A nurse at an inpatient treatment facility is admitting a client who has substance use disorder

Understanding the extent and nature of a woman's substance use disorder and its interaction with other life areas is essential for careful diagnosis, appropriate case management, and successful treatment. This understanding begins during the screening and assessment process, which helps match the client with appropriate treatment services. To ensure that important information is obtained, providers should use standardized screening and assessment instruments and interview protocols, some of which have been studied for their sensitivity, validity, and accuracy in identifying problems with women.

Hundreds of screening instruments and assessment tools exist. Specific instruments are available to help counselors determine whether further assessment is warranted, the nature and extent of a client's substance use disorder, whether a client has a mental disorder, what types of traumatic experiences a client has had and what the consequences are, and treatment-related factors that impact the client's response to interventions. This TIP makes no specific recommendations of screening and assessment tools for women and does not intend to present a comprehensive discussion of this complex topic. Rather, the TIP briefly describes several instruments that providers often use to examine areas of female clients' lives. Attention is given to instruments that have gender-specific normative data or are useful in attending to the biopsychosocial issues unique to women. Several of the screening and assessment instruments discussed in this chapter are provided in Appendix C.

This chapter introduces and provides an overview of current screening and assessment processes that may best serve women across the continuum of care. It covers several areas for which to screen, such as acute safety risk, mental disorders, sexual victimization, trauma, and eating disorders. The chapter also discusses factors that may influence the overall assessment, and reviews screening for substance abuse and dependence in settings other than substance abuse treatment facilities.

It provides information about instruments for use by drug and alcohol counselors, primary healthcare providers, social workers, and others. The assessment section includes general principles for assessing women, the scope and structure of assessment interviews, and selected instruments. Finally, other considerations that apply to screening and assessment are discussed, including women's strengths, coping styles, and spirituality.

The purpose of screening is to determine whether a woman needs assessment. The purpose of assessment is to gather the detailed information needed for a treatment plan that meets the individual needs of the woman. Many standardized instruments and interview protocols are available to help counselors perform appropriate screening and assessment for women.

Screening involves asking questions carefully designed to determine whether a more thorough evaluation for a particular problem or disorder is warranted. Many screening instruments require little or no special training to administer. Screening differs from assessment in the following ways:

Screening is a process for evaluating the possible presence of a particular problem. The outcome is normally a simple yes or no.

Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.

The treatment field depends on tools or questionnaires that, for the most part, have been found valid and reliable with two populations of women—Caucasians and African Americans. Although translations of some instruments for non–English-speaking populations have been made, the validity of the adapted instruments is not always documented.

Women need a thorough explanation of the screening and assessment process. Some women from diverse ethnic groups may find the process threatening, intrusive, and foreign. In some cultures, for example, questions about personal habits can be considered unnecessarily intrusive (Paniagua 1998). Many immigrant women have little experience with American medical care and do not understand the assessment process. Some women may have had negative experiences with human service agencies or other treatment programs and felt they were stereotyped or treated with disrespect.

Screening and assessment must be approached with a perspective that affirms cultural relevance and strengths. An understanding of the cultural basis of a client's health beliefs, illness behaviors, and attitude toward and acceptance of treatment provides a foundation for building a successful treatment program for the client. Whenever possible, instruments that have been normed, adapted, or tested on specific cultural and linguistic groups should be used. Instruments that are not normed for the population being evaluated can contain cultural biases and produce misleading results and perhaps inappropriate treatment plans and misunderstandings with clients.

Counselors and intake personnel may hold preconceived beliefs concerning the prevalence of substance abuse among women from particular ethnic groups. For example, counselors may overlook the need to screen and assess Asian women (Kitano and Louie 2002). All assessment staff members should receive training about the cultural and ethnic groups they serve; the appropriate interpersonal and communication styles for effective interviews; and cultural beliefs and practices about substance use and abuse, mental health, physical health, violence, and trauma. Through training, counselors can learn what cultural factors need to be considered to test accurately.

Advice to Clinicians and Administrators: Culturally Responsive Screening and Assessment.

Acculturation level may affect screening and assessment results. The counselor may need to replace standard screening and assessment approaches with an in-depth discussion with the client and perhaps family members to understand substance use from the client's personal and cultural points of view. The migration experience needs to be assessed; some immigrants may have experienced trauma in their countries of origin and will need a sensitive trauma assessment.

Specifically, the counselor may begin by asking the client about her country of birth and, if she was not born in the United States, the length of time she has lived in this country. Several screening tools are available to determine general acculturation level. The Short Acculturation Scale for Latinos (Marin et al. 1987) is a 12-item acculturation scale available in English and Spanish. Acculturation, as measured by this scale, correlates highly with respondents' generation, length of residence, age at arrival, and ethnic self-identification. The scale can be adapted easily for other groups. Two other useful scales are the Acculturation Rating Scale for Mexican Americans II (ARSMA; Cuéllar et al. 1980) and the Oetting and Beauvais Questionnaire, available at www.casaa.unm.edu, which assesses cultural identification for Caucasian Americans, Hispanics, American Indians, and African Americans. Scales also have been developed for Asian-American groups (Chung et al. 2004).

Counselors should be aware that although a client speaks English relatively well, she still may have trouble understanding assessment tools in English. It is not adequate to simply translate items from English into another language. Some words, idioms, and examples do not translate directly into other languages but need to be adapted. Ideally, interviews should be conducted in a woman's preferred language by trained staff who speak the language or by professional translators from the woman's culture. Differences in literacy level may require that some clients be screened and assessed by interview or that self-administered questions be adapted to appropriate reading levels. For women with low literacy levels, language comprehension problems, or visual impairments, screening personnel can read the questions to them; however, results may not be as accurate. Self-administered questionnaires should be available in a woman's preferred language if possible.

Counselors may have conscious or subconscious expectations based on socioeconomic status. Such perceptions have led to failures to diagnose drug or alcohol abuse in pregnant middle- and upper-class women, with tragic consequences for their infants. For example, primary care providers are much less apt to ask private middle-income patients about their use of drugs. Some healthcare providers may fear offending their patients by asking them about their substance use. Weir and colleagues (1998) found that clients with more than a high school education are less apt to disclose the use of drugs or alcohol during pregnancy.

Prior to screening and assessment, the counselor should inquire about current or past difficulties in learning, past participation in special education, a diagnosis of a learning disability, prior involvement in testing for cognitive functioning or learning disability, and problems related to self-care and basic life management skills.

Depending on the type and severity of the disability or impairment, these women will likely need more assistance throughout the screening and assessment process. Moreover, women with developmental disabilities or cognitive impairments are more likely to respond to items they do not understand by stating “yes” or by responding in a manner they think the assessment counselor will approve of instead of asking for clarification.

The Institute of Medicine's (IOM) report on lesbian health identifies substance abuse as one of the primary heath concerns among lesbians (Solarz 1999). While research has concluded that the CAGE instrument has similar reliability and concurrent validity among lesbian and heterosexual women, very few studies have addressed the issue of validity and reliability in screening and assessment tools for lesbians (Johnson and Hughes 2005). Consequently, counselors need to cautiously interpret screening and assessment results.

Screening often is the initial contact between a woman and the treatment system, and the client forms her first impression of treatment during screening and intake. For women, the most frequent points of entry from other systems of care are obstetric and primary care; hospital emergency rooms; social service agencies in connection with housing, child care, disabilities, and domestic violence; community mental health services; and correctional facilities. How screening is conducted can be as important as the actual information gathered, as it sets the tone of treatment and begins the relationship with the client.

Screening processes always should define a protocol or procedure for determining which clients need further assessment (i.e., screen positive) for a condition being screened and for ensuring that those clients receive a thorough assessment. That is, a professionally designed screening process establishes precisely how to score responses to the screening tools or questions and what constitutes a positive score for a particular possible problem (often called a “cutoff” score). The screening protocol details the actions taken after a client scores in the positive range and provides the standard forms for documenting the results of the screening, the actions taken, the assessments performed, and that each staff member has carried out his or her responsibilities in the process. Although a screening can reveal an outline of a client's involvement with alcohol, drugs, or both, it does not result in a diagnosis or provide details of how substances have affected the client's life. The most important domains to screen for when working with women include:

Substance abuse

Pregnancy considerations

Immediate risks related to serious intoxication or withdrawal

Immediate risks for self-harm, suicide, and violence

Past and present mental disorders, including posttraumatic stress disorder (PTSD) and other anxiety disorders, mood disorders, and eating disorders

Past and present history of violence and trauma, including sexual victimization and interpersonal violence

Health screenings, including HIV/AIDS, hepatitis, tuberculosis, and STDs

The goal of substance abuse screening is to identify women who have or are developing alcohol- or drug-related problems. Routinely, women are less likely than men to be identified as having substance abuse problems (Buchsbaum et al. 1993); yet, they are more likely to exhibit significant health problems after consuming fewer substances in a shorter period of time.

Substance abuse screening and assessment tools, in general, are not as sensitive in identifying women as having substance abuse problems.

Screening for substance use disorders is conducted by an interview or by giving a short written questionnaire. While selection of the instrument may be based on various factors, including cost and administration time (Thornberry et al. 2002), the decision to use an interview versus a self-administered screening tool should also be based upon the comfort level of the counselor or healthcare professional (Arborelius and Thakker 1995; Duszynski et al. 1995; Gale et al. 1998; Thornberry et al. 2002). If the healthcare staff communicates discomfort, women may become wary of disclosing their full use of substances (Aquilino 1994; see also Center for Substance Abuse Prevention [CSAP] 1993).

Advice to Clinicians: Substance Abuse Screening and Assessment Among Women.

Many instruments have been developed to screen for alcohol consumption, and several measures have been adapted to screen for specific drugs. While numerous screening tools are available, information about the reliability and validity of these instruments with women is limited. The following listing, while not exhaustive, individually reviews tools with available gender-specific information.

The Alcohol Use Disorder Identification Test (AUDIT; Babor and Grant 1989) is a widely used screening tool that is reproduced with guidelines and scoring instructions in TIP 26 Substance Abuse Among Older Adults (CSAT 1998d). The AUDIT is effective in identifying heavy drinking among nonpregnant women (Bradley et al. 1998c). It consists of 10 questions that were highly correlated with hazardous or harmful alcohol consumption. This instrument can be given as a self-administered test, or the questions can be read aloud. The AUDIT takes about 2 minutes to administer. Note: Question 3, concerning binge drinking, should be revised for women to refer to having 4 (not 6) or more drinks on one occasion.

The Texas Christian University Drug Screen II (TCUDS II) is a 15-item, self-administered substance abuse screening tool that requires 5–10 minutes to complete. It is based in part on Diagnostic Interview Schedule and refers to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA] 2000a) criteria for substance abuse and dependence. TCUDS II is used widely in criminal justice settings. It has good reliability among female populations (Knight 2002; Knight et al. 2002). This screen, along with related instruments, is available at www.ibr.tcu.edu.

CAGE (Ewing 1984) asks about lifetime alcohol or drug consumption (see Figure 4-1). Each “yes” response receives 1 point, and the cutoff point (the score that makes the test results positive) is either 1 or 2. Two “yes” answers results in a very small false-positive rate and the clinician will be less likely to identify clients as potentially having a substance use disorder when they do not. However, the higher cutoff of 2 points decreases the sensitivity of CAGE for women—that is, increases the likelihood that some women who are at risk for a substance problem will receive a negative screening score (i.e., it increases the false-negative rate). Note: It is recommended that a cutoff score of 1 be employed in screening for women. This measure has also been translated and tested for Hispanic/Latina populations.

A common criticism of the CAGE is that it is not gender-sensitive—that is, women who have problems associated with alcohol use are less likely than male counterparts to screen positive when this instrument is used. One study of more than 1,000 women found that asking simple questions about frequency and quantity of drinking, coupled with a question about binge drinking, was better than the CAGE in detecting alcohol problems among women (Waterson and Murray-Lyon 1988).

The CAGE is “relatively insensitive” with Caucasian females, yet Bradley and colleagues report that it “has performed adequately in predominantly black populations of women” (1998c, p. 170). Johnson and Hughes (2005) conclude that CAGE has similar reliability and concurrent validity among women of different sexual orientations. The CAGE-AID (CAGE Adapted to Include Drugs) modifies the CAGE questions for use in screening for drugs other than alcohol. This version of the CAGE shows promise in identifying pregnant, low-income women at risk for heavier drug use (Midanik et al. 1998).

Similar to other substances, women pay an exceptional price for using tobacco. The second leading cause of death in women is cancer (CDC 2004), with tobacco accounting for 90 percent of all lung cancers, according to the Surgeon General's Report on Women and Smoking (2001). Yet, women are less likely to be referred to smoking cessation programs or provided smoking cessation products (Steinberg et al. 2006). Therefore, screening for tobacco use and referral for nicotine cessation should be standard practice in substance abuse treatment. Counselors can simply screen for tobacco use beginning with current and past patterns of use, including type of tobacco, number of cigarettes smoked per day, frequency of use, circumstances surrounding use, and specific times and locations. For individuals who currently smoke, a more comprehensive assessment needs to be completed with recommendations incorporated into the woman's treatment plan.

Considering the devastating impact of substances on the developing fetus, routine screening for drug, alcohol, and tobacco use among pregnant women is imperative. Face-to-face screening interviews are not always successful in detecting alcohol and drug use, especially in pregnant women. However, self-administered screening tools have been found to be more likely to elicit honest answers (Lessler and O'Reilly 1997; Russell et al. 1996; Tourangeau and Smith 1996). Three screening instruments for use with pregnant women are TWEAK, T-ACE, and 5Ps Plus (CSAP 1993; Morse et al. 1997).

Women who smoked in the month before pregnancy are nine times more likely to be currently using either drugs or alcohol or both while pregnant (Chasnoff et al. 2001).

TWEAK (Russell et al. 1991) identifies pregnant women who are at risk for alcohol use (Figure 4-2). It consists of five items and uses a 7-point scoring system. Two points are given for positive responses to either of the first two questions (tolerance and worry), and positive responses to the other three questions score 1 point. A cutoff score of 2 indicates the likelihood of risk drinking. In a study of more than 3,000 women at a prenatal clinic, the TWEAK was found to be more sensitive than the CAGE and Michigan Alcohol Screening Test (MAST), and more specific than the T-ACE (Russell et al. 1996). The tolerance question scores 2 points for an answer of three or more drinks. However, if the criterion for the tolerance question is reduced to two drinks for women, the sensitivity of TWEAK increases, and the specificity and predictive ability decrease somewhat (Chang et al. 1999). In comparison with T-ACE, TWEAK had higher sensitivity and slightly lower specificity (Russell et al. 1994, 1996). It can also be used to screen for harmful drinking in the general population (Chan et al. 1993).

The TWEAK Questionnaire: Women.

The T-ACE is a 4-item instrument appropriate for detecting heavy alcohol use in pregnant women (Sokol et al. 1989). T-ACE uses the A, C, and E questions from CAGE and adds one on tolerance for alcohol (see Figure 4-3). The first question assesses tolerance by asking if it takes more than it used to to get high. A response of two or more drinks is scored as 2 points, and the remaining questions are assigned 1 point for a “yes” response. Scores range from 0 to 5 points. A total of 2 or more points indicates risk drinking (Chang et al. 1999). T-ACE has sensitivity equal to the longer MAST and greater than CAGE (Bradley et al. 1998c). It has been validated only for screening pregnant women with risky drinking (Russell et al. 1994).

In a study with a culturally diverse population of pregnant women, Chang and colleagues (1998) compared T-ACE with the MAST (short version) and the AUDIT. The study found T-ACE to be the most sensitive of the three tools in identifying current alcohol consumption, risky drinking, or lifetime alcohol diagnoses (Chang et al. 1998). Although T-ACE had the lowest specificity of the three tests, it is argued that false positives are of less concern than false negatives among pregnant women (Chang et al. 1998).

This screening approach has been used to identify women who are at risk for substance abuse in prenatal health settings. A “yes” response to any item indicates that the woman should be referred for assessment (Morse et al. 1997). Originally, four questions regarding present and past use, partner with problem, and parent history of alcohol or drug problems were used (Ewing 1990). However, several adaptations have been made, and recently a question about tobacco use in the month before the client knew she was pregnant was added (Chasnoff 2001). Chasnoff and colleagues (2001) reported that women who smoked in the month before pregnancy were 11 times more likely to be currently using drugs and 9 times more likely to be currently using either drugs or alcohol or both while pregnant. This version, the 5Ps, is shown in Figure 4-4.

In a study evaluating prevalence of substance use among pregnant women utilizing this screening tool, the authors suggest that it not only identified pregnant women with high levels of alcohol and drug use but also a larger group of women whose pregnancies were at risk from smaller amounts of substance use (Chasnoff et al. 2005). For a review on how to improve screening for pregnant women and motivate healthcare professions to screen for risk, refer to the Alcohol Use During Pregnancy Project (Kennedy et al. 2004).

Screening for safety related to intoxication and withdrawal at intake involves questioning the woman and her family or friends (with client's permission) about current substance use or recent discontinuation of use, along with past and present experiences of withdrawal. If a woman is obviously severely intoxicated, she needs to be treated with empathy and firmness, and provision needs to be made for her physical safety. If a client has symptoms of withdrawal, formal withdrawal scales can be used by trained personnel to gather information to determine whether medical intervention is required. Such tools include the Clinical Institute Withdrawal Assessment for Alcohol Withdrawal (Sullivan et al. 1989; See Appendix C for specific information) and the Clinical Institute Narcotic Assessment for Opioid Withdrawal (Zilm and Sellers 1978). While specific normative data are unavailable, it is important to screen for withdrawal to assess risk and to implement appropriate medical and clinical interventions.

Advice to Clinicians: At-Risk Screening for Drug and Alcohol Use During Pregnancy.

Not all drugs produce physiological withdrawal; counselors should not assume that withdrawal from any drug of abuse requires medical intervention. Only in the case of opioids, sedative-hypnotics, or benzodiazepines (and in some cases of alcohol), is medical intervention likely to be required. Nonetheless, specific populations may warrant further assessment and assistance in detoxification, including pregnant women, women of color, women with disabilities or co-occurring disorders, and older women. (Review TIP 45 Detoxification and Substance Abuse Treatment, [CSAT 2006a], pp. 105–113.) Specific to women who are pregnant and dependent on opioids, withdrawal during pregnancy poses specific medical risks including premature labor and mortality to the fetus. Note: Women who are dependent on opioids may misinterpret early signs of pregnancy as opioid withdrawal symptoms (review TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs [CSAT 2005a], pp. 211–224).

Considering that women are twice as likely as men to experience mood disorders, excluding bipolar and anxiety disorders (Burt and Stein 2002), all women entering substance abuse treatment should be screened for co-occurring mental disorders. If the screening indicates the possible presence of a disorder, a woman should be referred for a comprehensive mental health assessment and receive treatment for the co-occurring disorder, as warranted. Depression, anxiety, eating disorders, and PTSD are common among women who abuse substances (McCrady and Raytek 1993).

Because certain drugs as well as withdrawal symptoms can mimic symptoms of mental disorders, the continual reassessment of mental illness symptoms is essential to ensure accurate diagnosis and treatment planning. TIP 42 Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e) contains information on screening and treatment of persons with co-occurring substance use and mental disorders.

Symptom screening involves questions about past or present mental disorder symptoms that may indicate the need for a full mental health assessment. Circumstances surrounding the resolution of symptoms should be explored. For example, if the client is taking psychotropic medication and is no longer symptomatic, this may be an indication that the medication is effective and should be continued. Often, symptom checklists are used when the counselor needs information about how the client is feeling. They are not used to screen for specific disorders, and responses are expected to change from one administration to the next. Symptom screening should be performed routinely and facilitated by the use of formal screening tools.

Basic mental health screening tools are available to assist the substance abuse treatment team. The 18 questions in the Mental Health Screening Form-III (MHSF-III) screen for present or past symptoms of most mental disorders (Carroll and McGinley 2001). It is available at no charge from the Project Return Foundation, Inc., and is reproduced in TIP 42 Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e), along with instructions and contact information (a Spanish-language form and instructions can be downloaded from www.asapnys.org/resources.html). MHSF-III was developed in a substance abuse treatment setting and is referred to as a “rough screening device” (Carroll and McGinley 2001, p. 35).

The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a brief, structured interview for more than 20 major psychiatric and substance use disorders (Sheehan et al. 2002). Administration time is 15–30 minutes. Scoring is simple and immediate. M.I.N.I. can be administered by clinicians after brief training and by lay personnel with more extensive training. M.I.N.I. can be downloaded from www.medical-outcomes.com and used for no cost in nonprofit or publicly owned settings.

The Brief Symptom Inventory is a research tool that can be adapted for use as a screening checklist. This tool's 53 items measure 9 primary symptom dimensions as well as 3 global indices of distress. Respondents rate the severity of symptoms on a 5-point scale ranging from “Not at all” (0 points) to “Extremely” (4 points) (Derogatis and Melisaratos 1983).

Many formal tools screen for depression, including the Beck Depression Inventory-II (Beck et al. 1996a, b; Smith and Erford 2001; Steer et al. 1989), the Center for Epidemiologic Study Depression Scale (Radloff 1977), and the General Health Questionnaire—a self-administered screening test to identify short-term changes in mental health (depression, anxiety, social dysfunction, and somatic symptoms)—are available.

The U.S. Preventive Services Task Force (2002) recommends two simple questions that are effective in screening adults for depression:

Over the past 2 weeks have you felt down, depressed, or hopeless?

Over the past 2 weeks have you felt little interest or pleasure in doing things?

Programs that screen for depression should ensure that “yes” answers to these questions are followed by a comprehensive assessment, accurate diagnosis, effective treatment, and careful followup. Asking these two questions may be as effective as using longer instruments (U.S. Preventive Services Task Force 2002). Little evidence exists to recommend one screening method over another, so clinicians can choose the method that best fits their preference, the specific population of women, and the setting. Refer to TIP 48 Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (CSAT 2008) for more guidance in working with clients who have depressive symptoms. Note: Women who are depressed are more likely to report bodily symptoms, including fatigue, appetite and sleep disturbance, and anxiety (Barsky et al. 2001; Kornstein et al. 2000; Silverstein 2002).

An example of an instrument that can detect symptoms of anxiety is the 21-item Beck Anxiety Inventory (BAI; Beck 1993; Hewitt and Norton 1993). Among a group of psychiatric patients with a variety of diagnoses, women's BAI scores indicated higher levels of anxiety than men's BAI scores. However, the nature of the anxiety reported appears similar for women and men (Hewitt and Norton 1993).

Suicidal attempts and parasuicidal behavior (nonfatal self-injurious behavior with clear intent to cause bodily harm or death; Welch 2001) are more prevalent among women. The greatest predictor of eventual suicide is prior suicidal attempts and deliberate self-harm inflicted with no intent to die (Joe et al. 2006). While substance dependence and PTSD are associated with self-harm and suicidal behavior (Harned et al. 2006), the most frequent diagnoses associated with suicide are mood disorders, specifically depressive episodes (Kessler et al. 1999). Considering the prevalence of suicidal attempts, self-injurious behavior, and depression among women, employing safety screenings should be a standard practice. From the outset, clinicians should specifically ask the client and anyone else who is providing information whether she is in immediate danger and whether she has any immediate intention to engage in violent or self-injurious behavior. If the answer is “yes,” the clinician should obtain more information about the nature and severity of the thoughts, plan, and intent, and then arrange for an in-depth risk assessment by a trained mental health clinician. The client should not be left alone.

No tool is definitive for safety screening. Clinicians should use safety screening tools only as an initial guide and proceed to detailed questions to obtain relevant information. In addition, care is needed to avoid underestimating risk because a woman is using substances or has frequently engaged in self-injurious behavior. For example, a woman who is intoxicated might seem to be making empty threats of self-harm, but all statements about harming herself or others must be taken seriously. Overall, individuals who have suicidal or aggressive impulses when intoxicated are more likely to act on those impulses; therefore, determination of the seriousness of threats requires a skilled mental health assessment, plus information from others who know the client very well. Screening tools and procedures in evaluating risk are discussed in depth in TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (CSAT 2009a).

Substance abuse treatment programs need clear mental health referral and follow-up procedures so that clients receive appropriate psychiatric evaluations and mental health care. The American Association of Community Psychiatrists (AACP) developed the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) that evaluates clients along six dimensions and defines six levels of resource intensity. It includes an excellent tool for helping the counselor determine the risk of harm (AACP 2000; See Appendix C for specific information on the LOCUS). The potential risk of harm most frequently takes the form of suicidal intentions, and less often the form of homicidal intentions. The scale has five categories, from minimal risk of harm to extreme risk of harm. It is available at www.comm.psych.pitt.edu/finds/LOCUS2000.pdf and can be easily adapted for use in treatment facilities.

PTSD can follow a traumatic episode that involves witnessing, being threatened, or experiencing an actual event involving death or serious physical harm, such as auto accidents, natural disasters, sexual or physical assault, war, and childhood sexual and physical abuse (APA 2000a). During the trauma, the individual experiences intense fear, helplessness, or horror. PTSD has symptoms that last longer than 1 month and result in a decline in functioning in several life areas, such as work and relationships. A diagnosis of PTSD cannot be made without a clear history of a traumatic event (Figure 4-5 presents sample screening questions for identifying a woman's history of trauma). General symptoms of PTSD include persistently re-experiencing the traumatic event, numbness or avoidance of cues associated with the trauma, and a pattern of increased arousal (APA 2000a).

Questions to Screen for Trauma History.

Historically, women have not been routinely screened for a history of trauma or assessed to determine a diagnosis of PTSD across treatment settings (Najavits 2004). Among women in substance abuse treatment, it has been estimated that 55–99 percent have experienced trauma—commonly childhood physical or sexual abuse, domestic violence, or rape (Najavits et al. 1997; Triffleman 2003). Studies have reported that current PTSD rates among women who abuse substances range between 14 to 60 percent (Brady 2001; Najavits et al. 1998; Triffleman 2003). In comparison to men, women who use substances are still more than twice as likely to have PTSD (Najavits et al. 1997). Brief screening is paramount in not only establishing past or present traumatic events but in identifying PTSD symptoms. Upon identification of traumatic stress symptoms, counselors need to refer the women for a mental health evaluation in order to further assess the presenting symptoms, to determine the appropriateness of a PTSD diagnosis, and to assist in establishing an appropriate treatment plan and approach. Brief screenings are used to identify clients who are more likely to have PTSD. A positive response to any PTSD screen does not necessarily indicate that a patient has PTSD, but it does warrant further investigation.

Numerous screening and assessment tools are available to assess lifetime traumatic events, traumatic stress symptoms, and diagnostic criteria for PTSD. Screening and assessment for trauma-related symptoms and disorders are discussed in depth in the planned TIP Substance Abuse and Trauma (CSAT in development h). One specific screening tool that coincides with the symptoms and criteria listed in the DSM-IV-TR is the PTSD Checklist – Civilian Version (PCL-C) and the PCL-Military Version (Weathers et al. 1993). The PTSD Checklist is a 17-item, self-report rating scale. It was initially developed and validated for male Vietnam veterans; further empirical data support the reliability, validity, and diagnostic utility among women and among mixed-gender civilian groups (Andrykowski et al. 1998; Blanchard et al. 1996; Dobie et al. 2004). This instrument requires no formal training to administer and can be downloaded from the National Center for PTSD (http://www.ptsd.va.gov).

Women entering treatment for substance use disorders have consistently reported high rates of sexual abuse. Approximately two-thirds of all women entering treatment have specifically reported a history of sexual violence (Gil-Rivas et al. 1996; Lincoln et al. 2006). In 1998, Bassuk reported higher rates of lifetime occurrence of physical and sexual violence among women who are poor and homeless (82 percent and 92 percent, respectively; Bassuk 1998). More recent research focuses on sociocultural factors supporting the belief that socioeconomic status contributes more to women's vulnerability to abuse and stress symptoms than does ethnicity (Vogel and Marshall 2001).

During the intake process, many women are reluctant to reveal their sexual abuse before trust is established with the counselor. Some women may not realize that their experiences were not normal and were abusive. Some women do not remember the abuse. Therefore, a negative finding on abuse at an intake screening should not be taken as a final answer. The Substance Abuse and Mental Health Services Administration (SAMHSA)-funded Women, Co-Occurring Disorders and Violence Study includes questions about sexual abuse in its baseline interview protocol, presented in Figure 4-6. In addition, SAMHSA's CSAT has developed a brochure for women that defines childhood abuse and informs the reader of how to begin to address childhood abuse issues while in treatment (CSAT 2003a). TIP 36 Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000b) includes detailed information on this topic.

Questions Regarding Sexual Abuse.

Studies estimate that between 50 to 99 percent of women with substance use disorders have a history of interpersonal violence (Miller et al. 1993; Rice et al. 2001). In one study focused on sensitivity and specificity of screening questions for intimate partner violence, Paranjape and Liebschutz (2003) concluded that when three simple screening questions were used together, identification of lifetime interpersonal violence was effectively identified for women. This screening tool, referred as the STaT, is presented in Figure 4-7 (p. 72). Along with a sample personalized safety plan, additional screening tools, including the Abuse Assessment Screen (English and Spanish version), Danger Assessment, The Psychological Maltreatment of Women Inventory, and The Revised Conflict Tactics Scale (CTS2), are available in TIP 25 Substance Abuse Treatment and Domestic Violence (CSAT 1997b). Note: It is important to assess for interpersonal violence in heterosexual and homosexual relationships.

STaT: Intimate Partner Violence Screening Tool.

Women with disabilities are at a significantly greater risk for severe interpersonal violence and neglect (Brownridge 2006). As a counselor, additional screening questions tailored to address unique vulnerabilities associated with the specific physical disability may be warranted. For example,

Has anyone ever withheld food or medication from you that you asked for or needed?

Has anyone ever refused to let you use your wheelchair or other assistive devices at home or in the community?

Has anyone ever refused to assist you with self-care that you needed, such as getting out of bed, using the toilet, or other personal care tasks?

Has anyone used restraints on you to keep you from getting out of bed or out of your wheelchair?

Initial questions about trauma should be general and gradual. While ideally you want the client to control the level of disclosure, it is important as a counselor to mediate the level of disclosure. At times, clients with PTSD just want to gain relief; they disclose too much, too soon without having established trust, an adequate support system, or effective coping strategies.

Preparing a woman to respond to trauma-related questions is important. By taking the time with the client to prepare and explain how the screening is done and the potential need to pace the material, the woman has more control over the situation. Overall, she should understand the screening process, why the specific questions are important, and that she can choose not to answer or to delay her response. From the outset, counselors need to provide initial trauma-informed education and guidance with the client.

Be aware that weight gain during recovery can be a major concern and a relapse risk factor for women.

Eating disorders have one of the highest mortality rates of all psychological disorders (Neumarker 1997; Steinhausen 2002). Approximately 15 percent of women in substance abuse treatment have had an eating disorder diagnosis in their lifetimes (Hudson 1992). Three eating disorders are currently included in the DSM-IV-TR: anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (APA 2000a). Compulsive eating, referred to as binge-eating disorder, is not included as a diagnosis in the DSM. Currently, it is theorized that substance use disorders and compulsive overeating are competing disorders, in that compulsive overeating (binge-eating) is not as likely to appear at the same time as substance use disorders. Consequently, disordered eating in the form of compulsive overeating is more likely to appear after a period of abstinence, thus enhancing the risk of relapse to drugs and alcohol to manage weight gain.

Bulimia nervosa, characterized by recurrent episodes of binge and purge eating behaviors, has the highest incidence rates in the general population for eating disorders (Hoek and van Hoeken 2003), and it is the most common eating disorder among women in substance abuse treatment (Corcos et al. 2001; Specker et al. 2000; APA 2000a). For specific information regarding the co-occurring disorders of eating and substance use disorders, counselors should refer to TIP 42 Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e).

Screening for eating disorders in substance abuse treatment is based on the assumption that identification of an eating disorder can lead to earlier intervention and treatment, thereby reducing serious physical and psychological complications and decreasing the potential risk for relapse to manage weight. Eating disorder screenings are not designed to establish an eating disorder diagnosis but instead to identify the need for additional psychological and medical assessments by a trained mental health clinician and medical personnel. The EAT-26 (Garner et al. 1982), or Eating Attitudes Test, is a widely used screening tool that can help identify behaviors and symptoms associated with eating disorder risk (Garner et al. 1998). It is recommended that a two-stage process be employed using the EAT-26: screening followed by a clinical interview. Specifically, if the woman scores at or above a cutoff score of 20 on the EAT-26, she should be referred for a diagnostic interview. For a copy of the screening tool and scoring instructions, refer to Appendix C.

Figure 4-8 lists questions that probe for an eating disorder. A woman with an eating disorder often feels shame about her behavior, so the general questions help ease into the topic as the counselor explores the client's attitude toward her shape, weight, and dieting.

General and Specific Screening Questions for Persons With Possible Eating Disorders.

Healthcare providers such as nurse practitioners, physicians, physicians' assistants, and social service professionals have opportunities to screen women to determine whether they use or abuse alcohol, drugs, or tobacco. The most frequent points of entry from other systems of care are obstetric and primary care; hospital emergency rooms; probation officer visits; and social service agencies in connection with housing, child care, and domestic violence.

Our own preconceived images of women who are addicted, coupled with a myth that women are less likely to become addicted, can undermine clinical judgment to conduct routine screenings for substance use.

Between 5 and 40 percent of people seeing physicians and/or reporting to hospital emergency rooms for care have an alcohol use disorder (Chang 1997), but physicians often do not identify, refer, or intervene with these patients (Kuehn 2008). Even clinicians who often use the CAGE or other screening tools for certain patients are less likely to ask women these questions because women—particularly older women, women of Asian descent, and those from middle and upper socioeconomic levels—are not expected to abuse substances (Chang 1997). Volk and colleagues (1996) found that, among primary care patients who were identified as “at risk” for alcohol abuse or dependence by a screening questionnaire, men were 1.5 times as likely as women to be warned about alcohol use and three times as likely to be advised to stop or modify their consumption. Women may be less likely to have problems with alcohol or drugs than men (Kessler et al. 1994, 1995); however, when women have substance use disorders, they experience greater health and social consequences.

Screening must lead to appropriate referrals for further evaluation and treatment in order to be worthwhile. Missed opportunities can be especially unfortunate during prenatal care. In one study of ethnically diverse women reporting to a university-based obstetrics clinic, 38 percent screened positive for psychiatric disorders and/or substance abuse. However, only 43 percent of those who screened positive had symptoms recorded in their chart, and only 23 percent of those screening positive were given treatment. This low rate of treatment is of great concern, given the untoward consequences of substance use for maternal and infant health (Kelly et al. 2001).

To address the disconnection that often happens (beginning with the lack of identification of substance-related problems of the patient and extending to the failure of appropriate referrals and brief interventions), SAMHSA has invested in the Screening, Brief Intervention, and Referral to Treatment Initiative (SBIRT)—research, resources development, training, and program implementation across healthcare settings. Although studies have not focused on gender comparisons, SBIRT programs have yielded short-term improvements in individual health (for review, see Babor et al. 2007). Specifically, some SBIRT programs on the State level have tailored SBIRT to provide assistance to pregnant women (Louisiana Department of Health and Hospitals 2007).

The assessment examines a client's life in far more detail so that accurate diagnosis, appropriate treatment placement, problem lists, and treatment goals can be made. Usually, a clinical assessment delves into a client's current experiences and her physical, psychological, and sociocultural history to determine specific treatment needs. Using qualified and trained clinicians, a comprehensive assessment enables the treatment provider to determine with the client the most appropriate treatment placement and treatment plan (CSAT 2000c). Notably, assessments need to use multiple avenues to obtain the necessary clinical information, including self-assessment instruments, clinical records, structured clinical interviews, assessment measures, and collateral information. Rather than using one method for evaluation, assessments should include multiple sources of information to obtain a broad perspective of the client's history, level of functioning and impairment, and degree of distress.

Advice to Clinicians: Mental Health Screening and Women.

Assessment should be a fluid process throughout treatment. It is not a once-and-done event. Considering the complexity of withdrawal and the potential influence of alcohol and drugs on physical and psychological functioning, it is very important to reevaluate as the client engages into recovery. Periodic reassessment is critical to determine the client's progress and her changing treatment needs. In addition, reassessment is an opportunity to solicit input from the client on what is and is not working for her in treatment and to alter treatment accordingly.

The following section reviews core assessment processes tailored for women, including gender-specific content for biopsychosocial histories and assessment tools that are either appropriate or possess normative data for women in evaluating substance use disorders and consequences. It is beyond the scope of this chapter to provide specific assessment guidelines or tools for other disorders outside of substance-related disorders.

To provide an accurate picture of the client's needs, a clinical assessment interview requires sensitivity on the part of the counselor and considerable time to complete thoroughly. While treatment program staff may have limited time or feel pressure to conduct initial psychosocial histories quickly, it is important to portray to clients that you have sufficient time to devote to the process. The assessment interview is the beginning of the therapeutic relationship and helps set the tone for treatment.

Initially, the interviewer should explain the reason for and role of a psychosocial history. It is equally important that the counselor or intake worker incorporate screening results into the interview, and make the appropriate referrals within and/or outside the agency to comprehensively address presenting issues. The notion that the women's substance use is not an isolated behavior but occurs in response to, and affects, other behaviors and areas of her life is an important concept to introduce during the intake phase. This information can easily disarm a client's defensiveness regarding use and consequences of use.

Advice to Administrators: General Guidelines for Selecting and Using Screening and Assessment Tools.

The focus of the assessment may vary depending on the program and the specific issues of an individual client. A structured biopsychosocial history interview can be obtained by using The Psychosocial History (PSH) assessment tool (Comfort et al. 1996), a comprehensive multidisciplinary interview incorporating modifications of the Addiction Severity Index (ASI) designed to assess the history and needs of women in substance abuse treatment. Investigators have sought to retain the fundamental structure of ASI while expanding it to include family history and relationships, relationships with partners, responsibilities for children, pregnancy history, history of violence and victimization, legal issues, and housing arrangements (Comfort and Kaltenbach 1996). PSH has been found to have satisfactory test-retest reliability (i.e., the extent to which the scores are the same on two administrations of the instrument with the same people) and concurrent validity with the ASI (Comfort et al. 1999).

Treatment programs have their own prescribed format for obtaining a psychosocial history that coincides with State regulations as well as other standards set by Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Commission on Accreditation of Rehabilitation Facilities (CARF). While many States require screening and assessment for women, specific guidelines and specificity in incorporating women-specific areas vary in degree (CSAT 2007). Note: When using information across State standards, the following psychosocial and cultural subheadings should be included in the initial assessment for women, and these areas need to be addressed in more depth as treatment continues. Keep in mind that the content within each subheading does not represent an entire psychosocial and cultural history. Only biopsychosocial and cultural issues that are pertinent to women were included in the list below.

Medical History and Physical Health: Review HIV/AIDS status, history of hepatitis or other infectious diseases, and HIV/AIDS risk behavior; explore history of gynecological problems, use of birth control and hormone replacement therapy, and the relationship between gynecological problems and substance abuse; obtain history of pregnancies, miscarriages, abortions, and history of substance abuse during pregnancy; assess need for prenatal care.

Substance Abuse History: Identify people who initially introduced alcohol and drugs; explore reasons for initiation of use and continued use; discuss family of origin history of substance abuse, history of use in previous and present significant relationships, and history of use with family members or significant others.

Mental Health and Treatment History: Explore prior treatment history and relationships with prior treatment providers and consequences, if any, for engaging in prior treatment; review history of prior traumatic events, mood or anxiety disorders (including PTSD), as well as eating disorders; evaluate safety issues including parasuicidal behaviors, previous or current threats, history of interpersonal violence or sexual abuse, and overall feeling of safety; review family history of mental illness; and discuss evidence and history of personal strengths and coping strategies and styles.

Interpersonal and Family History: Obtain history of substance abuse in current relationship, explore acceptance of client's substance abuse problem among family and significant relationships, discuss concerns regarding child care needs, and discuss the types of support that she has received from her family and/or significant other for entering treatment and abstaining from substances.

Family, Parenting, and Caregiver History: Discuss the various caregiver roles she may play, review parenting history and current living circumstances.

Children's Developmental and Educational History (applicable to women and children programs): Assess child safety issues; explore developmental, emotional, and medical needs of children.

Sociocultural History: Evaluate client's social support system, including the level of acceptance of her recovery; discuss level of social isolation prior to treatment; discuss the role of her cultural beliefs pertaining to her substance use and recovery process; explore the specific cultural attitudes toward women and substance abuse; review current spiritual practices (if any); discuss current acculturation conflicts and stressors; and explore need or preference for bilingual or monolingual non-English services.

Vocational, Educational, and Military History: If employed, discuss the level of support that the client is receiving from her employer; review military history, then expand questions to include history of traumatic events and violence during employment and history of substance abuse in the military; assess financial self-reliance.

Legal History: Discuss history of custody and current involvement with child protective services, if any; obtain a history of restraining orders, arrests, or periods of incarceration, if any; determine history of child placement with women who acknowledge past or current incarceration.

TIPs that provide assessment information relevant to women in specific settings:

Barriers to Treatment and Related Services: Explore financial, housing, health insurance, child care, case management, and transportation needs; discuss other potential obstacles the client foresees.

Strengths and Coping Strategies: Discuss the challenges that the client has faced throughout her life and how she has managed them, review prior attempts to quit substance use and identify strategies that did work at the time, identify other successes in making changes in other areas of her life.

Addiction Severity Index (ASI): The ASI (McLellan et al. 1980) is the most widely used substance abuse assessment instrument in both research and clinical settings. It is administered as a semi-structured interview and gathers information in seven domains (i.e., drug use, alcohol use, family/social, employment/finances, medical, psychiatric, and legal). The ASI has demonstrated high levels of reliability and validity across genders, races/ethnicities, types of substance addiction, and treatment settings (McCusker et al. 1994; McLellan et al. 1985; Zanis et al. 1994; See Appendix C for specific information on the ASI).

ASI-F (CSAT 1997c): The ASI-F is an expanded version of ASI; several items were added relevant to the family, social relationships, and psychiatric sections. Additional items refer to homelessness; sexual harassment; emotional, physical, and sexual abuse; and eating disorders. The supplemental questions are asked after the administration of ASI. Psychometric data for ASI-F are limited.

Texas Christian University Brief Intake, the Comprehensive Intake, and Intake for Women and Children: These instruments are available electronically and are administered by a counselor. The seven problem areas in the Brief Intake Interview were derived from the ASI: drug, alcohol, medical, psychological, employment, legal, and family/social. Scoring is immediate, and the program generates a one-page summary of the client's functioning in 14 domains (Joe et al. 2000). The Comprehensive Intake has an online version for women (Simpson and Knight 1997.

Since women are more likely to experience greater consequences earlier than men, using an instrument that highlights specific consequences of use is crucial.

Drinker Inventory of Consequences (DrinC): This measurement is a self-administered 50-item, true-false questionnaire that elicits information about negative consequences of drinking in five domains: physical, interpersonal, intrapersonal, impulse control, and social responsibility (Miller et al. 1995). This instrument has normative data for women, men, inpatient and outpatient, and has good psychometric properties. Since women are more likely to experience greater consequences earlier than men, using an instrument that highlights specific consequences of use is crucial. A version that assesses drug use consequences is also available (Tonigan and Miller 2002). For a copy of the assessment tool, scoring, and gender profile in interpreting severity of lifetime consequences, see Appendix C.

Figure 4-9 (p. 80) provides available information on screening and assessment versions in languages other than English. This is not an exhaustive list, and counselors and administrators should not assume language availability is a sign that the instrument is appropriate for a particular culture, ethnic, or racial group.

Available Screening and Assessment Tools in Multiple Languages.

Focusing on a woman's strengths instead of her deficits improves self-esteem and self-efficacy. Familiarity with a woman's strengths enables the counselor to know what assets the woman can use to help her during recovery. In the Woman's Addiction Workbook (Najavits 2002a), the author provides a self-assessment worksheet that focuses on individual strengths. In addition to assessing strengths, coping styles and strategies should be evaluated (see Rotgers 2002).

Spirituality and religion play an important role in culture, identity, and health practices (Musgrave et al. 2002). In addition, women are more likely to embrace different coping strategies (including emotional outlets and religion) to assist in managing life stressors (Dennerstein 2001). Practices such as consulting religious leaders or spiritual healers (curanderas, medicine men) and attending to spiritual activities (including sweats and prayer ceremonies, praying to specific saints or ancestors) are common. The consensus panel believes it is important that programs assess the spiritual and religious beliefs and practices of women and incorporate this component into their treatment with sensitivity and respect.

A challenge in determining the effect of spirituality on treatment outcomes is how to assess the extent and nature of a person's spirituality or religiousness. Several assessment tools are available; however, they are more often used for research. They include, but are not limited to, the Religious Practice and Beliefs measurement (CASAA 2004), a 19-item self-assessment tool that reviews specific activities associated with religious practices; the Multidimensional Measure of Religiousness/Spirituality, an assessment device that examines domains of religious or spiritual activity such as daily spiritual experiences, values and beliefs, and religious and spiritual means of coping (Fetzer Institute 1999); and the Spiritual Well-Being Scale, a 20-item scale that examines the benefits of spirituality for African-American women in recovery from substance abuse (Brome et al. 2000; See Appendix C for specific information on the Spiritual Well-Being Scale).

Because women develop serious medical problems earlier in the course of alcohol use disorders than men, they should be encouraged to seek medical treatment early to enhance their chances of recovery and to prevent serious medical complications. Health screenings and medical examinations are essential in women's treatment. In particular, women entering substance abuse treatment programs should be referred for mental health, medical, and dental examinations. In many cases, they may not have had adequate health care because of lack of insurance coverage or transportation, absence of child care, lack of time for self-care, chaotic lifestyle related to a substance abuse, or fear of legal repercussions or losing custody of children. The acute and chronic effects of alcohol and drug abuse, the potential for violence, and other physical hardships (e.g., homelessness) greatly increase the risk for illness and injury.

Women may practice behaviors that put them at high risk for contracting sexually transmitted diseases (STDs) and other infectious diseases (Greenfield 1996). Testing for HIV/AIDS, hepatitis, and tuberculosis is important; however, it is as essential to have adequate support services to help women process test results in early recovery. Anticipation of the test results is stressful and may place the client at risk for relapse. Residential centers may offer medical exams onsite, but outpatient service providers may need to refer patients to their primary care provider or other affordable health care to ensure that each client has a thorough medical exam. Healthcare professionals may benefit in using the Women-Specific Health Assessment (Stevens and Murphy 1998), which assesses health and wellness and addresses gynecological exams, HIV/AIDS, drug use, STDs, pregnancy/child delivery history, family planning, mammography, menstruation, disease prevention, and protection behaviors.

Advice to Clinicians: General Guidelines of Assessment for Women.