Assessment of Mental Health and Addiction
Version 2.6 (C) 1999-2000, A.J. Anderson, Ph.D. & H. Bellfield, D.Clin.Psych. All Rights Reserved.
The Functional Assessment of Mental Health and Addiction (FAMHA) is a clinician rating scale that was specifically designed to assess current level of biopsychosocial functioning in dually diagnosed patients across a broad range of symptom and functional domains. It was developed in response to clinical and outcome research goals identified by the U.K. Department of Health (1996), which emphasized the need for extending research on the outcome of treatment for mental illness and substance misuse problems. The assessment scale is specifically tailored to assess the multifaceted needs of severely distressed, multiple needs patients and to identify specific areas for effective therapeutic interventions. Such assessments can also be used to monitor progress throughout the treatment cycle and specific outcomes of treatment for this population.
The 44 items of the scale document functional deficits across substance misuse - criminality, community living, interpersonal functioning, mood, psychological and health-physical levels of functioning in such a way as to capture the current state of overall functioning while demonstrating specific areas of therapeutic and rehabilitative need. Thus, the FAMHA is designed as both an indicator of the patient’s current individual level of functioning for diagnostic assessment and care/treatment planning, and as a repeated measure to demonstrate the changes that occur to patients throughout the treatment cycle and into community aftercare. Consequently, the FAMHA has direct applications in treatment outcome research.
The individual items that are assessed with the FAMHA were designed around clusters (dimensions) of symptom presentations and functional skills. Since sub-populations within the broad spectrum of dually diagnosed patients appear to respond more effectively to different treatment modalities, it was important to structure the FAMHA in such a way as to allow individual symptom constellations or bundles of symptoms to emerge in such a way as to readily identify not only the final individual profile of low functioning areas, but also position the patient into the appropriate sub-population as well.
Any member of clinical staff who has been trained to perform clinical assessments on patients is qualified to administer the FAMHA. The instrument was designed to capture critical aspects of patient functioning that become apparent or are elicited during a standard clinical interview. Thus, it assumes an in-depth clinical understanding of the patient, their characteristics, and their circumstances. Since the FAMHA was designed to be used in conjunction with a standard clinical interview, it relies on the interviewing skills of the clinician rater to explore patient functioning with sufficient scope and depth to obtain enough data with which to score the instrument. The subjective clinical opinion of the rater on each item is numerically scored to quantify the patient’s functional level on each item.
Similar in appearance to the other functional assessment scales, the FAMHA uses a seven point, three way anchored Likert-like scale, ranging from extremely dysfunctional symptoms or behaviors (Score 1) to normative levels of these behaviors and symptoms (Score 7). The low end, mid-point and high points of functioning are anchored by descriptors for each item. This allows for enhanced interrater reliability and validity of patient / clinic-wide functional assessments.
The scale was designed to quantify patient functional levels for dually diagnosed patients more systematically than the Global Assessment of Functioning (GAF)(APA, 1994) and provides for the systematic rating of functional deficits in critical areas of that would not otherwise be assessed in this population. In addition, FAMHA overall scores are designed with a coefficient that readily converts the total score to overall functioning scores. By summing each of the individual items in a particular dimension, a dimension subscore can be obtained and entered in the space provided. Summing each of the dimensional subscores will yield and overall level of functioning score. In this way, the FAMHA refines the diagnostic profile for individual patients and is therefore an aid in making an appropriate differential diagnosis for dually diagnosed patients.
Definition of Individual Items:
(All items are scored for frequency and intensity of the symptom during the previous 7 Day period.)
Enter the patient’s last name, first name; clinical location; age; sex; education in years; ethnicity (approximate); and number of previous treatment episodes. In the Drug and Alcohol use boxes, enter the type and amount of alcohol and drug use. Note that alcohol quantity is entered in alcohol units.
Substance Misuse and Criminality
Item 1. Life Threatening level of drug/alcohol use.This item assesses the immediate danger to the patient’s life. Life threatening behaviours may include dangerously high levels of drug or alcohol use that could immediately threaten the patient’s life, or could also mean dangerous binge use episodes of drug or alcohol.
Item 2. Daily intoxication. Barely noticeable levels of intoxication would received a mild rating, or intermittent frequencies of low levels of intoxication should be scored in the mild range. Daily severe or intermittently severe intoxication should be score in the low functioning range.
Item 3. Serious legal difficulties. Low functioning on this item would include pending cases or recent arrest for criminal assault, drug dealing, etc. Mild levels on this item would include such crimes as shoplifting, possession of a controlled substance, etc.
Item 4. Regularly engages in the illegal sale of drugs. The low end of functioning on this item refers to career drug dealers, while the mid point is generally reserved for those who only occasionally deal to maintain their addiction or opportunistically deal drugs to ease their financial situations.
Item 5. Destroys property of others – The lowest end of functioning refers to the chronic, malicious destruction of property, i.e. vandalism. The midpoint is reserved for occasional or situationally specific destruction property.
Item 6. Steals good from others almost daily. – Low functioning on this item would be satisfied by chronic shoplifting to obtain drug/alcohol funds. The midpoint would be scored if this is only an occasional or binge of illegal theft of goods.
Item 7. Assaultive and/or physically threatening – Chronic, daily assaultive or threats of assault would score rate a very low functioning score on this item, while only situationally specific or sporadic threats/assaults would rate the midpoint.
Community Living Skills
Item 8. No Income (Any Source) – This item is self explanatory
Item 9. No evidence of budgeting skills. - A low functioning score on this item would be indicated if the individual could not compute his income and expenses even verbally. The midpoint would be rated if the patient could at least identify his daily/weekly expenses and how that related to his/her income.
Item 10. No stable housing. - The lowest level of functioning on this item is reserved for the homeless or functionally homeless (i.e. living in abandoned buildings). The midpoint of this item would be indicated if the individual had marginal housing resources (i.e. friends or associates he/she could temporarily stay with).
Item 11. Children in foster or institutional care – This item is self explanatory
Item 12. Has sold/given away most possessions – The low point of functioning on this item would be indicated by homeless patients who had given away all clothing and possessions. The midpoint is reserved for those who sell their possessions to either obtain funds for drugs/alcohol or for basic necessities.
Item 13. No significant intimate relationships – The low end of functioning for this item would be rated if the individual has had not significant relationships for an extended period of time (beyond the 7 day period of this scale). The midpoint would be indicated if there was a significant relationship in the recent past. I.e. (past two months).
Item 14. Rejects contact with others – Isolative and withdrawn patients who reject the company of others would be scored in the low functioning range for this item.
Item 15. Extremely withdrawn and socially isolated – Low functioning would be indicated by individuals who are constantly withdrawn. Midrange is indicated for those who are only sporadically withdrawn.
Item 16. Guarded or evasive – This item refers to a behavioral observation from the rater. How is the patient upon presentation.
Item 17. Verbally aggressive or threatening to all. – This item refers to direct observation of aggressive or verbally aggressive behaviour or patient self reports of such behaviors with the past 7 days.
Item 18. Excessive Dependence on Others – This item also refers to a direct observation or patient self reports of what the rater feels are excessive dependent behaviors.
Item 19. Appears agitated or jumpy – This is a bahavioural observation made by the rater. However, self reports of agitation or jumpiness could indicate a midrange score.
Item 20. Conveys feelings of hopelessness. – Verbal or Behavioral expressions of what the rater feels are hopeless and helpless ideations/feelings. Again its the subjective opinion of the clinical rater to determine how sever the patient is.
Item 21. Expresses only sadness or despair – The rating for this item can be based on a bahavioural observation or verbal expressions by the patient.
Item 22. Considering a suicide plan – This must be verbally elicited by the patient for both low and mid-range scores on this item.
Item 23. Extreme and or sudden mood shifts. – Again, this item can be scored by either verbal reports from the patient, or bahavioural observations by the rater.
Items 24-36 – These items rate functioning on a cognitive and bahavioural level. As such, they can be rated from either direct, elicited verbal reports from the patient or from the clinical observations of the rater. As most of the items in this section are self explanatory, no additional description is deemed necessary for the purposes of completing this scale.
Health and Physical Functioning
Items 37 – 46. These items are primarily bahavioural in nature and relate directly to recent health and physical functioning. Though functioning on the items relating to appetite, sleep and sexual practices can only be assessed through patient self report, the detailed behaviours that are implied in each of these items are assessed on a behavioural basis by the rater for degree of dysfunction on each item.
Sum each of the items in each section and enter the total for the section in the Subscore section (i.e. if the 5 items,19 to 23, are all scored 6, the total would be 30). Next Sum each of the subscore sections and enter them in the ‘SUM RESPONSES TO ALL 46 ITEMS’ section at the end of the scale. Divide this sum total by 3.08 to obtain the ‘TOTAL SCORE’.
Finally, enter past or current primary mental health, primary substance misuse and medical diagnoses in the appropriate boxes at the end of the scale. Enter the name of the rater and the assessment date below the diagnoses.
Copyright © 2000, Southern Development Group, S.A. All Rights Reserved.
A Private Non-Profit Agency for the good of all, published in the UK & Honduras