Arthur J. Anderson, Ph.D.
Helen Bellfield, D.Clin.Psych.
Anderson, A. J., Bellfield, H. (1999) Functional Assessment of Mental Health
and Addiction. International Journal of Psychosocial Rehabilitation. 4,39-45
FAMHA Administration Guidelines
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a CSAT Analysis of Functional Assessment Scales
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The assessment of client functioning is a critical component of both treatment outcome evaluation and assessment of individual level of need for individual treatment planning and service delivery selection. This is especially true for the dually diagnosed client with multiple concomitant needs, on a variety of levels.. The Functional Assessment of Mental Health and Addiction scale (FAMHA) was specifically designed to meet both criteria.
While it is beneficial to note the positive client changes that occur due to the effects of treatment, it is perhaps more important to have a functional baseline or clinical yardstick with which to plan an effective strategies of biopsychosocial interventions. This is utmost importance for dually diagnosed clients, with multiple service needs in mental health, addiction treatment, and medical interventions.
A basic, core goal of all treatment is to produce substantial and enduring changes in client behaviors, cognitions and moods and more useful strategies for managing their day-to-day lives. The only other goal of treatment is then to reduce a client's distress to the greatest degree possible. By determining a client's specific level of functioning across all major biopsychosocial domains and an overall level of functioning, specific symptom and functional deficit profiles emerge that can then be used for more effective treatment planning. Such assessments are client centered by their very nature and specifically relate to the distress and difficulties that each patient must endure in their daily lives. Thus, functional assessments like the FAMHA are the key to not only measuring the outcomes of treatments on a broad scale, but crucial to the clinician's full understanding of patient's individual needs.
Description of the FAMHA
The Functional Assessment of Mental Health and Addiction (FAMHA; Anderson & Bellfield, 1999) is a clinician rating scale, specifically designed to accurately assess dually diagnosed, mentally ill substance users (MISU), substance using mentally ill (SUMI), and medically compromised - substance using patients (MCSU) across a broad range of symptom and functional domains. It was developed in response to clinical and outcome research goals identified by the Department of Health (1996) which emphasized the need for extending research on the outcome of treatment for substance misuse problems. The assessment scale is specifically tailored to assess the multifaceted needs of severely distressed patients and to identify specific areas for effective therapeutic interventions. The 46 items of the scale document functional deficits across all biopsychosocial functional domains in such a way as to capture the current state of overall functioning, whilst demonstrating specific areas of need. Thus, it can be used as both an indicator of current functioning for diagnostic assessment and as a repeated measure to demonstrate the changes that occur to patients throughout the clinical cycle.
Sciacca (1991) noted significant differences between various subpopulations of dually diagnosed patients (in both mental health and addiction treatment settings) that have an impact on treatment planning and service delivery for each patient population. The term dual diagnosis is somewhat broad and misleading (for example; mental illness and learning disabilities are dual diagnoses). The distinction between MISU, SUMI, and MCMU patients has a significant impact on the selection and use of a variety of intervention techniques and strategies. MISU patients generally present with symptoms of severe and enduring mental illness that has been complicated by the use of psychotopic substances. SUMI patients are characterized by their excessive use of psychotropic agents with the subsequent development of a concomitant severe and persistent mental illness. MCSU patients characteristically use large amounts of psychotropic agents in the presence of a long term or severe physical injury, illiness or ongoing medical condition. Traditionally, MISU patients have gravitated toward mental health treatment systems, SUMI patients have generally sought treatment in addiction treatment settings; while MCSU patients have relied on medical treatment facilities to seek therapeutic relief.
Each patient group with varying degrees of success (Bachrach, 1986-87). Mental illness, substance use/misuse and medical conditions must be approached differently for each group to achieve effective therapeutic outcomes (Sciacca, 1991). The severe and persistent mental illness of MISU patients make it difficult for them to engage in the motivational interviewing or more restrictive treatments often used in addiction treatment settings (Bachrach, 1984). On the other hand, SUMI and MCSU patients often require relief from the effects of addiction and withdrawal before they can fully focus on their treatment for the medical, psychological and social issues that have emerged or intensified as a result of their substance use. For this reason, the FAMHA was designed to assess individual differences in symptomatology, whilst differentiating these two populations on a functional level.
Effective treatment of MISU, SUMI and MCSU patients requires diagnostic clarification as the initial step in successful care planning. To address the problem of multiple diagnoses of mental illness, medical conditions and substance abuse, clinicians from addiction, medical, and psychiatric backgrounds must learn to make the clinical formulations for each of the concomitant disorders, using clear diagnostic standards and evidence based assessments. One of the principal goals of the FAMHA is to quantitatively measure the degree and intensity of mental illness and substance misuse. It also profiles the interactive effects of multiple disorders that must be explored on an individual basis. The consideration of which disorder came first, while perhaps etiologically important, should not interfere with the diagnosis and treatment of persistent conditions that exist and simultaneously interact on a functional level (Breakey, 1987; Miller, 1994). A major advantage of using the FAMHA is that it can be quickly and effectively administered to provide diagnostic indicators and monitor the effects of treatment over time.
The following list identifies many of the characteristics that distinguish MISU, SUMI and MCSU patients which can be quantitatively assessed on the FAMHA:
1. Severe mental illness exists independently of substance abuse; persons would meet the diagnostic criteria of a major mental illness even if there were not a substance abuse problem present.
2. MISU persons have a DSM-IV-R, Axis I (American Psychiatric Association, 1987)
diagnosis of a major psychiatric disorder, such as schizophrenia or major affective
3. MISU persons usually require medication to control their psychiatric illness; if
medication is stopped, specific symptoms are likely to emerge or worsen.
4. Substance abuse may exacerbate acute psychiatric symptoms, but these symptoms generally persist beyond the withdrawal of the precipitating substance.
5. MISU persons, even when in remission, frequently display the residual effects of major psychiatric disorders (for example, schizophrenia), such as marked social isolation or withdrawal, blunted or inappropriate affect, and marked lack of initiative, interest, or energy. Evidence of these residual effects often differentiates MISU from populations of substance abusers who are not severely mentally ill.
- SUMI patients have severe substance dependence (alcoholism; heroin, cocaine,amphetamine, or other addictions), and frequently have multiple substance abuse and/or polysubstance abuse or addiction.
- 2. SUMI persons usually require treatment in alcohol or drug treatment programs. SUMI persons often have coexistent personality or character disorders.
- 3. SUMI patients may appear in the mental health system due to "toxic" or "substance-induced" acute psychotic symptoms that resemble the acute symptoms of a major psychiatric disorder. In this instance, the acute symptoms are always precipitated by substance abuse, and the patient does not have a primary Axis I major psychiatric disorder.
- 4. SUMI patients' acute symptoms remit completely after a period of abstinence or detoxification. This period is usually a few days or weeks, but occasionally may require months.
(Sciacca, 1991, Chapter 6)
- 5. SUMI patients do not exhibit the residual effects of a major mental illness when acute symptoms are in remission.
MCSU patients continued to use large amounts of substances even after their medical conditions have gone into remission or have been successfully treated.
These patients begin using psychotropic agents in an effort to seek relief from physical pain due a medical condition.
MCSU patients often have long term medical conditions (i.e. HIV, Heart Conditions, Autoimmune deficiencies, etc.) that reduces their level of physical functioning and makes them vulnerable to substance use disorder.
The hopeless and helpless feelings associated with long term or severe medical conditions produce depressive states that are reduced by the use of intoxicating or pain relieving substances.
Development of the Scale
The loss of physical function and range of motion often produces a reduction in psychological functioning and increases the reliance on pharmacological agents.
The FAMHA was developed with a variety of criteria in mind. To adequately assess MISU, SUMI, and MCSU patients in naturalistic settings, specific criteria developed by Green and Greely (1987) were applied to the scale as it was modified in development phases and pilot trials. It was felt that the FAMHA should not only assess the obvious symptom categories of major mental illness and addiction, but should also:
The current version of the FAMHA meets all of these criteria and can be administered in as little as 8 minutes by a trained, experienced rater. The FAMHA builds on the strengths of the Specific Level of Functioning scale (SLOF) (Schnieder & Struening - 1983), Symptom Checklist 90 (SCL-90R)(Derogatis, 1975), the Bellevue Psychiatric Audit (BPA)(Hardesty & Burdock, 1962) and the Addiction Severity Index, 5th Edition (ASI)(McLellan et al, 1997). It combines a variety of clinical and functional dimensions into a 46 item clinician rating scale that is subdivided into 6 biopsychosocial dimensions:
- include functional domains that are deemed important for community based treatment clinics;
- demonstrate reliability and validity;
- possess sensitivity to treatment-related change;
- be appropriate and relevant to the dually diagnosed population that it functionally assesses;
- be a useful tool for treatment planning and clinical governance;
- have low administration costs;
- be relatively easy to use by all levels of clinical staff.
2. Social – Community Living
3. Social – Interpersonal Skills
5. Psychological Functioning
6. Physical Functioning.
In addition to the dimensional scales, data as to the patient’s primary and secondary drug of choice, alcohol consumption, prior mental health and addiction treatment episodes, demographics, and current medical, mental health and addiction diagnoses are also collected to add to the clarity of the diagnostic profile. It is expected that continued statistical analysis, including factor analyses of further trials, will yield more refined, discrete scale dimensions and add to the overall utility of the instrument.
Similar to the SLOF in appearance, 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. Like the SLOF and SCL-90R, each of the 46 items of the FAMHA is evaluated on the Likert-like scale. Due to the specific nature of each of these 46 functional items, the FAMHA assumes a high degree of assessor familiarity with the patient.
The scale was designed to quantify patient functional levels 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 could 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 GAF scores. Thus, it refines the diagnostic profile for individual patients that is necessary for appropriate diagnosis within both ICD-10 (WHO-1996) and DSM-IV (APA 1994) diagnostic systems.
Validity and Reliability:
The concordance rates between the FAMHA total scores, sub-scores and GAF scores are currently in clinical trials and cannot yet be reported on. However, due to the high degree of similarity between the SLOF and the FAMHA, it is assumed that patient scores on each FAMHA dimension will significantly correlate with overall GAF scores and subscores. The SLOF concordance rates for the various components were reported to be r=.67 for the social component, .60 for the psychological, and .50 for the physical component. Moderate associations were found between the SLOF substance abuse scale and the Drake et al. (1990) substance abuse scale (r=.73) (Uehara et al. 1994). This concordance rate should be mirrored in the FAMHA, since most of these specific SLOF items are embedded in the FAMHA as well.
Further clinical trials should conclusively demonstrate the usefulness of combining level of functioning information across mental health and addiction dimensions and ultimately, validate the FAMHA as an ideal instrument for assessing dually diagnosed patients in mental health and addiction treatment settings.
The FAMHA documents the outcomes of treatment by quantifying the substantial and enduring changes in client behaviors, cognitions, moods and day-to-day client functioning It also notes reductions in distress due to the effects of treatment. By determining a client's specific level of functioning across a number of domains and an overall level of functioning. specific profile emerge that can then be used for more effective treatment planning. FAMHA assessments are client centered by their very nature and specifically relate to the distress and difficulties that each patient must endure in their daily lives. Thus, such assessments are crucial to a clients mental health, substance use, and medical recovery.
The FAMHA was designed to meet the specific clinical and research needs of practitioners/researchers in a wide variety of treatment settings. From the data currently available, it is clear that the FAMHA is a sensitive diagnostic tool for use with MISU, SUMI and MCSU patients. It’s ability to document functional changes that occur throughout the treatment cycle and utility as a basic research tool to obtain specific epidemiological and diagnostic information make it an ideal instrument for use with on this severely dysfunctional and distressed population.
Download the FAMHA
Download FAMHA Administration Guidelines
Download an Analysis of Functional Assessment Scales
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