PSYU 511 Mental Health and Substance Use Assessments: the DHSI and the ASI The Deliberate Self-Harm Inventory (DSHI) The rising prevalence of reports of individuals who have selfharmed, and the lack of an agreed-upon definition of what constitutes self-harm, led to the creation of the DHSI, or the Deliberate Self-Harm Inventory (Gratz, n. d. ). The inventory does not include suicide attempts. drug usage, ingestion of objects and/or substances, or risky behaviors such as reckless driving.
What this inventory considers self-harm is operationally defined as “the deliberate, direct destruction or alteration of body tissue without conscious suicidal intent, but resulting in injury severe enough for tissue damage (e. g. , scarring) to occur” (Gratz, 2001, p254). Any data that is gleaned from the assessment will require further psychological assessment, and an examination made in relation to mental health disorders such as anxiety and depression.
This instrument seeks to identify the intentional, non-lethal behaviors that are repetitive and episodic; considered by many researchers to be a maladaptive coping strategy, or used as a mechanism to regulate emotions (Favazza, 1998; Haines & Williams, 1997; Linehan, 1993; van der Kolk, 1996, as cited by Gratz, 2001). Interestingly, many who report with this condition show no further signs of mental dysfunction, and are often highly functioning intelligent individuals, both male and female.
The DHSI is behaviorally based, and seeks to consolidate differing sparse inquiries concerning self-injurious behavior, self-mutilation, and self-harm found sparingly, albeit vaguely, on other instruments, while targeting specific behaviors commonly reported with deliberate self-harming actions. The Deliberate Self-Harm Inventory is a brief self-reported questionnaire that asks yes or no answers to questions concerning seventeen behaviors.
These behaviors are cutting, cigarette burning, lighter burning, carving words into the skin, carving pictures, severe scratching, biting, rubbing sandpaper, dripping acid onto skin, using bleach or other cleaners to scrub skin, piercing with small objects, rubbing glass into skin, breaking bones, punching oneself, head banging, preventing wound healing, and a spot to list any other behavior not on the list (Gratz, 2001). This measure also includes the frequency, severity, and duration of the self-harming behavior.
The two items of dripping acid and chemical scrubbing are not as commonly reported as other behaviors listed, although they were left on the scale as extreme examples that did occur to other individuals as documented in past literature. While generally tattoos are not considered to be examples of selfharm, and are common among many people currently, tattooing is under consideration to be added to the scale. This is solely because many respondents have said they have received tattoos for the same reason they engaged in other self-harm behaviors, and to these, tattoos serve the same purpose of deliberate self-inflicted harm (Gratz, 2001).
The questionnaire author, when measuring the psychometrics of the tool, would fully disclose prior to the assessment, and fully debrief after. Other important pre-assessment considerations include providing respondents an option to cease id they become too disturbed, an assurance that all answers will remain confidential, a clarification that the behaviors inquired about are intentional and not the result of an accident, and a plea to answer the questions with candid honesty. A packet containing clinical referral information and other resources for the selfharming individual was additionally given at the time of the debriefing (Gratz, 2001).
Strengths of this tool include that it is a substantive yet brief focus on specific behaviors, not generally on other instruments. As stated earlier, this assessment provides a definitive, standard definition that has been lacking in other tools, it follows that this specific focus ensures that what is being measured is clear and more detailed than simple one-sentence inquiries found on other assessments, ala “have you ever harmed yourself to release stress”. Another advantage is this separates these behaviors involving low-lethality with suicidal behaviors meant to result in death; as in the past these were often lumped together.
Limitations of this tool include the same limitations inherent in all self-reports, such as response bias, a lack of genuineness/reluctance to tell the truth, and comprehension level of the responder to answer correctly. Because of the nature of the topic, and the stigma attached to it, this may be an issue that is often underreported. As stated, studies have been done to test the psychometrics properties of the DSHI. The findings suggest that the instrument has high internal consistency, and what was described as adequate testretest reliability, construct validity, convergent validity, and discriminate validity (Gratz, 2001).
Cronbach’s alpha was calculated to determine the internal consistency of the DSHI items. Results show a high internal consistency; re-testers had adequate test-retest reliability over two to four weeks, indicating that the DHSI can reliably categorize participant as self-harmers or non-self-harmers; in addition, the number of behaviors between first and second test were highly correlated; and validity of the DHSI was more highly correlated than in other measures such as the Mental Health History self-harm items, the SBQ, and the DIB-R (Gratz, 2001).
The Addiction Severity Index (ASI) The ASI. or Addiction Severity Index (McLellan, Luborsky, Woody, & O’Brien, 1979). has been popular and in use since it was created in 1979, becoming a standardized measure utilized, boasting over a million administrations annually in the U. S. alone (Budman, 2000, as cited by Hays, 2013). The ASI is available in English, Czech, Danish, French, Italian, Lithuanian, Hungarian, Dutch, Polish, Portuguese, Swedish, and Russian languages (Grissom & Bragg, 1991).
It is an instrument that has utility both as a research evaluation tool and for clinical application, assessing multiple problems occurring for alcohol and addicted individuals. This feature allows it to be used in a variety of settings, and it can be used for referral decisions, intake evaluations, for use in treatment planning, and for repeated administrations in post-treatment (Allen, Wilson, & National Institute on Alcohol Abuse and Alcoholism, 2003).
The ASI is a semi-structured, objective, in-person interview meant to assess the consequences the client’s substance use has had in seven areas of the client’s life; these are: 1) the client’s medical status; 2) the client’s employment status; 3) the client’s legal status; 4) the client’s drug use; 5) the client’s alcohol use; 6) the client’s family and social status; and 7) the client’s psychiatric status (McLellan et al. 1979, as cited by Hays, 2013, and Grissom & Bragg, 1991).
This data provides basic diagnostic information in relation to the client before, during, and after treatment for substance use issues, and as a way to assess change in client status and treatment outcome (Grissom & Bragg, 1991); provides data on recent and lifetime problems in the seven areas, and provides an overview of substance use issues, rather than focusing on any single area in the client’s life (Allen, et al. 2003). Although it has been used with the mentally ill, pregnant, prisoner, gambler, and homeless populations its main use is for adults in substance use treatment programs. The ASi consists of one hundred and sixty-one multidimensional questions, that can be administered in forty-five minutes. The questions measure the number, duration, and extent of problematic symptoms, both for the last thirty days and over the client’s lifetime (Allen, et al. , 2003).
There is a multimedia version of the ASI known as the ASI-MV, and utilizes virtual interviewers; the computer generated addiction severity results are equal to, or better than human interviewers in reliability and validity (Budman, 2000, as cited by Hays, 2013). When the information from the ASI is compiled, it provides two types of measuresseverity ratings and composite scores (McLellan et al. , 1979). Severity ratings indicate client treatment needs; composite scores measure severity over the past thirty days, usually calculated by a computer program (Grissom & Bragg, 1991).
Specialized training is required to administer and interpret the interview scores, however the assessment can be scored in roughly five minutes by hand, or sixty seconds by the computer (Allen, et al. , 2003). When the computer scores the ASI, it is normed for the following treatment groups: alcohol, opiate, cocaine: public, private; inpatient, and outpatient (Allen, et al. , 2003). Research has found that the Addiction Severity Index has demonstrated test-retest reliability, split-half reliability, and internal consistency (Allen, et al. , 2003).
Studies measuring validity have also been conducted that measures content validity, predictive, concurrent, postdictive criterion validity, and construct validity, to positive results (Allen, et al. , 2003, and Hays. 2013). Strengths of the ASI are that is has utility in a variety of settings, has strong predictive value for treatment outcomes, it is easy to comprehend and use, is preferred by a majority of patients, and because it is over one hundred and fifty questions, it can relay much pertinent information beyond the seven subset focus areas.
Limitations of the ASI are that it drops in reliability when administered beyond the face-to-face method, the ASI-MV assumes that the respondent has a predetermined reading comprehension level, the wording around having issues in families is vague and alludes to it not being normal to have family conflicts, and it has poor use with older populations of addicts who have cognitive impairments (Allen, et al. , 2003).
In all, study after study has shown the ASI to be a useful, easy to use tool in all stages of treatment, for male and female adults, across varied populations, and in a variety of settings. It is a preference for some patients and clinicians alike, has reported strong reliability and validity, and creates a quick overview of key areas of the client’s life, including his or her use, and the common areas that fall prey to the ravages of continued use. It is relatively quickly administered and scored, and has proven successful as an assessment tool.
