A diagnostic system is a mechanism for classifying or categorizing individuals who are afflicted with a particular disorder, based on the kinds and severity of problems or symptoms that are associated with that disorder. Such a mechanism is used to make important distinctions across a heterogeneous population of individuals for the purposes of:
- obtaining a better understanding of the conditions and circumstances of those seeking help with specific problems or concerns
- improving communication among practitioners about the characteristics of these groups
- developing appropriate interventions for these groups (Maisto & McKay, 1995).
Thus, diagnostic systems effectively classify a particular disorder and have clinical utility. The intent of this module is to provide social work professionals with an evidence-based overview of key methods currently used in the diagnosis and assessment of alcohol use disorders. Individuals who are interested in becoming treatment specialists should obtain additional training in these methods, along with a strong practicum or internship with a program that delivers specialized alcohol treatment services.
Social work practice with individuals experiencing an alcohol use disorder is, by necessity, practice with applicability across groups that are diverse in age, gender, social class, race, ethnicity, sexual orientation, religious and spiritual beliefs, physical and mental health, abilities/disabilities, and national origin. The following approaches have been selected because of their widespread applicability to diverse populations and because they integrate a strengths perspective concerning the lives of the clients being treated. The strategies are presented with research-based validation because it is critical that social work professionals practice in ways that have been shown to be effective with alcohol-related problems.
By the end of this module, learners should:
A. Be familiar with the state of affairs in the diagnosis and assessment of individuals with alcohol use disorders
B. Understand the empirical evidence for using state-of-the-art diagnostic and assessment devices with individuals experiencing alcohol use problems
C. Recognize the continuum of activities from screening, to diagnosis and assessment, to intervention
D. Be able to apply the classification of disorder system
Earlier modules have emphasized the importance of screening for alcohol use problems in a wide range of social work practice settings. The next step in the social work process, diagnosis, is designed to facilitate decision-making about the most appropriate interventions for alcohol use. Multidimensional assessment includes the added dimensions of the client's biopsychosocial context and factors that might facilitate or impede resolution of the problems. In too many cases, social workers are seeing clients who have alcohol-related problems without recognizing these issues. Hence, it is important for social work professionals to become familiar with the empirically based diagnostic and assessment practices related to alcohol use disorders.
Consideration of the factors that will influence the client's participation in the later steps of intervention is critical during the processes of diagnosis and assessment. Although issues of motivation and motivational interviewing are discussed in a later module, they are really of utmost importance even during these earlier phases of the social work process. The diagnostic interview can and should become a motivating experience for the client with alcohol use problems and information about client commitment to the treatment process should be integrated into the assessment. Information and data gathered as part of the diagnosis and assessment phases should be related back to the client as part of the motivational process. Clients desire and deserve this type of personalized feedback.
What We Measure
Assessments need to be sufficiently broad to capture the extent and complexity of the many factors that accompany, potentially maintain, and are affected by alcohol use. A multidimensional assessment/diagnostic approach to alcohol problems should focus on four domains: (1) physiological, (2) behavioral, (3) psychological, and (4) social factors. In addition, we assess client motivation and commitment to the change process, also called Readiness to Change. Important data and information come from the client, the clinician, and the client's social networks (family, peers, co-workers, and others).
It is important in the diagnosis and assessment phase to develop an understanding of the etiology, course, and severity of the disorder, along with a certain level of client commitment to treatment. At the same time, it is necessary to clarify the interrelationship between an individual's everyday life problems and alcohol use. In addition, the client's strengths in the areas of daily living and social relationships should be acknowledged. Therefore, the various assessment domains should cover the following areas:
- The kinds of situations, moods, and behaviors that pose the highest risk for the individual's relapse, as well as those that are protective from relapse
- The strengths and deficits in individual and social coping resources needed to address potential or high risk occurrences
- The individual's level of readiness to change
In this way, hypotheses can be formed about what action steps will need to be taken in order to achieve sobriety or improvement. The following table (Table 1) provides a short list of suggested instruments for assessing alcohol use problems, high-risk situations, personal coping resources, and motivational readiness to change.
1: Multidimensional Assessment of Alcohol Use Problems
(Adapted from Donovan, 1999)
EXAMPLE OF INSTRUMENTS REFERENCES Assessment Domain: Alcohol Use Problems Serum Chemistry Profile (AST & ALT, GGT, MCV) Anton et al., 1995 Form-90 Miller, 1996 Time-line Followback Sobell & Sobell, 1992 Alcohol Dependence Scale (ADS) Skinner & Horn, 1984 Drinking Inventory of Consequences (DrInC) Miller et al., 1995 Assessment Domain: Relapse Risk Situations Inventory of Drinking Situations (IDS) Annis et al., 1987 Desired Effects of Drinking Simpson et al., 1996 Profile of Mood States (POMS) McNair, et al., 1981 Assessment Domain: Coping Resources Alcohol Abstinence Self-Efficacy Scale (AASE) DiClemente et al., 1994 Situational Confidence Questionnaire (SCQ-39) Annis & Graham, 1998 Coping Responses Inventory Moos, 1995 Assessment Domain: Motivational Resources Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) Miller & Tonigan, 1996 University of Rhode Island Readiness to Change Assessment (URICA) McConnaughy et al., 1983 Readiness to Change Questionnaire (brief RTC) Rollnick at al., 1992
Measures of alcohol use problems generally deal with quantity, frequency, and symptoms of alcohol use, as well as social, psychological, and physical consequences related to the drinking behavior. These data are used to assess both the dependence syndrome and a variety of negative consequences along a continuum of severity. The assessment data can be useful as feedback to promote client awareness of the extent and severity of alcohol use problems.
Measures of relapse risk situations and coping abilities (i.e., individual's confidence and temptation in handling situations associated with high risk for drinking) highlight those areas that pose the greatest threat to sobriety. The measures include domains that address negative emotional states, interpersonal matters, and intra-personal concerns. Assessing risk situations and deficits in the person's coping abilities allows the social worker and client to develop a treatment package specifically targeted to these areas. Some evidence suggests that individuals do better when they receive targeted services than when they do not (McLellan, Alterman, Metzger, Grissom, Woody, & Luborsky, et al., 1994). The likelihood of improvement may be greater when the special needs, problems, and circumstances of the client are matched to particular aspects or elements of treatment. For example, individuals with a mood disorder such as depression might be advised to participate in a treatment program that includes mood management training. At the same time, the social worker must help the client to identify social and individual coping resources that are present, or need to be developed, to engage successfully in a treatment regime.
Some evidence suggests that the likelihood of improvement may be greater when clients receive services targeted to their needs.
This resource issue is critical because some clients may be willing, but unable, to address their alcohol concerns due to a lack of individual or social coping resources. Without adequate resources and support, individuals may not be able to handle treatment task demands, such as those associated with participating in a partial hospitalization program five days a week
Sequential Approach: Assessing Alcohol Problems, Selecting Goals
A sequential approach is typically employed to assess individuals for alcohol problems (Donovan, 1999). This involves first employing screening procedures to identify persons with possible alcohol problems. Subsequently, assessment procedures are implemented to establish a diagnosis and develop a treatment plan. The goal is to develop an individualized, tailored treatment plan. Proper assessment helps to formulate working hypotheses as to why a client drinks. Furthermore, clients need to have information specifically about themselves and their own drinking problems, not just global "truths" about alcohol use disorders. It is interesting to note that merely asking individuals about their drinking problems may serve to increase their problem awareness, which is an important element in motivating them for treatment (DiClemente, Bellino, & Neavins, 1999). Finally, adequate assessment is an important tool in the ongoing process of evaluating treatment effects, as it provides important baseline data for use in aggregate reporting about treated populations.
Assessment is important for:
- Establishing a diagnosis
- Formulating a hypothesis as to why the client is drinking
- Providing clients with information about themselves
- Developing an individualized treatment plan
The assessment process should include functional analysis, a method of identifying the determinants of alcohol use for purposes of selecting and prioritizing appropriate treatment goals and methods. Determinants might include intra-personal issues, such as negative emotional states, as well as interpersonal matters, such as social pressure to drink (see Annis scales or AASE). Functional analysis is followed by a matching process. Matching involves employing a decision tree to triage individuals through a menu of options based on their personal or social coping resources, treatment needs, and individual preferences. When evaluating coping resources, the social worker must assess the degree of confidence and temptation the individual is experiencing in various at-risk situations (Donovan and Rosengren, 1999). This permits the social worker to assess the client's ability to handle a threatening event or the "strength of the pull" to drink in various high-risk circumstances.
When selecting treatment goals, social workers need to formulate working hypotheses about the individual's troubling life problems and alcohol use:
- What events or conditions are most likely to interfere with the continuation or cessation of problem drinking?
- What is the degree of risk posed by certain events or situations (i.e., unemployment, family conflict), intra-personal and negative emotional states (i.e., depression, boredom), and interpersonal stress/pressure to drink?
- What are the individuals' beliefs about their individual coping skills, social skills, and resources for handling an at-risk event (assessing the individual's self-efficacy)?
- What are the individuals' outcome expectancies for handling an at-risk event?
The social worker and client must negotiate a sequence of goals, starting with those that are both most manageable and have the greatest likelihood of achieving success. Clients are more likely to achieve treatment goals when employing active coping strategies associated with immediate rewards (Meichenbaum and Turk, 1987). At this juncture, it should be pointed out that empirical support is lacking for employing a decision tree in referring patients to specific treatment modules based on their expressed problems, needs, and preferences.
How We Diagnose
Within the field of alcohol treatment, the Structured Clinical Interview for the DSM-IV (SCID; Steinberg, Rounsaville & Cicchetti, 1990) is a popular, widely used diagnostic instrument to determine client eligibility or decision-making about treatment(s) that might be most suitable for addressing an individual's alcohol use problems. The DSM-IV (American Psychiatric Association, 2000) is popular in the U. S. and closely parallels the ICD-10 classification system (WHO, 1992). It is based on a clustering of symptoms to generate a diagnosis. Not all of the component symptoms must be present to make a specific diagnosis, and each cluster of symptoms is discrete from those that describe other disorders.
Alcohol Dependent or Alcohol Abusing:
- Tolerance or withdrawal symptoms
- Drinking despite recurring problems
- Drinking more than intended
- Reduced social or work involvement due to drinking
Based on the construct "alcohol dependence syndrome" developed by the World Health Organization (WHO), the SCID has served as a mechanism to classify individuals as either alcohol dependent or abusing alcohol based upon whether or not they:
(1) exhibit symptoms of physical dependence, such as tolerance and/or withdrawal
(2) continue using the substance despite experiencing recurring problems as a result of use
(3) take the substance in larger amounts than was intended
(4) give up or reduce their involvement in social, occupational, or recreational activities because of their drinking practices
Individuals who do not experience the aforementioned physical symptoms or fewer consequences (but manifest at least one of the consequences) are diagnosed as alcohol abusers. Key definitional differences exist between alcohol abusing and alcohol dependent individuals. Three or more dependence criteria must be met within the same year and must occur repeatedly as specified by duration qualifiers (e.g., 'often', 'persistent', or 'continued'). Alcohol dependence may occur with or without physiological dependence, whether or not evidence of tolerance or withdrawal is present.
Alcohol abuse is characterized by a maladaptive pattern of using alcohol that leads to clinically significant impairment or distress. Alcohol abuse is defined as intentional overuse in cases of celebration, anxiety, despair, self-medication, or ignorance, resulting in one or more of the following occurring within a 12-month period:
- Failure to fulfill major role obligations at work, school, or home
- Recurrent drinking in physically hazardous situations
- Recurrent alcohol-related legal problems
- Continued alcohol use despite having persistent or recurrent social and/or interpersonal problems caused or exacerbated by the effects of alcohol.
These symptoms tend to decline with adverse consequences. Alcohol abuse requires that the symptoms have never met the criteria for alcohol dependence (e.g., in persistence, frequency, quantity, etc.).
Alcohol dependence is characterized by impaired control over alcohol use during intoxication and/or inability to abstain from drinking ("broken promises") as evidenced by:
- The need for markedly increased amounts of alcohol to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount of alcohol (tolerance)
- Characteristic alcohol withdrawal syndrome with onset less than 24 hours after last "dose" of alcohol (tremors, sweats, nausea, anxiety, sleep disturbance, hallucinations, seizures)
- Persistent desire to drink, one or more unsuccessful efforts to cut down on drinking, and/or drinking in larger amounts than intended
- Giving up important social, occupational, and/or recreational activities because of drinking
- Spending a great deal of time in activities necessary to obtain alcohol or needing to drink to recover from the effects of alcohol
- Continued drinking despite knowledge of having persistent or recurring physical or psychological problem likely to be cause or exacerbated by alcohol use.
Three or more dependence criteria must be met within the same year and must occur repeatedly as specified by duration qualifiers (e.g., "often," "persistent," or "continued"). Alcohol dependence may occur with or without physiological dependence; whether or not evidence of tolerance or withdrawal is present. It should be noted that there is an important distinction between alcohol dependence with partial remission and alcohol abuse. Although the current diagnostic criteria may be the same, the past history of having been dependent is significant and relevant. It has important implications for future outcomes and for treatment. The definition of alcohol abuse requires that the symptoms have never met the criteria for alcohol dependence.
The SCID has several important limitations. The first is an over-reliance on interviewer discretion in obtaining information for a particular diagnostic category. Second, there is a lack of sensitivity in measuring dependence within certain age groups, such as the elderly or adolescents. For example, adolescents do not commonly demonstrate clear dependence symptoms because of the considerable length of time that it may take to develop such symptoms (Miller et al., 1995). A third limitation is the SCID's inherent deficiency as a method for prescribing psychosocial treatment. Not enough is currently known about such factors as the antecedents and consequences of alcohol abuse and dependence to ensure good clinical determinations about what kinds of treatment strategies will lead to changing harmful drinking practices. However, the SCID is a useful, general measure, particularly for program planning. This is because the measure permits identification of individuals who may need more intensive treatment, such as those with more serious alcohol-related disabilities, or those with co-occurring disorders.
Other, more focused diagnostic tools measure:
Severity of dependence Alcohol Dependence Scale (ADS) Skinner & Horn, 1984 Number of withdrawal symptoms Clinical Institute Withdrawal Assessment (CIWA) Sullivan et al., 1989 Degree of alcohol-related consequences Drinking Inventory of Consequences (DrInC) Miller et al., 1996 Diagnosis Triage Assessment of Addictive Disorders (TAAD) Hoffmann, 1995 Diagnosis Substance Use Disorders Diagnosis Schedule (SUDDS) Hoffmann and Harrison, 1995 Diagnosis Diagnostic Interview Schedule (DIS) Robins et al., 1981
The National Institute of Mental Health Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981) is designed for use by non-clinicians. These diagnostic measures also serve as aids for addressing treatment inclusion/exclusion criteria, referring patients to specific treatments (e.g., inpatient or outpatient treatment) and/or monitoring patient progress throughout the treatment and follow-up phases (Maisto and McKay, 1995).
There are many Multidimensional Assessment options related to Table 1 (see Table 2). The advantage of some of the single, comprehensive measures is that their use is manualized, their validity and reliability are known, and their scoring and interpretation are clear. The ASI is the most widely used instrument in the substance abuse diagnosis and assessment arena (McLellan, Luborsky, O'Brien, & Woody, 1980; McLellan, Kushner, Metzger, & Peters, 1992).
Table 2: Multidimensional Assessment
Single, comprehensive measures:
-Addiction Severity Index (ASI)
-Comprehensive Drinker's Profile (CDP)
-Alcohol Use Inventory (AUI)
Multiple, complimentary measures:
-Physiological, biological markers
The multiple, complimentary measures are flexible, but not necessarily standard approaches, and may not be available in the public domain. The CSAT website presents a number of relevant tools, along with translations into other languages (http://www.samhsa.gov/centers/ csat2002/csat_frame.html). The NIAAA has an annotative bibliography of assessment instruments that may still be accessible through University libraries (NIAAA, 1985). A compendium of rapid assessment measures for social work practice is in development by McMurtry, Rose, and Cisler. Finally, it is important to perform a full assessment to look for other psychiatric functions and diagnoses. Alcohol abuse does not exist in isolation, and very often occurs in conjunction with other drug use and/or psychiatric difficulties. Co-occurring drug use and psychiatric problems increase the complexity of diagnosis and assessment, and often predict poorer treatment outcomes.
Readiness to Change/Stages of Change
The field of health psychology has long recognized the fact that individuals who are engaged in voluntary behavior change generally progress through a recognizable process. The Stages of Change model (DiClemente and Prochaska, 1998; Prochaska et al., 1992) has proven utility when applied to a wide range of health promotion behaviors including smoking cessation, dieting, initiating exercise programs, adopting safe sex practices, reducing intimate partner violence, and overcoming substance abuse problems (Begun et al., in press; Carney and Kivlahan, 1995; Prochaska et al., 1994; Willoughby and Edens, 1996).
Research indicates that individuals typically progress through a predictable, but non-linear sequence of stages when modifying a specific problematic behavior. Each stage is characterized by a set of attitudes, intentions, and behaviors related to the change process itself, as well as to the specific target behavior. People progress through these stages whether or not the change process is being facilitated by formal treatment interventions. Individuals differ markedly in the amount of time and degree of effort exerted in each stage, but the sequence is remarkably similar for everyone.
Stages of Change
The first stage in the change process, Precontemplation, is characterized by a lack of intent to change the behavior because it is not viewed as being problematic (lack of awareness), the pros outweigh the cons (decisional balance), or the person is discouraged and demoralized by past failed attempts to change (self-efficacy). It is not uncommon for these individuals to appear in a treatment setting, but they are seldom there without pressure from family, job, or the law (Connors, Donovan, & DiClemente, 2001). A sub-group of individuals, who may be transitioning from this to the next stage, appear highly ambivalent about making change. They score high on precontemplation measures, but average on later stages.
The second stage is Contemplation. This stage is characterized by the individual considering making a change, seeking information related to the problem, and evaluating the pros and cons of changing-however, no overt change effort has begun. An individual who enters treatment may not be ready to take action (see later stages), but is seeking a means of reinforcing and continuing their contemplation processes (Connors et al, 2001).
Subsequent to this stage, individuals enter into the Preparation stage. Here a person solidifies the gains in Contemplation and begins to develop a concrete and upcoming (within one month) plan of action. The individual shows determination and may even begin some tentative changes and increase self-regulation. Furthermore, individuals at this stage are often able to recite valuable lessons learned from past failed attempts. This stage did not appear in early discussions of the model because it initially appeared as a blend of high Contemplation and Action processes, rather than as a distinct stage itself.
The most overtly obvious stage is Action. Behavior change has clearly begun as individuals acquire and practice skills and strategies needed to implement the change. They work to modify both their own behaviors and the environmental contexts of their behaviors (reducing and avoiding temptation experiences). These individuals also become aware of 'traps' that might work against their change efforts. The transtheoretical aspect of the Stages of Change model is most evident through this stage. Diverse intervention approaches seem effective in this stage even though many are ineffective for people in precontemplation or contemplation stages. Most of the treatment evaluation research explores interventions designed for people in this stage of the change cycle. The Action stage typically lasts an average of six months in the change of substance abuse behavior (Prochaska and DiClemente, 1992).
Finally, individuals may achieve the Maintenance stage. Individuals at this stage continue working to sustain the change gains made during the prior stages. They also actively work to avoid and prevent relapse (recurrences of the problem behavior). Termination of the change process does not occur until the person is fully confident and secure in the maintenance of change. This is the ultimate goal of the change process-to move through the spiral of stages, exiting through maintenance to termination.
Most people undergo several cycles of the stages of change process before achieving their ultimate change goals. It may take an average of 5-7 serious attempts (Prochaska, DiClemente, & Norcross, 1992).
The greatest potential contribution of the Stages of Change model is the possibility that it offers for intervention matching to enhance treatment effectiveness. Ideally, individuals at any stage of the process can be adequately assessed and offered an intervention that supports their progress to the next stage (Connors et al., 2001). Towards this goal, a variety of assessment instruments have been developed and tested for reliability and validity: URICA (McConnaughy, DiClemente, Prochaska,, & Velicer, 1983), RTC (Rollnick et al, 1992), and their ability to predict treatment outcome (DiClemente et al, 2001). Furthermore, intervention approaches are being identified and tested for their effectiveness with particular stages of the change process. Instruments such as the Situational Confidence Questionnaire (Annis and Graham, 1988) and the Alcohol Abstinence Self-Efficacy Scale (DiClemente et al, 1994) are useful to assess the self-efficacy component of the change spiral.
A comprehensive alcohol use assessment includes many elements. It includes a profile of drinking, or a "drinking checkup" to examine drinking patterns and a personalized picture of its effects. Remember that it is not the drinking that leads an individual to seek help, it is the consequences of the drinking. Thus, they should be addressed. A comprehensive assessment also includes identification of situations in which the problem occurs, and a focus on the client's strengths. The strengths are important since having early successes are critical to the individual's motivation to stay with the difficult process of recovery. Motivation to change and commitment to the change process are also critical aspects of the assessment process.
A critical feature of the diagnosis and assessment process is the nature of the helping relationship that becomes established. "The tenor of the assessment enterprise should be characterized as collaborative, with the assessor and client jointly committed to discovering those client features that will contribute to important decisions about future clinical management" (Allen, Columbus, & Fertig, 1995). Thus, the information obtained from assessment interviews should include specifics about procedures and practices that stimulate motivation and client commitment to the process.
Finally, when selecting the instruments for assessment and diagnosis, the social worker should keep several issues in mind. Reliability and validity should be assured. Reliability refers to the consistency or dependability of data collected in similar situations, under similar conditions. Validity refers to the extent to which measures accurately reflect the phenomena that they investigate. Reliability and validity are determined, in part, by the social worker's methods and process: "The interviewer is responsible for the integrity of the information collected and must be willing to repeat, paraphrase and probe until he/she is satisfied that the patient understands the questions and that the answer reflects the best judgment of the patient, consistent with the intent of the question." (ASI Manual, University of Pennsylvania, 1990).
When selecting an assessment strategy, the social worker should consider the:
- clinical utility
- target population
- reliability and validity
- ease of administration
- scoring and interpretation
RECOMMENDED CLASSROOM ACTIVITIES
- Locate copies of at least two of the assessment instruments discussed in this module. Review literature concerning their psychometric properties and usefulness in practice. Role-play their use.
- Read the article concerning the transtheoretical model and stages of change by Prochaska, DiClemente, & Norcross (1992) appearing in American Psychologist. As a class, analyze its implications for assessment and diagnosis with individuals who have alcohol use problems.
- Review the criteria for alcohol abuse and alcohol dependence. Develop some concrete examples of behaviors and symptoms that would clearly fit the criteria. Discuss examples that might be ambiguous or indeterminate.
- What are the existing policies (i.e., professional licensure/certification, reimbursement, etc.) that might have an impact on your social work assessment and diagnostic practices with individuals who have alcohol use disorders?
- What ethical issues are likely to arise in the course of assessment/diagnosis related to alcohol use problems?
- What modifications of the assessment instruments and procedures (techniques) should be considered in order to apply them in a culturally competent fashion with diverse populations? (Remember the "culture" in this sense can mean gender, sexual orientation, abilities/disabilities, etc., as well as ethnic group influences.)
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Updated: March 2005