Assessment Tools and Techniques
Description
Unit 2 aims to equip participants with the knowledge and skills needed to carry out comprehensive assessments of illicit substance addiction. Participants will learn to recognize signs and symptoms of addiction, build therapeutic relationships and structure assessment interviews and drug use histories.
Learning Outcomes
At the end of Unit 2, participants should be able to:
- Understand the importance of building a therapeutic relationship during the assessment.
- Demonstrate the ability to structure an assessment interview and gather relevant information.
- Be able to assess the use of substances, namely the pattern of use, frequency, quantity and consequences.
- Be able to assess motivation and readiness for treatment.
Knowledge
- Knowledge of the importance of building therapeutic relationships in the assessment process.
- Familiarity with the guidelines for structuring assessment interviews and maintaining confidentiality.
- Understand strategies for assessing past substance use and motivation for change.
- Know ethical principles and guidelines relevant to the assessment of substance use disorders.
Skills
- Carry out comprehensive assessments for illicit drug addiction
- Ability to build a trusting therapeutic relationship with the person during the assessment
- Structuring an assessment interview and asking relevant questions
- Ability to assess past drug use, including patterns, frequency and consequences
- Use motivational interviewing techniques to assess readiness for change
- Recognize signs and symptoms of substance addiction
- Building a therapeutic relationship based on trust that allows open communication
- Collect and summarize relevant information for the treatment plan
- Dealing with cultural and ethical considerations during evaluation
- Promoting a supportive and non-judgmental environment
Dynamization and Evaluation
The unit will be developed through:
- Case studies analyzing evaluation techniques and ethical considerations.
- Participation in debates or group activities that explore cultural competencies and strategies for addressing stigma and discrimination in the assessment process.
- Videos
The unit will be evaluated through:
- Written tasks on personal growth and development in carrying out comprehensive assessments
2.1 Signs and Symptoms of Illicit Drug Addiction
1. Possible physical, behavioral and psychological signs of addiction
Physical Signs:
- Changes in weight and appetite
- Pupil constriction or dilation
- Slowed speech or coordination difficulties
- Changes in sleep pattern
- Physical withdrawal symptoms when you are not using the substance.
Behavioral signs:
- Greater isolation, secrecy.
- Decline in personal hygiene and cleaning habits.
- Engaging in risky behavior to obtain the substance.
- Neglecting responsibilities at school, work and/or home.
- Legal and/or financial problems related to substance use.
Psychological signs:
- Mood swings and emotional instability.
- Irritability, agitation and/or anxiety
- Depression or apathy
- Cognitive difficulties or difficulty concentrating
- Craving or compulsive search for substances.
2. Recognizing Patterns of Substance Use and Dependence
During the assessment process, it is important for the professional to identify the pattern of substance use and to identify signs of dependence.
Patterns of use:
- Regular use: using the substance consistently over time, often increasing the amount of the substance to achieve the same effect.
- Compulsive use: consumption of large quantities of the substance in a short period, often followed by periods of abstinence.
- Intermittent use: sporadic use of the substance, with no predictable pattern of use.
Signs of addiction:
- Tolerance: the need to increase the amount of the substance to obtain the same effects.
- Abstinence: Experiencing physical or psychological symptoms when trying to stop or reduce consumption of the substance.
- Loss of control: inability to control or stop substance use despite the negative consequences.
- Continued use despite harm: persisting in substance use despite suffering adverse effects on health, relationships or functioning.
3. Understanding the Progression of Addiction and Its Effects on Health
Professionals need to understand that there can be a proximity between socially integrated substance use and the level at which it becomes uncontrolled and disruptive and can lead to a rapid loss of functionality.
Evolution of Addiction
- Experimentation: Trying substances out of curiosity or peer pressure.
- Regular use: Establishing a pattern of substance use, often leading to tolerance and increased consumption.
- Dependency
Phenomenologically, addiction represents an uncontrollable desire to repeat the administration of a psychoactive substance, even though there may be rational recognition of the repercussions at different levels and attempts to limit or discontinue the product.
A distinction can be made between:
Physical dependence: irrepressible urge that forces the person to consume the substance to avoid the syndrome of lack linked to deprivation of the product. It is characterized by the existence of a weaning syndrome (physical symptoms in the absence of the substance) and the manifestation of tolerance.
Psychological dependence: the need of the substance user to return to the sensations of pleasure, well-being, satisfaction and stimulation that the substance provides and to avoid the feeling of physical discomfort that manifests itself when they no longer have access to the substance. It is manifested by craving – a compulsive search for a substance, against reason and will, an expression of a greater and uncontrollable need.
Addiction: Loss of control over drug use, compulsive substance-seeking behavior and continued use despite negative consequences.
Health effects
- Physical health: Addiction can lead to a range of health problems, including cardiovascular disease, respiratory problems, liver damage and infectious diseases.
- Mental health: Substance use disorders commonly coexist with mental health disorders, exacerbating symptoms and impairing functioning.
- Social and economic consequences: Addiction can damage relationships, interfere with work or school performance and lead to legal or financial problems.
2.2 Evaluation Methods and Tools
1. Overview of the different evaluation methods
Clinical Interviews
The clinical interview is one of the most common assessment methods and an essential assessment tool. It can systematically include data collected through other methods.
As mentioned above, the first contact often involves an assessment, in the form of an interview (one-to-one), which is a key moment in establishing a therapeutic relationship.
The professional should, whenever possible, approach the person’s perception and interpretation of their problem, maintaining an empathetic and non-judgmental stance.
During the clinical interview, different topics should be covered, the most relevant being: the reason for the consultation/request for help, the history of the current illness/history of addiction, personal and family history and previous personality. This information should be complemented with information from a psychopathological examination, a summary neurological examination and other complementary diagnostic tests.
In addition to the clinical interview with the person with a substance use disorder, it can be useful to conduct interviews with external informants. These should be people close to the person (e.g. parents, siblings, partners, etc.), with the person’s permission and guaranteeing the confidentiality of the information collected. Interviews with external informants can be useful for gathering information related to the person’s previous personality, their view of the beginning and evolution of their use and personal information and/or family history that the person with a substance use disorder may not be aware of.
Questionnaires and surveys
Other tools that can be useful in assessment are questionnaires/surveys. These are standardized assessment instruments that consist of scripts with structured or semi-structured questions to assess different aspects of substance use, including frequency, quantity, consequences and related problems.
Self-administered questionnaires allow for efficient data collection and can be used in both clinical and research environments.
Screenings
Substance Use Screening Instruments
Often used in primary care or other healthcare settings to quickly detect problematic substance use and determine the need for further assessment or intervention.
Brief screening tools are useful for quickly identifying people who may be at risk of substance use disorders and who warrant further assessment.
Examples of screening tests include the Alcohol Use Disorders Identification Test (AUDIT), the Drug Abuse Screening Test (DAST) and the Substance Abuse Subtle Screening Inventory (SASSI).
Everyone who undergoes screening should be informed of the results of the test. In the event of a positive result, the person should be referred for a more thorough assessment using other types of instruments/tools.
Diagnostic Interviews
Diganostic Interviews are assessment instruments with a structured or semi-structured script used with the specific aim of making a diagnosis based on the diagnostic criteria defined in standardized classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the International Classification of Diseases (ICD-10).
Examples of these interviews are the Structured Clinical Interview for DSM Disorders (SCID) and the Composite International Diagnostic Interview (CIDI).
Severity ratings
Tools used to assess the severity of substance use disorders and monitor changes in symptoms or functioning over time.
Examples include the Addiction Severity Index (ASI), the Severity of Addiction Scale (SDS) and the Clinical Opiate Withdrawal Scale (COWS).
Understanding the Potential and Limitations of Different Evaluation Approaches
Potential
- Clinical interviews allow an in-depth exploration of the person’s experiences, motivations and challenges related to substance use.
- Questionnaires and screenings offer standardized assessment methods that can be easily administered and scored, facilitating efficient data collection.
- Standardized assessment tools, such as the DAST-10, provide a systematic way to screen for substance use disorders and guide treatment planning.
Limitations
- Clinical interviews can be time-consuming and resource-intensive, requiring trained professionals to conduct and interpret them.
- Questionnaires and screenings are based on self-reports, which can be subject to bias and inaccuracy, especially in people with limited knowledge or motivation to report accurately.
- Standardized assessment tools have specific populations and limitations and should be used as part of a comprehensive assessment rather than as stand-alone diagnostic tools
2.3 Conduct Comprehensive Evaluations
To conduct a comprehensive evaluation, several factors need to be taken into account, which will be explored in the following points.
1. Establishing a trusting therapeutic relationship
The quality of the therapeutic relationship is based on the directly established interaction that takes place in a setting that itself should facilitate the relationship rather than causing distractions, discomfort, or repulsion to the situation. The setting refers to the physical environment in which the assessment takes place and the set of variables of a constant nature. Ideally, the assessment should take place in a soundproof room with comfortable furniture, neutral colors and not too personalized, allowing for face-to-face interaction with the professional and the person.
On the other hand, it is important to take into account the time spent on the assessment: less than 30 minutes is difficult to get a good interview/session and more than 1:30 becomes too tiring.
Importance of the relationship
Building a therapeutic relationship creates a basis of support and trust between the professional and the person, facilitating genuine communication and collaboration.
Establishing a relationship of trust helps to reduce resistance, improve involvement and increase the likelihood of the person being genuine during the evaluation process.
Strategies for building the relationship
- Active listening: this involves adapting the posture of the assessor, who maintains eye contact, thus showing that he or she is interested in the person, adapts paralinguistics (adjusts the tone of voice, the cadence of speech) and is attuned (“verbal tracking“) to what is being said. They verbally follow what the person is saying, helping them to describe their narrative, they are alert to selective attention to certain topics, they follow the person’s rhythm and timing.
- Authentic non-verbal behavior: professionals must be aware of their non-verbal behavior and can self-regulate and contain certain reactions that occur during the evaluation process.
- Empathy: the professional must experience an empathetic understanding of the person’s internal reference scheme, validating the explanation given and trying to understand what is being said.
- Unconditional Positive Acceptance: there is no attitude of selective evaluation, the person must be considered as an individualized and unique person, who has their feelings and experiences.
- Respect and a non-judgmental attitude: Professionals should create a safe, non-threatening environment where people feel comfortable sharing their thoughts and feelings without fear of judgment or criticism.
- Confidentiality: is central to the development of a trusting and productive therapeutic relationship. No genuine assessment can take place unless the person trusts the private nature of their disclosures to the professional. It is the ethical responsibility of the professional to discuss the nature and purposes of confidentiality at the beginning of the assessment.
- Co-responsibility: it is important that from the start of the process, and for it to be successful, it is clear that there is co-responsibility on the part of the person and the team for the success of the intervention.
- Cultural competence: The professional must be sensitive to cultural differences, values, and beliefs and adapt communication styles and assessment approaches accordingly.
2. Structuring Assessment Interviews and Gathering Relevant Information
Planning and preparation
Before starting the assessment process, it is important that the professional clarifies the reason and objectives of the assessment and prepares the setting and the necessary materials.
Once again, you must guarantee the privacy and confidentiality of the data collected, giving the person room to air their doubts/questions and concerns.
Interview structure
It is important to start the interview with open questions to encourage the person to share their experiences and concerns freely. On the other hand, the use of open questions throughout the interview allows us to understand what underlies what has been said, enriches and refines the story, makes what has been said more concrete/specific (clarifies) and helps the person to construct their narrative of what is happening.
The structured or semi-structured interview allows for better guidance of the conversation and ensures that all relevant areas are addressed systematically.
On the other hand, it is important to ensure that the interview flows in a conversational tone (and not an interrogatory one) so that the person feels involved and comfortable. The topics brought up by the person should be respected, as should silences.
3. Assessing Substance Use History, Patterns, Consequences, and Motivation for Change
As previously mentioned, during the evaluation process it is necessary to address some specific issues to better characterize the problem. These include:
Toxicological History
- Explore awareness of consumption as a problem/disease;
- Address the evolution of consumption taking into account: age of onset; chronological evolution; motivations for consumption – including the desired subjective effects; the context in which they occur; periods and doses of maximum or minimum consumption; reason for changing substances; history of intoxication or overdose; periods of relapse and associated causes.
- Explore previous attempts at treatment and the results in days of abstinence.
Consumption Pattern
- After the retrospective analysis, the main psychoactive substance and the pattern of consumption over the last month should be assessed.Even if there is multiple consumptions, the substance of choice must be identified.
- The pattern of consumption should be explored in terms of frequency, dose, route of administration, time of day and context of use so that the severity of dependence can be established and the therapeutic plan subsequently outlined.
- It is important to consider the presence of precipitating factors (e.g. interpersonal conflicts, discomfort, peer pressure,…) and to assess the circumstances in which substance use occurs.
- The occurrence of tolerance and the pattern of withdrawal should also be assessed.
Consequences
- In terms of assessing the person’s overall functioning, the impact of substance use on various areas of life should be assessed, including physical health, mental health, relationships, work or school performance, and legal and economic status.
- The consequences of substance use, both in the short and long term, should be considered, and how these can motivate the person to seek change.
Motivation for Change
Generally, at an early stage, most people seek help of their own volition. However, in the course of the assessment and after a detailed analysis, external motivations (economic, legal, family, professional) can be found that drive the search for treatment and influence its continuity. There may be no correspondence between the verbalized reason for seeking help and the real reason.
As we explored in Unit 1, it is important to start by establishing what stage of motivation the person is in: pre-contemplation, contemplation, determination, moving to action or maintenance/withdrawal.
On the other hand, it is essential to understand the person’s real therapeutic goals, their expectations and preferences for the future.
4. Main factors hindering evaluation
Some factors can condition the evaluation process itself and that it is important to take into account when carrying it out:
- states of intoxication or withdrawal that make it difficult or impossible to collect information;
- acute episodes of other mental health problems (e.g. psychotic break);
- the urgency of wanting to solve the problem without evaluating the need/utility of the evaluation process;
- hiding information for secondary gain (e.g. legal, family);
- distrust of health professionals;
- attempts to direct the evaluation process towards a certain goal (e.g. obtaining drugs);
- rejection of the presence of external informants who can contribute to the evaluation process (Gonçalves, Romão and Ismail, 2022).