The importance of a good needs assessment cannot be overstated in the treatment of substance use disorders. When the needs assessment effectively synthesizes the client’s self-report with additional sources and sound clinical judgment on a wide array of client issues, the assessment more accurately identifies client needs. Those needs should then become the basis of the initial treatment plan and the foundation for the ongoing process of counselor-client collaboration in planning services and monitoring client progress.

There are several underlying principles of a good standardized needs assessment. First, the assessment must be designed to inform the treatment plan. Even the best intervention is ineffective when not aimed at the right target. If client needs are not identified or are misunderstood, the treatment recommendations may be incongruous with client needs, potentially leading to “treatment failure” that frustrates the client, the counselor and the payer.

Second, the assessment must help define the most salient clinical issues; it should not only identify problems, but also, help the clinician prioritize the problems that are most acute and show where additional information should be gathered in subsequent sessions to make effective treatment plans and referrals.

Third, the assessment should weigh the relationship of the client’s treatment history and current problem severity. When services have already been received for a given problem, there is always an effect — positive, neutral or negative — that can help inform the next treatment steps. A clinical response to the presence and severity of the current problem should always consider those prior interventions. This facilitates treatment planning that is tailored for individualized client progress.

Fourth, the assessment tool needs to help serve as a cross-check for inconsistencies in client self-reported information. Because most assessments for substance use disorders are primarily based on client self-report, the clinician must know how to use the full body of reported information to check for the possibility of inaccurate or misreported information that may affect the appropriateness of the treatment placement decision and treatment plan. Clients may over- or under-report information or have an asymptomatic self-report due to medication or environmental controls (such as being in jail for months prior to the assessment).

A good standardized assessment system that abides by these four principles can make the clinician’s job easier. It ensures that the treatment planning and placement decisions for the client are individualized and clinically appropriate, ultimately leading to better treatment outcomes.

Unfortunately, addiction professionals face challenges in implementing assessment tools that flow directly into individualized treatment planning. These challenges typically stem from two larger problems: (1) systemic change for treatment programs can be difficult and is often met with resistance; and (2) evidence-based assessment tools are typically not designed for maximum efficiency in treatment programs. While treatment programs and the developers of assessment tools have made forward movement and positive strides in the past 10 to 20 years, quite commonly, there is still some hesitation from both sides to fully engage in new systems.

Why treatment programs have not readily used evidence-based needs assessments

Treatment programs must operate with their staffing and program needs in mind. Each department within a treatment program has different information needs. Out of those needs come multiple small intake and assessment steps, each with distinct forms of documentation to fit the various requirements associated with billing, intake, case flow, treatment, etc. Systemic change is often necessary to bring all those small steps into one integrated process.

When a treatment program decides to implement a broader biopsychosocial assessment system, typically, the diverse clinical workforce — with varying levels of training, skill and experience — will pose challenges for maintaining a level standard of clinical care that effectively integrates diagnostic assessment and treatment planning. In the midst of these wide-ranging backgrounds, the field of addiction treatment has been challenged with various and sometimes competing philosophies and treatment approaches. The Center for Substance Abuse Treatment Technical Assistance Publication (TAP) 21,

Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice, suggests that the best assessment is a comprehensive process that is sensitive to a broad range of life areas in collecting information necessary for treatment planning and evaluating client progress (12). In reality, the field of addiction treatment is characterized by multiple service sectors (e.g., medical, legal). Each sector has its own model and has historically operated in a vacuum, with one-way referrals that tend to focus on different aspects of the client’s history.

Even within the substance abuse treatment system, counselor training programs often separate diagnostic assessment from treatment planning and do not present an integrated approach to these two interrelated components of service provision. The result is a fragmented approach both to training in the classroom and to service planning in the field. When a clinician’s learning experience is disjointed, the assessment goes in one drawer and an unrelated treatment plan comes out another drawer. If we accept the premise that the initial assessment should flow directly into treatment planning, then we can also make the case for counselor training programs that meld the assessment process and treatment planning in one multi-step process.

Finally, clinicians have found the unstructured clinical interview to be appealing because of its ability to immediately build  rapport between that client and counselor. As a result, evidence-based assessments that have more structure are often discounted as being impersonal and invasive.

Why evidence-based assessments don’t easily lend themselves to use in treatment programs

If a substance abuse treatment program is already using or considering an evidence-based assessment, the first step is to identify an assessment that would give the program everything it needs to proceed with treatment. Unfortunately, assessment tools typically focus heavily on diagnosis and do not always take the necessary steps to facilitate treatment planning. Diagnosis is an essential aspect of full and accurate problem definition. However, if diagnosis is merely a process for labeling or categorizing clients, the intent of the assessment is lost. What’s more, a client’s fear of being “labeled” can be a deterrent to seeking treatment services. If clients are assured that assessment questions are not merely used to label their problems but will be used to help both themselves and the provider to understand, define and prioritize problems and plan appropriate services, they may be inclined to give more accurate reports of their problems and behaviors.

Additionally, most assessment tools are not designed to be compatible with both the Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM-IV-TR) and the treatment planning guidelines of the American Society of Addiction Medicine Patient Placement Criteria (ASAM-PPC-2R). While DSM-IV-TR is a diagnostic tool and ASAM provides treatment planning guidelines, our experience suggests that addiction professionals are often hard-pressed to identify a single assessment tool that effectively manages the objectives of both these tools and incorporates their information into a single comprehensive report.

Finally, even those assessment tools that meet these clinical needs often use software that either does not easily fit into a treatment program’s client information system; does not provide the type of reports that would save clinicians time; is difficult to use; or requires a large amount of training. This can be especially challenging, given staff turnover rates in the field of addictions treatment. A good assessment system would: provide the basic information for client management and billing systems; support the intake process; offer diagnostic impressions on all five DSM axes; synthesize collateral information; identify case management needs; and facilitate treatment planning.

How one evidence-based assessment meets the challenge of addressing clinical needs

The Global Appraisal of Individual Needs (GAIN) was developed for both clinical and research use with adults and adolescents (3). The GAIN is actually a family of instruments developed through a long-standing (since 1993) collaboration of clinicians, researchers, policymakers and IT professionals. Of these tools, the easiest to use is the five-minute GAIN-Short Screener (GAIN-SS), developed for use in general populations to identify need for further assessment (often used in justice systems, schools and child welfare agencies to identify referrals to substance abuse treatment). The GAIN-Quick (GAIN-Q) is a 20-minute version used for screening and supporting brief intervention in targeted populations.

The most widely used version of the GAIN is the GAIN-Initial (GAIN-I), a 60 to 180 minute (depending on version used and client severity) comprehensive biopsychosocial assessment system designed to integrate research and clinical assessment into one semi-structured interview. The GAIN-I assesses clients on a wide array of issues, problems, characteristics and behaviors including: basic client demographics; substance use patterns and treatment history; physical health issues and treatment history; mental health issues and treatment history; risk behaviors associated with sexual activity; needle use; tobacco use; legal system involvement; educational, vocational and employment issues; and social and environmental issues.

Early use of the GAIN often included limited, project-specific clinical reports. The software was designed for data entry of information after the assessment had been administered with paper and pen. In 2000, Chestnut Health Systems released the Assessment Building System (ABS), including both a data entry option and an interactive interview option that navigated the assessment one item at a time. This software version included a standard report, the Individual Clinical Profile (ICP).

The ICP summarized the client’s self-report in graphic form and had some text and table statements that helped clinicians. The report was not editable and was not designed to support typical clinical paperwork needs. While clinical programs using the software appreciated the interactive interview capability of the software and felt it was easy to use, its developers continually heard (most frequently from Chestnut Health Systems’ own adolescent treatment program) that outside research grant use, no program would regularly use the GAIN unless there were an editable, sharable narrative report designed to meet clinicians needs and also save valuable paperwork time. A team of clinicians, researchers and IT specialists from across the country was put together under the direction of Dr. Michael Dennis, lead developer of the GAIN.

The team’s collaborative efforts resulted in the 2003 GAIN Recommendation and Referral Summary (G-RRS) release. This version of the report was a full biopsychosocial assessment that provided diagnostic impressions based on DSM, ASAM-based treatment planning guidelines and basic recommendations for treatment planning. The report came out as an editable MS Word document, and thus, could be easily revised.

The 2003 version of the report included prompts to add general treatment recommendations, but it lacked the ability to provide specific treatment plan statements that reflect individual client needs. And while it provided clinicians with the ability to edit the final report as an MS Word document, it did not allow the clinician to override and select alternative diagnoses from the actual database. Additionally, the software system worked well by itself in a small treatment program, but didn’t fill the needs of larger programs and entire regions that wanted to work together, and needed more sophisticated platforms. Recognizing these obstacles, substance abuse and mental health experts came together to improve the G-RRS report, while simultaneously working with a team of IT specialists to redesign the software into a web-based format that supports a new and more comprehensive clinical report.

In 2008, the new GAIN-ABS software was released and includes a greatly enhanced G-RRS report. The new version provides addiction professionals with a software-generated report (based on client self-report and clinician impressions) that facilitates the clinical ecision-making process from assessment to diagnosis, treatment planning, and ultimately, level of care placement. The new enhancements in GAIN software expanded the clinician’s ability to use the tool for supporting accurate problem definition and diagnostic impressions, based on all five axes of DSM, and for developing highly individualized treatment plans that flow directly from the diagnostic assessment.

Treatment recommendations in the G-RRS were enhanced with: options for responding to client requests; more specific intervention statements; prompts to review the client’s needs for specific services, further evaluation, placement, continued stay, discharge or transfer to a more- or less-intensive level of care based on the unique combination of problem severity and treatment responsiveness for the individual client on each ASAM dimension; and specific recommendations for special needs, priority population and high-risk situations.

Benefits of Using GAIN.

The GAIN reports support an assessment process that takes the necessary steps to facilitate treatment planning. As a text-based narrative designed to be edited and shared with specialists, clinical staff from other agencies, insurers and lay people, the G-RRS summarizes the data collected, and the software generates a set of individualized treatment planning statements based on the information provided. Treatment recommendations can be modified, added or deleted by the clinician.

Integrated case conceptualization for problem prioritization shows the clinician the severity level of the reported problems, based on three concrete factors: the problem’s recency; the current rate of prevalence; and the breadth of symptoms and services. This is useful both for diagnosis and for placement.

Recency looks at timing, specifically the most recent occurrence of a problem. It reflects whether a clinical problem occurred in the present, past or never. Things that happened in the past week, past month, or past 90 days will typically play a greater role in current treatment than those that happened three to 12 months, or one or more years ago. If there are current problems in any ASAM dimension, then a treatment recommendation, referral for further evaluation, or other ancillary services associated with that dimension will usually be included in the report.

Breadth looks at the severity of a current problem and is measured by the extent and diversity of the presenting symptoms or the service utilization history. Characteristically, more diverse presentations are associated with higher severity. For clinical problems, the focus generally will be on the past year (or since the last interview in follow-up assessments). For services, the focus will generally be on the lifetime pattern of service utilization.

Current prevalence looks at the frequency of a current problem and is measured by how often something has happened in the past 90 days. As a rule, things that happen more frequently (particularly if they interfere with responsibilities at home, work/school or socially) are going to be more important than those that happened only once or twice.

All three of these factors can interact. As a biopsychosocial assessment tool, the GAIN helps clinicians evaluate a client’s problem severity for recency, breadth and current prevalence for the sake of diagnosis and for treatment planning. As an example, a more recent problem with a broad presentation and high current prevalence is going to be the most acute situation: a client reports using alcohol within the past two days (recency); presents with a diverse presentation of alcohol-related problems including six diagnostic criteria for alcohol dependence along with multiple legal and vocational problems as a result of alcohol use (breadth); and reports using alcohol on 70 of the past 90 days (prevalence).

The same client also reports using amphetamines three to seven days ago (recency); endorses four diagnostic criteria for amphetamine abuse (breadth); and reports using amphetamines on 48 of the past 90 days (prevalence). Using those criteria, the more clinically significant problem is the alcohol use; while the amphetamine abuse will be a treatment priority, the client’s alcohol problems will play a greater role in the current treatment plan.

This rationale applies across all the treatment planning dimensions of ASAM. Conversely, a broad presentation of symptoms over the past year that has not been problematic recently, or has been problematic only infrequently, may have been addressed but should still be monitored for change. As the GAIN identifies the client problems, helps prioritize which are the most acute, and identifies where more information is needed, the assessment flows smoothly and logically into treatment planning.

Intersection of treatment history and problem history/severity. Treatment planning with the GAIN and its computer-generated reports helps clinicians look not only at the presence of a particular problem, but also helps them consider the client’s treatment history and the severity of reported problems.

While intake severity is important, it is also important to consider the interaction of each problem area with treatment/services over time. Typically, more severe problems indicate the need for a higher level of care, particularly if current or prior interventions have been unsuccessful. Lower severity problems may be addressed with a lower-intensity intervention, unless there is a prior history of intervention. Past problems for which a person is still receiving services would call for an assessment of the current intervention to determine the appropriateness of discharge or stepping down to a lower-intensity level of care. In the absence of any prior treatment history, a less invasive treatment intervention would generally be recommended. Reporting the same level of problems while already in treatment, in contrast, may be interpreted as a “non-response” to treatment and lead to a recommendation to increase the intensity or level of care.

Clinicians can use the GAIN to do this evaluation for the overall need for substance abuse treatment and for each of the specific ASAM dimensions (e.g., intoxication/withdrawal problems and detoxification services history; physical health problems and health care service utilization history; emotional/behavioral problems and mental health/legal intervention; readiness for change and motivational interventions; relapse potential and relapse prevention interventions; recovery environment and residential/environmental factors/interventions).

Cross-checks for client self-reported information. Because the GAIN is a self-reported instrument, the clinician must know how to use the full body of self-reported information to check for the possibility of inaccurate or misreported information that might affect the report’s validity. Clients may overreport or underreport information, or have an asymptomatic self-report due to the effects of medication or environmental controls (e.g., institutionalization). The client’s self-report is used in over 100 GAIN scales and indices, which use symptom- and problem-counts to form diagnostic impressions based on DSM-IV-TR. Clinicians can use other items in the GAIN that have a relationship to etiology, service utilization and consequences to check the validity of the self-report.

Additionally, built-in GAIN protocols (e.g., providing explanations about how data is used, definitions of key terms that might confuse clients, subsequent prompts to avoid problems, and even word order) are based on research, demonstrating the most effective ways to “reduce” the kind of underreporting and misreporting that is common in most unstructured or semi-structured assessments. GAIN administration training further assists clinicians in reducing inconsistent information by teaching common inconsistent areas and reviewing audiotaped interviews to provide feedback and suggestions on how to reduce inconsistencies and improve administration.

Identifies more client problems up front. The GAIN supports targeted use of face-to-face clinical time by identifying an array of problems at assessment and allows for problem prioritization. Among people in the community with psychiatric and substance disorders, multiple co-occurring diagnoses are the norm (1, 2, 7, 8, 9, 10, 11). Research suggests that 60 to 80 percent of people entering treatment for substance use disorders have one or more co-occurring psychiatric disorders, yet only 16 percent of adults and 28 percent of adolescents have a co-occurring disorder documented in their intake assessments (4, 5).

With the use of the GAIN for assessment, problems such as co-occurring disorders, abuse, traumatic victimization history and other issues that are often withheld by clients at assessment, have a greater likelihood of being identified, documented and addressed in the assessment and the treatment plan. By facilitating the introduction of a greater number of clinical and environmental problems early in the treatment process, the GAIN helps clinicians prioritize problems and use face-to-face clinical time for targeted problems that might not otherwise be disclosed for several weeks or months.

Standardizes assessment. Often, current assessment systems are inefficient and consumer unfriendly in that they ask the same or similar questions multiple times (e.g., phone, intake, primary counselor, nurse, psychiatrist) and fail to pass the information on efficiently or reliably (e.g., high staff turnover, no standardization in how questions are asked or documented, illegible documentation, failure to synthesize assessment, diagnosis, placement, treatment plans and progress notes).

Research shows that multiple and repeated administrations of assessments can lead to frustration among clients presenting with substance abuse problems, citing clients’ irritation with redundant information gathering or when information is not passed on within or between agencies (6). The GAIN Recommendation and Referral Summary is designed to be shared with professionals and with others outside the direct treatment system who may need access to the information. It is highly transferable, thereby eliminating the need for repeated assessments as the client moves through the provider system.

Facilitates client recall. The GAIN also helps to address a common complaint of clients: that they did not remember, know how, or even have an opportunity to articulate one or more of their problems. The GAIN assessment process helps clients define and communicate problems and desires that they might not have otherwise been able to discuss; and is empirically based on the kinds of problems, needs and strengths that people report. This is very different than traditional approaches that often focus on categorizing people based on diagnostic boxes or meeting paperwork or funding requirements.

Facilitates client understanding of their problems. Additionally, the GAIN reports assist the client in identifying the effect of substance use on his or her current life problems and the effects of continued harmful use or abuse. The GAIN has been explicitly designed to facilitate motivational interviewing and active participant involvement in the treatment planning process, thereby helping to ensure that treatment goals have been mutually determined. The result is that use of the GAIN can actually help boost the morale of clients, giving them a sense of mastery over their problems.

Helps synthesize substantial information. Another benefit of the GAIN assessment system is its ability to help clinicians synthesize a vast amount of information in a detailed, thorough, organized way. The GAIN captures the most common co-occurring mental disorders and organizes them into four areas: internalizing disorders (including: depression, anxiety, somatic disorder, traumatic distress, suicide); externalizing disorders (including: attention deficit, hyperactivity, conduct and other impulse control disorders); substance use disorders (including: abuse, dependence, other substance induced health or psychiatric problems); and crime and violence (including: interpersonal violence, drug-related crime, property crime, interpersonal or violent crime).For all these areas the GAIN gathers information on: age of onset, course, consequence, treatment and more, in a way that is organized for maximum efficiency and accuracy in treatment planning.

DSM/ASAM compatibility supports a direct flow from assessment to treatment plan. As a biopsychosocial assessment battery for people entering substance abuse treatment, the GAIN is designed to help clinicians and researchers make diagnostic impressions about participants based on DSM-IV-TR criteria. The GAIN also is designed to map on to ASAM-PPC-2R for specific levels of care. Thus, the GAIN uniquely bridges the two sets of guidelines supporting a direct flow from assessment to treatment plan, and reduces the common criticism of site reviewers that treatment plans are not driven by the assessment.

Supports clinical decision-making and enhances clinical judgment. While the GAIN assessment system is not intended to replace clinical judgment, it is one widely used way to support clinical decision-making and enhance clinical judgment. It is a tool for facilitating clinical supervision, clinical thinking and clinical training for less experienced staff.

Workforce development.

The GAIN system includes a training and certification program to address the workforce development needs of diverse clinical staff with varying levels of training, skill and experience. This includes setting up people within an agency who can train for turnover, and establishing clear credentials that can extend across agencies. In addition to extensive training in administering the GAIN, Chestnut Health Systems offers a specialized GAIN Clinical Interpretation training that helps treatment professionals interpret the GAIN reports and maximize the utility of the reports for diagnosis and clinical decision-making.

Facilitates professional communication. The GAIN assessment system facilitates a peer-to-peer social network, connecting subgroups of clinicians and researchers interested in particular populations (e.g., Native American, African American, Spanish speaking, opioid users, comorbidity); particular interventions (e.g., MET/CBT, ACRA, MST, MDFT, FFT); or particular placement issues (e.g., ASAM). It also supports multidisciplinary discussions by using language and standards that are applicable across professional lines.

Limitations of the GAIN system

The GAIN system is comprehensive and already in use in many service sectors (e.g., substance abuse treatment, mental health treatment, prevention, student assistance programs, employee assistance, child welfare and justice system). It is used by more than 700 agencies in 45 states, Canada, Mexico, England and elsewhere, with both adults and adolescents. However, like any evidence-based program, it is not right for every agency or every use. There are several limitations to using the GAIN system that may still prohibit programs from easily using it.

First, the GAIN includes only the most common co-occurring mental health disorders. Bipolar disorder and schizophrenia are two that are not captured. Second, even with software advancements, a comprehensive system requires comprehensive training and supervision. Any tool used improperly will be a detriment rather than a help. Third, it takes time and effort to implement a large change. It involves strategically thinking about the existing forms and processes that can be discontinued to avoid redundancies; helping clinicians easily incorporate its use into daily practice; and planning for staff turnover and retraining. Fourth, staff resistance to an evidence-based model can be potentially thwarting to the implementation effort. Ongoing communications and incentives can help remind everyone of the ultimate goal and can gain buy-in from all levels of the organization. Fifth, the shift to evidence-based practices takes time. Such systemic change must be approached systematically, patiently and strategically. Just as client recovery takes time, the shift in recovery services takes time as well. Finally, while the cost to use the GAIN is primarily in staff time and training, some software expenses are necessary to use the system. Provider systems using the GAIN find that the investment of time and money is well worth the return in terms of staff efficiency and improved quality of service delivery.

Looking toward the future

The new release of the GAIN ABS software with the enhanced G-RRS report, along with the use of several other existing specialized reports, like the Personalized Feedback Report (PFR) for use with motivational interviewing, is a large step in meeting the needs of clients, clinicians and treatment programs. Current and ongoing translation efforts are increasing, making the GAIN a feasible reality for many populations both in and outside the United States. The next specific step for development of the G-RRS report in GAIN ABS, is to provide clinicians with placement-decision information, developed from over 20,000 clients that have used the GAIN in recent years. This information will help suggest what colleagues would have done with similar cases. Towards this end, we are currently evaluating several methods for making actuarial estimates of expected outcomes by level of care based on patient characteristics, severity and treatment planning needs. This enhancement to the report is not intended to take the place of clinician judgment, but rather, to provide guidance, particularly for newer clinicians. This next step, like the most recent advancements, may also take years to become a reality.

LaVerne Hanes-Stevens, PhD is a GAIN Senior Clinical Consultant at the GAIN Coordinating Center of Chestnut Health Systems in Bloomington, IL.

Michelle K. White, PhD is a Scientist with QualityMetric, Inc. She previously served as the Assistant Director of the GAIN Coordinating Center and a Research Scientist at Chestnut Health Systems in Bloomington, IL.

References

1. Angst, J., Sellaro, R., & Ries, M. K. (2002). Multimorbidity of psychiatric disorders as an indicator of clinical severity. European Archives of Psychiatry and Clinical Neuroscience, 252, 147-154.   
2. Chan, Y.-F., Dennis, M. L., & Funk, R. R. (2008). Prevalence and comorbidity co-occurrence of major internalizing and externalizing disorders among adolescents and adults presenting to substance abuse treatment. Journal of Substance Abuse Treatment, 34(1), 14-24.
3. Dennis, M. L., Titus, J. C., White, M., Unsicker, J., & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN): Administration guide for the GAIN and related measures (Version 5). Bloomington, IL: Chestnut Health Systems. Retrieved April 1, 2008 from http://www.chestnut.org/LI/gain/index.html#Administration%20Manual.
4. Drug and Alcohol Services Information System (DASIS) (2004, April 9). Admissions with co-occurring disorders: 1995 and 2001. The DASIS Report. Retrieved April 1, 2008 from http://www.oas.samhsa.gov/2k4/dualTX/dualTX.htm.
5. Drug and Alcohol Services Information System (DASIS) (2005, December 23). Adolescents with co-occurring psychiatric disorders: 2003. The DASIS Report. Retrieved April 1, 2008 from http://www.oas.samhsa.gov/2k5/youthMH/
youthMH.htm
6. Ford, J. H., II, Green, C. A., Hoffman, K. A., Wisdom, J. P., Riley, K. J., Bergmann, L., & Molfenter, T. (2007). Process improvement needs in substance abuse treatment: Admissions walk-through results. Journal of Substance Abuse Treatment, 33(44), 379-389.
7. Kandel, D. B., Johnson, J. G., Bird, H. R., Weissman, M. M., Goodman, S. H., Lahey, B. B., Regier, D. A., & S

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