____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
of a person with a substance use disorder and thus a part of a substance-abusing family system (Straussner, 2011). Assessing the impact of familial substance abuse on mental health and daily functioning is an important intervention with all clients, regardless of their presenting problems. SCREENING AND ASSESSING SUBSTANCE USE Because anyone can have a substance use problem, best prac- tice is to use a simple screening instrument with everyone who enters into a clinical setting. Screening is simply the use of an inexpensive and noninvasive method to identify a possible problem earlier than it would be identified without screening. Screening is not diagnostic; it simply reveals who the clinician might need to look at more closely to determine whether a SUD is present. A brief screen in the waiting room or assessment of a client at the beginning of each session can take only a few moments. It is imperative to conduct screen- ing at several time points because a client could begin using substances during treatment and may not tell a provider if not explicitly asked about use. There may be some valid reasons that an individual is not willing to disclose substance use. Individuals could be fearful of losing their jobs or being judged by a provider. If substance use is suspected but the person is denying substance use, it may be possible to obtain information from family members or other sources if the client permits the provider to speak to others about his or her care. Some clients who deny substance use may even attend a session while under the influence of a substance or substances. Therefore, behavioral cues in session, including the smell of alcohol or marijuana or the wearing of long sleeves on a hot day to cover up needle marks, can be extremely informative. The stigma of SUDs makes it imperative to ask questions in a nonjudgmental manner to help clients feel comfortable with disclosing substance use. Individuals who are unwilling to reveal their substance abuse or who are unaware of the full extent to which substance abuse is dominating their lives commonly rely on unconscious defense mechanisms, namely denial, projection, and rationalization (Doweiko, 2015). For some, it can be easier to disclose legal substance use such as drinking alcohol than illegal substance use. Therefore, begin- ning with questions focused on alcohol use can be a way to ease into an assessment of SUDs. The following are examples of questions that can be included in an assessment: • “How many drinks do you typically have each week?” • “What do you typically drink?” (This is to help determine standard drinks.) • “What are the most drinks you have had in the past month on one occasion?” • “How often do you have four or more drinks in 2 hours or less? [for women; five or more drinks for men]”
• “What are the benefits of drinking?” • “What are some not-so-good things about drinking?” • “When do you find yourself drinking more? Do you have specific triggers that make you want to drink more?” • “Have you ever used [insert substance from the following list]? How much? How often? When did you start? Date of last use? Source of supply? Method of use [e.g., smoking, injecting]?” ‒ Marijuana ‒ Heroin ‒ Methadone ‒ Cocaine/crack ‒ Amphetamines/methamphetamines/uppers ‒ Sleeping medication (what kind?) ‒ Tranquilizers/downers (what kind?) ‒ Club drugs (what kind?) ‒ Other medications/drugs obtained from family/friends or on the street ‒ Other medications/drugs obtained from a doctor • “At what age did you begin to abuse alcohol or drugs?” • “Have you ever tried to cut down on your alcohol/ drug use? What happened?” • “Have you ever considered treatment for substance abuse? If so, have you ever been in treatment? What was it like?” • “Have you ever been to a self-help or peer-help group like AA or NA? What was it like?” • “Does/did your mother/father drink or use drugs?” • “What does your spouse/boyfriend/girlfriend think about your alcohol or drug use? Does he or she drink or use drugs? Do you drink or use drugs together?” • “Has anyone ever thought you had a problem with alcohol or drugs?” • “Have you ever been arrested or involved in any legal problems because of your alcohol or drug use?” • “Do you think you could benefit from reducing your alcohol or drug use or abstaining from use?” These questions can guide a fruitful conversation with a client regarding his or her alcohol or drug use and can help shape his or her treatment plan. However, it is recommended that the clinician also use a formal questionnaire such as the Alcohol Use Identification Test or Drug Abuse Screening Test (both described in Table 5-1) or even a standard interview such as the commonly used Structured Clinical Interview for DSM-5-TR
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