Newsletter Volume 1, Number 3
I have observed numerous changes in the treatment field. Attitudes about treating addiction changed several times and gradually a model developed that worked better for both patient and staff. Part of the shift was taking psychiatrists out of the medical director position and replacing them with a regular physician with addiction knowledge.
Ernest Hooker, NCAC II
Diagnosis of Alcoholism
In this third newsletter I want to discuss diagnosis of alcoholism and how in depth diagnosis is the key to successful treatment. To start with you can get information on diagnosis by using the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR which you can buy at many bookstores including: http://www.amazon.com/exec/
It is quite expensive and you can get the information by going to the library or on the internet such as the Mayo Clinic at: http://www.mayoclinic.com
When looking at a history and physical performed by a physician for a patient the basic diagnosis will be one of two choices alcohol abuse or alcohol dependence. Alcohol abuse simply means that the person has ongoing problems as a result of their use of alcohol use. Dependence means that there is physical dependence on alcohol. Physical dependence is demonstrated by the patient having withdrawal symptoms and frequently very dangerous withdrawal symptoms. A few physicians document alcohol abuse regardless of what the real diagnosis happens to be. There are several problems with diagnosing abuse when the reality is dependence. One problem is with abuse there is no withdrawal symptoms and if the person is inpatient and treated for withdrawal a representative from the insurance company has every right to deny paying for a problem that has not been identified. When a patient is seeking help for their alcoholism most the time the correct diagnosis will be alcohol dependence.
Sometimes you will hear addiction treatment staff use the word hangover as being synonymous with withdrawal symptoms and that absolutely is not true. Having withdrawal symptoms has a very different set of physical problems compared to a simple hangover. Calling it a hangover also undermines treatment because it is easier for the patient to believe that they are an ordinary drinker that just drank too much, so it discourages them from accepting that they have a dangerous medical condition.
Regular physicians with a willingness to be candid about the patient’s condition are one of the most important team members in the treatment team. For many years treatment of alcoholism was primarily considered to be some form of psychological counseling and the medical part was minimized. When it was discovered that alcoholism is first physical and later the psychological deteriorations sets in treatment improved dramatically. It then was appropriate to have a regular physician as medical director of treatment. Patients improved faster and were also much more accepting of treatment. Many recovering alcoholics have found that their physician has been the most helpful person in their recovery.
For a healthcare professional completing a diagnosis and making recommendations for treatment there are various tools. One of the essential tools is the ASI or Addiction Severity Index this can be found at http://www.tresearch.org/ASI.htm In certain cases the ASI is a legal requirement. Another resource is the SASSI and can be found at http://www.sassi.com/sassi/index.shtml SASSI stands for The Substance Abuse Subtle Screening Inventory is psychological screening measure that helps identify a substance use disorder.
In putting this together an H&P is needed the information from an ASI or similar interview and when available employer information, information from family and friends and any other assessments from healthcare professional.
Now what are you looking for the first thing is the person addicted and if so to what drug or drugs? Next what is the stage of the addiction? Do they need immediate medical attention? What resources do they have for medical coverage? At this point you are assessing their immediate concerns about their health and any emergency that may exist. They also need to be assessed for suicide risk.
If you go to my site at: http://alcoholismanswers.net/Forms.aspx you can download and print a chart that may will you assess the progression of their disease.
It is important to develop a priority list of problems. Severe medical and/or mental health issues would be first on the list. Next on the list would be the level of treatment and that will be the subject of a later newsletter.
Determining the timing of treatment and the best treatment approach is essential to a good outcome. What the timing refers to is the patient ready for groups counseling sessions or is their condition such that they are not capable of benefiting from psychological treatment for a few days or in some cases for a few weeks.
The treatment approach can be different based on many issues such as what personality disorders are present, are the withdrawal symptoms a problem, is the patient suffering from temporary paranoia, does the patient have temporary dementia and many other issues. Not making the necessary assessments on these many issues is often when the staff makes the judgment of a “bad patient”. So most of the time the bad patient syndrome is based on inadequate diagnostic skills.
One of the treatment functions lost over the years due to severely reduced funding for treatment and inadequately trained staff is having detox be part of treatment. Several years ago detox and treatment were separate units and very different functions. Detox needs to be a high level of care and low expectations for patients due to their medical limitations. Treatment needs to be very different and when the two are mixed treatment suffers and ends up being forced into an enabling mode.
More next time.
Ernie
| Newsletter Volume 1, Number 4
The training, education and experience required to demonstrate a professional level of skill in diagnosis, recommendations and delivering treatment has increased several times in the past thirty years. Thanks primarily to organizations such as ASAM http://asam.org, NAADAC http://naadac.org, CAADAC http://caadac.org and other organizations the special skills needed to work in the addiction field have been clarified, recommended and improved for anyone working in the addiction field.
Ernest Hooker, NCAC II
If you have friends who are interested in addiction treatment and recovery please forward this newsletter to them. If you have suggestions for a topic contact me and if possible I will include the information in a newsletter.
Diagnostic Interview and Recommendations
In this fourth newsletter I want to discuss the necessary skills required to complete an effective diagnostic interview and include recommendations. I definitely believe that adequate diagnosis is the most difficult task in treating addiction and requires the most skill. Diagnosis will generate a problem list and, based on this list, will develop a treatment plan and referral recommendation. So from this assessment interview and the recommendations rest much of the success or failure of patient’s treatment.
First I will focus on the setting. It needs to be private and the interviewer should not be behind a desk or between the patient and the door. If the patient has been exhibiting any paranoid features it might be a good idea to sit beside the patient. In some cases it can be useful to model some of the patient’s posture and speech patterns, but more about this at another time. There should not be anything that will provide a distraction. Early in treatment patients often have a great deal of difficulty with focusing. Most issues in the setting are just a matter of common sense and after a few hair raising experiences the staff person will learn to make the necessary adjustments.
Some years ago I was assessing an extremely paranoid patient and a quarter fell out of my pocket. When I picked it up and started to put it back into my pocket the patient said, ”What are you doing taking my quarter?” He seemed quite upset. I gave him the quarter, apologized and continued on with the interview. To do otherwise might have been catastrophic.
This part will refer to importance of the interviewer’s attitude about the patient and the purpose of the interview. The purpose of the interview is to get as much information relevant to the patient’s recovery needs as possible in a short time. For most interviewers it works to tell the patient it is somewhat of a boring interview and may be redundant; however, it is required by law and the insurance carrier. With discipline on the interviewer’s part the patient will usually present the specific information without any particular resistance. Most of the time I found it worked to speak in a monotone and move along as fast as the patient is able. It is not the time to confront any real or imagined denial or to attempt therapy. It is not a good practice to ask open ended questions. In a therapy session open ended question can at times have a purpose; however, in a diagnostic interview it leads to confusion and useless data.
At times the patient will clarify their psychological history in a few words. When I inquired about psychological history with one patient he replied “When I went to San Quentin the prison psychiatrist told me I was criminally insane.” This same patient had stated his closest contact was one of the higher echelon officers in the Hells Angels. Later on the history he gave proved to be quite accurate. Actually, he was a model patient.
Several years ago when I was training interns on diagnosis and recommendations, some of the interns complained about limiting time and avoiding open ended questions. Some of them believed it was necessary to spend a lot of time doing the interview and having the patient talk a lot after being asked open ended questions. Rather than argue with them we started a study on interviews that included the time spent and the quality and usefulness of the information. Some weeks later everyone in that group came to the conclusion that about 45 minutes seemed to be optimum length of time. It became apparent that interviews that lasted 2 hours or more were very nearly useless. Either the patient was unwilling or unable to participate or the interviewer was encouraging story telling. The long interviews contained a lot of information; however, little of it was of any use in the patient’s treatment. Generally long interviews were a matter of the patient telling stories without any real direction. Many of the long interviews had to be completed a second time to get the required information. It was the group’s conclusion that the long interviews were a problem primarily because the interviewer was seeing himself in the role of a therapist and not performing a structured interview.
The interviewer needs to have great clarity in both the physical and psychological symptoms of addiction. I developed a chart that many of the staff members found helpful in determining the progression of the problem. You can download the chart by going to http://alcoholismanswers.net/Forms.aspx or if you just want to check it out without downloading it goes to http://alcoholismanswers.net/Forms.aspx It is necessary to be able to read the patient’s medical chart and understand what it means, particularly in regard to their addiction problem. Understanding the patient’s psychological status so that it can be determined when and how the patient should start the next phase of their treatment. And, of course, referral, both short term and long term, is part of the recommendations.
The person doing the interview should be able to start a treatment plan that is simple and easy to understand by the patient and the staff.
An overview of the counselors areas of competence are medical, psychological, legal, ethical, insurance coverage, referral and an in-depth knowledge of addiction.
Ernie
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