Developing a comprehensive treatment plan
Developing a comprehensive treatment plan follows a thorough assessment. The assessment will normally consist of a psychosocial assessment completed by the MMT counsellor, supplemented by a medical examination by the attending physician.
In some instances, additional specialized assessment will be required, such as psychiatric assessment to investigate concurrent disorders or psychological assessment of cognitive functioning. Vocational assessment may also be indicated to explore vocational aptitudes and readiness for employment.
It is advisable for clients to complete a psychosocial assessment as soon as possible upon entry to methadone treatment and not later than four weeks after admission. In preparation, clients should be fully informed about the nature and purpose of the assessment process and should be clear about how the information gleaned from the assessment will be used and who will have access to it.
A psychosocial assessment should involve a standardized set of procedures. In Ontario this would usually involve the use of tools recommended in The Standardized Tools and Criteria Manual (Cross & Sibley-Bowers, 2002).
The psychosocial assessment has two primary goals. First, it is an opportunity to clarify information related to the client's decision to seek treatment. This information can help clarify goals and motivation for change. Second, the assessment also helps to identify specific problems — information that can be used to design an individually tailored treatment plan. Consideration should be given to using a standardized tool (such as the Addiction Severity Index) that can be re-administered periodically both to track client changes and facilitate ongoing treatment planning.
Some clients may regard methadone as the answer to their problems. They may see little value in engaging in a psychosocial assessment or counselling for that matter. All members of the treatment team should emphasize to clients that their treatment success could be enhanced significantly if they participate in counselling.
Opportunities to engage clients in a psychosocial assessment and later in counselling can be improved if the psychosocial assessment is scheduled to immediately follow the medical assessment and to precede the client's first dose of methadone. However, it is not advisable to delay the administration of the first methadone dose once the suitability of MMT has been established.
There are two fundamental stages to a comprehensive assessment. These are:
- identification of problems or changes the client would like to make
- development of a treatment plan.
The problem areas listed below in the assessment checklist should be covered in the comprehensive psychosocial assessment, as well as any other areas that appear relevant.
- Past history of use (e.g., age of onset, type of substance, route of administration, duration of use, amount, frequency)
- Current substance use behaviour, including risks associated with use
- Primary and secondary substance problem
- Prescribed medications (including how the client's prescriptions are paid for, e.g., insurance, Trillium, etc.)
- Past history of use (e.g., age of onset, duration, amount, frequency, current use, complications from use)
- Current serious health problems
- Prescribed medications for any conditions
- Psychological problems in the past 30 days
- History of psychiatric problems (treatment for psychiatric problems, hospitalization, medication)
- Suicide attempts and any current thoughts
Social and/or Family Supports
- Close friends or family
- Violence in any current relationship
- Legal mandate for treatment
- Potential limits of confidentiality
Education and/or Occupational Status
Knowledge/skills level and capacity for employment
Readiness for Change
- Level of client's motivation to commit to change process (e.g., client's stage of change)
Information concerning the above areas can be gathered through an unstructured interview. When inquiring into these areas, the counsellor should prioritize the exploration of problems and concerns so that certain areas are covered first (e.g., medical problems should precede questioning about vocational skills; McCann et al., 1994).
It is usually unwise to inquire about highly personal or emotional areas, such as abuse history, until a rapport between client and counsellor has been established.
A comprehensive psychosocial assessment can include the application of structured assessment tools. The assessment instruments identified for use in Ontario substance abuse treatment services are suitable for use in MMT programs. These include tools to assess drug use history, adverse consequences of drug use, problem behaviours and symptoms, perceived social support, self-efficacy, readiness for change, and general health. For a detailed description of these instruments and their application, see Cross and Sibley-Bowers (2002).
Addiction Severity Index
The Addiction Severity Index, or ASI (McClellan et al., 1992) is a structured assessment tool that has been widely used in U.S. MMT programs. The ASI is a structured clinical and research interview. This interview is designed to assess the severity of problems that clients experience across a wide range of areas of functioning.
The problem areas assessed include legal, psychiatric, social and family, drug use, medical and employment and/or other support. When using the ASI, the interviewer asks various questions in each of these areas concerning the number, extent and duration of problems.
In addition, clients are asked to rate the degree to which these problems bother them and whether they want counselling for these problems.
Selected items from each problem area are summed to produce an estimate of the problem severity.
One advantage of the ASI is that it is brief (approximately one hour to administer). Another advantage is that it can be re-administered at various points during treatment and can therefore be used to monitor treatment progress. Outcome measures have also been incorporated within the ASI and these are useful for evaluation purposes.
Some familiarity with the interview is necessary. Training tapes are made available through the ASI author (A.T. McClellan, Department of Psychiatry, University of Pennsylvania).
Beck depression inventory
An instrument that is useful when assessing for the presence of depressive symptoms is the Beck Depression Inventory or BDI (Beck et al., 1961). Upon entry to methadone treatment, many clients report feelings of depression. Often, substance-induced depressive symptoms resolve within four weeks after the client has abstained from substance use.
To assess the client's level of motivation for change, the Socrates Questionnaire (Cross & Sibley-Bowers, 2002) can be used. This instrument is a brief self-report instrument requiring approximately 15 minutes to administer. Clients' responses are summarized, and a profile indicating the client's Stage of Change can be obtained.
Readiness for change can also be assessed using a stage-of-change algorithm (Annis et al., 1996).