Assessment as a basis for action

The PHC worker should have in mind a broad plan to guide the assessment process. The plan should be derived from the treatment strategy, since good assessment provides the basis for action. The following is one commonly used strategy for treatment, involving five points:

· improving social relationships and supports;
· developing confidence in ability to change;
· identifying reasons to change;
· developing alternative activities;
· learning to prevent relapse.

Helping people to change is covered in Chapter 5, but the PHC worker should be thinking about formulating an action plan even during the first interview. The assessment should be designed to collect useful information linked to the five components of treatment listed above.

One way of remembering these five points Remember the word SCRAP which stands for: S = social relationships C = confidence in ability to change R = reasons to change A = alternative activities P = preventing relapse

The questions listed below, under five headings, will help the PHC worker to collect relevant information and formulate an action plan in each of these areas.

Social relationships

Ask questions such as the following:

"If you are feeling bored or depressed, do you have a friend, or friends, that you can talk to?"

"Is there a family member who is able to give you help and support?"

"If you wanted to go for a long walk, play sport, see a film, etc., is there a friend, or friends, that you could ask to go with you?"

"Are there any clubs that you could join?"

"Do you know anybody who would be willing to help you for the next six months?" (e.g., member of Alcoholics Anonymous, relative, priest, or friend) .

Confidence In ability to change

Here, the aim is to explore the feelings of helplessness that a client might be experiencing. Ask the following:

"Have you tried to cut down, or stop, your drug or alcohol use? How successful were you?"

"In the future, if you were able to stop taking drugs or alcohol for two weeks, and then experienced a strong desire to start again, how confident are you that you could resist?"

Reasons to change

When an action plan is devised, the first essential is to obtain the client's commitment to change. A good assessment should therefore explore the client's perception of the reasons why changes need to be made. Questions such as the following might be appropriate.

"If you were to stop, or reduce, your drug/alcohol use:

· Do you think that you would sleep better?
· Would your marriage improve?
· Would you live longer?
· Would you save a lot of money?
· Would your relationships improve?
· Do you think that you would achieve more in your life?
· Would you be better at your job? "

The PHC worker should attempt to assess the importance of these expected consequences. For example, a client might say, "Yes, my marriage would improve, but I don't care."

Alternative activities

If a drug user, or heavy drinker, is going to change dramatically, then an alternative life-style will have to be developed. This involves a little planning, and questioning along the following lines might help to pinpoint possible activities:

"What types of things have you enjoyed learning in the past?" (e.g., sports, chess, languages).

"What types of trips have you enjoyed in the past?" (e.g., to the sea, to the mountains, to the country).

"What types of things do you think you could enjoy if you had no worries about failing?" (e.g., painting, acting, playing a musical instrument).

" What have you enjoyed doing alone?" (e.g., long walks, playing a musical instrument, sewing).

"What have you enjoyed doing with others?" (e.g., talking, having a meal with a friend, playing table-tennis).

" What have you enjoyed doing that costs no money?" (e.g., playing with a dog, going to the library, reading).

"What have you enjoyed doing that costs very little?" (e.g., going to a museum, taking a short bus ride).

" What activities have you enjoyed at different times?" (e.g., in the morning, on Sunday, in the spring, in autumn).

Preventing relapse

The desire to use drugs or alcohol heavily goes up and down depending on mood, the availability of drugs, and the social setting. The PHC worker should explain this and attempt to identify the main high-risk situations or cues. The following list will help:

· Parties	· Criticism	· Family	· Particular people
· Feeling lonely	· Moods	· After work	· Sleeplessness
· Boredom	· Places	· Arguments	· Weekends
· When others are using drugs	· Feeling of failure	· Tension

In addition, the following questions will help to pinpoint relapse situations, thoughts, and mood.

"Would you be able to resist using drugs or drinking heavily if:

· something good happened and you felt like celebrating?
· you suddenly remembered how good you can feel after taking drugs or alcohol?
· other people treated you unfairly? e you were having problems with people at work?
· someone criticized you?
· you were having arguments at home?"

The information collected on social relationships, confidence in ability to change, reasons to change, alternative activities, and high-risk situations will be very helpful when an individual treatment programme is being devised.