Marco Institucional

Assessment

StandardMedicalHistory andPhysical Exam,WithParticularAttentionto thePresenceofAnyoftheFollowing

•Physicalsignsorcomplaints(e.g.,nicotinestains,dilatedorconstricted pupils,needletrackmarks,unsteadygait,tattoosthatdesignategang affiliation,“noddingoff”)

•Neurologicalsignsorsymptoms(e.g.,blackoutsorotherperiodsofmemory loss,insomniaorothersleepdisturbances,tremors)

•Emotionalorcommunicativedifficulties(e.g.,slurred,incoherent,ortoo rapidspeech;agitation;difficultyfollowingconversationorstickingtothe point)

SkinnerTraumaHistory

Sinceyour18thbirthday,haveyou

•Hadanyfracturesordislocationstoyourbonesorjoints? •Beeninjuredinaroadtrafficaccident?

•Injuredyourhead?

•Beeninjuredinanassaultorfight(excludinginjuriesduringsports)? •Beeninjuredafterdrinking?

Source:Skinneretal.1984. AlcoholandDrugUseHistory

•Useofalcoholanddrugs(beginwithlegaldrugsfirst)

•Modeofusewithdrugs(e.g.,smoking,snorting,inhaling,chewing,injecting) •Quantityused

•Frequencyofuse

•Patternofuse:dateoflastdrinkordrugused,durationofsobriety,longest abstinencefromsubstanceofchoice(whendiditend?)

•Alcohol/drugcombinationsused

•Legalcomplicationsorconsequencesofdruguse(selling,trafficking) •Craving(asmanifestedindreams,thoughts,desires)

Family/SocialHistory •Marital/cohabitingstatus

•Legalstatus(minor,incustody,immigrationstatus)

•Alcoholordrugusebyparents,siblings,relatives,children,spouse/partner (probefortypeofalcoholordrugusebyfamilymemberssincethisisfre- quentlyanimportantproblemindicator:“Wouldyousaytheyhadadrinking problem?Canyoutellmesomethingaboutit?”)

•Alienationfromfamily

•Alcoholordrugusebyfriends

•Domesticviolencehistory,childabuse,battering(manysurvivorsand perpetratorsofviolenceabusedrugsandalcohol)

•Otherabusehistory(physical,emotional,verbal,sexual) •Educationallevel

•Occupation/workhistory(probeforsourcesoffinancialsupportthatmay belinkedtoaddictionordrug-relatedactivitiessuchasparticipationin commercialsexindustry)

•Interruptionsinworkorschoolhistory(askforexplanation)

•Arrest/citationhistory(e.g.,DUI[drivingundertheinfluence],legal infractions,incarceration,probation)

SexualHistory:SampleQuestionsandConsiderations

•Sexualorientation/preference—“Areyoursexualpartnersofthesamesex? Oppositesex?Both?”

•Numberofrelationships—“Howmanysexpartnershaveyouhadwithinthe past6months?Year?”

•Typesofsexualactivityengagedin;problemswithinterest,performance,or satisfaction—“Doyouhaveanyproblemsfeelingsexuallyexcited?Achieving orgasm?Areyouworriedaboutyoursexualfunctioning?Yourabilitytofunc- tionasaspouseorpartner?Doyouthinkdrugsoralcoholareaffectingyour sexlife?”(Avarietyofdrugsmaybeusedorabusedineffortstoimprove sexualperformanceandincreasesexualsatisfaction;likewise,prescription andillicitdruguseandalcoholusecandiminishlibido,sexualperformance, andachievementoforgasm.)

•Whetherthepatientpracticessafesex(researchindicatesthatsubstanceabuse islinkedwithunsafesexualpracticesandexposuretoHIV).

•Women’sreproductivehealthhistory/pregnancyoutcomes(inadditionto obtaininginformation,thisitemoffersanopportunitytoprovidesomecoun- selingabouttheeffectsofalcoholanddrugsonfetalandmaternalhealth).

MentalHealthHistory: SampleQuestionsandConsiderations

•Mooddisorders—“Haveyoueverfeltdepressedoranxiousorsufferedfrom panic attacks? How long did these feelings last? Does anyone else in your family experiencesimilarproblems?”(Ifyes,dotheyreceivemedicationforit?) •Othermentaldisorders—“Haveyoueverbeentreatedbyapsychiatrist,

psychologist,orothermentalhealthprofessional?Hasanyoneinyourfamily beentreated?Canyoutellmewhattheyweretreatedfor?Weretheygiven medication?”

•Self-destructiveorsuicidalthoughtsoractions—“Haveyoueverthought aboutcommittingsuicide?”(Ifyes:“Haveyouevermadeanattempttokill yourself?Haveyoubeenthinkingaboutsuiciderecently?Doyouhavea plan?”[Ifyes,“Whatmeanswouldyouuse?”]Dependingonthepatient’s responseandtheclinician’sjudgment,amentalhealthassessmenttoolsuchas theBeckDepressionInventoryortheBeckHopelessnessScalemaybeusedto obtainadditionalinformation,ortheclinicianmayopttoimplementhisown predefinedproceduresforaddressingpotentiallyseriousmentalhealthissues.)

Source:CSAT1997a.

tokeepthatfamilyoutofthetreatment process.Forsafetyreasons,theseriousnessof conflictshouldbeassessed,andtheclientwill needsometimetoadjustandbuildrapport withthecounselorbeforebeingintroducedto familytherapy.

Eventually,almostallclientswithsubstance usedisorderscanbenefitfromsomeformof familytherapy,becausetheeducationalses- sionsforfamiliesthatarecommonlyusedin substanceabusetreatmentsettingsarenot always sufficient to bring about necessary, lastingsystemicchangesintheclient’sfamily relationships.Anumberoffactorswillinflu- enceadecisionaboutthetypesandrelative intensityoftreatmenttheclientshouldreceive. Theclient’slevelofrecoverymayhavethe greatesteffectonherabilitytoparticipateboth insubstanceabusetreatmentandfamilythera- py,aswellastheusefulnessofthattherapyfor allmembersofthefamily.(Seechapter4fora discussionofthelevelsofrecovery.)

Whilefamilytherapyinadditiontosubstance abusetreatmentishighlydesirable,managed careguidelinesandgovernmentregulationsare certain to affect referrals. The decisions of

payorswillconsequentlybeamajordetermi- nantoftheservicesaprogramoffersandthe servicesaclientiswillingtoseek.Iffunding agenciesdonotsupportfamilytherapy,the counselormaydecidetoworkonfamily dynamicsonlythroughthesinglesymptomatic individual. There is a great need for the training ofsubstanceabusecounselorstodofamily therapyaswell.Thiscanbedoneifthecoun- seloristrainedtodofamilytreatmentwitha singleindividual.Additionally,familythera- pistsneedbetterpreparationingraduate schoolplussupervisedworkinordertowork effectivelyinthefieldofsubstancetreatment specifically.(Seechapter4foradiscussionof integratedtreatment.)Thesearevitalfirst stepstowardintegratingthetwoapproaches. Anintegratedapproachmightwellhavean importanteffectonfundingpolicies,allowing moreindividualstoreceivesubstanceabuse treatmentintegratedwithfamilytherapy.

Family therapists and screen-