Conducting Assessments of Drinking/Substance Use

A reader contacted me asking my thoughts on conducting assessment and which instruments I might recommend...good topic and question, although I may not have “the” answer...I do have an opinion and a couple thoughts...

I find the BASICS (Brief Alcohol Screening and Intervention with College Students) approach to provide the best “assessment.” Although it does not yield a “likelihood” of a particular pathology or individual scales that can be indicative of co-occurring issues like the SASSI (Substance Abuse Subtle Screening Inventory), its opportunity to provide genuine feedback in a “what do you think” manner open more conversations and ultimate referrals than other “instruments.” That said, I do like the ASI (Addiction Severity Index) as it is relatively non-invasive when administered by a trained practitioner and its results tie in nicely with the development of a formal treatment plan, although it is something of a bear to administer and can take time. It is also not likely that a pre-contemplative or even a contemplative (early stage of readiness to change) client will be very helpful/compliant in completing the ASI.

I have found that the old standards work quite well too – MAST, CAGE, etc. — but I have modified their use. Instead of ask the questions associated with these screening tools, I answer them for the client after having invited the client to share his/her story. This “narrative” approach accomplished 2 things: (1) it recognizes that clients are “more willing to share their stories” with someone willing to listen than to “tell an ‘interrogator’ their business” and, (2) I can always answer questions like the closed-ended MAST or CAGE based on a history in which the client has addressed these “areas” in response to individual open-ended questions intended to facilitate conversation. Coincidentally, by the time I have listened to a client’s story, perhaps through 2 sessions, I have often earned my “street creds” that enable me to provide the feedback, including an interpretation of the MAST and CAGE without having the client, “up and run.”

Almost as an aside, how one looks at assessments is as important a determinant affecting outcome as is what is done during the assessment. For example, if I am interested in uncovering pathology and categorizing problems, I will approach the individual with whom I am working in a different manner than if I am interested in encouraging that individual to look at the “facts” in his or her life from a different perspective in order to better answer the basic question, “Is what I am getting worth what I have to pay to get it.” The “old objective” suggests that it is “me,” the practitioner, who needs to know what is really going on with a client so that I can then “fix the problem.” This works well when the ‘patient’ has shoulder problems and a diagnosis of a torn rotator cuff is made and a surgical intervention is planned to fix the problem. Such an approach, I believe, is not quite so well suited to interacting with a substance using individual in order to “address the drug problem.”

We know from the literature and research done on Motivational Interviewing that the old “you have a problem and I know this because of these diagnostic symptoms and this is how you can fix it” approach does not work well...as a matter of fact this results in counseling being more about “wrestling” with clients than “dancing” with them to borrow from Wm. Miller’s metaphor. If I approach assessment as not so much the pursuit of what “I need” to “fix your problem,” but rather a process by which I invite the individual to consider the facts related to personal use in such as to more accurately answer the question, “is what you get worth what it costs you to get it,” then the outcome can be much different. It is something akin to the City Slicker’s experience in this old “Pa and Pa Kettle” movie clip from the 40s – see http://www.youtube.com/watch?v=yG7vq0EMvgE In the clip Ma & Pa argue their position much like individuals with no intention of changing behavior argue theirs, in other words, like many collegians when approached about their drinking...I do not need to change because you are wrong in your assertion that a problem exists. If the goal of counseling is to show the client the errors of his or her way, then this is a contest where someone can only win by someone else losing. Traditional assessment tools often facilitate this “battle of the wills” approach to addressing questions related to drinking “problems.”

To summarize, we professional counselors have to assess client needs before attempting to treat them. But the onus is on us to determine why we are doing this. If it is so I know if John or Mary has problem “X” or not, that may yield an entirely different result—mind you, not necessarily “wrong,” just different—than if my quest is to invite John and Mary to looks at the facts in their lives from a different perspective. Remember Sandra Anise Barnes’ quote, “It’s so hard when I have to, and so easy when I want to.” It is like someone living in Boston considering how to get to Philadelphia...is I-95 always (ever?) the best way? The answer is, “it depends.” If the assessment process helps us better articulate the variables that affect the admonition, “it depends,” I submit that the assessment process will be beneficial. If, however, the assessment is to stockpile facts and evidence to prove why the client is wrong or quantify “the problem,” I am not so sure the result is the same.

What do you think?