History of and current reasons for help-seeking

Enquiry should be made both about help sought by the patient in the past and help being given at present. It is then essential to understand the patient’s reasons for coming to this present consultation – the pressures they see themselves as experiencing (a court order or threats from a partner, for instance), what crisis may suddenly have precipitated the immediate help-seeking, or what inner sense of need is driving the motivation. Once more, the process of history-taking is an experience for the patient as well as it giving information to the clinician. The patient is exploring the question of why he or she is in this room and is trying to understand the ambiguous, confused, or contradictory motivations that have brought them here. Such knowledge is an important basis for later work. The history has to be taken with an awareness that motivation is often ambivalent: the patient both wants to go on drinking and wants to stop drinking. These conflicting forces should be identified and labeled rather than the reality of conflict being evaded.

Physical examination and investigations

Physical examination and laboratory investigations will be part of the assessment routine in a medical setting. In a social work or probation office, this aspect of assessment is not within expected practice, but there would be an advantage to such agencies in ensuring that the patient receives a physical examination from a medical professional with the results fed back. This insistence on the importance of making a medical connection may go against the usual working methods of some nonmedical agencies and be seen as burdensome. However, the likelihood of physical disorder in the patient with a drinking problem puts that person in a different category from many other social work clients.

What might go into a 15-minute assessment?

The way that constricted time is best used must be, to an extent, patient- and setting-specific. The following notes offer some general suggestions:

Assessment with the partner or other significant individual in the patient’s life

For a range of reasons, patients do not always provide full or accurate information during an assessment. If the patient consents, it is therefore extremely useful for the clinician to talk to an important person in the patient’s life who has knowledge of the patient’s drinking. Most commonly, this individual will be a partner, but the many other possibilities include a grandfather who is raising an adolescent whose parents are absent, a sibling with a particularly close relationship to the patient, and a member of the clergy who has known and counselled the patient since childhood. Whether this assessment is conducted with the patient present or independently depends on the specifics of the case and the clinician’s judgement of whether the other informant has any fear of contradicting the patient or will be seen by the patient as an ally in the development of an accurate assessment.

Structuring the interaction requires sensitivity and flexibility. In some cases, it will quickly become apparent that the informant has serious difficulties of his or her own, for example, in a couple where both members of a romantic relationship drink to excess as a shared activity. The clinician may be tempted to plunge into a full assessment of the informant’s life, but this is inappropriate if the informant is in contact to help the patient but has no interest in pursuing treatment of his or her own. However, it is entirely appropriate for a clinician to express concern about problems in the informant’s life and to offer separate or conjoint treatment, as appropriate.

Case formulation and treatment planning

After a thorough assessment, the clinician’s task is to pull together a large and diverse range of information into a coherent case formulation. A well-constructed formulation is a creative act of empathy rather than just an ordering of information under headings.

The additional investment of time to develop a case formulation pays handsome returns. The clinician is directionless until the formulation is made. Furthermore, when the notes and questionnaires are put aside for a few weeks and the patient reattends treatment, the freshness of understanding has often faded unless the formulation has been written. The original formulation will also be of great use if a case is reopened after a gap of a year or two or if the patient’s case is eventually taken over by a different care provider.

A formulation should not be of inordinate length or it defeats its purpose. Ideally, the formulation should be a summary of key information consumable in less than 10 minutes that explains the evolution and current state of the patient’s predicament; his or her strengths, weaknesses, and aspirations; and the environmental supports and impediments to change. It is entirely appropriate, particularly early in treatment, for the formulation to include a note that certain areas of the patient’s life remain to be explored in further detail and what this will require (e.g., a referral to a neuropsychologist for a cognitive assessment).

Reference has already been made to the necessity of the formulation serving the needs of the patient as well as the therapist. Before making final notes on the formulation, there should have been an interchange in which the therapist says, “What we have talked through is valuable … I see it this way … What we ought to do is perhaps this … How do you see it? … Can we agree then? …” Such discussion ensures that not only is the clinician standing back from the data and gaining a whole view, but that the patient is doing the same, and they are doing so together.

Once completed and reviewed with the patient, the formulation becomes the basis for selecting the appropriate goals and modality of treatment. On the basis of what has already been laid out in the preceding sections of the formulation, it should be possible to set up a series of specific treatment goals. At least one goal should concern drinking behaviour, but other goals may be about other important life domains such as family and work.

With as much specificity as possible, the clinician and patient should then agree to a course of treatment that follows from the case formulation and the goals of the intervention. “Treat the alcohol problem” is not a sufficiently specific treatment plan; something like “Meet once or twice a week for cognitive-behavioural therapy directed at returning to moderate drinking” is better. Plans to evaluate progress or lack of progress at a designated point are typically valuable, and the treatment goals and modality may be revisited in light of what is evident at that time.

Related posts:

Alcoholics Anonymous and other mutual-help organizations Religion, spirituality, and values in treatment Managing setbacks and challenges in treatment Alcohol and other drug problems Case-finding and intervention outside of specialty settings Introduction, settings, and roles

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