ADDICTION SEVERITY INDEX NARRATIVE REPORT

Transcription

1 S.M.A.R.T. Treatment Planning Module 2 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful ADDICTION SEVERITY INDEX NARRATIVE REPORT JOHN B. SMITH 444 MAIN STREET PHILADELPHIA, PA Date of Birth: 07/30/1959 ID# 101 Social Security Number: Site Id # Date of Interview: 08/26/2004 Time Int. Began: 10:51:21 Type of Interview: Intake Time Int. Ended: 11:25:21 Interviewer Name: Deni Carise Interviewer Id #: 01 GENERAL INFORMATION SECTION The following is a clinical summary based on an in-person interview with John Smith, on 08/26/2004. This summary is based on the client's self report regarding lifetime and recent Medical, Employment, Alcohol, Drug, Legal, Family/Social and Psychiatric involvement and/or problems. Included in each of these sections is the interviewer's severity rating, suggesting the client's need for treatment (or additional treatment beyond what he's already receiving). This is based on the information provided by the client. John is a 40 year old, white (non-hispanic) male. He states his religious preference is Catholic. John reports he actively practices his faith and attends church every Sunday. He feels his spirituality will be a big part of his recovery. He has lived at his current address for approximately 3 years. Neither he nor his family owns this residence. John reports paying $ month rent. John reports spending 2 of the past 30 days in a jail or prison facility in which his freedom was restricted and/or prohibited. This could have limited his ability to use alcohol or drugs, as well as his interactions with family and others. Client was arrested for driving under the influence and spent 2 nights in jail. ALCOHOL & DRUG SECTION Lifetime and Recent Alcohol Use: In his lifetime, John drank regularly for a period of 15 years. For 7 years, his drinking was regular and heavy (generally defined as 5 or more drinks in one day). In the past 30 days, he drank 20 days, and has drank heavily, having more than five drinks per day, on each of those days. He reports having spent $100 on alcohol in the past 30 days. He has never experienced alcohol delirium tremens. Lifetime and Recent Drug Use: John has a history of ongoing heroin use for a period of 4 years, he also used methadone regularly for one year. John appears to have no lifelong problems with other opiates, additionally he reports no periods of ongoing barbiturate use. He has used sedatives, hypnotics, or tranquilizers regularly (generally defined as three times per week or more), for a period of 2 years. John reports using unprescribed Xanax for several years in the early 1980s. John has used cocaine regularly or problematically for a period of 8 years; he has no history of ongoing amphetamine use. John has a 15 year history of ongoing, regular cannabis use; he has no history of ongoing use of hallucinogens.

2 S.M.A.R.T. Treatment Planning Module 2 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful He has no history of regular or ongoing use of inhalants. John has a history of using multiple substances, on an ongoing basis, for a period of 15 years. He has never overdosed, either intentionally or unintentionally, on drugs. In the past 30 days, John has used heroin 8 days and methadone on 2 days. He has been buying methadone on the street for past 6 months. John has not used any other opiates, barbiturates, or sedatives in the past 30 days. John has used cocaine 3 days in the past 30; he has not used amphetamines during this time. John has used cannabis 10 days in the past 30; he has not used any hallucinogens. He has not used any inhalants in the past month. John has used two or more drugs together (or drugs and alcohol) on 20 days in the past month. In the past 30 days, John reports that he spent $100 on alcohol and $300 on other drugs. Alcohol and Drug Treatment History: John has received treatment 2 times for alcohol problems. None of these were brief detoxification treatments. He attended outpatient programs 2 times in John has received treatment 2 times for drug problems; none were limited to detoxification. These occurred at the same time he was treated for alcohol use. John s last period of continuous abstinence from alcohol and drugs lasted for 6 months, ending approximately 60 months ago. He attended four outpatient sessions for drug or alcohol problems in the past 30 days. This may include AA, NA, or CA attendance. John s outpatient sessions were limited to 4 AA meetings in the past month. Client Perception of Severity of Alcohol and Drug Problems and Desire for Treatment: John experienced alcohol-related problems on 30 of the past 30 days and is bothered considerably by these problems. Obtaining alcohol treatment is extremely important to John. John experienced problems on 10 of the past 30 days related to drug use and is bothered considerably by these problems. Obtaining drug treatment is extremely important to John. Interviewer Impressions and Recommendations - Alcohol and Drugs: It is my impression that John understood all of the questions and that he did not deliberately misrepresent information about his drug or alcohol use and history. It is the interviewer s belief that both alcohol and drugs are his most significant substance abuse problem. He has an alcohol problem of substantial concern and help obtaining appropriate treatment is vital at this time. John has a drug problem of substantial concern and help obtaining appropriate treatment is necessary at this time. Additional Alcohol and Drug Comments: Client appears sincerely motivated to attain treatment for his alcohol and drug problems. He would like to be a better father to his children and resume friendship with his wife. He believes his use of alcohol and drugs is responsible for his problems with his family members. FAMILY / SOCIAL SECTION Marital and Living Situation for Majority of the Past Three Years: John is currently divorced, and is generally satisfied with this situation. He has been divorced for about 4 years. John has lived alone for most of the past three years and appears to feel fairly indifferent to this circumstance. He has been in this living arrangement for about 4 years.

3 S.M.A.R.T. Treatment Planning Module 2 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful Recovery Environment and Social Contacts: No one residing with him has problems with alcohol or drugs. John currently spends most of his free time alone and is generally dissatisfied with this situation. He would like to establish better relationships with his children and his ex-wife. He reports having 4 close friends on whom he can rely. Relationship Problems Lifetime: John reports that he has had close, long lasting relationships with family and friends in his lifetime. In his lifetime, he has had significant problems getting along with his partner, but not with his children. In his lifetime, he has not had any serious problems getting along with either his mother or father. He has not had serious problems getting along with other significant family members in his lifetime. He has not had any significant problems getting along with either siblings or close friends. He has not had any serious problems getting along with either neighbors or co-workers. John reports no history of emotional, physical, or sexual abuse in his life. Relationship Problems Past Thirty Days: In the past 30 days, he has had significant problems getting along with his partner, but not with his children. In the past 30 days, he has not had any serious problems getting along with his mother. He has not had significant problems getting along with either his siblings or close friends. He has not had any serious, recent problems getting along with co-workers. John has not experienced any recent emotional, physical, or sexual abuse. Client Perception of Severity of Family and Social Problems and Desire for Treatment: Overall, John reports having 10 days of family related problems in the past 30, and is considerably troubled by these problems. He considers his problems with ex-wife to be most pressing. Obtaining treatment for family difficulties is profoundly important to John. He reports experiencing no problems with others and is not troubled or bothered by social issues. Consequently, help obtaining treatment for social related difficulties is not important to John. Interviewer Impressions and Recommendations - Family and Social: It is my impression that John understood all of the questions and that he did not deliberately misrepresent this information. John has family or social problems of substantial concern and help is necessary at this time. Additional Family & Social Comments: John is considerably bothered by the lack of involvement in his children's lives. He and his ex-wife argue over the children and he does not see them as often as he would like. During this section of the interview, John s affect was sad and he had difficulty maintaining composure. PSYCHIATRIC SECTION Serious Emotional and Psychological Problems Lifetime: John does not have a significant past history of psychiatric problems. He does not have a history of being prescribed psychotropic medications. He does not have a history of treatment for psychological or emotional problems. He does not receive any financial compensation for a psychiatric disability.

4 S.M.A.R.T. Treatment Planning Module 2 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful Recent Serious Emotional and Psychological Problems: John has had serious problems with depression in the past 30 days; he was not obviously depressed at the time of the interview. John acknowledges serious problems controlling violent behavior in the past 30 days; he was not hostile at the time of the interview. John reports he has trouble controlling his rage and anger toward ex-wife when she blocks his visits with children. Client Perception of Severity of Emotional and Psychological Problems and Desire for Treatment: John experienced psychological or emotional problems on 4 of the past 30 days, and is bothered by them. Obtaining psychological or emotional treatment is slightly important to him. Interviewer Impressions and Recommendations - Psychiatric: It is my impression that John understood all of the questions and that he did not deliberately misrepresent his psychological/emotional information. He appears to have a moderately severe psychological or emotional problem; treatment is needed. Additional Psychiatric Comments: Client states he has concerns that one day he is not going to be able to control himself if his wife continues to withhold the children from seeing him. LEGAL SECTION History of Charges and Arrests: John s participation in this substance abuse evaluation was suggested by a representative from the criminal justice system. He was referred as a consequence of his recent DWI arrest. John reports being arrested and charged once with driving while intoxicated twice, and twice for drug crimes. The drug related crimes were 1991 and 1995 possession charges, both reduced and dropped. His most recent charge was 3 weeks ago, and the case is still pending. He was charged with burglary, larceny, or breaking & entering on one occasion; he has no robbery charges. This charge was in 1985, and he was convicted, served 3 months in jail, and paid a fine. John was charged with disorderly conduct, vagrancy, or public intoxication on one occasion (public intoxications, 1990); he has never been charged with contempt of court. He was convicted on at least 1 of these charges. John has a history of being incarcerated for 3 months. His incarceration lasted about 3 months and was for burglary/larceny/b&e. Current Legal Involvement: In the past 30 days, John was detained/incarcerated on 2 days; he did not engage in any illegal activities for profit. He is awaiting either charges, trial, or sentencing for driving while intoxicated. He is not on probation or parole. Client Perception of Severity of Legal Problems and Desire for Treatment: John is slightly bothered by his legal problems; nevertheless, he feels that counseling for his legal problems is not important. Interviewer Impressions and Recommendations - Legal: It is my impression that John understood all of the questions, and that he did not deliberately misrepresent his legal information. He appears to have a minor legal problem or concern, but counseling does not look as though it is necessary. John has legal counsel for his current charges.

5 S.M.A.R.T. Treatment Planning Module 2 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful Additional Legal Comments: No comment. MEDICAL SECTION Medical History: John was hospitalized once for medical problems. This hospitalization was 5 years ago. He reports this hospitalization was for a routine appendectomy in the summer of He has a chronic medical problem (asthma) and is prescribed medications (inhaler) for this problem. He does not receive any financial compensation for physical disabilities. Client Perception of Severity of Medical Problems and Desire for Treatment: John does not report any medical problems in the past 30 days, and is not bothered by medical problems. Help obtaining treatment is not important to him at this time. Interviewer Impressions and Recommendations Medical: It is my impression that John understood all of the questions and that he did not deliberately misrepresent his medical information. He appears to have no need for medical treatment at this time. Additional Medical Comments: Client reports his overall health is very good. His asthma has been under control for several years now. He has expressed some concern regarding his alcohol and drug use and how that is affecting him physically. EMPLOYMENT SECTION Employment History: John has worked full time for most of the past three years. John's longest full time job lasted for 14 years. He works for a construction company. The majority of his employment in the past few years has been skilled manual work. Current Financial Resources: John reports working 24 days and making $7200 income in the past month. He reports he usually works a six day week. He did not receive any income from either unemployment compensation, welfare, pensions, benefits, or social security in the past month. He has not received any money from family or friends in the past month. John says that he has not made any money illegally in the past month. John has 4 dependents for whom he is financially responsible. John pays support to wife and three children. No one contributes any cash, food, housing, etc. for his support. Education, Training and Resources: He completed 14 years of traditional schooling obtaining a high school diploma and taking some college level courses as well as receiving 12 months of technical or vocational training. John has the skill base necessary to acquire a job. He does carpentry and masonry work and completed training in these areas. He has a valid driver's license but does not have use of a car for employment purposes.

6 S.M.A.R.T. Treatment Planning Module 2 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful Client Perception of Severity of Employment Problems and Desire for Treatment: Overall, he reports experiencing no problems related to obtaining or maintaining employment and is not troubled or bothered by employment related difficulties. Consequently, help obtaining treatment for employment related difficulties is not important to John. Interviewer Impressions and Recommendations - Employment: It is my impression that John understood all of the questions and that he did not deliberately misrepresent this information. He appears to have no need for employment counseling at this time. Additional Employment Comments: Client has had a very stable work history for the past fourteen years. He is very satisfied with this status and has no desire to pursue training or additional education. Interviewer Comment The above information is based on John Smith s responses to questions from the Addiction Severity Index interview and was completed on 08/26/2004. This information will be used to guide John s placement into treatment and to develop his specific treatment care plan (Interviewer s Name)

7 S.M.A.R.T. Treatment Planning Module 2 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful GRAPHS The following is a graph showing the client's perception of his problems, column A, and his desire for treatment, column B. Client Perception of Problem and Need for Treatment A B A B A B A B A B A B A B A B Medical Employ Alcohol Drug Legal Family Social Psych A = Client s Rating of Problem B = Client s Rating of Desire for Treatment Legend: 0-Not at all, 1-Slightly, 2-Moderately, 3-Considerably, 4-Extremely A = Perceived Problems, B = Desire for Treatment.

8 S.M.A.R.T. Treatment Planning Module 2 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful The following is a graph showing the interviewer's severity rating of the client's need for treatment or additional treatment in each of the seven sections of the Addiction Severity Index. INTERVIEWER SEVERITY RATINGS Medical Employ Alcohol Drug Legal Family Psych Legend: 0-1: No real problem, 2-3: Slight Problem, 4-5: Moderate Problem, 6-7: Considerable Problem, 8-9: Extreme Problem

9 ASI Master Problem List Date Identified Problem Code Client: John Smith Problem Statement Status Date Resolved 6/29/05 M1 Has a chronic medical problem that interferes with her/his life A/D 1 A/D 2 A/D 3 A/D 4 A/D 5 Reports several or more episodes of drinking alcohol to intoxication in the past month Reports regular, lifetime use of alcohol to intoxication Reports using heroin in past month Reports lifetime, regular use of heroin Reports lifetime, regular use of sedatives, hypnotics, or tranquilizers A/D 6 A/D 7 A/D 8 A/D 9 A/D 10 A/D 11 A/D 12 L1 L2 L3 Reports using cocaine in past month Reports lifetime, regular use of cocaine Reports using marijuana in past month Reports lifetime, regular use of marijuana Reports simultaneous use of multiple substances in past month Reports lifetime, regular use of multiple substances Reports having problems with alcohol in past month Is troubled by alcohol problems and is interested in treatment The admission was prompted or suggested by someone in the criminal justice system Is awaiting charges, trial, or sentencing Has been detained or incarcerated within past 30 days F1 F2 F3 P1 P2 P3 P4 P5 Not satisfied with how she/he spends her/his free time Reports having serious problems w/ family members in past month Is troubled by family problems and is interested in treatment Has had significant problems with depression in past month Has had trouble controlling violent behavior in past month Has experienced psychological or emotional problems in past month Is troubled by psychological or emotional problems in past month Is troubled by psychological or emotional problems and is interested in treatment Status Code Client Name John Smith D = Deferred R = Resolved T = Transferred ID # S.M.A.R.T. Treatment Planning Module 2 Handout 2 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

10 ASI Treatment Plan (ASI/DENS Format) Client Problem Plan Alcohol & Drug Client Name: John Smith Counselor Name: Demo Date Problem Statement Goals D/C Criteria Objectives What will the client say or do? Under what circumstances? How often will he/she say or do this? Interventions What will the counselor/staff do to assist client? Under what circumstances? Service Codes Target Date Resolution Date Participation in Treatment Planning Process Participation by Others in the Treatment Planning Process Note: All participants may not have participated in every area. Client Signature/Date Counselor Signature/Date Service Codes I=Individual G=Group F=Family C=Couples P=Psychoeducational H=Homework R=Reading M=Media V=Videotape A=Audiotape R=Referral S.M.A.R.T. Treatment Planning Module 2 Handout 3 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

11 ASI Treatment Plan (ASI/DENS Format) Client Problem Plan Medical Client Name: John Smith Counselor Name: Demo Date Problem Statement Goals D/C Criteria Objectives What will the client say or do? Under what circumstances? How often will he/she say or do this? Interventions What will the counselor/staff do to assist client? Under what circumstances? Service Codes Target Date Resolution Date Participation in Treatment Planning Process Participation by Others in the Treatment Planning Process Note: All participants may not have participated in every area. Client Signature/Date Counselor Signature/Date Service Codes I=Individual G=Group F=Family C=Couples P=Psychoeducational H=Homework R=Reading M=Media V=Videotape A=Audiotape R=Referral S.M.A.R.T. Treatment Planning Module 2 Handout 4 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

12 ASI Treatment Plan (ASI/DENS Format) Client Name: John Smith Date Problem Statement Client Problem Plan Family Counselor Name: Demo Goals D/C Criteria Objectives What will the client say or do? Under what circumstances? How often will he/she say or do this? Interventions What will the counselor/staff do to assist client? Under what circumstances? Service Codes Target Date Resolution Date Participation in Treatment Planning Process Participation by Others in the Treatment Planning Process Note: All participants may not have participated in every area. Client Signature/Date Counselor Signature/Date Service Codes I=Individual G=Group F=Family C=Couples P=Psychoeducational H=Homework R=Reading M=Media V=Videotape A=Audiotape R=Referral S.M.A.R.T. Treatment Planning Module 2 Handout 5 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

13 EXAMPLE ASI Treatment Plan Medical Domain (ASI/DENS Format) Client Name: John Smith Counselor Name: Demo Date Problem Statement 06/01/2005 John reports having a chronic medical problem that requires ongoing care. 06/01/2005 John reports having been diagnosed with a chronic pain problem. 06/01/2005 John reports having been diagnosed with an infectious illness or sexually transmitted disease and requires assistance obtaining medical services. Goals Gain control of John s chronic medical problems, decreasing impact on addiction. Ensure John is obtaining and taking necessary medications. Reduce the impact of John s medical problems on his recovery and relapse potential. D/C Criteria Objectives What will the client say or do? Under what circumstances? How often will he/she say or do this? Required John will obtain an assessment of his medical problems from the staff physician assistant. Required Optional John will understand his chronic pain diagnosis and maintain his health by complying with treatment recommendations. John will visit a medical center/clinic for assessment and treatment of his medical problems. Interventions Service Target Resolution What will the counselor/staff do to assist client? Under what circumstances? Codes Date Date Staff will arrange medical services at treatment program. I 06/05/05 06/10/05 Staff will call a medical service provider/clinic with John to make an appointment for necessary medical services. Staff will review list of 3 things John can do constructively to address his medical problems. I 06/05/05 06/15/05 G 06/10/05 Participation in Treatment Planning Process John reports that he did contribute to this plan, but it is unclear if he agrees with it. John reports that he is aware of the content of this plan. Participation by Others in the Treatment Planning Process Family members were invited and participated in the treatment planning process. Family members agree with this plan. Significant others were invited to participate in the treatment planning process but were unable to do so. Note: All participants may not have participated in every area. Client Signature/Date Counselor Signature/Date Service Codes I=Individual G=Group F=Family C=Couples P=Psychoeducational H=Homework R=Reading M=Media V=Videotape A=Audiotape R=Referral S.M.A.R.T. Treatment Planning Module 4 Handout 1 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

14 EXAMPLE S.O.A.P. NOTE 01/03/05: IND: IND GRP FAM COL TYPE OF NOTE INDIVIDUAL SESSION GROUP SESSION FAMILY SESSION COLLATERAL SESSION Note: Standardized Abbreviations S: I wanted to talk to my kids about how guilty I feel about my drinking. O: Tearful at times; gazed down and fidgeted with shirt buttons A: Consumer has gained awareness in how drinking behavior has embarrassed and hurt his teenage children. He expresses intense feelings related to his drinking and appears to assume responsibility for his past behaviors. P: Completed Tx Plan Goal #1, Obj 1. Continue with Goal #1, Obj 2, in next session. Sally Jones, CAC OTHER COMMONLY USED DOCUMENTATION FORMATS D.A.P. NOTE VERSION 1 D = Describe A = Assess P = Plan D.A.P. NOTE VERSION 2 D = Data A = Assess P = Plan OTHER: *Note other documentation formats used in agency/regional area OTHER: *Note other documentation formats used in agency/regional area S.M.A.R.T. Treatment Planning Module 4 Handout 2 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

15 S. O. A. P. NOTE FORMATS USED IN DOCUMENTING CONSUMER PROGRESS S = Subjective or summary statement by the client. Usually, this is a direct quote. The statement chosen should capture the theme of the session. 1. If adding your own explanatory information, place within brackets [ ] to make it clear that it is not a direct quote. Example of session theme: When he raises his voice, I just... what do I do?... Yes, I ll talk more in group. 2. If client refers to someone else s name, indicate that other person by initials. This makes it clear that the client is the focus, not the person the client is talking about. It also guards against any breeches in confidentiality. This is especially true when a client refers to another client. Example of client using someone else s name: She really made me mad... You think I should make an appointment to talk to her? I don t like dealing with this stuff [case worker S.P.]. 3. If the client didn t attend the session or doesn t speak at all, use a dash on the S line. Example: S: --- O = Objective data or information that matches the subjective statement. Descriptions may include body language and affect. Example: 20 minutes late to group session, slouched in chair, head down, later expressed interest in topic. A = Assessment of the situation, the session, and the client, regardless of how obvious it might be based on the subjective and/or objective statements. Example: Needs support in dealing with scheduled appointments and taking responsibility for being on time to group. Example: Needs referral to mental health specialist for mental health assessment. Example: Beginning to own responsibility for consequences related to drug use. P = Plan for future clinical work. Should reflect interventions specified in treatment plan including homework assignments. Reflect follow-up needed or completed. Example: Begin to wear a watch and increase awareness of daily schedule. Example: Complete Tx Plan Goal #1, Objective 1. Example: Consider mental health evaluation referral. Example: Contact divorce support group and discuss schedule with counselor at next session. Adapted from work by Larry T. Mark and presented by Donna Wapner, Diablo Valley College. Handout included in materials produced by the Pacific Southwest Addiction Technology Transfer Center, S.M.A.R.T. Treatment Planning Module 4 Handout 3 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

16 Case Note Scenario You are a case manager in an adult outpatient drug and alcohol treatment program. The center you work for provides only intensive outpatient and outpatient services. As a case manager for the outpatient component, you have an active caseload of 25 patients. You primarily work with young adults between the ages of 18 and 25 who have some sort of involvement with the adult criminal justice system. Jennifer Martin is your patient. She attends both group and individual therapy sessions. For the past three weeks she has missed two group sessions, one individual session and has been 15 minutes late to another individual session. Jennifer is on probation for possession of a controlled substance and grand larceny. She has been in treatment for approximately two months. You, as her case manager, have asked her to attend this session after missing her last individual appointment. Case Manager: Jennifer: Case Manger: Jennifer: Case Manager: Jennifer: Case Manager: Jennifer: I am glad to see you made it today, Jennifer. I am starting to get worried about your attendance for the past two weeks. I ve just been really busy lately. You know, it is not easy staying clean, working, and making counseling appointments. Are you really worried about me or are you just snooping around trying to get information about me to tell my mom and probation officer? You seem a little defensive and irritated. Are you upset with me or your mom and your probation officer, or with all of us? I don t know...it just feels like everyone is on my case. I am tired of having to report to everyone where I am going, what I am doing, why I am doing things, and not doing others. I am just so tired of everyone watching me. I guess that includes you too. So I am included on this list of people who watch over you. How did I get on this list? You told my probation officer that I had missed group and individual sessions before you talked to me. And that makes you feel... Pissed off. I thought you were different. I thought I could trust you, but you are just like everyone else in my life. S.M.A.R.T. Treatment Planning Module 4 Handout 4 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

17 Case Manager: Jennifer: Case Manager: Jennifer: Case Manager: Jennifer: Case Manager: Jennifer: Case Manager: Jennifer: Just like everyone else, meaning? You go over my head, treat me like a child, don t talk with me first. I hate when people do that. Why did you have to talk to my probation officer before talking with me? It sounds like I hurt your feelings and broke some kind of trust with you. Yeah, it feels like that. (Jennifer stops talking and looks at the ground, wiggling her leg back and forth.) Have you felt this way before, Jennifer? Hurt, and like the person you trusted has let you down? (Jennifer slowly raises her head and nods.) When did you feel like this, Jennifer? When my dad divorced my mom, about two years ago. He promised he would stay in contact with me. Oh, he did for a while, about six months after the divorce, but his calls and visits got more and more sporadic. I didn t hear from him until I got arrested and put on probation. I hate talking about this stuff! I know it is hard talking about this and it brings up a lot of strong feelings for you, but we need to do this. How are the feelings you have regarding trust related to your use of methamphetamine? I don t want to talk about this; its too painful! Jennifer grabs her backpack and walks out of the counseling room. The Case Manager attempts to get her to return, but Jennifer keeps walking. S.M.A.R.T. Treatment Planning Module 4 Handout 4 Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful

18 Here s What You ll Get Today... S.M.A.R.T. Treatment Planning Utilizing the ASI: Making Required Data Collection Useful How to use ASI information to make a counselor s job easier Build an individualized or client-driven treatment plan Practice, practice, practice 2 Training Expectations 1. Identify characteristics of a programdriven and an individualized treatment plan 2.Understand how individualized treatment plans improve client retention and ultimately lead to better outcomes Training Expectations 3.Use Master Problem List (provided) to formulate treatment plans and develop: Problem Statements Goals based on Problem Statements Objectives based on Goals Interventions based on Objectives 3 4 Training Expectations What is Not Included in Training 4.Practice writing documentation notes reflecting how treatment plan is progressing (or not progressing) Administering and scoring the ASI Administering any other standardized screening/assessment tool Training on clinical interviewing 5 6 1

19 The Goal of this Training is... To Marry the assessment and treatment planning processes Treatment Plans are... Meaningless & time consuming Ignored Same plan, different names 7 8 The What, Who, When, How of Treatment Planning What is a Treatment Plan? A written document that: Identifies the client s most important goals for treatment Describes measurable, time sensitive steps toward achieving those goals Reflects a verbal agreement between the counselor and client 9 Center for Substance Abuse Treatment, Who Develops the Treatment Plan? Client partners with treatment providers (ideally a multi-disciplinary team) to identify and agree on treatment goals and identify the strategies for achieving them When is the Treatment Plan Developed? At the time of admission And continually updated and revised throughout treatment

20 How Does Assessment Guide Treatment Planning? The ASI, for example, identifies client needs or problems by using a semistructured interview format The ASI guides delivery of services that the client needs How Does Assessment Guide Treatment Planning? Treatment goals address those problems identified by the assessment Then, the treatment plan guides the delivery of services needed What is the ASI? A reliable and valid instrument, widely used both nationally and internationally Conducted in a semi-structured interview format Can be effectively integrated into clinical care Cacciola et al., 1999; Carise et al., 2004; Kosten et al., 1987; McLellan et al., 1980; 1985; What is the ASI? Identifies 7 potential problem areas 1. Medical status 2. Employment and support 3. Drug use 4. Alcohol use 5. Legal status 6. Family/social status 7. Psychiatric status 16 What the ASI is NOT? A personality test A medical test A projective test such as the Rorschach Inkblot Test A tool that gives you a diagnosis Why Use the ASI? 1.Historical Reasons 2.Clinical Applications 3.Evaluation Uses

21 1.1 History of ASI 1.2 Recent Developments Developed by Pennsylvania University for research studies conducted in Veterans Hospitals Not intended for national distribution Frequently used because of mandates* Efforts focused on making the ASI more useful for clinical work (Example: Using ASI for treatment planning) The Drug Evaluation Network System (DENS) Software uses ASI information to create a clinical narrative. *Crevecoeur et al., 2002; McLellan et al., ASI Now More Clinically Useful! New and Improved DENS Software (2005) Uses ASI information to auto-populate possible problem lists and prompt and guide clinician in developing a treatment plan! 2.1 Clinical Application Why use the ASI? Uses a semi-structured interview to gather information a counselor is required to collect during assessment Shown to be an accurate or valid measure of the nature and severity of clients problems 21 Kosten et al., 1987; McLellan et al., 1980; 1985; Clinical Application Why use the ASI? Prompts counselor to focus session on important problems, goals, and objectives Basis for continued stay reviews and documentation Basis for discharge plan 2.3 Clinical Application Why use the ASI? NIDA Principle 3 To be effective, treatment must address individual s drug use and any associated medical, psychological, social, vocational, and legal problems ASI assesses all these dimensions

22 2.4 Clinical Application Clinical use of ASI improves rapport... If patients problems are accurately assessed, they may feel heard by their counselor potentially leading to the development of rapport and even a stronger helping alliance. 2.5 Clinical Application Using ASI to match services to client problems improves retention... Patients whose problems are identified at admission; and then receive services that are matched to those problems, stay in treatment longer. Barber et al., 1999, 2001; Luborsky et al., 1986, Carise et al., 2004; Hser et al., 1999; Kosten et al., 1987; McLellan et al., Evaluation Uses For Program Directors Identifies types of client problems not addressed through in-house services Quantifies client problems Identifies trends over time 3.2 Evaluation Uses For Program Directors Assists with level of care choices Provides quantifiable measure of program success Documents unmet client service needs Includes data needed for reports to various stakeholders Evaluation Uses For Program Directors Positions programs for increased funding though participation in clinical trials and other research opportunities 3.4 Evaluation Uses For Clinical Supervisors ASI data can be used to: Identify counselor strengths and training needs Match clients to counselor strengths Identify trends in client problems

23 Other Organizational Considerations 1. Information requirements of funding entities/managed care? 2. Is there duplication of information collected? 3. Is technology used effectively? 4. Is paperwork useful in treatment planning process? Field of Substance Abuse Treatment: Early Work Program-Driven Plans One size fits all Program-Driven Plans Client needs are not important as the client is fit into the standard treatment program regimen Plan often includes only standard program components (e.g., group, individual sessions) Little difference among clients treatment plans 33 Program-Driven Plans Client will Attend 3 AA meetings a wk 2. Complete Steps 1, 2, & 3 3. Attend group sessions 3x/wk 4. Meet with counselor 1x/wk 5. Complete 28-day program Still don t fit right Program-Driven Plans Often include only those services immediately available in agency Often do not include referrals to community services (e.g., parenting classes) ONLY baggy jeans? Treatment Planning: A Paradigm Shift Individualized Treatment Plans Many colors/styles available Custom style & fit

24 Individualized Plan Sized to match client problems and needs To Individualize a Plan, What Information is Needed? 1.What does a counselor need to discuss with a client before developing a treatment plan? 2.Where do you get the information, guidelines, tools used, etc.? To Individualize a Plan, What Information is Needed? Possible sources of information might include: Probation reports Screening results Assessment scales Collateral interviews Biopsychosocial Model... Biological Psychological Sociological Biopsychosocial Model Example... Does the client have a car? Can they access public transportation? Sociological How available are drugs or alcohol in the home? ASI Problem Domains and the Biopsychosocial Model... Biological (e.g., Medical Status) Psychological (e.g., Psychiatric Status) How close do they live to the treatment center? 41 Sociological (e.g., Family & Social Status) 42 7

25 Case A Assessment Information: Jan Case B Assessment Information: Dan 27 year old, single Caucasian female 3 children under age 7 No childcare readily available Social companions using drugs/alcohol Unemployed No high school/ged 2 arrests for possession of meth & cannabis + 1 probation violation 36 year old, married African-American male 2 children 2 arrests and 1 conviction for DUI Arrest BAC.25 Employed Rates high severity - family problems The Old Method (Program-Driven) Alcohol Dependence Problem Statement Not individualized Not a complete sentence Doesn t provide enough information A diagnosis is not a complete problem statement The Old Method (Program-Driven) Goal Statement Will refrain from all substance use now and in the future Not specific for Jan or Dan Not helpful for treatment planning Cannot be accomplished by program discharge The Old Method (Program-Driven) Objective Statement Will participate in outpatient program Again, not specific for Jan or Dan A level of care is not an objective The Old Method (Program-Driven) Intervention Statement Will see a counselor once a week and attend group on Monday nights for 12 weeks This sounds specific but describes a program component

26 Why Make the Effort? Individualized Treatment Plans Leads to increased retention rates which are shown to lead to improved outcomes Empowers the counselor and the client, and focuses counseling sessions 49 Why Make the Effort? Individualized Treatment Plans: Like a pair of jeans, this plan fits the client well ASI: Like measurements, the ASI items are used to fit the client s services to her/his needs 50 What is included in any treatment plan? What Components Are Found in a Treatment Plan? 1. Problem Statements 2. Goal Statements 3. Objectives Interventions 52 Treatment Plan Components 1. Problem Statements are based on information gathered during the assessment 2. Goal Statements are based on the problem statements and reasonably achievable in the active treatment phase Problem Statement Examples Van* is experiencing increased tolerance for alcohol as evidenced by the need for more alcohol to become intoxicated or achieve the desired effect Meghan* is currently pregnant and requires assistance obtaining prenatal care Tom s* psychiatric problems compromise his concentration on recovery *May choose to use client last name instead e.g., Mr. Pierce; Ms. Hunt 9

27 Goal Statement Examples Van* will safely withdraw from alcohol, stabilize physically, and begin to establish a recovery program Meghan* will obtain necessary prenatal care Reduce the impact of Tom s* psychiatric problems on his recovery and relapse potential *May choose to use client last name instead e.g., Mr. Pierce; Ms. Hunt 55 Treatment Plan Components 3. Objectives are what the client will do to meet those goals 4. Interventions are what the staff will do to assist the client Other common terms: Action Steps Measurable activities Treatment strategies Benchmarks Tasks 56 Examples of Objectives Intervention Examples Van will report acute withdrawal symptoms Van will begin activities that involve a substance-free lifestyle and support his recovery goals Meghan will visit an OB/GYN physician or nurse for prenatal care Tom will list 3 times when psychological symptoms increased the likelihood of relapse 57 Staff medical personnel will evaluate Van s need for medical monitoring or medications Staff will call a medical service provider or clinic with Meghan to make an appointment for necessary medical services Staff will review Tom s list of 3 times when symptoms increased the likelihood of relapse and discuss effective ways of dealing with those feelings 58 Review: Components in a Treatment Plan Treatment Plan Components 1. Problem Statements (information from assessment) 2. Goal Statements (based on Problem Statement) 5. Client Strengths* are reflected 6. Participants in Planning* are documented 3. Objectives (what the client will do) *The DENS Treatment Planning Software includes these components 4. Interventions (what the staff will do)

28 ASI Narrative and Master Problem List Master Problem List Refer to ASI Narrative Report (Module 2, Handout 1) Review case study Focus on problems identified in the: alcohol/drug domain medical domain family/social domain ASI Master Problem List Date Domain Problem Status Date Resolved Identified Alcohol/Drug The client reports several or more episodes of drinking alcohol to intoxication in past month. Considerations in Writing... All problems identified are included regardless of available agency services The client reports regular, lifetime use of alcohol to intoxication. The client reports using heroin in past month. Include all problems whether deferred or addressed immediately Medical Family/Social Client has a chronic medical problem that interferes with his/her life The client is not satisfied with how he/she spends his/her free time Each domain should be reviewed The client reports having serious problems with family members in the past month The client is troubled by family problems and is interested in treatments A referral to outside resources is a valid approach to addressing a problem Master Problem List 63 Master Problem List 64 Tips on Writing Problem Statements Changing Language Non-judgmental No jargon statements Client is in denial. Client is co-dependent. 1.Client has low self-esteem. 2.Client is in denial. 3.Client is alcohol dependent. Use complete sentence structure Problem Statements Problem Statements 11

29 Changing Language Changing Language: Pick Two 4.Client is promiscuous. 5.Client is resistant to treatment. 6.Client is on probation because he is a bad alcoholic. Think about how you might change the language for 2 of the preceding problem statements Rewrite those statements using non-judgmental and jargon-free language Problem Statements 67 Problem Statements 68 Changing Language - Examples Changing Language - Examples 1. Client has low self-esteem. Client averages 10 negative self-statements daily 2. Client is in denial. Client reports two DWIs in past year but states that alcohol use is not a problem 3. Alcohol Dependent. Client experiences tolerance, withdrawal, loss of control, and negative life consequences due to alcohol use 4. Client is promiscuous. Client participates in unprotected sex four times a week 5. Client is resistant to treatment. In past 12 months, client has dropped out of 3 treatment programs prior to completion 6. Client is on probation because he is a bad alcoholic. Client has legal consequences because of alcohol-related behavior Problem Statements 69 Problem Statements 70 Case Study Problem Statements Date ASI Treatment Plan Format Problem Statement Alcohol/drug domain Medical domain Family/social domain 06/01/2005 John reports having a chronic medical problem that requires ongoing care. 06/01/2005 John reports having been diagnosed with a chronic pain problem. Goals Gain control of John s chronic medical problems, decreasing their impact on addiction. Ensure John is obtaining and taking necessary medications. D/C Criteria Objectives Required John will obtain an assessment of his medical problems from the staff Physician Assistant. Optional John will visit a medical center/clinic for assessment and treatment of his medical problems. Interventions Service Target Resolution Codes Date Date Staff will arrange medical services at treatment program. I 06/05/05 06/10/05 Write 1 problem statement for each domain Staff will review list of 3 things John can do constructively to address his medical problems. G 06/15/05 Treatment Plan Update Due: 06/30/2005 Participation in the Treatment Planning Process John reports that he did contribute to this plan, but it is unclear if he agrees with it. John reports that he is aware of the content of this plan. Participation by Others in the Treatment Planning Process Problem Statements 71 Family members were invited and participated in the treatment planning process. Family members agree with this plan. Significant others were invited to participate in the treatment planning process but were unable to do so

30 Now that we have the problems identified... Remember Maslow s Hierarchy of Needs? 5 Self-actualization How do we prioritize problems? 3 4 Self-esteem Love & Belonging 2 Safety & Security 1 Biological/Physiological Physical Needs Substance Use Physical Health Management Medication Adherence Issues Safety & Security Mental health management Functional impairments Legal issues 1 Biological/Physiological PHYSIOLOGICAL 2 Safety & Security Love & Belonging Needs Self-Esteem 3 Love & Belonging Social & interpersonal skills Need for affiliation Family relationships 4 Self-Esteem Achievement and mastery Independence/status Prestige

31 Self-Actualization Self-Esteem & Self-Actualization 5 Self-Actualization Seeking personal potential Self-fulfillment Personal growth 5 Self-actualization 4 Self-esteem Is self-esteem specific? How would you measure it? Self-actualization Self-esteem Relationship Between ASI Domains & Maslow s Hierarchy of Needs ASI Domain 5 Family/Social Relationships Love & Belonging ASI Domain 2 Employment/Support Status ASI Domain 4 Legal Status Safety & Security Biological/ Physiological ASI Domain 1 - Medical ASI Domain 3 Drug/Alcohol Use ASI Domain 6 Psychiatric Status 81 Practice Prioritizing Pick 3 ASI problem domains for John Smith which appear most critical Which domain should be addressed 1 st, 2 nd, 3 rd and why? 82 Begin Writing Goal Statements Use ASI Treatment Plan Handouts 1. Alcohol/Drug Domain 2. Medical Domain 3. Family/Social Write at least 1 goal statement for each domain Write in complete sentences Check-In Discussion Will the client understand the goal? (i.e., No clinical jargon?) Clearly stated? Complete sentences? Attainable in active treatment phase? Is it agreeable to both client and staff?

32 Now let s build S.M.A.R.T. treatment objectives and interventions S Specific R Realistic A Attainable M Measurable T Time-limited 85 S.M.A.R.T. Objectives & Interventions S Specific Objectives and interventions are specific and goal-focused Address in specific behavioral terms how level of functioning or functional impairments will improve 86 S.M.A.R.T. Objectives & Interventions Measurable Objectives and interventions are measurable Achievement is observable Measurable indicators of client progress Assessment scales/scores Client report Behavioral and mental status changes M 87 S.M.A.R.T. Objectives & Interventions Attainable Objectives and interventions attainable during active treatment phase Focus on improved functioning rather than cure Identify goals attainable in level of care provided Revise goals when client moves from one level of care to another A 88 S.M.A.R.T. Objectives & Interventions S.M.A.R.T. Objectives & Interventions R Realistic Time-limited T Client can realistically complete objectives within specific time period Goals and objectives are achievable given client environment, supports, diagnosis, level of functioning Progress requires client effort 89 Focus on time-limited or shortterm goals and objectives Objectives and interventions can be reviewed within a specific time period 90 15

33 S.M.A.R.T. Clinical Example S.M.A.R.T. Clinical Example Problem Statement: Client reports 3 emergency room visits for physical injuries (bruised ribs, broken arm) in the last 6 months due to physical altercations with live-in boyfriend S R A M T 91 Example Goal: Client will develop a safety plan and discuss it in group sessions Example Objective: Client will attend 6 domestic violence awareness classes during the next 6 weeks Example Intervention: Counselor will assist client in contacting the Committee to Aid Abused Women by a specified date S R A M T 92 Do Examples Pass S.M.A.R.T. Guidelines? S M A R T Yes, the examples include specific activities Yes, the counselor can evaluate how many classes the client attended Yes, client has transportation to attend classes Yes, the client has the ability to attend classes Treatment Planning Process Review 1. Conduct assessment 2. Collect client data and information 3. Identify problems 4. Prioritize problems 5. Develop goals to address problems 6. Write S.M.A.R.T. Objectives to meet goals Interventions to assist client in meeting goals Yes, the class runs for 6 weeks ASI Treatment Plan Format Date Problem Statement 06/01/2005 John reports having a chronic medical problem that requires ongoing care. 06/01/2005 John reports having been diagnosed with a chronic pain problem. Goals Gain control of John s chronic medical problems, decreasing their impact on addiction. Ensure John is obtaining and taking necessary medications. The Stages of Change Illustrated D/C Criteria Required Optional Objectives John will obtain an assessment of his medical problems from the staff Physician Assistant. John will visit a medical center/clinic for assessment and treatment of his medical problems. Interventions Staff will arrange medical services at treatment program. Staff will review list of 3 things John can do constructively to address his medical problems. Service Codes I G Target Date 06/05/05 06/15/05 Resolution Date 06/10/05 Adapted from Prochaska & DiClemente,, 1982; 1986 Treatment Plan Update Due: 06/30/2005 Participation in the Treatment Planning Process John reports that he did contribute to this plan, but it is unclear if he agrees with it. John reports that he is aware of the content of this plan. Participation by Others in the Treatment Planning Process Family members were invited and participated in the treatment planning process. Family members agree with this plan. Significant others were invited to participate in the treatment planning process but were unable to do so

34 Consider Stages of Change 6. Relapse 1. Pre-Contemplation Pre-Contemplation I don t have a problem 2. Contemplation 5. Maintenance 3. Preparation 4. Action Prochaska & DiClemente, 1982; Person is not considering or does not want to change a particular behavior. 98 Contemplation Preparation Maybe I have a problem. I ve got to do something. Preparation Contemplation Pre- Contemplation Person is certainly thinking about changing a behavior. 99 Contemplation Pre- Contemplation Person is seriously considering & planning to change a behavior and has taken steps toward change. 100 Action Action I m ready to start. Maintenance How do I keep going? Maintenance Action Preparation Preparation Person is actively doing things to change or modify behavior. Contemplation Pre- Contemplation Contemplation Person continues to maintain behavioral Pre- change until it becomes Contemplation permanent

35 Relapse What went wrong? Maintenance Relapse Action Contemplation Pre- Contemplation Preparation Person returns to pattern of behavior that he or she had begun to change. 103 S.M.A.R.T. Objectives and Interventions 1. Alcohol/Drug Domain Write 2 objective statements Required or optional for discharge? Write 2 intervention statements Assign service codes and target dates 104 S.M.A.R.T. Objective/Intervention Test S.M.A.R.T. Objectives and Interventions Specific? Will client understand what is expected and how program/staff will assist in reaching goals? Measurable? Attainable? Realistic? Can change be documented? Achievable within active treatment phase? Is it reasonable to expect the client will be able to take steps on his or her behalf? Is it agreeable to client and staff? Time-Related? Is time frame specified? Will staff be able to review within a specific period of time? Medical Domain 3. Family/Social Domain Write 2 objective statements Required or optional for discharge? Write 2 intervention statements Assign service codes and target dates 106 Other Required Elements Documentation Basic Guidelines New, Improved DENS Software (2005) Guides counselor in documenting: Client Strengths Dated, Signed, Legible Referral Information Documented Participants in Planning Process Client Name on Each Page 107 Client Strengths/ Limitations in Achieving Goals Source of Information Clearly Documented

36 Documentation: Basic Guidelines Entries should include... Your professional assessment Continued plan of action Documentation: Basic Guidelines Describes... Changes in client status Response to and outcome of interventions Observed behavior Progress towards goals and completion of objectives Documentation: Basic Guidelines The client s treatment record is a legal document Clinical Example: Agency Trip Documentation: Basic Guidelines Legal Issues & Recommendations: Document non-routine calls, missed sessions, and consultations with other professionals Avoid reporting staff problems in case notes, including staff conflict and rivalries Chart client s non-conforming behavior Record unauthorized discharges and elopements Note limitations of the treatment provided to the client S.O.A.P. Method of Documentation Subjective - client s observations or thoughts, client statement Objective counselor s observations during session Assessment - counselor s understanding of problems and test results Plan goals, objectives, and interventions reflecting identified needs 113 S.O.A.P. Note Example 06/30/05: Individual Session S: My ex-wife has custody of the kids and stands in the way of letting me see them. O: Tearful at times; gazed down and fidgeted with shirt buttons. A: Client has strong feelings that family is important in his recovery process. He has a strong desire to be a father to his children and is looking for a way to resolve conflicts with his ex-wife. P: Addressed Tx Plan Goal #4, Action Step 1. Continue with Tx Plan Goal #4, Action Step 2 in next session. Mary Smith, CADAC

37 Tx Plan Reflected in Documentation? C.H.A.R.T. Method of Documentation Client quote Physiological observations? S: My ex-wife has custody of the kids and stands in the way of letting me see them. O: Tearful at times; gazed down and fidgeted with shirt buttons. Client Condition Historical Significance of client condition A: Client has strong feelings that family is Problem statements, important in his recovery process. He has a testing results, ASI severity ratings, strong desire to be a father to his children and non-judgmental is looking for a way to resolve conflicts with professional assessment his ex-wife. Action What action counselor took in response to client condition Response How client responded to action Goals, Objectives, Interventions P: Addressed Tx Plan Goal #4, Objective 1. Continue with Tx Plan Goal #4, Objective 2 in next session. 115 Treatment Plan How it relates to plan Roget & Johnson, Case Note Scenario You are a case manager in an adult outpatient drug and alcohol treatment program. The center you work for provides only intensive outpatient and outpatient services. As a case manager, for the outpatient component, you have an active caseload of 25 patients. You primarily work with young adults between the ages of 18 and 25 who have some sort of involvement with the adult criminal justice system. Jennifer Martin is your patient. Case Manager: I am glad to see you made it today, Jennifer. I am starting to get worried about your attendance for the past two weeks. Jennifer: I ve just been really busy lately. You know, it is not easy staying clean, working, and making counseling appointments. Are you really worried about me or are you just snooping around trying to get information about me to tell my mom and probation officer? Write a Documentation (Progress) Note DISCHARGE PLAN SCREENING & ASSESSMENT TX PLAN INITIAL SERVICE AUTHORIZATION LEVEL OF CARE REFERRALS Case Manager: You seem a little defensive and irritated. Are you upset with me or your mom and your probation officer, or with all of us? 117 TREATMENT PLAN REVIEWS Continued Stay Reviews ONGOING DOCUMENTATION 118 Other Organizational Considerations 1. Information requirements of funding entities/managed care? 2. Is there duplication of information collected? 3. Is technology used effectively? 4. Is paperwork useful in treatment planning process?

38 TRI science addiction Drug Evaluation Network System (DENS) Software Overview The DENS Software Suite is an electronic ASI data collection system created with substance abuse treatment providers in mind. It automates administration of the ASI through an intuitive, time-saving interface used mainly by counselors at treatment facilities. The software takes very little time to learn and has a host of benefits unavailable to states and/or programs currently using paper and pencil instruments. To schedule a DENS training or more information on the public domain DENS Software System, contact Meghan Love, Treatment Systems Section Coordinator, at MLove@tresearch.org. Comprehensive intake assessment The DENS Suite is a vehicle for the collection of the ASI, the most widely used substance abuse assessment instrument in the world. Mandated by numerous state governments as well as the Veteran s Administration, it is a standardized, semi-structured, multi-focused screening and assessment tool collecting client information in many different areas of the client s life (General Information, Medical, Employment, Alcohol/Drug, Legal, Family/Social, and Psychiatric). Every question on the ASI form is included in the software, which uses the same semi-structured format as the original ASI instrument to ensure questions are posed in the order intended. With the click of a button, interviewers can administer either the complete ASI interview or a shortened interview called the ASI-Lite. Less personally sensitive questions are asked toward the beginning, with more invasive items and sections appearing toward the end. This allows a counselor to build rapport before posing questions regarding intimate details to their clients. Advanced functionality with little or no learning curve The software was designed to be as easy to use as possible, especially for those with little or no previous experience with computers. All major functions are accessed through point-and-click button pressing, and all frequently used buttons have graphics to provide a visual aid. In addition, there are no menus, or options screens to configure. After a brief initial sign-in and registration process (completed by either TRI or site staff), every aspect of the DENS Suite is configured and available for immediate use by counselors, who can perform all software functions without the need to memorize commands or complex procedures. On-screen help is present at all times (for both software functions and the ASI interview), and there is room within the title bar of the program to enter a telephone number users may call should they have a question or require further assistance. DENS software training is normally an inherent part of the TRI ASI training protocol. We have found consistently that even those with the most elementary level of computer literacy feel more comfortable using the DENS Suite once they are properly trained and have spent some time practicing using the software. Treatment Research Institute

39 Coding, Crosschecks, and Defaults The DENS Suite contains a number of embedded quality assurance measures to assure the data collected is as accurate as possible. Most visible among these is a series of Crosschecks and Defaults within the ASI portion of the software. Sample Crosscheck: Drug and Alcohol section If a counselor codes a client with more days drinking to intoxication than the number of days coded for drinking at all, a pop-up message will appear warning the counselor that this situation is not possible, prompting them to recode either days drinking or days drinking to intoxication. The computer will automatically send the counselor to the item to be recoded. Sample Default: Legal Section If a counselor codes a client as not awaiting trial or sentencing for any criminal charges, the software will automatically code the next item (asking for the specific charge for which they are awaiting trial or sentencing) with a zero (0). Crosschecks and Defaults guard against contradictory responses throughout the course of a client s intake assessment and ensure the counselor is coding consistently and according to standardized ASI coding conventions. In addition to these safeguards, each text field within the DENS Suite is set to accept only a particular set of characters as a response (i.e., a how many days in the past 30 question will only accept a numerical answer between 0-30). This feature guards against typographical errors, and ensures the counselor is attuned to the specific information being requested in each field. Hints and Comments Each ASI item within the DENS software is displayed along with a hint at the bottom of the screen. These hints provide information on the intent of the item, any special coding rules, and recommended additional probes to provide clinicians with more detailed information. The content of the hint box changes each time the counselor clicks on a new item within the ASI, assuring that the display is always relevant to the question being asked. Also included in the software is a text box for entering comments. This is available for each item on the ASI and allows a counselor to enter additional information and detail for each question. The content of the comments box refreshes as the counselor moves from item to item (similar to the hints), and all comments are automatically integrated in understandable text and logical sequence into the ASI Print-Out and Narrative Summary alongside their related items. Finally, there is a place at the end of each ASI section for counselors to write additional comments or note information gathered beyond the standard ASI items. Treatment Research Institute

40 1. Automated Reports (Client-Level and Aggregate) The DENS Suite produces two types of reports, Client Level and Aggregate reports. Client-Level reports are summaries of an individual case, and are available in three formats the ASI Print- Out, the ASI Narrative Report and the Treatment Care Plan Problem List. These are useful in treatment planning, creating a biopsychosocial report of the client s case, tracking changes in a client over time, etc. Aggregate reports summarize all of the cases on a particular computer, and are available from various perspectives (male compared to female clients, clients receiving welfare vs. those who are not, etc.). These are typically used for tracking trends in a client population, performing program evaluation, submitting responses to data requests, etc. Client-Level Reports ASI Print-Out This patient-level report lists all questions in the ASI along with the client s responses. Any comments entered by the counselor related to a specific question will appear in the print-out immediately following the response to the item. ASI Narrative Summary The narrative is a ten (10) page report suitable for use as an intake summary. It converts the client s ASI responses into sentences and paragraphs, in effect telling the story of the client s intake interview. As with the ASI Print-out, any interviewer comments are automatically inserted within the narrative following the question item to which they refer. This allows the report to be customized for each client, allowing reporting of information observed but not necessarily collected through the ASI questions. Many facilities involved in the DENS research study use this stand-alone report as their biopsychosocial assessment. Treatment Care Plan Problem List This is a list of potential problem statements derived from items on the ASI to which the client responds above or below a certain threshold. The statements include such details as The client reports lifetime, regular use of heroin, or The client is troubled by psychological or emotional problems and is interested in treatment. Included with this report is a blank treatment care plan template, used by counselors to construct a full treatment plan based on the provided problem list. Treatment Care Planning (Coming Soon!) Although not yet available, a full treatment care planning module is currently under development. This module will include suggested problem statements, goals, objectives and interventions for every ASI section and question as well as space for counselors to enter problem statements of their own, objectives, goals, diagnosis codes, etc. This software should be available by winter Treatment Research Institute

41 Aggregate Reports These reports summarize the entire database on a particular computer, providing an overall look at the clients at a particular facility. They compare each of the following pairs of groups to each other, listing averages for nearly all items included on the ASI. a. Male vs. female client data b. Clients entering treatment last year vs. this year c. Welfare vs. non-welfare-receiving clients d. Criminal Justice System (CJS) vs. non-cjs-involved clients 2. Additional Questions (for agencies [e.g. state or local governments] that will be collecting data on their own SQL server from a group of distinct treatment programs) In addition to providing an electronic means of collecting ASI data, the DENS Suite has the capability of incorporating additional questions of current interest. Up to five additional questions can be inserted into each section of the ASI (a total of 40 questions). With the proper training, inserting additional questions to the software is a relatively simple process for provider or state IT staff. The questions will be automatically uploaded into each remote site computer the next time those machines connect to the server to transmit ASI data. The result is a system allowing an agency to quickly gather new information from their sites without needing to budget large amounts of time and finances to roll out and collect data from an addendum to a pre-existing paper instrument. Examples of additional questions inserted for other studies includes collection of data on club drug use, OxyContin use, homelessness issues, increased use or psychiatric problems after 9/11, trauma issues, spirituality questions, etc. 3. Security Several security features are built into the software to guard against client information being accessed by an unauthorized party. The entire client database is password protected, making it difficult for someone to simply copy the file from a facility computer and view it outside the DENS software environment. Within the software itself, there is a password protected login screen, preventing access by anyone other than users sanctioned by a treatment program. Furthermore, when adding usernames to the software a system administrator can decide whether or not to grant new users administrative access, which gives them permission to add and delete users themselves. This feature helps administrators limit access (if desired) to only those counselors who have passed the required ASI competency measures. Another security feature embedded in the DENS software protects a treatment facility from transferring identifying information about their clients to TRI via modem or the internet. When data is exported, the software automatically strips the database of any and all client identifying information. This feature allows DENS to be in compliance with HIPAA requirements and protects the security of client information. Treatment Research Institute

42 4. Training and Competency It is important to ensure that counselors using the software within a treatment program are competent and comfortable with its operation before they attempt to utilize it during an assessment. To this end, there is a practice section within the software program which allows counselors to complete mock interviews just as they would if a client were present. The screens in this portion of the software function exactly the same as the normal ASI screens, but the data entered is only stored temporarily, and in a separate location than actual client data. Counselors can do as many practice ASIs as they want, and TRI offers a series of competency measures should an organization wish its staff to become officially certified in ASI administration. 5. Administrative Functions In the administrative functions of the software, users will find all the tools necessary to maintain the software and manage their data. Here, counselors can backup their client database, so no data is lost in the event of a computer malfunction. They can also use these screens to transmit their non-identifying data, or export it to a floppy disk for manual transmission. Aggregate reports are generated from the administrative area of the DENS Suite, and counselors can batch printed client narrative summaries from here as well. In addition to being able to print multiple narratives at once, counselors can use the batch printing feature to customize the order in which ASI sections appear within the narrative report. This feature is useful for facilities that report to a specific agency that only requests certain information about clients (i.e. only Legal and Alcohol/Drug data). 6. DENS Data Export Software Available along with the DENS Suite intake software is a program called DENS Data, which allows a facility to export its client database to a statistical analysis package such as SPSS or SAS. The program can also convert a DENS database to Microsoft Excel spreadsheets. DENS Data is a useful utility for performing more advanced analyses on your site s data than the DENS Suite software is capable of completing on its own. Furthermore, if you have more than one computer at your site running DENS, this data export utility offers a way of merging the data from several machines into one database, allowing you to get an overall picture of your site s clientele. All DENS software programs are in the Public Domain. Treatment Research Institute

43 TRAINER GUIDE S.M.A.R.T. Treatment Planning Utilizing the Addiction Severity Index (ASI): Making Required Data Collection Useful REFERENCES Appelbaum, P. S., & Gutheil, T. G. (1982). Clinical aspects of treatment refusal. Comprehensive Psychiatry, 23(6), Barber, J. P., Luborsky, L., Crits-Christoph, P., Thase, M. E., Weiss, R., Frank, A. et al. (1999). Therapeutic alliance as a predictor of outcome in treatment of cocaine dependence. Psychotherapy Research, 9(1), Barber, J. P., Luborsky, L., Gallop, R., Crits-Christoph, P., Frank, A., Weiss, R., et al. (2001). Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse collaborative cocaine treatment study. Journal of Consulting and Clinical Psychology, 69(1), Cacciola, J. S., Koppenhaver, J. M., McKay, J. R., & Alterman, A. I. (1999). Test-retest reliability of the lifetime items on the Addiction Severity Index. Psychological Assessment, 11(1), Carise, D., Gurel, O., Kendig, C., & McLellan, A. T. (2004, in submission). Giving clinical meaning to patient assessment: Technology transfer to improve treatment care planning and service delivery. Drug and Alcohol Dependence. Center for Substance Abuse Treatment (2002). Addiction counseling competencies: The knowledge, skills, and attitudes of professional practice. Technical Assistance Publication (TAP) Series, Number 21. DHHS Pub. No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Crevecoeur, D., Finnerty, B., & Rawson, R. (2002). Los Angeles County Evaluation System (LACES): Bringing accountability to alcohol and drug abuse treatment through a collaboration between providers, payers, and researchers. Journal of Drug Issues, 32(1),