Chapter 3 Screening, assessment and treatment planning - Alcohol

Engaging the patient in treatmentPatient engagement may be viewed in terms of intensity and duration of treatmentparticipation. Higher levels of engagement are predictive of positive treatmentoutcomes and are, in turn, contingent upon patient, clinician and cliniccharacteristics.• Patient characteristics include pre-treatment motivation, severity of disorderand prior treatment experiences, strength of therapeutic relationship,perceived helpfulness of the treatment services.• Clinician factors include degree of empathy, therapeutic relationship andcounselling skills.• Clinic factors include removal of practical access barriers such astransportation, fees, hours, physical surroundings, and perceptions aboutother patients of the service.In addition to identifying clinical disorders and effective interventions, negotiation oftreatment goals requires clarification of the patient’s insight, values and expectation.There is also evidence that providing the patient with a choice of treatment optionsimproves treatment retention (Rokke et al. 1999).Treatment adherence and completion are prominent issues in alcohol and other drugtreatment and the factors that improve it are not yet well understood (Mattson andFriedman 1994; Mattson et al. 1998). A focus in early interactions with patientsshould be on maximising engagement with the professional and the service andfostering a sense of collaboration (Zweben 2002; Zweben and Zuckoff 2002).Central to the provision of any intervention is a strong bond and therapeutic alliancealliance between patient and clinician (Shand et al. 2003). Basic counselling “microskills” including warmth, empathy and optimism, and strong interpersonal skills areassociated with better retention in treatment and indirectly with better treatmentoutcomes (Shand et al. 2003; Miller and Rollnick 2002).Goal setting: abstinence, moderation and reduced drinkingIdentifying and agreeing upon treatment goals regarding alcohol consumption is animportant process for many patients.For patients with no or low levels of dependence, and who are not experiencingsignificant alcohol related harms, a goal of moderation may be achievable (Sitharthanet al. 1997; Heather 1995).For patients with severe alcohol dependence, and/or those presenting withassociated problems such as organ damage, cognitive impairment and co-existingmental health problems, the most realistic drinking goal is likely to be abstinence(Edwards et al. 2003).Often patients may wish to drink at levels that can continue to cause harm, or maynot be realistically sustained. Several options can be considered when the patient’s38