Clinical Assessment and Substance Abuse Treatment: The Target Cities Experience

4. Identifying Service Needs among Substance Abuse Treatment Participants

C H A P T E R 4 Identifying Service Needs among Substance Abuse Treatment Participants Mark A. Foss, Nancy Barron, and Cynthia L. Arfken Each Target Cities site created a centralized intake and assessment function in the community. Centralization was designed to provide rapid access to an array of services, both inside and outside of the substance abuse treatment system, to address the many co-occurring needs of the individuals seeking treatment. Such accessibility was seen as central to maximizing participants’ entry and retention in treatment, as well as perhaps alleviating or eliminating other problems that might have a bearing on their substance abuse. But what were the other issues and concerns faced by participants, and what array of services might best serve them? People seeking substance abuse treatment often present with an array of problems (Claus & Dailey, chap. 3 in this book). Some of these problems (e.g., medical or psychiatric) may mask symptoms or reduce the effectiveness of substance abuse treatment. Other problems such as unemployment, legal problems, or family and social conflict may affect retention and relapse potential. Long-term success of substance abuse treatment depends in part on addressing through ancillary or specially designed services the problems that commonly co-occur with substance abuse (e.g., McLellan, Arndt, Metzger, Woody, & O’Brien, 1993). Identifying co-occurring problems was an integral part of the Target Cities Program. As such, each site was required to address the range and diversity of service needs among those presenting for substance abuse treatment. These activities included a comprehensive, standardized assessment of participants’ problems with procedures 55 for matching participants to treatment programs; linkage and integration among existing substance abuse treatment and other health and human service agencies; and case management services to assure participant access and utilization of available services (see Arfken, Klein, Agius, & di Menza, chap. 7 in this volume). The challenge of developing an integrated system is not only obtaining the resources to address various service needs but also to develop programs and facilities that can efficiently address the needs of individuals with multiple , interrelated problems. The research conducted within the Target Cities Program has demonstrated that it is not efficient to conduct a needs assessment to estimate the number of individuals with problems that indicate specific areas of service need (medical, job training, child care, etc.) without also analyzing the co-occurrence of problems within individuals. The approach presented here uses cluster analyses to define common profiles of problems. These profiles can then be used to construct solutions in system and clinical program design that address service need complexes rather than those which target each need separately. Leff, Lieberman, and Wise (1995) made a similar argument to that presented here for the usefulness of cluster analysis in system planning. However, they conducted a retrospective investigation of mental health service utilization data rather than conducting a needs assessment. Other researchers have classified people involved in substance abuse treatment using various techniques. Most studies have focused on dual diagnosis participants with co-occurring conditions of substance abuse and mental illness. For example, Luke, Mowbray, Klump, Herman, and BootsMiller (1996) reported results from cluster analyses of the Addiction Severity Index (ASI) Severity Scores among psychiatric patients with substance abuse problems that found “extreme heterogeneity,” indicating the need for “individualized treatment programs [to] match the particular needs of patients” (p. 298). Lehman, Myers, Dixon, and Johnson (1994) found that alcohol, drug, family, and psychiatric ASI composite scores differed in expected ways among substance abuse participants with differing psychiatric problems , and they suggested different service strategies for each group. Other researchers have made service recommendations based on profiles of participants, but examined only a limited set of co-occurring conditions (e.g., Barry, Fleming, Greenley, Kropp, & Widlak, 1996; Brown, Huba, & Melchior, 1995; Brunette & Drake, 1997; Carey, 1996; Drake, Osher, & Wallach, 1989; Lambert, Griffith, & Hendrickse, 1996; Kaskutas, 1997; Reed & Mowbray, 1999; Singer, Kennedy, & Kola, 1998). Other researchers have argued for an integrated treatment sys56 Mark A. Foss et al. tem as the best approach to the multiple problems of dually diagnosed clients, thus asserting the usefulness of combinations of participant problems for system planning (e.g., Carey, 1996; Drake, Bartels, Teague, Noordsy & Clark, 1993; Hoff & Rosenheck, 1999; Lehman, Myers, Johnson, & Dixon, 1995; Mueser, Bellack & Blanchard , 1992; Osher, 1996; Singer et al., 1998). System planning based on combinations of participant problems has yielded some positive results. Ridgely, Lambert, Goodman, Chichester , and Ralph (1998) reported a 1-year increase...