ASSESSMENT

Assessment & Goal Setting Start of the therapeutic process Clinical interview Assessment tools (Questionnaires) Objective feedback Solicit the client’s view Negotiate treatment goals & strategies (initial contract)

Assessment Considerations Often first time client has given any concentrated thought to their drinking and related problems Sometimes drink to excess, often not When seeking treatment, alcohol problems are not usually dominating their life Often see their drinking problem as a nuisance rather than major threat to their well-being Assessment can heighten their consciousness about their drinking behavior and enhance motivation for change

Decisional Balance Pros and Cons of moderating or stopping Pros and Cons of not changing

Assessment Tools Clinical face-to-face interview is by far most important assessment tool Washton New Patient Questionnaire Alcohol Use Disorders Test (AUDIT)

AUDIT A lcohol Use Disorders Identification Test Takes only 5 minutes to complete Can be self-administered by client Asks about past year alcohol use Response categories based on standard drink units

AUDIT 1. How often do you have a drink containing alcohol? (0) never (1) monthly or less (2) 2-4 times/month (3) 2-3 times/week (4) 4 or more times/week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) 1-2 (1) 3-4 (2) 5-6 (3) 7-9 (4) 10 or more

AUDIT 3. How often do you have 6 or more drinks on one occasion? (0) never (1) less than monthly (2) monthly (3) weekly (4) daily/almost daily 4. How often during the last year have you found that you were not able to stop drinking once you had started? (0) never (1) less than monthly (2) monthly (3) weekly (4) daily/almost daily

AUDIT 5. How often during the last year have you failed to do what was normally expected from you because of drinking? (0) never (1) less than monthly (2) monthly (3) weekly (4) daily or almost daily 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (0) never (1) less than monthly (2) monthly (3) weekly (4) daily or almost daily

AUDIT 7. How often during the last year have you had a feeling of guilt or remorse after drinking? (0) never (1) less than monthly (2) monthly (3) weekly (4) daily/almost daily 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? (0) never (1) less than monthly (2) monthly (3) weekly (4) daily/almost daily

AUDIT 9. Have you or someone else been injured as a result of your drinking? (0) No (2) Yes, but not in the last year (4) Yes, during the last year 10. Has a relative, friend, physician, or other health professional been concerned about your drinking or suggested that you cut down? (0) No (2) Yes, but not in the last year (4) Yes, during the last year

AUDIT Scores Under 8: Low Risk Drinker 8-20: At-Risk or Problem Drinker 20+: Likely Alcohol Dependent

Substance Use Profile In-depth functional analysis (typology) of the nature, extent, role, aftermath, and consequences of use Types, amounts, frequency of substances used Routes of administration Temporal pattern (continuous, episodic, binge) Changes over time

Substance Use Profile Environmental antecedents (external “ triggers ” ) Emotional antecedents (internal “ triggers ” ) Settings and circumstances of use Aftermath of use (physical, emotional, relational) Linkage between use of multiple substances Linkage with non-chemical compulsive behaviors (sex, gambling, spending, eating)

Substance Use Profile Perceived positive benefits of use What first attracted you? How has it helped you? (self-medication value) Does it still work as well? What would be the downside of not using? Adverse consequences Physical, psychological, vocational, social, etc.

Choosing Goals

Abstinence or Moderation? Total abstinence is the safest, most informative course But only the client can choose, no matter what you think is best Many refuse abstinence, but willing to try moderation Some willing to try “experiment” or trial period with abstinence Your goal is to “start where the person is” Goals must be patient driven, not diagnosis or clinician driven ! The first and foremost goal is to engage the patient in a therapeutic relationship

Menu of Goals Abstinence (temporary “experiment” or open-ended) Total- from all psychoactive substances Partial- from substances causing the most harm Gradual tapering toward abstinence (“warm turkey”) Temporary or open-ended moderation No specific plan right now for changing alcohol consumption, ask permission to continue the dialogue …..

Suggested Starting Points Take a break from drinking (experiment with abstinence) for 30 to 90 days. The longer, the better, but be willing to compromise Cut drinking volume and frequency by at least 50% Drink no more than 2-3 drinks on no more than 3-4 days per week, preferably not on consecutive days and no faster than one drink per hour

Why “Experiment” with Abstinence? Breaks old habits, stops creation of new consequences Immediate sense of accomplishment and self- control- sometimes drastic change is easier Provides and unclouded opportunity to assess your relationship with alcohol and its role in your life Reveals nature and extent of reliance on chemical coping-“self medication” Chance to see things through a “different set of eyes”

Why “Experiment” with Abstinence? Opportunity to practice drink refusal skills Reveals impact of drinking cessation on mood, affect, stress sensitivity, relationships, coping skills Provides opportunity to identify internal/external triggers of drinking Reveals ability or inability to stop drinking Reveals the “void” left by not drinking

Learn how to safely manage (“surf”) drinking urges Encourage clients to pay close attention to moods, thoughts, feelings, dreams, and physical sensations that both precede and follow drinking Careful, detailed, nonjudgmental debriefing and deconstruction of any instances drinking or “close calls” Reduces alcohol tolerance Why “Experiment” with Abstinence?

Moderation Strategies

Establish specific amount/frequency limits Keeping a log of alcohol consumption Switch to lower-proof beverages Space drinks and sip more slowly

Moderation Strategies Eat before and during drinking episodes Drink water or soda to dilute the effects Avoid drinking with heavy drinkers Avoid drinking when emotionally upset Avoid drinking on consecutive days

Treatment Considerations Non-intensive, outpatient basis Not in groups with alcohol-dependent clients Individual sessions more appealing than groups Often unwilling to try or return to AA (although some are) May be willing to try online self-help groups such as MM, HAM, or SMART

Treatment Considerations Short-term (brief) treatment model Individualized (negotiated) treatment goals Tapering frequency of sessions Extended follow up, one year, if possible

Other Useful Self-Control Strategies Don’t buy alcohol Don’t keep it in your residence or in sight Stock up on your favorite non-alcoholic drinks Avoid social events and celebrations where heavy drinking is encouraged Structure and occupy your time Remind yourself of why you are doing this

Moderation Skills Understanding what is “enough” Thinking ahead Measure drinks Count drinks Thirst management Blood sugar management Delaying

Moderation Skills Eating Sipping Alternating Never drink alone Know your drinking triggers Ask for help

Drinking Tracker Card

Drinking Analyzer Card

Medications to Facilitate Moderation or Abstinence Disulfiram (Antabuse) Naltrexone (ReVia) Acamprosate (Campral) Topiramate (Topamax) Gabapentin (Neurontin) Lioresal (Baclofen) Benzodiazepines (Ativan, Klonipin, Valium)