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Drug and alcohol assessments are performed to determine the intended patient’s needs, severity rating, and required level of care. Many factors go into a drug and alcohol assessment, some of the most critical being direct questioning while addressing the information provided by the substance user. In other words, drug and alcohol assessment comes down to honesty, consistency, and addressing discrepancies. Is the substance user giving information that is true, false, or in between? Unfortunately, the one performing the assessment can only work with what they’re told. An effective assessment will come from a seasoned assessor who can see discrepancies between the substance user’s story and the facts and then challenge them if necessary.
An example would be an alcohol user reporting little to no alcohol use, no history of alcohol use. When asked about legal issues or pull their criminal history, you find they are on probation and have just received their third DUI. Most assessments are designed to catch discrepancies. Drug and alcohol assessments are as accurate as the substance users’ provided information and the assessor’s ability to catch any discrepancies.
One way to obtain assessment accuracy is by basing the assessment on data from multiple sources, primarily friends and family. The picture the substance user is painting and what the family is saying are two different viewpoints. The same substance users are taking their distorted perception to the assessment alone, without intervention and family feedback. We’re trying to establish that the substance user sees things one way and others see it much differently. So what to expect from a drug and alcohol assessment when it is just the substance user providing the data is often an assessment that is not accurate. Next, the substance user often enters a level of care or is misdiagnosed and not properly treated. Not all substance users do this, and many do. Lack of honesty is another reason why treatment today is not effective. Treatment has moved to let the substance user run the show. Modern-day treatment believes the substance user is the most qualified individual to know their needs. When treatment was the opposite approach, when professionals knew the user was the least qualified to know what their needs were, it was a time when we saw successful outcomes significantly greater than they are today.
What is a Drug and Alcohol Assessment?
As previously stated, a drug and alcohol assessment is designed to determine the needs of the substance user and the severity and level of care. Assessments are often composed of multiple data sources such as current tests and past tests, psychological history, treatment history, mental illness, family, legal, health, social, employment, past and present alcohol and drug use. The goal is to ensure the substance user is placed in the appropriate setting for optimal results. It is important to understand that assessments for drugs and alcohol are ever-evolving as the substance users’ needs, severity, and level of care change throughout their treatment stay. One of the most significant drawbacks of treatment assessments is the focus on external repair needs and addressing the symptoms or loss of things. Assessments greatly lack attention to behaviors and perception; tests do a much better job. It would be helpful to address the causes of the substance use disorder as a primary focus rather than the symptoms or losses that came with it.
Along with current assessment tools, they should include an entire section on accountability to the problem and the solution. When the attention is on needs such as employment, housing, and legal concerns, it should be followed up by asking how the person feels or thinks they lost these things. The answer should have more depth than saying, “Because of drugs and alcohol.” This could help the treatment team understand the substance users’ thoughts when entering treatment. The lesser the accountability and the greater the diversion and finger-pointing, the higher the level of care and the longer the length of stay could be suggested.
Assessments are a good base, and unfortunately, the focus is heavily on addressing the symptoms caused by the behaviors that the person created with the use of drugs and alcohol. Assessments should be used as just that, a base. Clinicians and integrated treatment teams should look well beyond the external needs and symptoms and help the substance use disorder client focus on internal needs. We should be looking at how and why they act behaviorally and how and why it leads to substance use to mask underlying problems that create more problems and symptoms. Unfortunately, most clinicians and treatment centers are held to assessment criteria for treatment planning. They discharge clients with plans to address their symptoms and losses, which is important without question. If they don’t look to why those things happened or why they were lost, then the substance use disorder client will likely come back with many more problems and symptoms. The assessment does not address past childhood experiences, traumas, or emotional states as in-depth as possible. Although this is the job of the treatment team, these are the primary reasons substance users destroy their lives with drugs and alcohol.
What does a Drug and Alcohol Assessment Consist Of?
There are many assessment tools for the evaluation of a substance use disorder. The most common are:
MAST (Michigan Alcohol Screening Test)
The MAST is 25 questions (0-24). Each question has a point value, and the results are determined by:
- 5 points or more would determine the client alcoholic
- 4 points would be considered potential alcoholism
- 3 points or less would consider the person non-alcoholic
CAGE Test (Cut, Annoyed, Guilty, Eye-Opener)
CAGE tests are a personal assessment that focuses questions on:
- Cutting Down
- Annoyed by people concerned about your substance use
- Guilty feelings about your substance use
- Eye-Opener to start your day with substances
ASAM (American Society of Addiction Medicine)
ASAM criteria focus on 6 different dimensions.
The six are:
- Acute Intoxication and Withdrawal
- Bio-Medical Conditions and Complications
- Cognitive, Behavioral, and Emotional Conditions
- Readiness and Motivation
- Relapse, Continued Use, Continued Problem
- Recovery Environment
DSM (Diagnostic Statistical Manual)
This is a manual of mental disorders, including substance use disorders, published by the American Psychiatric Association (APA). The DSM Diagnostic for Substance use disorder is 11 questions used to determine severity. The scores are determined by answering 11 yes-no questions.
- 2-3 is considered Mild
- 4-5 is considered Moderate
- 6 or more is considered Severe
ASI (Addiction Severity Index)
ASI was invented by Thomas McLellan, Ph.D., Deni Carise, Ph.D., and Thomas Coyne, Ed.D. LCSW. Similar to ASAM, the ASI seeks to uncover problems in certain areas. The ASI focuses on two periods of time, The past 30 days and lifetime. The problem areas that are addressed are:
- Employment/Support Status
SBIRT (Screening, Brief Intervention, and Referral to Treatment)
SBIRT is an evidence-based assessment tool used for high-risk populations and those currently using drugs or alcohol at levels of concern. SBIRT is used early on to aid in the prevention of future problems.
The focus of SBIRT is:
- Applying intervention strategies based on behaviors of concern
- Preventing problems such as medical and legal from drug and alcohol use early on
- Avoid future problems
- Reduce health and substance use treatment costs later on
Many more assessment instruments can be used at the discretion of the agency, clinician, or person administering the assessment. All assessments are a base to determine needs, placement, and level of care. Ongoing assessments by the integrated treatment team of the substance use disorder client are necessary to optimize successful treatment outcomes.
Common Steps in Assessments
The first step is the safety and well-being of the intended patient. The person providing the assessment wants to focus on accuracy and use their knowledge and expertise to ensure the substance use disorder client receives the appropriate care and recommendations. The initial assessment may not include medical history and case notes from other professionals. Once the client is stabilized and in the appropriate level of care, the client can sign an ROI (release of information) so that other professionals and agencies can acquire any necessary documentation. This is why the assessment does not stop after intake, it is ever-evolving, and treatment plans change based on ongoing assessments and discoveries. The first step when using ASAM criteria is determining whether or not the intended patient needs detox and stabilization. It is not uncommon for a substance use disorder client to need inpatient detoxification so they can be observed medically during the process. Substances such as alcohol and benzodiazepines can result in seizures and death if not medically supervised. Once this critical determination is made, the client’s treatment team can conduct ongoing assessments to address the client’s needs in other areas.
Assessments are constantly changing based on the client’s progress or lack thereof during treatment. Some of the most productive assessments come from seasoned clinicians who listen and observe their clients’ behavior and speech. Clinicians don’t just want to listen to change talk; they want to see it backed up with action. Ongoing tests such as the NEO, Milan, and Myers-Briggs can help and are often administered after the person has entered treatment.
Other Drug and Alcohol Evaluation Factors
A critical evaluation factor is how many times the substance user has been to treatment. Discussion about what was helpful and what was not can help with an assessment. The number one predictor of outcomes in treatment is the client/counselor relationship. Determining why someone may not be getting what they need could be this relationship and not the actual treatment provided. Studies show that the right counselor can deliver the wrong treatment and still get farther with the client than the right treatment given by the wrong counselor. Although assessment tools do not focus on this, an open discussion with the client during the assessment can be helpful to determine ineffective strategies that have been previously applied.
In addition to drug and alcohol evaluation factors, sometimes tests are performed in the treatment facility. Common tests are the NEO, Millon, and Meyers Briggs. These three tests are described here:
Also known as the NEO PI-R, NEO is a personality test that looks at the following five personality traits:
- Openness to experience
The NEO PI-R is often performed early in treatment and towards the end of treatment. The NEO personality inventory can help clinicians and treatment teams take a deeper dive into the client’s behaviors and personality, something assessment tools lack. The NEO is not only used in substance use disorder treatment but can also be useful in consideration for employment.
Millon Clinical Multiaxial Inventory was designed to work with the Diagnostic Statistical Manual (DSM) published by the American Psychiatric Association (APA).
The Millon focuses on two categories that can uncover ten different personality disorders:
- How the client gains positive and negative reinforcement.
- Determining coping strategies as either active or passive.
Millon uncovers many personality disorders or behaviors that are often present in substance use disorder clients. This is why it is important to offer the Millon and the NEO PI-R upon entering substance abuse treatment and again upon exit. This can help the clinical team determine if and how much of the behaviors were drug or alcohol-induced as opposed to actual mental or personality disorders. It can also help determine if the client’s outlook has changed due to treatment. It would be helpful to retest every three to six months during the first two years of substance use recovery.
Myers-Briggs is a test to determine how people perceive information and make decisions based on the information they receive. Myers Briggs focuses on four dimensions:
- The Focus of Your Attention. Where do you draw your conclusions from? Are you an extrovert, focusing on people and objects, or are you an introvert who focuses on concepts and environment?
- Sensing and Intuition. The score determines if you use your intuition or senses to make decisions.
- Thinking and Feeling. Do you make decisions based on logic or value?
- Judging and Perceiving. Are you organized or spontaneous?
The Myers-Briggs is an excellent tool for substance use disorder clients. Time and time again, we have stressed the importance of understanding behavior as the underlying driving force to substance use. Tests such as these will not cure anyone, and they can certainly help any clinical team better understand their client and how they feel about things, perceive, and process information. Substance use comes with an overwhelming need for external validation and extreme distortion of perception to the point the user thinks their untruths are truths. Changing behavior and perception is an impactful component of substance use recovery.
How Long Will It Take?
If you ask how long an assessment will take, you may not be making the assessment your priority. There are far too many assessment instruments used for far too many scenarios to discuss how long an assessment will take. Some instruments are brief and do not take very long, and others can take much longer. If the goal is to provide accurate data and interact with the assessor, it will take as long as it takes, and the client will most likely be placed in a treatment program with a treatment plan that can provide effective results.
We understand everyone is busy, and knowing what you are getting into and how long you will be assessed is important. When you think about all the time wasted on obtaining and using drugs or alcohol, the time spent at an assessment should not be that big of a concern. The answer to how long an assessment will take is that it takes as long as necessary to help the client get to where they need to be to effectively address their past, present, and future problems.
How Much Does It Cost?
Assessments do not typically cost anything unless it is a DUI assessment that is court-ordered. Most agencies that offer substance use disorder treatment perform the assessment and provide recommendations. Most agencies that perform the assessment can and will consider you for admission after the assessment.
Asking how much an assessment costs is similar to asking how long it will take. If you need a drug or alcohol assessment, the costs are probably the least of your current problems. It is understood that expenditures can be difficult, especially during drug and alcohol use. If the assessment costs a fee, you can look at what you have spent on substances and weigh the value of continuing to spend money on substances or investing in your assessment and entering a treatment program. If there are costs involved with substance use disorder treatment, family and friends can help cover those costs as long as they give the money to the agency and not the substance user.
Courts are increasingly sending people to treatment over incarceration. Many first-time offenders, and sometimes multiple offenders, both with non-violent charges related to substance use, are allowed to choose a court-ordered drug or alcohol program and probation or jail. Most substance users select treatment, but not all do. Most states and counties have their own version of drug court for those who choose treatment. It usually consists of an assessment and evaluation followed by placement and a treatment plan. The assessments are not all that different from an assessment performed at a private or public agency. The biggest difference would be that the courts would be made aware of the assessment outcome and your compliance with treatment recommendations. After a court-ordered assessment, the patient has to complete the treatment recommendations of the assessment and follow discharge instructions successfully. The substance user will most likely be monitored on supervision or probation afterward. This monitoring often comes with random drug and alcohol screens, holding down employment and verifying employment with pay stubs, watching for new arrests or criminal activity, 12-step meeting compliance, and safe and stable housing such as sober living.
Courts have become more open to treatment than jail. They often give multiple chances for crimes related to substance use. They still have their breaking point if the substance user continues to commit crimes or use drugs and alcohol. At some point, courts are left no choice other than incarcerating the substance user. Although jail may not be the best place for substance users, it has been known to keep them and society safe while they are incarcerated. Most families would rather have their loved ones in jail over not knowing where they are or not being with them anymore.
Entering a Treatment Facility
After an assessment and recommendation, the substance user can either follow through with recommendations based on the evaluation or not. Those who follow through and enter treatment are at a much more significant advantage of addressing their substance use disorder. Many make a mistake by not entering treatment or going against the assessment recommendations, taking it upon themselves to figure out what they feel is a better option. Those who decide to surrender and take action by entering treatment will enter detox if required and then follow through with the treatment center curriculum.
What substance users and their families can expect after entering treatment is volatility. Almost no substance user goes to treatment without turbulence at take-off. Detox to drugs and alcohol is short compared to the lifetime of behavior modification and trauma work. The behaviors do not go away when the drugs or alcohol use goes away. For almost every substance user, the behaviors worsen before they get better. When you enter treatment, you are separated from the only coping mechanism you have known. Most have not had any genuine emotions and feelings for a long time. Many react in anger that comes from the fear of how bad things have become. Some will not realize they are in treatment for behaviors, trauma, and perception and only address the symptoms. Once they feel they can better manage their chaos, off they go, onto the next bender. Entering a treatment center for external reasons is OK and certainly is why almost every substance user enters treatment. If the substance user stays in treatment to only address the external problems and does not cross over to staying in treatment for internal reasons, they are often doomed.
One of the best layers of accountability for a substance user is family boundaries when the substance user enters treatment. Most can not manage their addiction on their own resources, and they need help from others. These can be financial, emotional, physical, and mental resources taken from others to support an addiction. Families who take their lives back and educate themselves while holding boundaries, accountability, and consequences when the substance user does not enter treatment, leave treatment, or relapses, see much better outcomes for their recovery and sanity as well as their loved one’s success in addiction recovery.
Family First Intervention has spent significant time and resources creating and fine-tuning our family program. We certainly could have left things the way they were. We could have been like other interventionists and just came into your home to talk your loved one into treatment while providing you a handout of the obvious dos and don’ts of enabling. But we realize the profound effects of family involvement in the recovery process.
Backed by Behavioral Couples Therapy (BCT), an evidence-based treatment, we understand that both sides are affected and need recovery. So much of the substance user’s addiction is kept alive due to the roles a dysfunctional family system plays along with codependency and enabling. We see that the greatest reason people do not enter treatment or leave treatment against medical advice (AMA) is family that keeps providing or goes back to providing comfort and resources for their loved one. When a family learns about addiction and behaviors, they understand the importance and necessity of boundaries, accountability, and consequences. All addiction experts agree that people do not make a change and enter treatment unless they see a need to do so. In other words, as long as it is more comfortable to continue using drugs and alcohol than it would be to stop using drugs and alcohol, chances are the substance user will not enter treatment.
Almost every family we speak with says there is nothing they can do until their loved one wants help or hits bottom. The feedback is, they are correct. The question is not whether or not they have to want help or hit bottom; it is, “What is being done by enablers, dysfunctional family systems, and friends to prevent these things from occurring?” Whether physically enabling or allowing the substance user to roam free while mentally holding you responsible for their problems, the more comfortable a family makes it for them to be victims and not go to treatment the more likely they will not enter treatment. When families are involved in their recovery and the family system shifts back to a healthier group, it is more difficult for the substance user to continue the manipulation and mind games that keep the addiction alive. This is not to say there is a guarantee that the substance user always follows when the family gets better. The family only has control over themselves and how they react to the substance user. The less support the family gives them in any area other than support for treatment, the greater the likelihood they will see the need to make a change and enter treatment. The more recovery a family has, the greater the chances of coming to a place of acceptance and knowing they can only control how they effectively help their loved one.
Help for Your Family and Your Loved One Suffering from Addiction
When a family is ready for change, we can help. A family’s greatest fear is the change and the unknown resulting from an intervention. As tricky as a family’s situation is, it is all they know, and they have acquired a way of coping with the situation. Although these coping skills are maladaptive, they are the norm, and doing something different is scary and risky in the mind of a family member. When we speak with families, you would think they would receive our information as an effective solution that can bring life-changing outcomes. The sad reality is most don’t see it that way. They interpret the intervention as us taking something away from them. This could be several things, and for most, it includes the fear of trying something different.
The same thought process applies to the addict or alcoholic when you think about it. Most know they can’t continue forever, and most want to stop and can’t. For the addict, the drug and alcohol use is giving them something, and the thought of not getting it anymore is terrifying. The addiction is devastating, yet it is all they know, and they have come to rely on the maladaptive coping skills they have acquired during their addiction. Both family and substance users choose inaction as a solution for the same reasons. They both feel that the attempt of change would be worse than staying the same. If this were false, then what are you waiting for?
Family First Intervention can help your family and the substance user start your respective roads of recovery. After all of this time, we know for sure one thing; we have never made a situation worse than it already was. Coincidentally, this is every family’s fear. Families often feel that if they attempt to do something about the addiction, the consequences will be greater than their current experience. This just simply isn’t true. Families have a harder time when their loved one accepts help than when they don’t. Why is this? Sure, they are initially excited, and then the silence sets in. Just like the addict getting worse before getting better when in treatment, the family goes through the same volatility of emotions. Most families and substance users couldn’t imagine a life outside of the chaos they have become accustomed to. Interventions help people through their uncomfortable fears, not to make situations worse. We would be happy to show you the way when you are ready.