The assessment examines a client's life in far more detail so that accurate diagnosis, appropriate treatment placement, problem lists, and treatment goals can be made. Usually, a clinical assessment delves into a client's current experiences and her physical, psychological, and sociocultural history to determine specific treatment needs. Using qualified and trained clinicians, a comprehensive assessment enables the treatment provider to determine with the client the most appropriate treatment placement and treatment plan (). Notably, assessments need to use multiple avenues to obtain the necessary clinical information, including self-assessment instruments, clinical records, structured clinical interviews, assessment measures, and collateral information. Rather than using one method for evaluation, assessments should include multiple sources of information to obtain a broad perspective of the client's history, level of functioning and impairment, and degree of distress.
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Advice to Clinicians: Mental Health Screening and Women.
Assessment should be a fluid process throughout treatment. It is not a once-and-done event. Considering the complexity of withdrawal and the potential influence of alcohol and drugs on physical and psychological functioning, it is very important to reevaluate as the client engages into recovery. Periodic reassessment is critical to determine the client's progress and her changing treatment needs. In addition, reassessment is an opportunity to solicit input from the client on what is and is not working for her in treatment and to alter treatment accordingly.
The following section reviews core assessment processes tailored for women, including gender-specific content for biopsychosocial histories and assessment tools that are either appropriate or possess normative data for women in evaluating substance use disorders and consequences. It is beyond the scope of this chapter to provide specific assessment guidelines or tools for other disorders outside of substance-related disorders.
The Assessment Interview
To provide an accurate picture of the client's needs, a clinical assessment interview requires sensitivity on the part of the counselor and considerable time to complete thoroughly. While treatment program staff may have limited time or feel pressure to conduct initial psychosocial histories quickly, it is important to portray to clients that you have sufficient time to devote to the process. The assessment interview is the beginning of the therapeutic relationship and helps set the tone for treatment.
Initially, the interviewer should explain the reason for and role of a psychosocial history. It is equally important that the counselor or intake worker incorporate screening results into the interview, and make the appropriate referrals within and/or outside the agency to comprehensively address presenting issues. The notion that the women's substance use is not an isolated behavior but occurs in response to, and affects, other behaviors and areas of her life is an important concept to introduce during the intake phase. This information can easily disarm a client's defensiveness regarding use and consequences of use.
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Advice to Administrators: General Guidelines for Selecting and Using Screening and Assessment Tools.
The focus of the assessment may vary depending on the program and the specific issues of an individual client. A structured biopsychosocial history interview can be obtained by using The Psychosocial History (PSH) assessment tool (), a comprehensive multidisciplinary interview incorporating modifications of the Addiction Severity Index (ASI) designed to assess the history and needs of women in substance abuse treatment. Investigators have sought to retain the fundamental structure of ASI while expanding it to include family history and relationships, relationships with partners, responsibilities for children, pregnancy history, history of violence and victimization, legal issues, and housing arrangements (). PSH has been found to have satisfactory test-retest reliability (i.e., the extent to which the scores are the same on two administrations of the instrument with the same people) and concurrent validity with the ASI ().
Psychosocial and Cultural History
Treatment programs have their own prescribed format for obtaining a psychosocial history that coincides with State regulations as well as other standards set by Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Commission on Accreditation of Rehabilitation Facilities (CARF). While many States require screening and assessment for women, specific guidelines and specificity in incorporating women-specific areas vary in degree (). Note: When using information across State standards, the following psychosocial and cultural subheadings should be included in the initial assessment for women, and these areas need to be addressed in more depth as treatment continues. Keep in mind that the content within each subheading does not represent an entire psychosocial and cultural history. Only biopsychosocial and cultural issues that are pertinent to women were included in the list below.
Medical History and Physical Health: Review HIV/AIDS status, history of hepatitis or other infectious diseases, and HIV/AIDS risk behavior; explore history of gynecological problems, use of birth control and hormone replacement therapy, and the relationship between gynecological problems and substance abuse; obtain history of pregnancies, miscarriages, abortions, and history of substance abuse during pregnancy; assess need for prenatal care.
Substance Abuse History: Identify people who initially introduced alcohol and drugs; explore reasons for initiation of use and continued use; discuss family of origin history of substance abuse, history of use in previous and present significant relationships, and history of use with family members or significant others.
Mental Health and Treatment History: Explore prior treatment history and relationships with prior treatment providers and consequences, if any, for engaging in prior treatment; review history of prior traumatic events, mood or anxiety disorders (including PTSD), as well as eating disorders; evaluate safety issues including parasuicidal behaviors, previous or current threats, history of interpersonal violence or sexual abuse, and overall feeling of safety; review family history of mental illness; and discuss evidence and history of personal strengths and coping strategies and styles.
Interpersonal and Family History: Obtain history of substance abuse in current relationship, explore acceptance of client's substance abuse problem among family and significant relationships, discuss concerns regarding child care needs, and discuss the types of support that she has received from her family and/or significant other for entering treatment and abstaining from substances.
Family, Parenting, and Caregiver History: Discuss the various caregiver roles she may play, review parenting history and current living circumstances.
Children's Developmental and Educational History (applicable to women and children programs): Assess child safety issues; explore developmental, emotional, and medical needs of children.
Sociocultural History: Evaluate client's social support system, including the level of acceptance of her recovery; discuss level of social isolation prior to treatment; discuss the role of her cultural beliefs pertaining to her substance use and recovery process; explore the specific cultural attitudes toward women and substance abuse; review current spiritual practices (if any); discuss current acculturation conflicts and stressors; and explore need or preference for bilingual or monolingual non-English services.
Vocational, Educational, and Military History: If employed, discuss the level of support that the client is receiving from her employer; review military history, then expand questions to include history of traumatic events and violence during employment and history of substance abuse in the military; assess financial self-reliance.
Legal History: Discuss history of custody and current involvement with child protective services, if any; obtain a history of restraining orders, arrests, or periods of incarceration, if any; determine history of child placement with women who acknowledge past or current incarceration.
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TIPs that provide assessment information relevant to women in specific settings:
Barriers to Treatment and Related Services: Explore financial, housing, health insurance, child care, case management, and transportation needs; discuss other potential obstacles the client foresees.
Strengths and Coping Strategies: Discuss the challenges that the client has faced throughout her life and how she has managed them, review prior attempts to quit substance use and identify strategies that did work at the time, identify other successes in making changes in other areas of her life.
Assessment Tools for Substance Use Disorders
Addiction Severity Index (ASI): The ASI () is the most widely used substance abuse assessment instrument in both research and clinical settings. It is administered as a semi-structured interview and gathers information in seven domains (i.e., drug use, alcohol use, family/social, employment/finances, medical, psychiatric, and legal). The ASI has demonstrated high levels of reliability and validity across genders, races/ethnicities, types of substance addiction, and treatment settings (; ; ; See Appendix C for specific information on the ASI).
ASI-F (): The ASI-F is an expanded version of ASI; several items were added relevant to the family, social relationships, and psychiatric sections. Additional items refer to homelessness; sexual harassment; emotional, physical, and sexual abuse; and eating disorders. The supplemental questions are asked after the administration of ASI. Psychometric data for ASI-F are limited.
Texas Christian University Brief Intake, the Comprehensive Intake, and Intake for Women and Children: These instruments are available electronically and are administered by a counselor. The seven problem areas in the Brief Intake Interview were derived from the ASI: drug, alcohol, medical, psychological, employment, legal, and family/social. Scoring is immediate, and the program generates a one-page summary of the client's functioning in 14 domains (). The Comprehensive Intake has an online version for women (.
Since women are more likely to experience greater consequences earlier than men, using an instrument that highlights specific consequences of use is crucial.
Drinker Inventory of Consequences (DrinC): This measurement is a self-administered 50-item, true-false questionnaire that elicits information about negative consequences of drinking in five domains: physical, interpersonal, intrapersonal, impulse control, and social responsibility (). This instrument has normative data for women, men, inpatient and outpatient, and has good psychometric properties. Since women are more likely to experience greater consequences earlier than men, using an instrument that highlights specific consequences of use is crucial. A version that assesses drug use consequences is also available (). For a copy of the assessment tool, scoring, and gender profile in interpreting severity of lifetime consequences, see Appendix C.
Available screening and assessment tools: Language availability
Figure 4-9 (p. 80) provides available information on screening and assessment versions in languages other than English. This is not an exhaustive list, and counselors and administrators should not assume language availability is a sign that the instrument is appropriate for a particular culture, ethnic, or racial group.
Figure 4-9
Available Screening and Assessment Tools in Multiple Languages.
Other Considerations in Assessment: Strengths, Coping Styles, and Spirituality
Looking at women's strengths
Focusing on a woman's strengths instead of her deficits improves self-esteem and self-efficacy. Familiarity with a woman's strengths enables the counselor to know what assets the woman can use to help her during recovery. In the Woman's Addiction Workbook (), the author provides a self-assessment worksheet that focuses on individual strengths. In addition to assessing strengths, coping styles and strategies should be evaluated (see ).
Measurements of spirituality and religiousness
Spirituality and religion play an important role in culture, identity, and health practices (). In addition, women are more likely to embrace different coping strategies (including emotional outlets and religion) to assist in managing life stressors (). Practices such as consulting religious leaders or spiritual healers (curanderas, medicine men) and attending to spiritual activities (including sweats and prayer ceremonies, praying to specific saints or ancestors) are common. The consensus panel believes it is important that programs assess the spiritual and religious beliefs and practices of women and incorporate this component into their treatment with sensitivity and respect.
A challenge in determining the effect of spirituality on treatment outcomes is how to assess the extent and nature of a person's spirituality or religiousness. Several assessment tools are available; however, they are more often used for research. They include, but are not limited to, the Religious Practice and Beliefs measurement (CASAA 2004), a 19-item self-assessment tool that reviews specific activities associated with religious practices; the Multidimensional Measure of Religiousness/Spirituality, an assessment device that examines domains of religious or spiritual activity such as daily spiritual experiences, values and beliefs, and religious and spiritual means of coping (); and the Spiritual Well-Being Scale, a 20-item scale that examines the benefits of spirituality for African-American women in recovery from substance abuse (; See Appendix C for specific information on the Spiritual Well-Being Scale).
Health Assessment and Medical Examination
Because women develop serious medical problems earlier in the course of alcohol use disorders than men, they should be encouraged to seek medical treatment early to enhance their chances of recovery and to prevent serious medical complications. Health screenings and medical examinations are essential in women's treatment. In particular, women entering substance abuse treatment programs should be referred for mental health, medical, and dental examinations. In many cases, they may not have had adequate health care because of lack of insurance coverage or transportation, absence of child care, lack of time for self-care, chaotic lifestyle related to a substance abuse, or fear of legal repercussions or losing custody of children. The acute and chronic effects of alcohol and drug abuse, the potential for violence, and other physical hardships (e.g., homelessness) greatly increase the risk for illness and injury.
Women may practice behaviors that put them at high risk for contracting sexually transmitted diseases (STDs) and other infectious diseases (). Testing for HIV/AIDS, hepatitis, and tuberculosis is important; however, it is as essential to have adequate support services to help women process test results in early recovery. Anticipation of the test results is stressful and may place the client at risk for relapse. Residential centers may offer medical exams onsite, but outpatient service providers may need to refer patients to their primary care provider or other affordable health care to ensure that each client has a thorough medical exam. Healthcare professionals may benefit in using the Women-Specific Health Assessment (), which assesses health and wellness and addresses gynecological exams, HIV/AIDS, drug use, STDs, pregnancy/child delivery history, family planning, mammography, menstruation, disease prevention, and protection behaviors.