Assessment Strategies for Substance Use Disorders

Abstract

The assessment of substance use disorders is a process of acquiring and synthesizing information on the impact of psychoactive substance use on the lives of consumers of human services. The process of assessment involves developing a productive therapeutic alliance with consumers in order to engage them in treatment and to develop an understanding of the role substances play in a person’s life across multiple psychosocial domains. Assessment must also include the development of an understanding of how consumers conceptualize their own substance use and their readiness to change substance use behaviors. Information gathered from the assessment is then synthesized into a collaborative plan of action designed to meet the short- and long-term goals as identified by the consumer. This chapter includes an overview of how co-occurring substance use disorders and serious mental illness impact the assessment process and outlines the five common components of a substance use assessment: screening, diagnosis, psychosocial assessment, functional analysis, and assessing readiness for change. The development of stage appropriate treatment plans based on assessment information using an illustrative case study is also provided.

Appendices

Appendix I Case Study: Jessica

Jessica, a 30-year-old Caucasian woman has been referred to your team for treatment by local law enforcement for assessment and treatment for mental illness and substance abuse.

Jessica is a bright, engaging, and humorous individual. Jessica likes to be in nature. She has enjoyed cycling and meditation in the past. She also enjoys reading and writing poetry. In college she was a business major until she dropped out in her junior year. She refers to this as, “my biggest mistake.” She has dreamed of finishing her degree and going into marketing someday, as she states, “when I’m not such a nutcase.” At this point she says, “I just want to get my life somewhat stable so I can work a little and keep an apartment and not kill myself or anyone else.”

Jessica has been diagnosed with major depressive disorder. When she is depressed she often sleeps all day, refuses to see anyone, does not eat and becomes suicidal. Jessica has attempted suicide several times in the past Jessica states, “When I go through one of those periods my life is blown to pieces. The darkness comes and I go under. It’s like I’m trying to keep my head above water in the darkest, scariest place on earth and there is no one there to save you. It swallows you up.”

Jessica states that she began using cocaine when she was 20. By the time she was 24 she was using it every day and needing more and more of it to get high. She states that she has been in rehab for cocaine at least four times. She states that she often stops using for a while, but then starts back up. Once she starts using it is hard for her to stop. She states, “it (cocaine) takes over my life. I can’t think about anything else but getting high.” In the past year, she has lost 2 entry level jobs and has been forced to move twice due to her aggressive behavior and substance use. She states, “when I binge I don’t show up to work, there’s a lot of traffic in and out of my house and I tend to get a bit wild. That’s when I lose my job or get thrown out of apartments.” Currently, she has a studio apartment. She is not employed at the moment and is living off of some savings, support from parents and her small unemployment check from her last job which will run out in 1 month. Jessica’s short-term goals are that she wants to find a job in order to pay her rent. Jessica had not used cocaine for the past 2 months. She has also reduced her alcohol intake, drinking only one or two drinks every other week during this time. During this time she has been steadily looking for work and has not had any problems with her landlord or the legal system. However, last 2 weeks Jessica has missed her appointments with you and did not call to cancel or reschedule. Today, Jessica shows up at your office without an appointment asking if she can see you for a session. She looks very tired and unkempt which is also unlike Jessica. Having a gap in your schedule you accommodate her request. The following is a description of the clinical interaction.

Clinician	Jessica, I’m glad to see you. I hadn’t seen you in a while and was getting concerned. How have things been going lately?
Jessica	I used cocaine a bunch of times last week.
Clinician	You used cocaine last week?
Jessica	Yeah. I was out with friends at a bar. After the bar closed we went over to someone’s house and out came the cocaine. I turned them down at first, but everyone was having such a good time and they kept asking me if I wanted any and what was wrong with me, and c’mon party with us and blah, blah, blah and after a while I just said the hell with it and before I knew it I was using.
Clinician	So you refused their offers at first, but they were persistent and you ended up using. What did you say to them when you refused?
Jessica	I just said something like, “Oh, I’m not really feeling like it right now.” Which was a total lie. I wanted to get high—real bad. Everyone was just having a good time and I was feeling so lousy for so long that I just wanted to feel good for once. I thought I would be fine at first. I knew there was going to be coke where I was going, but I was feeling so good just to be out of the house and hanging out with people that I didn’t want the night to end. I didn’t want to go back to that apartment so I thought, “Well, I got two months clean—that should be enough to get me through this. I’ll just say ‘no’ and that’s it.” Well, that didn’t work so good.
Clinician	So on the one hand you didn’t want to use at first and you thought that if it was there you could handle it. You just wanted to hang out with your friends. But on the other hand, when the coke came out you had a craving to use that was pretty strong and you ended up wanting it and using it. Is that right?
Jessica	Yeah, that’s about right. Once the stuff came out, everyone was just using and after awhile I just wanted to join in and be a part of it and feel good. I didn’t go there to use. I went there to hang out. I just got swept up. I should’ve known better—me being a screw-up, junkie and all.
Clinician	So, tell me what happened next?
Jessica	Once the coke was gone I went home. Crashed the whole next day and felt worse than I had before I went out. Right back in the hole. And now I just blew two months of sobriety so I was feeling like, “Fuck it-why bother, you know?” “It’s always going to be this way.” I called my friend up and we scored some cocaine and some weed and went back to my apartment and got high again. The next day, crashed again. Then I really started to want to get high. I knew I was headed down that bad road again. So I said, I gotta get some help and I went to a couple of (NA) meetings. That was two days ago and now here I am. I haven’t used since then. I really don’t know what I want at this point. I just know I don’t want to fall all the way back this time.
Clinician	Jessica, it takes lot of strength to recognize the situation you were in and take action. I don’t think you’re giving yourself enough credit for that and I want to make sure you know that I’m proud of you for recognizing the situation for what it was and seeking out help. And I’m glad you’re here and that you’re OK. You wouldn’t have been able to do this a year ago. You mentioned a couple of times that you felt pretty lousy for a while before you used cocaine and that you didn’t want to leave the party and go back to your apartment. Could you tell me about what was going on before the first time you used cocaine? Before you went to the bar—what was going on in your life?
Jessica	At first I was just really, really sad, you know? Sleeping all day. No showering. “Who cares?,” you know. I can’t find a job. I’m alone. It started with feeling sad and then I just shut myself off from the world and when I’m alone with myself for a long time. It gets pretty ugly.
Clinician	So things weren’t going well for you and you got really depressed and you didn’t know how to get out of it. What were you thinking?
Jessica	Well, after a while the voices started yapping. You know, from my past. “You’re a piece of shit.” And “You’re ugly.” “You’re a whore.” “No one loves you.” “You should just die; You’re never going to be anything.” Oh, what else? “You’re a loser.” “You’re a junkie.” “Die. Die. Die.” It wasn’t the worse I’ve been. But it was pretty bad. Couldn’t sleep at night. Slept all day. Stopped eating after awhile. And then—Chain smoking. Cable TV. Soda. Sleep. Repeat. And then after a while I just didn’t really feel anything. Just zombied out.
Therapist	So it sounds like you started thinking a lot of really negative thoughts about yourself and this led to having trouble sleeping and just having a real hard time all around. It must have been awful. So, what did you do?
Jessica	I had a couple of drinks.
Therapist	You started drinking. And what happened?
Jessica	I started to feel better. I slept a bit. I felt less sad. I know what you’re thinking, but, booze isn’t my problem. I’m not a drunk like my father. I’m a junkie. Cocaine is my problem. Drinking and weed? I can take them or leave them. And sometimes they help me feel better. So after I drank a few beers I actually felt kind a good for the first time in over a week. I didn’t want to kill myself. I felt like I wanted to see people and have a good time and so I called my friends, maybe the wrong ones, and asked them to go out. We went out and I felt alive for awhile and you know the rest. Say what you want—but if it wasn’t for the cocaine—I could have been alright.

Appendix II Case Study Analysis: Jessica

The case of Jessica demonstrates a person with a number of strengths and who has survived a great deal and who has clear and important dreams. It is also clear that Jessica struggles with major depressive disorder and addiction. Jessica’s cocaine addiction meets the criteria for Cocaine Dependence. She exhibits an extreme loss of psychological control that is the hallmark of this disorder. Jessica experiences physical and psychological cravings, spends a lot of time and money using substances, has unsuccessfully tried to cut down on her use, and engages in risky and unhealthy behaviors when using. It is unclear if Jessica experiences the physical characteristics of tolerance or withdrawal.

Jessica’s alcohol use is also a concern due to her major depressive disorder. Alcohol, a depressant, can exacerbate depressive symptoms. Given the severity of her depressive symptoms and cocaine addiction, even moderate alcohol use can lead to significant consequences. As can be seen in the vignette, but may not be clear to Jessica at this point, is her attempts to cope with her depressive symptoms by using alcohol actually places her at risk of cocaine use relapse and probably increases her depressive symptoms over the long run despite giving her relief in the short term. Jessica’s statements indicate that she is most likely in precontemplation regarding her alcohol use. In regard to Jessica’s cocaine use, she is most likely in preparation or (early) action stage. She is motivated to stop use and has made attempts to do so. The fact that she came to the clinician’s office despite feeling ashamed indicates a strong therapeutic bond and engagement.

Jessica’s long-term dream is to return to school, finish her degree, and work in marketing. That is where treatment planning starts. The clinical goal will be to build a ladder to that dream through the achievement of short-term goals. The fuel to this process will be repeated affirmation, support, and celebration of successes. It is clear in Jessica’s speech that she lacks hope and self-efficacy. One of the clinician’s tasks is to build up Jessica’s hope and self-efficacy through practical and emotional support. However, Jessica’s immediate needs are to find employment, meet the requirements of her probation, and to regain her footing in her battle with cocaine addiction. Achieving both the short- and long-term goals must involve a conversation about Jessica’s cocaine and alcohol use.

The threat of negative legal consequences is relevant since she is on probation. However, as can be seen, Jessica’s addiction is powerful enough to override her fear of legal repercussion from her probation officer if she were to fail a drug test. One negative consequence that Jessica discussed is her sense of shame and despair over losing control over her use. This may be an area to tap into through open and honest discussion and may be a motivating factor in helping Jessica prevent future relapses. It is clear the Jessica could benefit greatly from the development of skills such as substance refusal skills, identifying triggers for relapse and craving management as well as ways to prevent relapse such as developing healthier recreational activities. Jessica could also benefit greatly from psychoeducation that would help her understand how her substance use and mental illness interact. The use of medication-assisted treatments to reduce her cravings may also be effective and relevant here. Equally important would be cognitive behavioral approaches designed to help her manage negative thoughts about herself and to cope with fears of loneliness that often accompanies sobriety by helping her develop sober supports either through self-help and/or reengaging in pleasurable activities.

Since Jessica is in precontemplation regarding her alcohol use, a treatment planning goal in this area may be simply to discuss her alcohol use for a few minutes each session and monitor her use. Psychoeducation may also be an option given her psychiatric symptoms (Mueser et al., 2003). An analysis of her recent relapse through motivational interviewing techniques may help to increase Jessica’s ambivalence about her alcohol use. However, providing ways to relieve her depressive symptoms either through medication and/or other wellness activities are needed to replace the use of alcohol as a coping response.