What Makes a Good Substance Abuse Evaluation

The domains of psychological evaluation and substance abuse evaluations share core characteristics necessary for accurate assessment and intervention. Traditional psychological evaluations focus on assessment of cognitive, emotional, and behavioral processes. Likewise, effective substance abuse evaluations should examine several domains of psychological functioning, with a focus on substance abuse itself and also any related mental health issues impacting or resulting from substance use. Lastly, if the substance abuse evaluation is forensic in nature, i.e., results may be used in a court case and have potential secondary gain or loss for a person, it is vital multiple sources of data (and not only self-report) are used to determine diagnosis and recommendations.

If Forensic in Nature: Collaterals, Records, and Drug Testing

It can be helpful if the evaluation is court-ordered to include in the order any collaterals you would like the evaluator to speak with who might have relevant information but who the person being evaluated might not otherwise ask the evaluator to speak with. Likewise, the order can include the evaluator be allowed access to any specific records either side is aware of that could provide information on substance use. You should also expect if the evaluation is forensic in nature that the evaluator would have required the client to sign release of records for all mental health treatment, related medical treatment, and legal involvement for several  years (i.e., we request the past five years).

These questions can also be important in determining what drug testing, if any, to incorporate. This is an important factor in forensic substance abuse evaluations and you should expect your evaluator will know how to consider and add drug testing as needed. Drug testing is most useful for illicit substances as they should not occur in someone’s system at all. Testing for overuse of prescription drugs is complicated as the drug should show up in someone’s system but results do not provide information on if a drug has been overused; however, medication fill/refill records can show a pattern of obtaining more medication than would normally be needed (pharmacy hopping, refill requests based on meds being lost, etc.). Drug testing for alcohol use is not sophisticated enough to determine overuse. There is a urine test that will detect alcohol use over the past 80 hours (so longer than a breathalyzer), but that still does not show if use was excessive. There are also some markers for long term alcohol use (such as a long term alcoholic), but these markers cannot definitely say a person overused alcohol. Concerns about alcohol misuse usually are best supported by collateral contacts who have observed this over time, or may sometimes show up in general physician records if the person has happened to talk to their MD about cutting down their drinking.

Alcohol and Drug Use

The types of substances used, the frequency of use, the onset of use, and attempts at quitting all provide vital information for diagnosis and treatment planning. While no single measure currently encompasses all aspects of substance use behavior, the combination of self-report measures, psychometric tests, structured clinical interview, review of records and collateral contacts can be effective in understanding the scope of a client’s use.

Emotion

Problems with emotion regulation (intense anger, depression, guilt, etc.) could be a potential motivator to engage in substance use or a product of use. Problems with alcohol and other substances often arise due to a person’s difficulty expressing emotion or coping with unpleasant emotions. As with any psychological assessment, substance abuse evaluations should assess a person’s emotional status, both currently and prior to the onset of substance use.

Personality

Personality traits like impulsivity, aggressiveness, and self-esteem issues are often associated with substance abuse. Good substance abuse evaluations should include multidimensional personality measures.

Social Adjustment

The concept of social adjustment can encompass many facets of a person’s daily functioning. Issues maintaining friendships, substance-use supportive peers, and deficits in interpersonal skills are all common among substance abusers. A person’s functioning in various domains (school, work, leisure activities) can all be influenced by substance use and can be useful in assessing severity of use and its impact on functioning. Various self-report measures and rating scales for family, friends, and teachers exist to assess these domains. 

Cognitive

Understanding a person’s cognitive abilities can be useful in determining proper treatment and formulating a differential diagnosis. The effects of prolonged alcohol and drug use on a person’s cognitive functioning are well documented, and severe limitations can interfere with a person’s progress in treatment, as well as their daily functioning. If long term use impacting cognitive functioning is suspected, cognitive testing can be added to determine potential cognitive deficits.

Family History and Functioning

The effects of family organization, quality of family interactions, and family attitudes and rituals regarding consumption are important in understanding substance abuse issues. Family members with substance use issues and psychiatric disorders may be indicators of more severe psychological problems.  Likewise, abuse and family disfunction are often associated with substance abuse, either as precipitating events or results of substance use. Self-report measures examining family functioning and structured clinical and collateral interviews can be useful in understanding family dynamics. In family court cases it is important to assess if the substance use could impact parenting. If you strongly suspect it has, it could be important to also have a Parental Capacity Evaluation versus just a substance abuse evaluation.

In Summary

Effective, thorough substance abuse evaluations should take into account all of the above-mentioned factors, in order to best assess the client’s functioning, determine any diagnoses and treatment needs, and provide appropriate recommendations to the courts and for the benefit of the client and his or her family.