Assessment in an EAP setting: by more thoroughly assessing presenting problems and linking clients with appropriate resources, EA professionals can greatly improve treatment outcomes and help demonstrate their value to work organizations.

Employee assistance programs (EAP) operate to enhance the development and well-being of people as employees. Service objectives in this arena are accomplished through the EAP Core Technology, which includes assessment and referral.

In recent years, a host of factors have led to technological simplification and service fragmentation in EAP settings, and simplified assessment technologies have become fait accompli. The clinical process of determining the nature, cause, progression, and prognosis of the problems for which help is sought has become abbreviated at best and cursory at worst.

The thought of physicians performing medical treatment without engaging in an earnest effort to determine the nature or presence of disease or abnormality is frightening. In employee assistance and mental health arenas, however, professionals are often expected to intervene with clients in the absence of thorough evaluation. This has not always been the case--managed care requirements and resource deficits have moved the field toward rapid assessments and reliance on general and vague terms to characterize the mental, emotional, and behavioral processes of clients. In a climate of greater accountability for treatment efficacy, this is conspicuously ironic.

This article presents a proposal for a promising assessment practice in an EAP setting. The first part of the proposal includes an overview of assessment systems in clinical practice, followed by a discussion of practical implications for culturally sensitive diagnoses. The final section offers a promising model of assessment and research methodology.

ASSESSMENT INSTRUMENTS

In clinical practice it is understood that gathering information about clients and their presenting problems is a prerequisite to service provision (Shear et al. 2000; Franklin and Jordan 1992; Mattaini and Kirk 1991). Clinicians embark upon the arduous task of intrapsychic repair only after obtaining an overall understanding and appreciation of the complexity of a client and his/her situation. There is not, however, a grand assessment protocol (Clair and Prendergast 1994; Thomas et al. 1993), and little consensus exists regarding proper assessment practice.

Although most clinicians are trained in qualitative assessment practices (Shear et al. 2000), many are encouraged to use assessment methods grounded in empiricism. These appraisals quantify various aspects of clients' functioning. Because clinical impressions are not required, these assessments are assumed to be superior to subjective models at deriving reliable psychodiagnoses (Korchin and Schuldberg 1981; Basco et al. 2000; Franklin and Jordan 1995; Springer, Abell, and Nugent 2002; Shear et al. 2000; Kaplan and Sadock 1998).

Clinicians invariably use instruments with psychometric properties to identify treatment needs and monitor the outcome of interventions. Currently, the most popular scales for tapping into psychological and interpersonal functioning are the Rapid Assessment Inventory (RAI), the Minnesota Multiphasic Personality Inventory (MMPI), the Millon Clinical Multiaxial Inventory (MCMI), the Structured Clinical Interview for DSM (SCID), the Butcher Treatment Planning Inventory (BTPI), and the Quality of Life Inventory (QOLI).

Objective measures alone cannot provide practitioners with complete clinical pictures (Shear et al. 2000). Open-ended interviewing is indicated for accessing idiosyncratic meaning systems, schemas, values, motivations, and cultural realities. Listening and probing can uncover full psychosocial histories. Inasmuch as this is true, clinical interviewing is an imperative assessment practice (Franklin and Jordan 1995; Strickland 1994; Thomas et al. 1993).

APPRECIATING CULTURAL DIVERSITY

In pluralistic societies, competent clinicians must appreciate cultural diversity It is not enough to be aware of the many distinct groups within a society; professionals must be adept at incorporating the values, experiences, and needs of the various groups into practice.

For most people, cultural diversity connotes variations in race, ethnicity, and national origin. While these are important cultural variables, they are by no means a definitive representation of culture. Cultural diversity, cultural pluralism, and multiculturalism are interchangeable expressions that allude to variations in race, ethnicity, and national origin as well as gender, religion, physical and mental ability, age, class, and sexual orientation (Anderson and Collins 2001; Lorber 1998).

Because most psychological theories and psychiatric rating scales are based on white, middle-class, male values, practitioners must be skilled at deciphering what is culturally explicable and what is pathological. In the assessment process, cultural norms, communication styles, taboos, symptoms of distress, and rites of passage must be attended, and societal and environmental factors such as racism, sexism, homophobia, poverty, and violence must be considered.

Evidence-based clinical practice and advocacy are key components of the multicultural assessment. Critical thinking skills are obligatory One should think divergently, but make judgments based on reason and common sense--all moralities are not equally good, nor are all belief systems equally true.

Clients should be matched to appropriate treatment modalities and services once the presenting problem has been sufficiently defined. At this juncture, practitioners should turn to the empirical literature to support treatment decisions and foster desired outcomes (Howard, McMillen, and Pollio 2003; Reid 1988).

PROVING VALUE TO ORGANIZATIONS

Surprisingly, the search for best practices in clinical appraisals fails to produce any literature on assessments in EAP settings. In fact, few articles in EAP publications center on clinical matters; instead, the literature is saturated with articles that present a business case for employee assistance services.

By and large, this is due to the defensive position EAPs must maintain in fiscally tortuous environments. EAPs must prove useful or valuable to the organization they serve while at the same time being cost-effective. So, not only must these programs be economical, their value to the organization must be argued repeatedly.

In fact, EAPs benefit organizations inasmuch as they can--

* Lower absenteeism and tardiness;

* Improve interpersonal work relationships;

* Address underlying issues affecting quality of work;

* Decrease the risk of liability;

* Manage disability costs;

* Promote more effective supervision;

* Improve retention rates; and

* Foster employee morale.

To attain these objectives, EA professionals must possess the skills and resources to link employees to needed services with all possible speed. The following assessment protocol is a promising means to this end.

A PRETREATMENT MODEL

The contemporary EAP was developed from the occupational alcoholism program (OAP), which sought to aid workers in recovery by adopting rehabilitation practices as an alternative to job termination. In the 1970s, the OAP changed to the EAP and the program was expanded to include any problems that could interfere with job performance.

Today, employees present at EAPs with a gamut of problems, from psychological to societal to environmental. Many EA professionals believe that substance abuse/use cases now account for only a small percentage of their utilization rates. Kurzman (1993), for instance, notes that stress, disability, work/family balance, developmental disorders, and mental illness are the principle presenting issues in EAP settings.

EAP assessments and referrals are significant interventions, as they are intended to maintain favorable conditions for organizations (the resource providers). Insofar as clinicians can make accurate assessments, link employees to appropriate services, and assist them in following through with treatment plans, they can indeed attain program objectives and thrive in fiscally tortuous environments.

The goal of the following assessment practice, which can also be conceptualized as a "pretreatment" model, is to increase program efficacy through accurate and thorough assessments, appropriate referrals, and reduced treatment dropout rates. It is intended for programs providing face-to-face services with qualified clinical professionals. The model is most effective for employees whose initial presentation is characterized by a mood or anxiety disorder, interpersonal difficulties, or other problems in daily living. It is contraindicated for employees who are overtly psychotic, at risk (i.e., suicidal or homicidal or in domestic violence situations), in job jeopardy, chemically impaired, or seeking concrete referrals (financial, housing, child care, and so on).

The model uses quantitative and qualitative data collection methods to ascertain the psychological abilities and concrete needs of employees. It pays special attention to cultural and sociopolitical factors that may influence the mental state and/or basic needs of clients and their ability to comply with treatment. Practitioners are encouraged to use a breadth of theoretical frameworks to elicit information from clients, such as the following:

* Pychodynamic questions to gather information about a client's past and its impact on the present, inner conflicts and ambivalence, defenses, attachment, and hidden anxieties and urges;

* Cognitive-behavioral queries to draw forth the client's schemata--that is, automatic thoughts about self, others, and the future;

* Life model questions to identify stresses resulting from stage-of-life transitions, interpersonal processes, and environmental obstacles; and

* Solution-focused queries to learn about a client's strengths and motivations.

Brief treatment interventions are also a crucial component of this model. Practitioners use these interventions to help clients identify troubling issues, determine clients' motivation(s) for treatment, and prepare motivated participants for long-term therapy. These interventions are as follows:

* Engagement and collaboration, which (1) invite clients to discuss their feelings and perceptions about seeking help and what they hope to accomplish, (2) elicit feedback about the assessment process, and (3) gather interpretations of feelings, attitudes, behaviors, and patterns of relating;

* Feedback and interpretation, in which EA professionals respectfully point out overt behaviors, feelings, and attitudes and offer explanations for them;

* Focus and partialization, which identify a focal theme based on information gathered and help the client separate the problem into smaller, more manageable parts; and

* Psycho-education, designed to answer questions about the process and provide information about various treatment modalities and how to access needed resources or services.

Throughout the process, the practitioner gathers relevant clinical data to understand the presenting problem in light of past and present realities. S/he formulates and revises hypotheses as new information is received, limiting data collection to that which is necessary The practitioner should use simple language when offering interpretations and information about the treatment process.

SIX-SESSION ASSESSMENT FORMAT

The practitioner who adheres to the following six-session format can expect to gather enough information to make an accurate diagnosis:

In session one, initiate an alliance, assess safety, and explain assessment procedures. The practitioner should elicit information about the client's chief concerns and his/her understanding of the situation, then appraise the intensity, frequency, and duration of the presenting problem as well as the client's level of hopefulness. Before concluding, determine the client's reaction to and expectations for the interventive process.

In the first half of session two, provide the client with an opportunity to discuss the presenting problem. Reserve the second half of the session for screening positive mental health characteristics and issues in daily living (use the Quality of Life Inventory for this purpose). After the client completes the instrument, review it with him/her and gather relevant information.

In session three, gather a psychosocial history by gingerly probing into the client's medical, psychiatric, educational, developmental, adaptive, and traumatic experiences.

In session four, evaluate the client's interaction with relevant social systems. Use the genogram and ecomap to gather information about social, environmental, and familial influences. Depending on the client's level of distress, reserve time for him/her to ventilate about the presenting problem.

In session five, screen for common psychological disorders. Use the Structured Clinical Interview for DSM to assess for mood, anxiety, psychotic, dissociative, and substance abuse disorders. If necessary, allow time for the client's primary concerns.

In the sixth session, discuss what has occurred over the course of the work. Present a tentative case formulation that draws on all the data collected and seeks feedback from the client. Explain appropriate treatment modalities, services, and resources and encourage the client to express his/her wishes for treatment. If the client is seeking referral, facilitate the initial contact and follow up to be sure the contact was fulfilled.

SCIENTIFIC EVIDENCE NEEDED

This assessment model is based on integrative, multicultural, and brief treatment principles. To this point, however, the model is only a "promising" assessment practice. Scientific evidence is required before it can be deemed a state-of-the-art technology.

I posit that an appropriate methodology for evaluating this model would--

* Randomly assign eligible employees to one of two groups at intake;

* Provide the experimental group with an assessment based on the six-session model while offering employees in the control group the standard program assessment; and

* Follow up with employees and referral sources at the end of the evaluation period (three to six months) to determine the level of compliance with the treatment plan and the degree of improvement in the presenting problem.

References

Anderson, M.L., and P.H. Collins. 2001. Race, Class, and Gender: An Anthology. 4th ed. Belmont, Calif: Wadsworth/Thomson Learning.

Basco, M., J.Q. Bostic, D. Davies, A.J. Rush, B. Witte, W Hendrickse, and V. Barnett. 2000. "Methods to Improve Diagnostic Accuracy in a Community Mental Health Setting." American Journal of Psychiatry 157 (10): 1599-1605.

Clair, D., and D. Prendergast. 1994. "Brief Psychotherapy and Psychological Assessments: Entering a Relationship, Establishing a Focus, and Providing Feedback." Professional Psychology, Research, and Practice 25 (1): 46-49.

Franklin, C., and C. Jordan. 1992. "Teaching Students to Perform Assessments." Journal of Social Work Education 28 (2): 222-241.

--. 1995. "Qualitative Assessment: A Methodological Review." Families in Society: The Journal of Contemporary Human Services (May): 281-295.

Howard, M.O., C.J. McMillen, and D.E. Pollio. 2003. "Teaching Evidence-Based Practice: Toward a New Paradigm for Social Work Education." Research on Social Work Practice 13 (2): 234-259.

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Kurzman, P.A. 1993. "Employee Assistance Programs: Toward a Comprehensive Service Model." In P.A. Kurzman and S.H. Akabas (eds.), Working and Well Being: The Occupational Social Work Advantage. Washington, D.C.: NASW Press.

Lorber, J. 1998. Gender Inequality: Feminist Theories and Politics. Los Angeles, Calif.: Roxbury Publishing Company.

Mattaini, M.A., and S.A. Kirk. 1991. "Assessing Assessment in Social Work." Social Work 36 (3): 260-265.

Reid, W.J. 1988. "Service effectiveness and the social agency." In an edited book, Managing for service effectiveness, pp. 41-58. USA: The Haworth Press, Inc.

Shear, M.K., C. Greeno, J. Kang, D. Ludewig, E. Frank, H.A. Swartz, and M. Hanekamp. 2000. "Diagnosis of Nonpsychotic Patients in Community Clinics." American Journal of Psychiatry 157 (4): 581-587.

Springer, D.W., N. Abell, and W.R. Nugent. 2002. "Creating and Validating Rapid Assessment Instruments for Practice and Research: Part 2." Research on Social Work Practice 12 (6): 768-795.

Strickland, L. 1994. "Autobiographical Interviewing and Narrative Analysis: An Approach to Psychosocial Assessment." Clinical Social Work Journal 22 (1): 27-41.

Thomas, J.K., Riley, P., Staver, N., Steinman, C.Z., and Trust, C. 1993. A successful private practice referral service. Social Work, 38 (2), pp.227.

Raquel Warley is an EA professional in the Mount Sinai-New York University employee assistance program and an adjunct lecturer at Hunter College's School of Social Work. She is also a Ph.D. candidate at the City University of New York's Graduate Center.