Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
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Chapter 10--Assessment
Chapter 10--Assessment
Pages 242-278
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From page 242... ...
determining treatment outcome. Considering assessment, matching, and outcome determination in separate chapters is an arbitrary division of material for the purposes of discussion.
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From page 243... ...
Otherwise, any changes subsequent to treatment cannot be compared with the individual's pretreatment status. Some persons coming for treatment, for example, will have high alcohol consumption levels, and others will not.
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Thus, in one study, half again as many individuals seeking help for alcohol problems appeared in treatment after receiving a comprehensive assessment compared with those who were not assessed (Annie and Skinner, 1984~. In another study, 95 percent of a random sample of such individuals who were given an assessment battery returned for their second appointment, compared with only 56 percent of those who were not given the assessment (Sutherland et al., 1985~.
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From page 245... ...
Some of these problems may be the result of alcohol consumption; some may result in drinking (for example, for symptomatic relief) ; still others may be independent problems.
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A turbulent social context may entirely negate any attempts at individual treatment and may need to be directly addressed as the initial order of business. Individuals with problematic family or home situations or both are unlikely to sustain participation in outpatient treatment programs (H.
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Comparable data from all treatment programs would be invaluable in revealing which segments of the community were being served and in planning further services for those who are not entering existing programs. Planning Treatment for the Individual , , , ~.
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In future, it is to be hoped that the self-image of persons seeking treatment could be determined in advance, and that only those with positive self-images would be assigned to "attacks therapy. In other words, assessment prier to treat forms the basis on which individual patients are matched to particular treatment programs.
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From page 249... ...
In fact, treatment programs offering different treatments could assemble around -- a shared clinical data base and use the information contained in it to guide the selection of treatment for all individuals presenting to the programs collectively (see Chapter 13~. For this proposal to be feasible, however, a comprehensive pretreatment assessment must be an integral part of the clinical process.
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Ideally, both the screening stage and the problem assessment stage are uniform in their content for all persons seeking treatment. Such uniformity is desirable because all such persons may or may not have alcohol problems.
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The second stage comprises the problem assessment, that is, the characterization of the alcohol problem that screening has indicated is present. The third stage is the personal assessment stage, in which the nature of the individual who is experiencing the problem is fully and uniquely characterized; the emphasis in this stage is on areas in which personal problems are being experienced.
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From page 252... ...
Such a history would include information as to the time in life the individual began to drink and the length and circumstances of periods of nonuse, as well as the pattern of use over the last few years prior to seeking treatment. Thus, an adequate assessment of an individual's use of alcohol would include information on the level of use, the pattern of use, and the history of use.
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of patients in different treatment programs could readily be established. If the treatment provided then proved to be effective, it would be much more securely known for whom the treatment was effective.
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As has already been indicated, however, assessment itself is not commonly carried out in treatment programs. Even in research studies, which explicitly aim at widespread generalizability, characterization of the alcohol problem is often incomplete.
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whether an alcohol problem is present and (2) if so, whether it is likely to require brief intervention or specialized treatment.
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Additional information may be needed to gauge the prognosis, to assist in matching individuals to appropriate treatment, to determine whether prevalent comorbidities are present, to help plan living and working circumstances, to understand certain etiologic possibilities, and for other purposes. There may be some overlap between information gathered as part of the personal assessment and information gathered as part of the problem assessment when the consequences of alcohol use are being considered.
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The use of tobacco arid other drugs by persons seeking help for alcohol problems is another area of personal assessment that should be surveyed as a matter of routine rather than on the basis of contingent screening. Available data suggest that the correlations between use of alcohol and use of tobacco and other drugs are regularly impressive.
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Rather, in keeping with the assessment goal of obtaining treatment-relevant information, the intent is to identify personality factors or patterns that may affect in a significant way which treatment programs individuals are likely to find suitable and which they are likely to reject. Certain pathological personality types, especially antisocial personality but also borderline personality, have been found to have prognostic value in this regard (Schuckit, 1973; Vaillant, 1983; Nace et al., 1986; Cloninger, 1987~.
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Screening I Problem Is an alcohol Alcohol Clinical Index identification problem present? CAGE AUDIT Others II Indicated Is specialist Alcohol Clinical Index response treatment required?
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Related to but different from life events are situationalfactors. These tend to be more complex constellations of individuals, feelings, and circumstances than are life events, but may also be closely related to individual variations in alcohol consumption.
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comprehensive and at least nartlv uniform assessment across all programs. Desirable Qualities of Assessment Content To be as useful as possible, the information gathered on individuals seeking treatment for alcohol problems should possess certain qualities.
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Persons with elevated blood alcohol levels tend characteristically to underreport their alcohol consumption (M.
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, hypothetical patient profiles were constructed from actual patient data and were submitted to three groups of staff for disposition. One staff group was not connected with any particular treatment program but ordinarily made dispositional decisions on court-referred cases to a variety of treatment programs.
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, five individuals were carefully trained to give histories about their use of alcohol and their concerns about that use; the levels of use and concern chosen by the investigators, although not negligible, did not objectively indicate either the presence of serious alcohol problems or a need for inpatient treatment. Each of these individuals then presented himself or herself to six local agencies that were selected on the basis of their aggressive recruitment practices.
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From page 265... ...
Cross-referral probably does exist, but the rate of cross-referral may not be high. If the purpose of assessment is to provide objective data to serve as a basis for the appropriate referral of those seeking treatment to the variety of treatment programs that are available, the foregoing information is not encouraging.
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From page 266... ...
The arrangement could also provide built-in safeguards such as the regular and independent monitoring of disposition patterns and structural provision for cross-referral to other treatment programs. Methods of Obtaining Assessment Information In providing assessment information, individuals seeking treatment may interact with an interviewer, with a questionnaire or other assessment instrument, or with a suitably programmed computer.
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From page 267... ...
Much of the information gathered during an assessment is of a sensitive nature, and the neutrality of test instruments or of computers may be advantageous in obtaining it. In one study, patients with alcohol problems reported higher levels of alcohol consumption to a computer, lower levels to a psychiatrist, and still lower levels to a higher status psychiatrist (Lucas et al., 1977~; both medical status and senior status apparently were intimidating.
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interview, which measures past lifetime alcohol consumption. Its reliability has been examined (L.
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.._ lo The nrnhlPm assessment stage is highly multidimensional (see Table 10-2~. Finally, assessment should be uniform to a significant degree for all persons seeking treatment, so that data from different subjects can be pooled and data from different programs can be compared.
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British Journal of Addiction 81:23-46.
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1978. Evaluating alcoholism treatment programs: An integrated approach.
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Saint Paul, Minn.: Chemical Abuse/Addiction Treatment Outcome Registry (CATOR) , Ramsey Clinic.
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1987. The Cleveland Admission, Discharge, and Transfer Criteria: Model for Chemical Dependency Treatment Programs.
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1990. Problems associated with average alcohol consumption and frequency of intoxication in a medical population.
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1987. The utility of self-report and biological measures of alcohol consumption in alcoholism treatment outcome studies.
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1987. World Health Organization Collaborative Project on Identification and Treatment of Persons with Harmful Alcohol Consumption: Report on Phase I Development of a Screening Instrument.
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1988. Executive summary: The assessment setting: Should assessment/referral centers be independent of treatment programs?
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Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Wilkinson, D
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