcohol Dependence

aFrom World Health Organization, The ICD-10 Classification of Mental and Behavioural Disorders, Clinical Descriptions and Diagnostic Guidelines (Geneva: World Health 0rganization, 1992). Reprinted with permission of the World Health 0rganization.

bReprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Copyright 2000 American Psychiatric Association.

Symptoms of Alcohol Dependence

Essential: Drinking or a desire to drink; the subjective awareness of compulsion to use is most common during attempts to stop or control drinking.

At least three of the following:

Evidence of tolerance to the effects of alcohol.

A physiological withdrawal state (characteristic alcohol withdrawal syndrome or drinking to relieve or avoid withdrawal symptoms).

Difficulties in controlling drinking behavior in terms of onset, termination, or levels of use.

Progressive neglect of alternative pleasures or interests because of drinking, increased amount of time to obtain or to drink alcohol, or to recover from its effects.

Persisting in drinking despite clear evidence of harmful consequences which may be physical, psychological, or cognitive.

A strong desire or compulsion to drink.

Also a consideration: a narrowing of the repertoire of drinking patterns (e.g., drinking in the same way, regardless of social constraints that determine appropriate drinking behavior).

A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by three or more of the following:

Tolerance defined as (a) a need for markedly increased amounts of alcohol to achieve intoxication or desired effect or (b) markedly diminished effect with continued use of the same amount of alcohol.

Withdrawal, as manifested by (a) the characteristic alcohol withdrawal syndrome or (b) alcohol or a closely related substance taken to relieve or avoid withdrawal symptoms.

Drinking in larger amounts or over a longer period than intended.

Persistent desire or unsuccessful efforts to cut down or control drinking.

A great deal of time spent obtaining alcohol, using alcohol, or recovering from its effects.

Important social, occupational, or recreational activities given up or reduced because of drinking.

Continued drinking despite knowledge of a persistent or recurring physical or psychological problem caused or exacerbated by alcohol use.

Duration Criteria for Alcohol Dependence

At least three of the above criteria have been met during the previous year. Three or more symptoms have occurred at any time in the same 12-month period.

Specifiers for Alcohol Dependence

None.

With physiological dependence. Evidence of tolerance or withdrawal (i.e., symptoms 1 or 2 above are present).

Without physiological dependence. No evidence of tolerance or withdrawal (i.e., neither symptom 1 nor 2 is present).

Course Modifiers or Specifiers for Alcohol Dependence

Currently abstinent.

Currently abstinent, but in a protected environment.

Currently on clinically supervised maintenance or replacement regime.

Currently abstinent, but receiving aversive or blocking drugs (e.g., disulfiram).

Currently drinking.

Continuous drinking.

Episodic drinking.

Remission Specifiers

(Do not apply if individual is on agonist therapy or in a controlled environment.)

Early remission.

Early full remission. No criteria for abuse or dependence met in last 1 to 12 months.

Early partial remission. Full criteria for dependence not met in last 1 to 12 months, but at least one criterion for abuse or dependence met, intermittently or continuously.

Sustained remission.

Twelve months of early remission have passed.

Sustained full remission. No criterion for abuse or dependence met at any time in past 12 months or longer.

Sustained partial remission. Full criteria for dependence not met in past 12 months or longer, but at least one criterion for abuse or dependence met.

Additional Specifiers

No criteria for alcohol dependence or abuse have been met for at least one month.

On agonist therapy.

In a controlled environment.

Comparison of Criteria for ICD-10 Harmful Use of Alcohol and for DSM-IV-TR Alcohol Abuse

Symptoms

Harmful Use of Alcohol

Clear evidence that a pattern of alcohol use was responsible for:

Actual physical damage to the user.

or

Actual mental damage to the user.

Alcohol Abuse

A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one or more of the following:

Recurrent drinking resulting in failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance).

Recurring drinking in situations in which it is physically hazardous (e.g., driving an automobile).

Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct).

Continued alcohol use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments, physical fights).

Duration Criteria for Harmful Use and Alcohol Abuse

None. One or more symptoms have occurred at any time during the same 12-month period.

Exclusionary Criteria Related to Alcohol Dependence

Does not presently meet criteria for alcohol dependence, a psychotic disorder, or other drug- or alcohol-related disorder. Never met criteria for alcohol dependence.

Sources: From ICD-10. Classification of Mental and Behavioural Disorders, Clinical Descriptions and Diagnostic Guidelines, World Health Organization, 1992, is reprinted by permission of WHO. From The Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision, Copyright © 2000 American Psychiatric Association. Reprinted with permission of the American Psychicatric Association.

FIGURE 5.3

Cocaine Dependence and Abuse

Cocaine Dependence

Cocaine has extremely potent euphoric effects, and individuals exposed to it can develop dependence after using cocaine for very short periods of time. An early sign of Cocaine Dependence is when the individual finds it increasingly difficult to resist using cocaine whenever it is available. Because of its short half-life, there is a need for frequent dosing to maintain a “high.” Persons with Cocaine Dependence can spend extremely large amounts of money on the drug within a very short period of time. As a result, the person using the substance may become involved in theft, prostitution, or drug dealing or may request salary advances to obtain funds to purchase the drug. Individuals with Cocaine Dependence often find it necessary to discontinue use for several days to rest or to obtain additional funds. Important responsibilities such as work or child care may be grossly neglected to obtain or use cocaine. Mental or physical complications of chronic use such as paranoid ideation, aggressive behavior, anxiety, depression, and weight loss are common. Regardless of the route of administration, tolerance occurs with repeated use. Withdrawal symptoms, particularly hypersomnia, increased appetite, and dysphoric mood, can be seen and are likely to enhance craving and the likelihood of relapse. The overwhelming majority of individuals with Cocaine Dependence have had signs of physiological dependence on cocaine (tolerance or withdrawal) at some time during the course of their substance use. The designation of “With Physiological Dependence” is associated with an earlier onset of dependence and more cocaine-related problems.

Cocaine Abuse

The intensity and frequency of cocaine administration is less in Cocaine Abuse as compared with dependence. Episodes of problematic use, neglect of responsibilities, and interpersonal conflict often occur around paydays or special occasions, resulting in a pattern of brief periods (hours to a few days) of high-dose use followed by much longer periods (weeks to months) of occasional, non-problematic use or abstinence. Legal difficulties may result from possession or use of the drug. When the problems associated with use are accompanied by evidence of tolerance, withdrawal, or compulsive behavior related to obtaining and administering cocaine, a diagnosis of Cocaine Dependence rather than Cocaine Abuse should be considered. However, since some symptoms of tolerance, withdrawal, or compulsive use can occur in individuals with abuse but not dependence, it is important to determine whether the full criteria for dependence are met.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Copyright 2000 American Psychiatric Association.

A historical controversy in the field of treatment for alcohol problems centered on whether identifying and treating the underlying causes of alcoholism (e.g., various psychological problems) would result in remission of alcohol problems. This approach has not proven satisfactory for two reasons. First, scientists have yet to discover the exact etiologies of substance use disorders, and second, even if the underlying causes were known, substance use disorders often become problems in their own right. Our discussion of diagnosis generally refers to substance abuse or dependence as a major or primary problem presented by the client, requiring specific treatment. The reader may have also encountered the term secondary diagnosis. In 1972, the Criteria Committee of the NCA (1972a,b) wrote:

Reactive, secondary, or symptomatic alcohol use should be separated from other forms of alcoholism. Alcohol as a psychoactive drug may be used for varying periods of time to mask or alleviate psychiatric symptoms. This may often mimic a prodromal [early] stage of alcoholism and is difficult to differentiate from it. If the other criteria of alcoholism are not present, this diagnosis must be given. A clear relationship between the psychiatric symptom or event must be present; the period of heavy alcohol use should clearly not antedate the precipitating situational event (for example, an object loss). The patient may require treatment as for alcoholism, in addition to treatment for the precipitating psychiatric event.

It may even be that excessive alcohol or drug use that developed following a traumatic event, such as loss of a loved one, may remit without specialized substance abuse treatment once an adjustment is made to the new life circumstance. But this is different from the situation in which alcohol or drug use itself has become a problem for the individual. Take, for example, the case of an individual who blames his diagnosis of alcohol dependence on a divorce that occurred ten years ago. Although it may be true that his drinking escalated at that time, alcohol dependence itself has become a problem, requiring it to be addressed as such. Exploring the issues that caused the client to fixate on his divorce may also be helpful at some point, but this alone is unlikely to resolve his years of alcohol problems. Many practitioners believe that treatment must first focus on arresting the alcohol dependence.

Today, we recognize that a substantial number of people with mental disorders also have diagnoses of alcohol or drug disorders. Although their drinking or drug use may have been precipitated by the desire to relieve symptoms of mental disorders (hallucinations, anxiety, etc.), many of them require treatment for substance use disorders as well as treatment for mental illness. The subject of dual or co-occurring diagnoses has become of such importance that we devote Chapter 13 to it.

Assessment

The APA and the WHO’s diagnostic criteria are important in establishing whether an individual has a substance use disorder, but more information is needed to plan for the client’s treatment. The DSM-IV-TR (APA, 2000) recommends a multiaxial assessment, which also considers factors such as the individual’s cognitive abilities, medical condition, psychosocial and environmental problems, and overall level of functioning.

Addiction Severity Index

A multidimensional assessment tool widely used in the chemical dependency field is the Addiction Severity Index (ASI) (McLellan et al., 1985). The ASI is a structured interview accompanied by a numerical scoring system to indicate the severity of the patient’s or client’s problems in seven life areas: alcohol, drugs, vocational, family and social supports, medical, psychological or psychiatric, and legal. Chemical dependency professionals and other human service professionals who have been trained in its use can administer the ASI. The ASI has a follow-up version that has also contributed to its use in treatment and research to measure client progress and to assess the effectiveness of treatment programs. Similar instruments for use with adolescents have also been developed (Friedman & Utada, 1989; Kaminer, Wagner, Plummer, & Seifer, 1993).

Drug Use Screening Inventory

Another tool designed to assess the severity of adults and adolescents’ problems on multiple dimensions and to rank these problems is the Drug Use Screening Inventory-Revised (DUSI-R) (Tarter & Hegedus, 1991; Tarter & Kirisci, 2001; also see Allen & Wilson, 2003). The 10 domains of the DUSI-R are frequency of and degree of involvement in drug and alcohol use (including drug preference), behavior patterns (such as anger and self-control), health status (including accidents and injuries), psychiatric disorder, social competence, family system, school performance/adjustment, work adjustment, peer relationships, and leisure/recreation. The DUSI-R contains 159 items requiring yes or no answers.

The DUSI is used in three phases. First, each domain is assessed using the basic assessment instrument. This instrument is written at a fifth-grade level and takes about 20 minutes to complete as a paper-and-pencil test or by computer, and it can be read to those with lower reading levels. Second, instruments are available to assess further those areas that appear to be problematic in order to provide a more comprehensive evaluation. Third, the information from stages one and two is used to develop an individualized treatment plan for the client.

Versions of the DUSI-R are available to provide information for the past week, past month, and past year. There are no scores that distinguish between types of treatment needed; instead, this is left to clinical judgment once the DUSI-R and other assessment information is compiled to give a full picture of the client’s needs. Like the ASI, the instrument may be used to chart the client’s progress, and client information can be aggregated for program evaluation studies. The DUSI-R’s developers report that it has good ability to classify adults and adolescents with DSM substance disorders and that it also has good ability to identify those with no psychiatric disorders.

The information obtained from screening, diagnosis, and assessment is used to determine the type of substance abuse or dependence treatment the client needs. Chapter 6 describes the components of the chemical dependency treatment system, indicating clients’ situations that are likely to warrant the various services. Since many alcoholics and addicts initially seek help for marital, family, job, legal, or health problems rather than for alcohol or drug problems, it is incumbent on helping professionals from all disciplines and in various treatment settings to be knowledgeable about screening, diagnosis, and assessment for chemical abuse and dependency problems. Similarly, tools such as the ASI are important to professionals in the chemical dependency field because they are concerned with the client’s overall quality of life. A unidimensional approach indicates that the treatment goal of abstinence (or reduced use) is expected to result in improvement in other areas of the client’s life, whereas a multidimensional approach suggests that each of the client’s major problems be targeted for treatment since abstinence (or reduced use) alone may not resolve them (Babor, Dolinsky, Rounsaville, & Jaffe, 1988; McLellan, Luborsky, Woody, O’Brien, & Kron, 1981). The multidimensional or systems view of assessment and treatment seems to have taken precedence over the view that chemical dependency is a unitary phenomenon and that chemical dependency professionals need be concerned only about clients’ alcohol and drug problems (Babor et al., 1988; Callahan & Pecsok, 1988; Pattison, Sobell, & Sobell, 1977).

Taking a Social History

Taking a client’s social history is particularly important because it is the type of assessment that exemplifies the systems or ecological perspective of this book.* Our discussion is intended to alert the new professional to some of the issues involved in doing a thorough assessment, focusing on the client’s strengths as well as problems. There are many formats for doing social histories, from checklists to structured interviews to more open-ended formats. The social history outline found in Figure 5.4 can be used to structure an assessment or intake interview with adults who recognize that alcohol and/or drugs are a problem in their lives. A skillful interviewer may also be able to use this tool to reduce defensiveness in clients who are less willing to discuss their alcohol or drug use and to begin to engage the client in the treatment process and increase motivation for change (see Donovan, 1988; Miller, 1985). Although not exhaustive of all the avenues that can be explored with a client, the topics and questions suggested in the outline can help the interviewer capture information both about problems in the client’s life and about the assets the client brings to the recovery process. The social history format is flexible and can be adjusted depending on the client and treatment setting. Sometimes, a comprehensive intake interview or social history is done at an initial session. In other cases, the material is obtained over several sessions. Clients may initially give limited answers to questions but reveal more information over time as comfort and trust with the treatment professional increases. Assessment is not a single event; it takes place throughout the treatment process as clients’ needs and circumstances change.

*Thanks to William J. McCabe, who taught me a great deal about many of the elements of the social history.

FIGURE 5.4 The Social History as it Relates to Drinking and Drug Use

I. Education

How long did the client stay in school?

How did the client like or feel about school?

Did the client do well in school?

Did the client have a history of alcohol and/or other drug use or abuse during the school years?

Did the client have friends and close relationships during the school years? If so, were these individuals alcohol or drug users/abusers?

What work is the client educated to do?

II. Employment

What is the client’s current job or when did the client last work?

What other jobs has the client held?

How often has the client changed jobs?

What is the client’s favorite type of work?

Has the client experienced job difficulties? If so, what seems to be the cause of these problems?

If the client is not working, is he or she obtaining financial support from other sources?

III. Military History (if applicable)

If not currently in the military, what type of discharge did the client receive?

What was the client’s last rank in the military?

What were the client’s patterns of socialization in the military?

How long did the client remain in the military?

If the client experienced problems in the military, were they related to alcohol, other drug use, or other factors?

IV. Medical History

Does the client have current or past medical problems?

Has the client ever been hospitalized for medical problems?

Are past medical records available?

Is the client currently taking medications or has the client taken medications in the past?

Has the client abused prescription or nonprescription drugs?

Are any of the client’s medical problems directly related to or exacerbated by alcohol or other drug use?

Will participation in treatment for alcohol or drug problems require any accommodation for medical disabilities?

V. Drinking and Drug Use History

If the client uses drugs, what drugs does he or she use; if the client drinks alcohol, what beverages does the client drink, and has the client consumed products containing alcohol that are not meant for human consumption?

How often does the client consume alcohol or other drugs?

How much alcohol and/or drugs does the client use?

What is the client’s drinking or drug use pattern (daily, weekend, periodic, etc.)?

When did the client’s drinking or drug use begin?

Does the client give a “reason” for his or her drinking or drug use?

Has the client experienced periods of abstinence?

Has the client experienced blackouts or other indications of chemical abuse problems?

Has the client experienced withdrawal symptoms from alcohol or other drugs?

Has the client ever received treatment for a drinking or other drug problem?

Are past treatment records available?

VI. Psychological or Psychiatric History

Does the client express feelings of being tense, lonely, anxious, depressed, etc.?

Has the client ever contemplated, threatened, or attempted suicide?

Has the client received any counseling or psychiatric treatment on an outpatient basis?

Has the client ever had a psychiatric hospitalization?

Are records of past treatment available to determine the exact nature of the problem and treatment received?

Will participation in treatment for alcohol or drug problems require any accommodation for mental disabilities?

VII. Legal Involvement (if applicable)

Is the client currently on probation or parole or incarcerated?

What types of charges or other legal problems has the client had?

Were any legal charges related to alcohol or other drug use directly (sale, possession) or indirectly (e.g., embezzlement, theft)?

Does the client have any charges pending? If so, what are they, and does the client believe that chemical dependency treatment will result in reduced legal penalties?

If the client was arrested for DWI or DUI, what was his or her blood-alcohol level or are other tests results available indicating the presence of drugs?

VIII. Family History

What are the drinking and drug use habits of members of the client’s family of origin (mother, father, grandparents, siblings, aunts, uncles, etc.)?

Do members of the client’s family of origin have alcohol or other drug problems?

What were the attitudes toward drinking alcohol and other drug use in the client’s family of origin?

How does the client describe his or her relationship with family of origin members?

Was there a history of psychological or physical (including sexual) abuse in the family? What was the client a direct victim?

What is the client’s current relationship with family members?

IX. Relationship with Spouse, Children, and Other Significant Individuals

What is the client’s current marital status and marital history?

If the client has a spouse/partner and/or children, what is the quality of the relationship with them?

What are the spouse/partner’s or children’s drinking and drug-taking habits?

Are the client’s spouse/partner and/or children experiencing problems (psychological or physical abuse, etc.)?

What are the client’s living arrangements?

What is the extent of the client’s other social relationships?

X. Religion/Spirituality

In what religious or spiritual tradition, if any, was the client raised?

Does the client have a particular religious preference or spiritual beliefs at this time?

Does the client view his or her religion or spiritual beliefs as a source of strength or a source of difficulty in his or her life?

XI. Why the Client is Seeking Help Now

(e.g., are there legal, medical, family, work, or other pressures to do so?)

In conducting a social history, the interviewer determines which questions to ask at a given time and the order of the questions. In approaching each section of this social history with the client, the interviewer might begin by commenting not only on the type of information that might be gathered but also on the reasons for gathering it. Often, the social history starts with information considered to be least threatening to the client. The sections on education and employment may be good starting points. Basic questions about how much education the client has had and whether the client has professional or vocational education are generally considered routine and are usually easily answered by clients without resistance.

Education

School adjustment may be a useful avenue to explore, especially for younger clients, as it may be particularly relevant to their current situation. With older clients, the interviewer may ask whether he or she liked school, did well, and fit in, or if school was a frustrating or unsatisfactory experience. Did the client initiate alcohol and/or other drug use or abuse in primary or secondary school or in college? Were his or her friends involved in alcohol and drug use in the same way? These questions may help establish the time frame and circumstances during which alcohol or drug use first became a problem. If the client has no high school diploma or no college or vocational education and wishes to pursue further education, the chemical dependency professional may note the client’s need for a referral to a general equivalency diploma (GED) program or other educational or vocational program. If the client did well in school and has substantial education, these may be noted as assets to recovery.

Employment

Questions about employment often follow logically after questions about education. Is the client currently employed and is the client’s job secure or has it been threatened by substance abuse or dependence? During assessment interviews, individuals (such as those referred by an employee assistance program or by the correctional system) may deny employment problems related to alcohol or drug use. The pattern of employment—whether it is stable or erratic—is important to note. An erratic employment history is not necessarily the result of a substance use disorder, but it may be an indication of it or other problems in the client’s life. Discussion of employment may provide an opportunity for the assessment specialist to help clients identify how alcohol or drug use has negatively affected their work.

Another clue to problems may be the client’s employment in a job that is well below his or her educational level. For example, an individual with a graduate degree may be working in a convenience store. Perhaps this work is what the individual prefers, perhaps this is the only work available, or perhaps a substance use disorder has interfered with other employment. Seeming incongruities in the individual’s life such as these can be explored to help determine if substance abuse or dependence is a problem.

The client may have a job that is an obstacle to recovery. An obvious example is working as a bartender, where constant exposure to alcohol presents a problem for the client. Or perhaps the individual spends long periods on the road alone and is used to going to bars at night to relieve loneliness or boredom. Some clients frequently find themselves in situations where alcohol or perhaps other drug use is common or expected. For some of these individuals, learning how to engage in alternative activities or assertiveness training to learn how to refuse drinks or drugs may prove useful. For others, a key to attaining sobriety may include employment changes. A referral to a vocational rehabilitation agency, an employment counselor, or an employment agency may be appropriate. These referrals may be made at the time of the intake or assessment interview or at a later date, depending on the client’s circumstances.

Some clients are in immediate need of a job. Professionals who work with clients who are homeless or living in very impoverished circumstances generally know the street corners or programs in town where a client can try to get a day labor job, or they know employers who hire and pay individuals by the day. The professional’s interest in the whole client, not just the client’s substance abuse or dependency problem, is reflected in addressing employment concerns. Productive employment can be a useful tool in maintaining sobriety. For some clients, current employment may be identified as an asset. For example, an individual referred by an employee assistance program may have a job that he or she is anxious to keep. The interviewer may also ask questions about work hours or work habits to determine whether the client is currently working to the detriment of other aspects of his or her life.

When clients are not working, it may be appropriate to inquire about their current means of support. They may be receiving public assistance or Social Security payments, or they may need a referral to apply for these benefits. Some clients may be getting help from family or friends, or they may be dealing drugs or engaging in other criminal activity to support themselves.

Military History

Questions about military service are often not asked unless the client is currently in the service or is in a Veterans Administration facility. However, these questions may be important, because young adults may be introduced to alcohol and other drugs while in the military. A problematic military history may have been the result of alcohol or drug problems. Questions that might be asked to probe into this area involve the rank or ranks the client held in the military and the type of discharge the individual received. For example, being demoted in rank or receiving a medical, general, administrative, or dishonorable discharge may have been a consequence of alcohol or drug problems.

Medical History

An obvious reason that questions about medical problems are asked is to determine if they may be related to substance use. The client may not have made a connection between his or her medical problems (e.g., sores, gastritis, or neuropathy) and alcohol or other drug use. Some medical problems are not caused by substance use, but alcohol and drug use may be contraindicated if the client has a particular condition(e.g., diabetes or epilepsy). Another reason to ask these questions is to determine if the client is receiving appropriate care for any current conditions. If the client does not have personal resources to obtain medical attention, the interviewer may act as a referral source to community clinics, the local health department, or other services, although many communities lack the resources to provide anything but emergency medical care to those who do not have health insurance.

Also important are any prescribed or over-the-counter (OTC) medications the client is taking. Some clients are taking medication but do not understand what it is, only that the doctor told them to take it. Many are unaware of the adverse consequences that alcohol can have when combined with common OTC medications such as ibuprofen, acetaminophen, and aspirin, or the additive effects of combining alcohol with other sedative drugs (Weatherman & Crabb, 1999) or the contraindications of combining illicit drugs with OTCs or prescribed medications.

An important reason health questions are asked, especially in inpatient and residential programs, is for staff to be prepared if the client experiences medical problems. For example, a history of epilepsy would be of concern in order for staff to be prepared for seizures, and it is important to know if a history of seizures is related to epilepsy or to alcohol or drug withdrawal. There is a growing body of literature on those who are dually diagnosed with chemical dependency problems and major physical disabilities (see Chapter 13).

A release or consent form signed by the client is generally needed to obtain information about prior health history and medical treatment. This information should be requested if it would be useful in assisting the client in the chemical dependency treatment setting.

Legal History

Questions about the client’s legal problems are also important. Many referrals to chemical dependency treatment programs are motivated by the legal system. A brush with the law may help the client confront a chemical dependency problem, or a client may seek treatment in the hope of obtaining a lighter or deferred sentence. Probation and parole officers and attorneys frequently refer clients to chemical dependency programs. The courts may routinely require those convicted of a driving while intoxicated (DWI) or DUI offense to submit to a screening or assessment to determine whether they have an alcohol or drug problem.

Often, a client admits to getting into legal difficulties as a result of using alcohol or drugs but denies an inability to control alcohol or other drug use. An important clue to a drinking problem in these cases may be blood-alcohol level (BAL) or blood-alcohol content (BAC).A breathalyzer or intoxilizer is frequently used to measure BAL or BAC, typically following arrest on suspicion of DWI or DUI. A high level maybe an indication of tolerance to alcohol or alcohol dependence. For example, a person with a 0.20 percent BAL may deny a problem, but 0.20 is at least twice what is commonly referred to as the “legal limit” of 0.08 in most states. Most people would be unable to drive at a 0.20 level, yet those with a high tolerance may be able to do so despite its recklessness.

Asking how much alcohol was consumed before the arrest may be another clue to the client’s candidness in responding to questions. When an individual says she had two cocktails but her BAL is 0.20, something is amiss. Two cocktails (of the type typically served in a bar) would not produce such a high BAL. Sometimes a blood test is used to determine BAL or the presence of other drugs. In accidents where a person is seriously injured and is taken to the hospital, the use of a blood test is common. Previous DWI or DUI arrests or other history of alcohol- or drug-related arrests are also strong clues to consider. Most people would not make the mistake of getting a second DWI or DUI because the consequences can be severe. The person with an unrecognized problem is far more likely to make this costly misjudgment.

Other common types of alcohol- and drug-related arrests are public intoxication (in locations where this offense is still a crime), disorderly conduct, and offenses related to the possession and sale of controlled substances. Transients who have chemical dependency problems are frequently arrested for vagrancy. Arrests for family violence may be due to alcohol abuse. White-collar crime, such as embezzlement and forgery, may also result from having a drug habit. With the advent of drug screening in the workplace, urinalysis, previously used most by the criminal justice system and in therapeutic communities, has become an increasingly common tool to identify job applicants or employees who use illicit drugs.

Clients may bring other legal problems to the interviewer’s attention, such as fears that past behavior may result in prosecution if discovered. Other legal matters worrying clients may be how to deal with an abusive partner or civil matters such as eviction, child custody, and child support. Referrals to legal services may help clients address these problems so that they can better avail themselves of treatment.

Drinking and Drug History

Naturally, the individual’s drinking and drug history are paramount in conducting an assessment for substance use disorders. What psychoactive substances has the client used in his or her life? What drug or drugs is the individual currently using, including frequency and amount of use? Many clients have problems related to alcohol and drugs or more than one drug. Clients may also be asked if they have ingested technical products that contain alcohol but are not meant for human consumption (e.g., rubbing alcohol, after-shave lotion, Sterno, etc.) or sniffed or inhaled other household products (e.g., paint, glue, etc.). What problems has the individual experienced as a direct result of alcohol or other drug use, such as blackouts or violent behavior or withdrawal symptoms like tremors, seizures, hallucinations, or delirium tremens?

In obtaining information from or about clients who are not detoxified, it is especially helpful to know about previous withdrawal symptoms that the client has experienced. Such information may indicate the need for immediate referral to a detoxification program and can be very helpful to the medical staff assisting the client through withdrawal. The client may be intoxicated or otherwise unable to provide this information, and others who know the information may not be available. This is frequently the case when a transient individual is brought to a hospital emergency department or to a community detoxification center (see Chapter 6).

It is also important to know if the individual has made attempts to stop using alcohol or other drugs in the past and if he or she has had periods of abstinence (no alcohol or drug use, often referred to as “sober time” or being “clean”). These periods may also indicate that the individual is an alcohol or drug abuser, since others usually do not need to make special efforts at abstinence. Periods of abstinence should be considered an asset, and the chemical dependency counselor can discuss with the individual behaviors or circumstances that may have contributed to the ability to remain alcohol or drug free. Another question is whether the client has had previous treatment for alcohol or other drug problems. The client may be asked to give consent to obtain treatment records or to talk with previous treatment providers in order to provide a better understanding of his or her progress and setbacks in treatment. Information of this nature may also be helpful in determining whether the client is best served in an inpatient, residential, or outpatient chemical dependency treatment program.

A possible avenue to explore is whether the individual perceives that his or her alcohol or drug problems were precipitated by particular events or circumstances. This may seem like an unusual question since no one really knows what causes substance use disorders. Asking the question is not done to give the client an opportunity to place blame on some internal or external factor. It is done to understand better the client’s own perception of his or her substance abuse or dependence. This is a reflection of the principle of “starting where the client is.” Many clients need help in understanding the dynamics of chemical abuse and dependence. Remember the client mentioned earlier who blamed his drinking on a divorce that occurred ten years ago? He may be correct in identifying that drinking or other drug use escalated at that point, but he is probably incorrect if he thinks that reuniting with his former spouse will solve the problem. The professional taking the social history may make note, however, that this will be an important point to which to return with the client. Additionally, knowing events that generally precede episodes in which the client drinks or uses drugs may help to establish plans that can avert relapse (see Chapter 6 regarding relapse).

Psychological or Psychiatric History

Psychological or psychiatric history is yet another aspect of diagnosis and assessment. Does the client have one or more mental disorders? Of immediate concern are current and serious psychological or psychiatric problems the client is experiencing, especially thoughts or plans related to suicide. Some individuals, particularly those who have made past suicide attempts or are dependent on depressant drugs such as alcohol, are at high risk for suicide. An immediate referral for psychiatric evaluation or to an inpatient psychiatric unit may be needed. Some clients with chemical dependency problems have serious mental disorders such as schizophrenia, or they may have personality disorders or other mental illnesses (also see Chapter 13).

If adequate information on psychiatric history is not available and mental health problems are suspected, a psychological or psychiatric evaluation should be obtained. An accurate diagnosis is necessary to determine the range of services the client needs and who may best treat the client. A referral to a mental health program or, where available, a program specifically for those with co-occurring chemical dependency and mental disorders may be the best alternative. Individuals with co-occurring disorders may also be directed to mutual-help or other support groups designed specifically for them.

Family History

The family history section of the assessment refers to the client’s family of origin. These questions should probably be asked after some rapport has been established because they can be particularly emotionally charged for the client. Many people who become dependent on alcohol have a parent who was dependent on alcohol (this may even be the case for both parents). It has also become more common to see families with intergenerational drug problems. If so, it is useful to know whether the client’s parent is (or was) in recovery and, if so, at what point in the client’s life this happened. Do other family members (such as siblings, aunts, uncles, and grandparents) have drinking or drug problems?

Other useful information concerns family attitudes about alcohol and drug use. Was there an intolerant attitude toward any use of alcohol? Were drinking or drug use seen as acceptable, and how was abuse of these substances viewed? To what extent were family attitudes related to particular cultural or religious beliefs (also see Chapter 11)? Knowing whether there was a history of psychiatric or other problems among family members may also be helpful in understanding the client’s situation.

Questions about the client’s current relationship with members of his or her family of origin are also important. Is the client in contact with other family members or estranged from them? Are family members seen as potentially supportive of the client’s recovery, or might they present obstacles by reinforcing or encouraging the client’s alcohol or other drug use? It may be appropriate to consider involving family members in the client’s treatment. How much the client is asked to reveal about his or her family of origin will depend on the treatment setting and its purpose. In a brief detoxification program, medical history is more important than family history. In an intensive inpatient or extended outpatient treatment setting, the social history may delve further into family matters.

Not so long ago, chemical dependency professionals were unlikely to ask clients questions about previous physical, sexual, and emotional abuse inflicted on them by family members or others. However, as professionals began hearing about this from clients, particularly women, it could not continue to be overlooked. These problems may surface during treatment and can present serious obstacles to recovery if not addressed appropriately. The topic of physical, sexual, and psychological abuse may or may not be broached in the initial assessment interview, depending on professional judgment. Unless the client offers this information, it may be premature to do so because it may be too distressing for the client to address very early in the process of alcohol or drug treatment. These problems may be better addressed once a relationship between client and professional has developed, and they may require referral to a qualified mental health practitioner.

Current Family and Social Relationships

Other vital questions concern the client’s relationship to any current or former spouse, other partners, or children. If the client’s sexual orientation is not clear, the professional should take care not to make an erroneous assumption about the gender of the client’s partner (also see Chapter 12 on gay men, lesbians, and bisexual and transgendered individuals). How do the client’s significant others perceive his or her drinking or drug use? Are they aware that the client has come for help? Are they similarly engaged in alcohol or drug use, or have they pushed the client to contact the treatment program? Including significant others in the treatment process can be helpful for all parties involved. The interviewer should explore whether significant others are likely to be supportive and inquire as to whether the client wishes to involve them in treatment. Clients are often encouraged to include them, though in some cases it is not advisable (e.g., when there are concerns about retaliation from an abusive partner). In other cases, the client may be threatened with an unwanted separation or divorce, and his or her partner may wish to sever all ties rather than participate in treatment. Sometimes, child abuse or neglect becomes apparent or is suspected, or threats on a partner’s life are made and may have to be reported in keeping with state statute or the “duty to warn.”

Stable living arrangements make the process of becoming alcohol and drug free easier, but some clients have no suitable home or are living with others who have active substance use disorders. Professionals in the alcohol and drug rehabilitation fields have always worked with individuals who are drifters or find themselves with no roof over their heads. Deinstitutionalization of people with mental illness, unemployment, and lack of affordable housing in addition to alcohol and drug disorders have added to the ranks of people who need housing or residential treatment in order to make rehabilitation a viable option.

Questions about close friends, other social relationships, and involvement with organizations and associations also help to determine the extent of social supports the client has in the community. Many clients need assistance in establishing friendships with sober or “clean” individuals and with pursuing activities not centered on alcohol and drug use.

Religion and Spirituality

Religious affiliation and spiritual beliefs are addressed to determine if they may be an avenue of support and strength for the client or if they are causing the client difficulty. Some clients find solace in their religious and spiritual beliefs, and their priest, minister, rabbi, or other clergy member may be a resource to whom they turn in times of crisis. Church groups may also be of assistance to the client in recovery. In other cases, the church or religious group in which the individual has participated over the course of his or her life may hold punitive attitudes toward people with alcohol problems that have contributed to the client’s guilt or denial. Clients may also feel that if only their faith was stronger, they could overcome their problem with alcohol or drugs, and do not take other steps needed for recovery.

The role of religion and spirituality in the recovery process has become an area of empirical study. Clients who do not subscribe to a particular religion may have deeply held spiritual beliefs. More treatment providers are including the religious or spiritual dimension in the client assessment and treatment process (see Hodge, 2001).

Why the Individual Is Seeking Services

Finally, if it is not clear why the individual is seeking services at this particular time, the interviewer may want to inquire about this. Many clients have abused psychoactive drugs for a long time but have not previously sought help. Is there some particular concern, such as threat of job loss, divorce, or legal consequences, that has motivated the individual to seek help at this time? Or perhaps, as the saying goes, the individual is just “sick and tired of being sick and tired.”

Initial appointments or assessment interviews may be done free of charge even by private-for-profit treatment programs as a way of encouraging people to consider some type of treatment or to encourage use of a particular program. For clients who want further services, the initial appointment usually also involves determining whether the individual has insurance or another means of paying for treatment. If the client does not have the financial resources required by the program or needs services the program does not offer, professionalism generally requires that a referral to another resource be offered.

Denial, Resistance, and Motivation for Recovery

It is probably impossible to work in a substance abuse or treatment program without hearing the terms denial and resistance during the course of the workday. Tarter, Alterman, and Edwards (1984) describe the ways in which the term denial has been used in the chemical dependency field:

Denial ... has frequently been used to explain an alcoholic’s failure to recognize the role of his feelings in instigating and sustaining drinking. Denial has also long been believed to reflect a conscious refusal by an alcoholic to recognize the effects of continued and excessive drinking on himself and his environment, thereby contributing to the alcoholic’s resistance to initiating treatment, as well as ensuring poor treatment prognosis. Within the rubric of psychodynamic theory, denial has been conceptualized as an ego defense, and as such is considered to be indicative of an unconscious attempt by an alcoholic to protect himself from the threatening or aversive aspects of drinking behavior. (pp. 214–215)

As a largely unconscious process, denial differs from lying or an outright attempt at deceit (George, 1990). Tarter and colleagues (1984) propose a biopsychological interpretation of denial, suggesting that some alcoholics have a “disturbed arousal regulation process” in which they fail “to perceive or label internal cues accurately” (pp. 214–215; also see Donovan, 1988). This causes them to underestimate the severity of stress in their lives, thereby promoting denial.

Everyone employs defense mechanisms to cope with life’s stresses and strains. For example, news of the death of a family member or that one has a serious illness may be initially met with denial (see Kinney, 1996). In these cases, denial initially serves a protective function until the individual can begin to integrate the event and move along to the next stages of the grief process. Clearly, it is necessary to utilize some level of defenses in order to maintain healthy psychological functioning, but when one is unable to move past denial, well-being is jeopardized. This is frequently the case with the individual who has a substance abuse or dependence problem. As Weinberg (1986) puts it:

Denial is a way the human mind often deals with a situation involving incompatible perceptions, thoughts, or behaviors. In the case of drinking problems, the two elements are the powerful reinforcement derived from the drug and the unwanted side effects produced at the same time. The former is comprised of positive reinforcement (euphoria and energy) and/or negative reinforcement (temporary reduction of such unwanted feelings as tension, depression, self-hate, boredom, and sexual inadequacy). (p. 367)

Another function of denial is to shield substance abusers from feelings of hopelessness (George, 1990). Kinney (1996) notes that many patients are actually unaware that their problems are a result of substance abuse.

Weinberg (1986) and Kinney (2000) recommend helping clients reduce their denial gradually, since it is serving an important, protective function. A critical task of the treatment professional is to help clients recognize the relationship between their drug use and its negative consequences. To facilitate this process with cocaine abusers, Washton (1989) developed the Cocaine Assessment Profile (CAP), which can be useful in assessment and in addressing denial. The CAP questions about drug use and its consequences help clients understand the magnitude of their substance abuse and the need for treatment.

Family members and other loved ones are also likely to engage in denial. It is equally painful for them to recognize that someone they care about is chemically dependent. They may blame themselves for the client’s problem or they may just be plain embarrassed about the situation. Consequently, people with alcohol and drug problems and their significant others reinforce each other’s denial. In a well-known pamphlet published by Al-Anon (1969), Reverend Joseph L. Kellerman likened the process of denial to being on a merry-go-round, but he noted that “the alcoholic cannot keep the Merry-Go-Round going unless the others [family, friends, employers, etc.] ride it with him and help him keep it going” (p. 13). When more than one member of the family is chemically dependent, denial can be especially strong.

In addition to denial, clients and their significant others may use a variety of other defenses. These include rationalization (attempts to find reasons to explain or excuse the chemical use), projection (blaming or attacking others for problems), avoidance or evasion of discussions of chemical use, recollection of the positive effects and experiences associated with chemical use, minimization of chemical use and its effects, and repression of painful events and feelings (George, 1990; Johnson, 1973). But George notes that “denial is a more prominent approach, because it blocks the need for the use of the other defense mechanisms entirely” (p. 36). It is also important to remember that the individual’s defensiveness may result in behaving in grandiose, aggressive, and belligerent ways when often his or her feelings, especially during periods of sobriety, are actually remorse, guilt, inferiority, and helplessness.

Just as clients vary in their expression of denial and other defenses, they also vary in the extent to which they enter treatment voluntarily. Individuals who call a 24-hour crisis line asking for help with a drug problem or those who walk into a treatment program are generally considered voluntary clients. Of course, external factors may have motivated them to request help—for example, fear that their marriage or their work is suffering. Less voluntary clients may be those who have been committed or ordered to treatment through civil procedures (these laws and procedures vary by state). In these cases, family members or others have appealed to the court because the individual has refused to seek help and is in serious danger due to alcohol or other drug use. Other clients have been referred through their employer because their jobs are at stake, or their probation officer has told them to get help. These clients may recognize the problem and may participate willingly in treatment. Others may attend simply to remain employed or to fulfill the terms of their court order. Even so, there is ample evidence that some degree of pressure or coercion may be helpful in prompting treatment entry and promoting better client outcomes (Burke & Gregoire, 2007; Center for Substance Abuse Treatment, 2005; Hiller, Knight, Broome, & Simpson, 1998; Leukefeld & Tims, 1992; National Institute on Drug Abuse [NIDA], 2009; Perron & Bright, 2008; Trice & Beyer, 1982).

Clearly, individuals differ in their willingness or ability to terminate substance use and desire to engage in the treatment process. It may take some time for treatment providers to develop rapport with clients and to help them work through their defenses, but clients who come to counseling sessions or stay in halfway houses or therapeutic communities and never engage in the treatment process may be told that there is nothing more that the treatment program can do for them at this time.

Many individuals make an initial appointment at a treatment program to satisfy others but are not seeking long-term services. Following the assessment interview, they may thank the interviewer, saying they now understand the problem and are sure they can quit or control alcohol or other drug use on their own. Sometimes a brief intervention can help problem drinkers reduce their drinking (see chapter 6). But many individuals have substance use disorders that are more serious than a brief intervention can address. Even so, unless the individual is in an immediate life-threatening situation, treatment providers cannot force someone to receive services. Some professionals object to the idea that a client would be pressured or coerced at all. Treatment providers generally consider their services voluntary, even if a client is under a civil court order or a parole or probation officer requires them to attend.

If an individual appears to have an alcohol or drug problem but resists treatment, the assessment specialist may encourage him or her to attend an educational program, a few individual or group counseling sessions, or some meetings of a mutual- help group before rejecting the notion of treatment entirely. If none of these alternatives is accepted, the professional should be supportive of the individual for his or her willingness to come in at all, being sure to leave the door open should he or she want to return later. Sometimes individuals are willing to make an agreement with the assessment specialist—if they are unable to stay clean or sober, use more than specified amounts of alcohol or drugs during a given time period, or encounter negative consequences of alcohol or drug use, they will concede that they cannot control their use, and they agree to re-contact the assessment specialist for treatment. This approach sometimes works in helping individuals identify alcohol and drug problems, especially those who are certain that they can control their use. Some chemical dependency specialists may use more direct approaches, depending on the client and the situation, but there is a growing interest today in less confrontational and more supportive approaches, such as those described in Box 5.1 called The Motivation to Change.

Finally, it may be useful to remember that labeling a client unmotivated or resistant to treatment may be unfair or unwarranted. There is a great deal experts do not know about how to treat substance use disorders. Some individuals are able to maintain sobriety or stay “clean” only after dozens of detox admissions. Others try hard but never achieve long periods of clean and sober time. The types of approaches available to treat substance abuse and dependence are relatively limited. Professionals rely heavily on cognitive-and behavior-based strategies, though there is increasing evidence of a genetic component to chemical dependence. There may be many types of alcoholism and drug addiction, each with its own complex etiology. In sum, clinicians do not yet have the tools to treat all individuals successfully, and this, rather than lack of client motivation, may be at the heart of why so many struggle with recovery.

Ethics of Chemical Dependency Treatment

Ethical dilemmas arise each day in the chemical dependency field that warrant professionals’ careful attention (see Taleff, 2010). The professional organizations and licensing and certification bodies that represent social workers, psychologists, chemical dependency counselors, and other human service professionals generally have codes of ethics to which members are expected to subscribe. For example, the code of ethics of NAADAC, the Association for Addiction Professionals (2011), covers areas such as the counseling relationship, confidentiality, cultural diversity, supervision and consultation, and policy and political involvement. According to this code, NAADAC members should provide clients “only that level and length of care that is necessary and acceptable.” Members governed by the code are encouraged to be proactive in seeing that individuals and groups of all ethnic and social backgrounds have access to treatment. The code also addresses factors such as culture or disability that require consideration in working with clients. Members of other human service professions are bound by similar codes of ethics.

BOX 5.1 The Motivation to Change

Most people want to change something about themselves. They might want to study harder, spend more time with loved ones, lose weight, exercise more, reduce drinking, or stop smoking or using other drugs. Many won’t make substantial changes in these areas. They may think about it or they may try, while others will be only marginally aware that a problem even exists.

What makes people change is an important question in psychotherapeutic treatment. When it comes to alcohol and other drug problems, some people think that a serious crisis must occur before a person develops sufficient motivation to change. Others contend that professionals can intervene before a client “hits bottom” and help motivate him or her to change.

Stages of Change

Prochaska, DiClemente, and Norcross (1992) have devoted a great deal of study to the process of change—the type that is made on one’s own and the type that takes place in the psychotherapeutic process. They believe that a series of stages typifies the change process in both types of situations, regardless of the behavior the individual wishes to change (also see Prochaska & DiClemente, 1982). Much of their initial research was done with smokers. Considerable research on the model has also been conducted with people who have alcohol and other drug problems (see, for example, Connors, Donovan, & DiClemente, 2001). They call their model transtheoretical because they believe it is compatible with a wide range of treatments. The five stages of change they identified are:

Precontemplation, in “which there is no intention to change in the foreseeable future” and people may be “unaware or underaware of their problems.”

Contemplation, “in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action” (in this stage, the pros and cons of the problem and solution are weighed).

Preparation, in which individuals intend “to take action in the next month.”

Action, in which individuals have successfully modified their situation “from one day to six months.”

Maintenance, in which people continue to change and prevent relapse. (Prochaska et al., 1992, pp. 1103–1104)

Prochaska and colleagues note that change is generally not a linear progression through these five stages but often involves reverting to an earlier stage before additional progress is made. Although some people may remain stuck at the first or second stage, the researchers note that individuals usually learn something at each point and generally do not regress completely. The techniques that will be successful with clients depend on the stage at which they are.

Just how does one move from one stage to the next, and how can treatment providers facilitate this process? Table 5.2 indicates the processes that seem to facilitate movement between stages.

Motivation, Not Confrontation

Miller and Rollnick (1991, 2002; Miller, 1999) also address the process of change in their work on motivational interviewing: Motivational interviewing is a particular way to help people recognize and do something about their present or potential problems. It is particularly useful with people who are reluctant to change and ambivalent about changing. It is intended to help resolve ambivalence and to get a person moving along the path to change. (Miller & Rollnick, 1991, p. 52)

TABLE 5.2 The Right Change Process at the Right Time: What Helps Clients Move from Here to There?

Stage of change

Precontemplation to contemplation Contemplation to preparation Preparation to action Action to maintenance Staying in maintenance

Most relevant change processes

Consciousness raising

Dramatic relief

Self-reevaluation

Environmental reevaluation

Self-reevaluation

Environmental reevaluation

Social liberation

Self-liberation

Stimulus control

Counter-conditioning

Helping relationships

Self-liberation

Stimulus control

Counter-conditioning

Helping relationships

Reinforcement management

Helping relationships

Self-liberation

Stimulus control

Counter-conditioning

Helping relationships

Reinforcement management

Social liberation

Experiential Processes

Consciousness raising: Individual gains knowledge about him/herself and his/her behavior through discussion, reading, etc.

Dramatic relief: Individual experiences and expresses feelings about the problem and solutions through grieving losses, role playing, etc., or may have a significant emotional experience related to the problem.

Self-reevaluation: Individual recognizes how a current behavior conflicts with his/her goals and values(values clarification).

Environmental reevaluation: Individual recognizes effects his/her behavior has on others and his/her environment through empathy training, other processes.

Self-liberation: Individual decides to make commitment to change often with specific goals; may share decision with others and ask for their support.

Behavioral Processes

Stimulus control: Individual avoids or counters stimuli (“triggers”) that elicit problem behavior through restructuring environment (e.g., avoiding bars), avoiding high risk cues (e.g., arguments), etc.

Counter-conditioning: Individual substitutes healthy behaviors for problem behavior using relaxation, desensitization, assertion, positive self-statements, etc.

Helping relationships: Individual utilizes therapeutic alliance (open, trusting relationship), social support, mutual-help groups to discuss/address problem.

Reinforcement management: Individual rewards self or is rewarded (directly or indirectly) by others for making changes.

Social liberation: Individual works for changes in society through policies/political action, advocating for rights of oppressed, empowerment.

Sources: Based on tables in “In Search of How People Change” by James Prochalska from American Psychologist, vol. 7, # 9, Sept 1992 and from Mary Marden Velasquez et al., Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual, Table, 1.1., p. 10. Guilford Press (2001). Used by permission.

Miller and Rollnick stress the importance of the therapist’s role in the treatment process, saying that therapists have widely varying success rates with clients. They advocate the use of non-possessive warmth, genuineness, and particularly accurate empathy (reflective listening, rather than identification with the client, as described by noted psychotherapist Carl Rogers [1959]), and they see accurate empathy as much more productive than confrontation. Miller and Rollnick also consider reasons that alcohol and drug treatment providers have used confrontation. For example, myths developed that alcoholics and drug abusers were especially defensive and that leaders in the field of addiction treatment advocated confrontation to break down those defenses. Miller and Rollnick call both these ideas erroneous. Denial, they contend, is not more characteristic of alcoholics than of others; it is a normative reaction in the face of strong confrontation. In addition, neither Vernon Johnson (1973), who developed the technique called “The Intervention” (see Chapter 10 of this text), nor the Minnesota Model nor Alcoholics Anonymous (see Chapter 6) advocate heavy, aggressive confrontation. Education of helping professionals generally does not include aggressive or authoritarian confrontation. Table 5.3 describes the “spirit” of motivational interviewing and contrasts it with an opposite approach to counseling, and Table 5.4 describes the four general principles of motivational interviewing.

TABLE 5.3 The Spirit of Motivational Interviewing

Fundamental Approach of Motivational Interviewing Mirror Image Opposite Approach to Counseling

Collaboration. Counseling involves a partnership that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change. Confrontation. Counseling involves overriding the client’s impaired perspectives by imposing awareness and acceptance of “reality” that the client cannot see or will not admit.

Evocation. The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals, and values. Education. The client is presumed to lack key knowledge, insight, and/or skills that are necessary for change to occur. The counselor seeks to address these deficits by providing the requisite enlightenment.

Autonomy. The counselor affirms the client’s right and capacity for self-direction and facilitates informed choice. Authority. The counselor tells the client what he or she must do.

Source: From MOTIVATIONAL INTERVIEWING, 2/e, by William R. Miller and Stephen Rollnick. Used by permission of Guilford Press.

Change and a Systems Approach

The models we have reviewed rely primarily on individual factors to promote change. Using a social work perspective, Barber (1995) recommends a holistic or systems model to address addictions because it better captures “the role of supply-side and demand-side drug prevention policies (mesosystem) or the (sub)cultural (exosystem) factors surrounding the overuse of certain drugs. If only because drug use is not randomly distributed within society, sociocultural factors, such as socioeconomic deprivation, norms, and anomie, must have explanatory and predictive utility” (p. 44) in our work with people who experience alcohol and drug problems.

Barber believes that his model focuses more on what can be done to promote change among precontemplators, such as the use of environmental strategies. Thus, the text you are reading considers not only pharmacological interventions and psychosocial interventions with individuals, families, and groups, but it also considers cultural perspectives (see Chapters 11 and 12), prevention strategies (see Chapter 7), and policy approaches (see Chapter 8) that might affect alcohol and other drug problems.

TABLE 5.4 Principles of Motivational Interviewing

Principle 1.

Express empathy:

Acceptance facilitates change.

Skillful reflective listening is fundamental.

Ambivalence is normal.

Principle 2.

Develop discrepancy:

The client rather than the counselor presents the arguments for change.

Change is motivated by a perceived discrepancy between present behavior and important goals or values.

Principle 3.

Roll with resistance:

Avoid arguing for change.

Resistance is not directly opposed.

New perspectives are invited but not opposed.

The client is a primary resource in finding answers and solutions.

Resistance is a signal to respond differently.

Principle 4.

Support self-efficacy:

A person’s belief in the possibility of change is an important motivator.

The client, not the counselor, is responsible for choosing and carrying out change.

The counselor’s own belief in the person’s ability to change becomes a self-fulfilling prophecy.

Source: From MOTIVATIONAL INTERVIEWING, 2/e, by William R. Miller and Stephen Rollnick. Used by permission of Guilford Press.

Human service professionals are expected to represent their credentials fairly, to treat clients only within their areas of expertise, and to make referrals when needed. Licensing and certification boards generally require that members participate in continuing education in order to keep their knowledge and skills current.

Perhaps the most frequent complaint filed with licensure and certification boards is that professionals have violated professional ethics by engaging in sexual relationships with current or former clients. Professionals should also not provide services to individuals with whom they have had prior sexual relationships. There are also taboos against other dual relationships with clients, such as not engaging with them in business ventures and other activities for profit.

Another issue that arises in the human service professions (and that has special import in the fields of chemical dependency and mental illness) is that of impaired professionals (Bissell & Royce, 1994) since a substantial number of chemical dependency professionals are themselves in recovery. Codes of ethics require that professionals address their own problems when these issues might prove to be detrimental to clients. Some professional organizations have peer-assistance programs that help professionals obtain treatment for such problems. When a professional does not take steps to rectify his or her own problems, colleagues who are aware of these problems may be obligated to report them to the appropriate licensing or certification authority. For professionals who are also in recovery, another issue is whether or how much information to disclose to clients about their own status as a recovering individual. Some professionals refrain from revealing this personal information. There is no absolute way to handle such disclosure, and the professional may address it on a case-by-case basis, especially if clients ask about it directly.

Respect for client confidences is an important aspect of the codes of ethics of human service professionals. Professionals working in alcohol and drug programs should be aware of the portion of the Federal Register called “Confidentiality of Alcohol and Drug Abuse Patient Records” (42 CFR, Part 2) as well as the Health Insurance Portability and Accountability Act (HIPAA). Generally 42CFR is more restrictive than HIPAA and was intended to provide strong protections for client confidentiality in order to encourage people to seek treatment (see Brooks, 2004, for information on legal aspects of confidentiality). Chemical dependency professionals need to know this information to protect their clients and themselves. We describe some of its major points and discuss other issues relevant to confidentiality. These comments are no substitute for good legal counsel and are meant only to suggest some of the issues in the field.

Without an individual’s written permission, treatment providers are usually prohibited from revealing whether or not the person is a patient or client in a chemical dependency treatment facility or any other information about the individual or his or her treatment. Providing information to those outside the treatment program and requesting information from other sources generally require the client’s written permission. A client’s written authorization to release information must state the name of the agency, program, or individual requesting the information; the agency, program, or individual from which the information is requested; the type of information that the client wishes to be provided; the purpose for which the information will be used; the date the release is signed and the date on which the release expires; and the client’s signature and a witness’s signature as proof of permission.

As noted earlier, staff may wish to obtain certain types of information, such as medical or psychological information, that may help them better serve the client. A consent or release-of-information form is also required for the staff to communicate with the client’s spouse or other loved ones, since it should not be assumed that these individuals know that the client is receiving treatment or that the client wants the staff to communicate with them. Professional conduct also suggests that information about the client not be shared or discussed with other staff in the facility, unless they have a need to know this information to serve the client or in cases where a consultation is needed. Clients should be informed of the extent to which staff may need to share information with each other.

Sometimes a client requests that the treatment program give information to others. For example, a client may want his employer to know that he is attending treatment, or a client may be anxious for her probation officer to hear that she is making progress in treatment.

Exceptions to the right to confidentiality should be explained to the client. For example, under certain circumstances, treatment records of alcohol and drug abuse patients may be subject to subpoenas or court orders. Attempts may be made to subpoena records in cases where there are criminal charges against the client, in child custody cases, and under other circumstances. The issue of what to record in clients’ charts or files is an important one. Many helping professionals do not enjoy privileged communication with their clients; that is, they may be ordered by the courts to provide information even about matters not contained in the client’s case record. When a professional thinks that releasing information would not be appropriate, he or she should be given an opportunity to explain that to the court so that the court can decide the matter.

In a medical emergency, information necessary to save the client’s life may be released. If the individual may be harmful to himself or herself, such as in the case of a client with a plan to commit suicide, the professional usually has a responsibility to seek protection for the client through an appropriate mental health referral. Sometimes this involves asking the local mental health crisis team or law enforcement agency that handles these problems to intervene. If a client threatens serious harm to another, there may be a “duty to warn” and the professional may be liable for injury sustained if appropriate steps are not taken. Child abuse and neglect must be reported according to state statutes. State laws may also require reporting of elder abuse and other crimes. Knowledge of state and federal law is thus necessary in the chemical dependency field.

Chemical dependency researchers may be afforded special confidentiality protections by obtaining a certificate of confidentiality from a federal agency such as NIAAA or NIDA. The certificate covers information obtained for research (not treatment) purposes only, but it does not provide an exemption from reporting child abuse and neglect. The certificate is particularly useful when subjects are asked about substance use or illegal activity (e.g., illicit drug use or crimes committed); since it is designed to protect researchers from having to release such information in any type of court (administrative, civil, criminal, etc.). The research must be legitimate, but the federal government or other external source does not have to fund the research for it to qualify for a certificate of confidentiality.

Legal issues arise more frequently than ever in the chemical dependency field, as they do in most fields, yet the appropriate responses are not always clear. Questions about what procedures to follow if law enforcement officers arrive at the door with an arrest warrant for a client or a subpoena for a file are not unusual. Good legal counsel is important—so is education about legal matters, since staff may be pressed to respond quickly.

Legal obligations are not always synonymous with ethical obligations. For example, a state may not have a legal “duty to warn,” but a professional may feel morally obligated to do so. The highest calling may be to one’s own ethical standards, but that may result in legal repercussions, such as being held in contempt of court for not releasing information if there is a proper court order to do so.

Referrals

Human service professionals of all types and in virtually all settings encounter individuals with substance use disorders and their loved ones. From elementary and secondary schools to the child welfare agency to the workplace to the nursing home, substance use disorders appear. Although social workers, psychologists, and other human service professionals should be prepared to screen for these problems, they may not be qualified to diagnose and treat them. When this is the case, a referral for further assessment or services is indicated. Some agencies—for example, family service agencies—may be able to provide these services in house. In other cases, knowing the local alcohol and drug abuse treatment agencies, their purposes, and their staff members can facilitate a referral. For example, a child protective services worker suspects that a child neglect case is due to alcohol abuse, but he needs a confirmatory diagnosis to help the mother get treatment so that she can retain custody of her children. Knowing the woman’s limited financial resources, he refers her to a community mental health center with a substance abuse treatment component. An adult protective services worker contacts an inpatient chemical dependency treatment to assist with a client whose dependence on alcohol and benzodiazepines is preventing her from living independently. Or a parole officer makes sure a bed in a therapeutic community for offenders with chemical dependency problems will be available before a parolee who is addicted to heroin is released from prison.

Chemical dependency professionals not only accept referrals, they also make referrals to other agencies. As indicated in the discussion of assessment, clients with alcohol or other drug dependence often need additional services, such as vocational guidance, parent education, medical care, public assistance, and legal assistance. Keeping abreast of the services available in the community and developing cooperative working relationships with those who provide them are important professional responsibilities. Some agencies, such as the local offices of the state vocational rehabilitation agency, may designate a particular counselor or counselors to work with clients who have alcohol or other drug problems, or counselors may have general caseloads that include clients with substance use disorders. Informal knowledge of staff of other agencies that are most favorably disposed to working with clients who have substance use disorders can be a big help, and it usually does not take long to learn who these individuals are.

Making a referral on which the client follows through can involve more than writing a name and a phone number on a piece of paper. No one wants to act as an enabler (in the negative sense of the word) or increase a client’s dependency. However, informing the client of the referral’s purpose and what the referral source may or may not be able to do, calling ahead for a client, and letting the client know specifically for whom to ask can be helpful. Clients who have mental or physical disabilities in addition to alcohol and drug problems may need extra support or assistance. This may mean providing transportation, accompanying them to the referral agency, or helping them complete application forms and compile necessary information. Clients who are desocialized or particularly unassertive may also benefit from someone to accompany them until they can develop the skills to negotiate these situations themselves.

Additional obstacles, such as lack of child care and language barriers, may also need to be addressed before a client can take advantage of referrals. In making referrals for health care, it is particularly helpful to know if the client has traditional private health insurance; belongs to a health maintenance organization (HMO) or other managed-care program; receives Medicaid or Medicare; has another type of coverage; or is entitled to services from the U.S. Department of Veterans Affairs.

Many professionals also refer clients to mutual-help groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) (see Chapter 6), but making these referrals is different. These groups do not have a staff of professional human service workers, and arrangements for clients generally cannot be made in advance. Anonymity of mutual-help group members is stressed, so there is no list of members’ names and telephone numbers. The professional can give the client a list of meeting times or a website address or encourage the client to call the group for information. Some mutual-help groups have telephone lines that are staffed 24 hours a day; others have 24-hour answering services. Some have limited hours when telephones are staffed, and they may use a recording to give callers information or allow them to leave messages at other times.

Providing a list of meetings is not necessarily an effective way of encouraging clients to visit mutual-help groups. Many individuals do get to their first meetings on their own, but clients are frequently hesitant to go to a group about which they know very little. Professionals can make the process considerably easier. One way is to educate clients about what to expect in advance.

Some professionals “wear two hats”—they are human service professionals and they are members of mutual-help groups. Initially, they might accompany clients to a meeting or two (perhaps a meeting they usually do not attend) and explain what “working” a mutual-help program is about. Professionals who are not members of these groups may assist by accompanying the client to an open meeting, where those who are not “alcoholics” or “addicts” are welcome.

Many communities have a number of mutual-help groups. Even professionals who are recovering from alcohol or drug problems do not attend all the groups in their community. Some groups are only for men or only for women, some are for Spanish speakers, some are for nurses and doctors, and some are for gay men or lesbians. It is not possible for someone who wears two hats to fit in all the groups that his or her clients might need. Neither is it healthy for counselors to fill all these roles for clients. It may blur the professional-personal boundary in ways that raise ethical concerns. Professionals also do not have time to fill this function for all their clients, and clients can benefit from widening the circle of recovering individuals they know. “Twelve-step work” refers to the desire of AA and NA members to take the message of these programs to others. It may be more effective for professionals to maintain contact with recovering individuals in the community who wish to assist newcomers to the many mutual-help groups that have emerged for individuals who have alcohol and drug problems. Clients may be more likely to follow through on a referral when arrangements have been made for someone to accompany them to a meeting or they have been in contact with a member.

There are also mutual-help groups for loved ones (spouses, partners, children, and other family members and friends), such as Al-Anon and Naranon. Similar procedures can be used to make referrals to these groups. Mutual-help groups regard themselves as strictly voluntary programs. Many do allow the secretary of the group to sign slips of paper so that attendees can verify their presence at the meeting if the courts or probation or parole officers require this.

Chapter 5 Screening, Diagnosis, Assessment, and Referral

This chapter presents a systems or biopsychosocial ap

proach to determining whether an

individual has a chemical abuse or dependency problem. The first steps in this approach are

screening and diagnosis. The chapter also considers the extension of this process, called

assessment, to examine the client’s needs

further. A thorough assessment is generally

needed to develop a treatment plan and to make referrals to appropriate resources.

Some individuals with alcohol and drug problems experience medical emergencies

(intentional overdoses, accidental alcohol or dr

ug poisoning, pancreatitis, delirium tremens,

seizures, etc.) that require immediate attention. Social workers, psychologists, and other

human service professionals should know what these emergencies are, but these problems

can be diagnosed and treated onl

y by qualified medical personnel. This chapter focuses

primarily on the work of helping professionals once such medical crises have been resolved

or when a client is seen by a helping professional before these medical complications arise.

We begin by disc

ussing screening, which may be defined as the use of rapid assessment

instruments and other tools to determine the likelihood that an individual has a chemical

abuse or chemical dependency problem. In practice, much screening is informal and is not

done wi

th structured or standardized instruments. For example, after reviewing a parolee’s

“rap sheet” containing repeated alcohol

-

or drug

-

related arrests, a parole officer may feel that

is all the screening necessary for referring the client to a chemical depen

dency treatment

program or insisting on participation in a mutual

-

help group as a condition of parole.

Diagnosis is the confirmation of a chemical abuse or dependency problem based on

established clinical criteria. The diagnostic process generally involve

s an interview with the

patient or client and often includes information from other sources such as a medical

examination, including laboratory tests, and previous medical, psychological or psychiatric,

criminal, school, and other records. Consultation wit

h other professionals might also be used

as is information from collaterals (e.g., family) who know the patient or client well.

The term assessment is sometimes used synonymously with the term diagnosis, but we

use it to mean an in

-

depth consideration of

the client’s chemical abuse or dependency

problems as they have affected his or her psychological well

-

being, social circumstances

(including interpersonal relationships), financial status, employment or education, health, and

so forth. This process also i

ncludes consideration of the individual’s strengths and resources

that may be assets in treatment and recovery. Going beyond a confirmatory diagnosis, this

type of multidimensional or biopsychosocial assessment provides the basis for treatment

planning.

T

he cornerstones of screening, diagnosis, and assessment are knowledge of substance

use disorders and good interviewing skills, including the ability to establish some level of

rapport with clients in a relatively brief period. Denial is a pervasive issue i

n work with clients

who have alcohol and drug problems. Helping professionals must frequently work with clients

and their significant others to reduce defensiveness and resistance; thus, this chapter

addresses these topics. The assurance of confidentiality

in treatment and research settings

Chapter 5 Screening, Diagnosis, Assessment, and Referral

This chapter presents a systems or biopsychosocial approach to determining whether an

individual has a chemical abuse or dependency problem. The first steps in this approach are

screening and diagnosis. The chapter also considers the extension of this process, called

assessment, to examine the client’s needs further. A thorough assessment is generally

needed to develop a treatment plan and to make referrals to appropriate resources.

Some individuals with alcohol and drug problems experience medical emergencies

(intentional overdoses, accidental alcohol or drug poisoning, pancreatitis, delirium tremens,

seizures, etc.) that require immediate attention. Social workers, psychologists, and other

human service professionals should know what these emergencies are, but these problems

can be diagnosed and treated only by qualified medical personnel. This chapter focuses

primarily on the work of helping professionals once such medical crises have been resolved

or when a client is seen by a helping professional before these medical complications arise.

We begin by discussing screening, which may be defined as the use of rapid assessment

instruments and other tools to determine the likelihood that an individual has a chemical

abuse or chemical dependency problem. In practice, much screening is informal and is not

done with structured or standardized instruments. For example, after reviewing a parolee’s

“rap sheet” containing repeated alcohol- or drug-related arrests, a parole officer may feel that

is all the screening necessary for referring the client to a chemical dependency treatment

program or insisting on participation in a mutual-help group as a condition of parole.

Diagnosis is the confirmation of a chemical abuse or dependency problem based on

established clinical criteria. The diagnostic process generally involves an interview with the

patient or client and often includes information from other sources such as a medical

examination, including laboratory tests, and previous medical, psychological or psychiatric,

criminal, school, and other records. Consultation with other professionals might also be used

as is information from collaterals (e.g., family) who know the patient or client well.

The term assessment is sometimes used synonymously with the term diagnosis, but we

use it to mean an in-depth consideration of the client’s chemical abuse or dependency

problems as they have affected his or her psychological well-being, social circumstances

(including interpersonal relationships), financial status, employment or education, health, and

so forth. This process also includes consideration of the individual’s strengths and resources

that may be assets in treatment and recovery. Going beyond a confirmatory diagnosis, this

type of multidimensional or biopsychosocial assessment provides the basis for treatment

planning.

The cornerstones of screening, diagnosis, and assessment are knowledge of substance

use disorders and good interviewing skills, including the ability to establish some level of

rapport with clients in a relatively brief period. Denial is a pervasive issue in work with clients

who have alcohol and drug problems. Helping professionals must frequently work with clients

and their significant others to reduce defensiveness and resistance; thus, this chapter

addresses these topics. The assurance of confidentiality in treatment and research settings