How to assess

It’s important to remember that people with alcohol or drug problems will be stigmatised and will often feel ashamed. Therefore you need to have clearly thought through how you are going to ask any questions relating to a person’s use, communicate why you are asking about it and what will be done with the information from the start.

How you talk to someone about their substance use will vary according to context. Talking to a young person experimenting with alcohol or drugs is likely to be different to talking to a parent whose substance problems, in your opinion, are seriously affecting their ability to care for their children.

There have been various attempts at guidance on how to assess a person’s substance use. Approximately 10 years ago the British Association of Social Workers (BASW) published a document (undated) that offered practice and policy guidance on working with drug users and assessing drug use. The Assessment Framework included a tool for assessing adult alcohol use but not drug use. However, anecdotal evidence suggest practitioners report rarely using this tool.

There are some questions you need to ask yourself before considering asking a service user about their substance use:

• Have you got/read your agency policy on working with alcohol and drug users?
• Who are the alcohol and drug agencies in your locality?
• Have you met with/visited the agencies?
• Do you understand their perspectives?
• Do they undertake family work, couples counselling, family support?
• Have you got/asked for a contact in the agency?
• How do you make a referral to them?
• Do they have a waiting list?
• What are their policies on child protection and working with young people?

Finally and perhaps the most important question to ask yourself is:

• What are you going to do with the information once you’ve got it?

In other words if you’re not going to do something with it, or haven’t got enough knowledge to interpret it correctly, don’t ask! If you remain concerned speak to a partner or local alcohol or drug agency that can advise you on what to do and, ideally, may be able to work with you.

What questions do I ask?

There is no simple answer to this as it will depend on the particular circumstances, eg. why you are asking, is it part of a larger assessment or a crisis response, are other people are at risk, who else is present (confidentiality or safety issues?), the age and educational level of the person concerned…the list could go on. 

• Start by asking yourself what is it you want to know and why.  Once you’re clear on that, then this is probably what you want to tell the person concerned!  Openness and honesty is best.  Some examples:
  • “I am a bit concerned that your drug use is not helping you to look after James and Katy as best as you could.  I want to be honest with you about what I’m thinking.”
  • “I am worried that your drinking is not mixing well with your medication.  I think it might have a bad effect on your health.”

You also need to remember that because of the shame and stigma attached to alcohol and drug problems people may be defensive when you raise the issue for the first time – “Are you calling me a junkie/alcoholic!?”. As you are aware the tone and manner in which you ask questions can make all the difference so make sure you are conscious of the way you’re asking and be ready to reassure the person that you are not jumping to conclusions.

• This can then be followed by either an open or closed question.  Examples include:
  • Closed:  1) “Can we talk about this for a bit?” or 2) “Do you mind if I ask you some questions to help me understand better?” or 3) Tell me about how your drinking/drug use makes you feel?”
  • Open: 1) “How does your drug use/drinking make you feel?” or 2) “What are the good things about drinking/using drugs?” or 3) “When are you drinking/using drugs most?”

If you ask a closed question, you may not get the answer you want, so be prepared for a negative response.  If there is no immediate crisis but your concerns remain, you may want to leave it on this occasion and come back to it next meeting/visit, or you could say that you remain worried and ask the person to think about talking to you about it next time. Use your judgement.  

If it is a crisis situation, you may have to point out that not talking about it means you have to make decisions based on guess work about what’s happening and that your guess work is probably worse than the reality.  You may want to, or need to, try again and ask an open question. 

Whether it is a crisis or not, it will probably be helpful to make it explicit that you are not making any judgements about them, or the rights or wrongs of their drinking or drug use, but that you need to understand their situation better.

• The Stages of Change model used by many alcohol and drug services can help you to decide the types of questions you should ask (see ‘Types of treatment’ page under ‘Specialist intervention and treatment’ section for diagram and details).  Once you’ve established which stage you think a person is at, then it can help you to determine a) the point of you asking the questions and b) what type of questions you should ask.  Social work interventions can help people at every stage in the cycle.  The skills that are required are not new – they are standard good social work practice skills involving effective questioning (the person is the expert on themselves), person centred practice and partnership working (providing no-one is at risk of harm).
  
  

The following gives examples based on the five main stages on the model:


Pre-contemplation/not thinking about it/denying there’s a problem
The point of asking questions in this stage of the cycle will be to raise the issue of substance use and state your concerns.  If there is other evidence of problems relating to their substance use you may want to be open about it at this point, eg. GP or health visitor concerns, related criminal justice involvement.  Just don’t be accusatory or back people into a corner!  Present your concerns and any other evidence as supporting your concerns.  Give people a chance to take in what’s been said and respond.  You can also offer reassurance, support, or offer to discuss again later if you meet resistance. 

If you are there for crisis intervention and immediate action has to be taken to safeguard an adult or child, then you may not have the luxury of such discussion.  It is still important to state your concerns about the substance use, its impact on any decisions you have to make and clarify any choices the person has at that point.  It is important not to end contact with the crisis intervention.  Follow up contact once the immediate crisis is over should support the person and set out their choices including those relating to their substance use.  Evidence suggests that crises can be turning points for people, particularly where children are involved, so such opportunities to help people change their substance use should not be lost.

Contemplation/thinking about change
At this stage people are thinking about changing their substance use behaviour either on their own or with professional support.  Here motivational questions should be used, for example, “what would be the advantages and disadvantages of making some changes” or “what will you lose and gain by making some changes” or even “why are you considering changing at this time”. The key here is to ask questions that acknowledge both the benefits of change and the costs.  Asking a couple of extra questions that highlight the positives of change can be encouraging but don’t ignore the disadvantages of change and don’t try to do a ‘hard sell’ on professional help as this is likely to meet with resistance.

When people are thinking about change it is also a good time to leave them some information or leaflets to look at about alcohol or drug agencies locally and/or talk to them about what’s available.  If people have not had professional help before they may have a negative image of professional help, eg. they have to attend groups or disclose their personal lives.  Remember that disclosing alcohol or drug problems is incredibly hard so it is a big step for people to take.

Action/doing or nearly doing something
If somebody has decided to make changes or is about to, then encouragement and practical support may be what is needed most. Do they need support or help making the appointment?  Do you need to refer them to services?  Can you provide information on the service they are thinking of attending?  Other questions may include what the practical arrangements will be for getting to the appointment, can someone supportive go along with them, are there children or dependent adults that need looking after?  Your job would be to ask these questions and help them find solutions as well as look ahead to the future. 

Also important is helping the person to think about who can support them at this time.  This may be friends or family members they’ve lost touch with through their substance use.  If a person has been drinking or using for a long time, it is probable that their friends are also drinking and using drugs.  Talk with them about the people they could contact that would provide this support and ‘replace’ their drinking and drug using friends.  Evidence shows that positive social support is important in helping people change problematic substance using behaviours.

If someone has sought help and/or made changes already, you can ask questions about how it went, how it feels to have taken such a step, and to revisit with them the reasons they have made these changes. You may also want to ask them about whether they’d like you to work alongside the alcohol or drug service and get permission if they do. Talking through these issues at this stage also ensures that if the appointment or experience of change has not been a positive one then you can discuss alternatives before the motivation and commitment to doing something wanes.

Maintenance/maintaining the reduction in, or abstinence from, substance use
Most people find this the hardest stage of changing substance use.  Once the first big step has been taken and the initial period of change has passed successfully, people can become complacent or over confident and/or may be lonely and fearful about the future without the substance.  Questions here need to focus on what they are doing to help themselves maintain the change and if there’s anyway you can help, what their risk factors are for relapse and what strategies they have in place to cope with the risks. 

When people have developed problems with their alcohol or drug use this usually happens over a long period of time.  Therefore changing that use and maintaining that change often means a complete, and often sudden, change of lifestyle, socialising, interests.  Supporting people at this stage to explore their options and interests is vital in helping them to maintain the change.

Relapse/reverting to problematic substance use after stopping or cutting down
People ‘relapse’ when they go back to using a substance they have had a problem with.  This can be a time of great anxiety and vulnerability and there is a risk they will develop problems associated with their substance use.  Often when people have sustained change for a time it will be unexpected stress or unforeseen circumstances that trigger a return to using (which could include having become a little over-confident).  If they are in contact with a social worker or other helping professional this time can potentially be a very positive opportunity for learning and change.  Most helpful here are questions that explore what led to the relapse and lessons that could be learned from it, what would make the person want to try again, what made them stop/cut down before, what worked, what didn’t work.  Motivational questions will also help if the person is thinking about having another go (see point 2 above).  This can help them make a more detailed and better developed plan to avoid these recent pitfalls in future and to build on their experience of having successfully changed before.  People will often feel they have failed when they relapse so acknowledge their success prior to relapse and the strength that was needed to do that. 

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