The process of gathering information for a substance abuse evaluation is usually complicated enough to challenge any therapist. Clinicians have to become detectives, searching for clues to chemical dependency that are often shrouded by the patient’s delusion or guardedness. But the process becomes even more complicated when we conduct evaluations for clients with a chronic mental illness. Although we can make important mistakes by relying too heavily on traditional substance abuse techniques and measurements, much of the solution to an accurate assessment lies in learning to ask the right questions.
For dual-diagnosis patients, the right questions are those that recognize the complex interaction between chemical dependency and mental illness — an interaction that produces bewildering cultural, social, financial, medical, spiritual and emotional problems. Mental illness and chemical dependency mix together like a match and gasoline, reacting upon each other in sometimes surprising and always destructive ways. The spark that ignites the problems can be relatively small, but powerful.
Traditional measurements of chemical dependency generally look in the wrong direction when assessing patients with a chronic mental illness. This is especially true of self-report alcoholism questionnaires, often used for quick reference. They are directed toward mainstream adults, and tend to be meaningless to most institutionalized psychiatric patients. For example, the first three questions of the Alcohol Dependence Scale, describing symptoms of intoxication, could not be answered accurately by someone experiencing side effects of psychotropic medication. The Michigan Alcoholism Screening Test, asking patients to self-assess “normal” patterns of drinking, disregards the social isolation of chronic mental illness. And the National Council on Alcoholism Test focuses on occupational dysfunction, problem-response drinking, and alcohol tolerance through examples totally foreign to most institutionalized psychiatric patients (see sidebar).
An effective chemical dependency assessment for a person with a chronic mental illness cannot depend on the format routinely used with other patients. Questions must be individualized around the patient’s unique lifestyle and experiences. The following five open-ended questions can be used in either a brief assessment or as part of a comprehensive substance abuse evaluation. With these questions, clinicians can determine problematic drug use and develop effective treatment recommendations.
This question asks clients to explore the negative effects of their drug use. It is a standard question used in assessments, but people with a thought disorder are often extremely concrete, so check your assumptions with the patient. I recall, for example, talking with a patient who complained his drinking brought about suicidal behavior, physical injuries, alienation from his family and a string of legal problems. I said the obvious: “It looks like alcohol has been a serious problem in your life.”
He thought a moment and answered, “No, not really.” The impact of drug abuse, and the patient’s perception of the impact, are not always one and the same.
This is probably the most important question of an assessment. From the patient’s answer, we determine how important the drug is in the person’s life, and get clues to the resistance to abstinence we might expect. If you are able to explore this question in detail with the patient, you will start to understand the range and depth of the person’s problems. For instance, psychiatric patients often use street drugs to medicate symptoms. It is common to hear them assert that heavy alcohol or nicotine use reduces symptoms of their thought disorder, or that marijuana controls their impulsive behavior.
Get perspectives from the patient, family, physician, hospital staff, mental health counselors, and anyone else who can describe the nature of the patient’s psychiatric illness, what has worked in the past and what hasn’t. Without this information, your treatment recommendations can inadvertently set off a chain reaction that does more harm than good to the patient. For instance, the change in a person’s metabolism when you prescribe total abstinence from alcohol could affect the efficacy of the psychotropic medication he is taking. Stabilizing a patient on the right dosage of medication is often difficult, requiring constant monitoring. The effectiveness of medication can easily fall off balance with any change in a daily regimen.
Motivational interviewing techniques are effective in developing a patient’s commitment to change. For patients with a thought disorder, mood disorder or personality disorder, however, motivation can be especially mercurial. Your treatment recommendations should be designed to reassess motivation frequently. Keep in mind though that, because chronic mental illness robs a person of control over so many personal decisions, patients may retreat to oppositional behavior when they perceive the intrusion of more “helpers” in their life.
Mental illness isolates. It isolates a person physically, mentally, socially and emotionally. For some, a support system may evolve slowly, for others the desire for support may change with their moods, and for still others the constant need for support and attention is overwhelming. The amount and quality of support a person wants or needs may change completely when the patient abstains, or when a psychiatric illness either improves or worsens. Patients may feel especially vulnerable to supportive relationships because of a past history of physical or sexual abuse. They may have endured social stigma and rejection, and are probably in need of a trusted guide. If substance abuse treatment is recommended, case management should be built into the recommendations.
Summary
A comprehensive substance abuse evaluation for patients with chronic mental illness must
take many things into account, including the complex interaction of drug use and mental
illness, the impact of even small amounts of drug experimentation, and the constant and
dramatic changes in a dual-diagnosis person’s life that alter the person’s mood, perception,
therapy and commitment to change. Asking the wrong questions in an evaluation can lead to
tragic neglect and oversight, but the right questions can lead to the unique and individualized
treatment plan a person needs.
Sample Questions from Substance Abuse Questionnaires
Larry Tyler is a licensed substance abuse counselor, trainer and clinical supervisor. He is the co-founder of Resources in Mental Health and Substance Abuse, Inc., and is currently a sex-offender therapist at Klinikos in Augusta, Maine. He is the director of the MidCoast Coalition to Prevent Domestic Abuse.