Addiction Severity Index (ASI): Versi Treatnet

Treatnet Training Volume A: Module 2 – Updated 9 September 2007

Addiction Severity Index

Standardized, semi-structured, alat skrining dan asesmen dengan berbagai fokus domain Digunakan untuk mengumpulkan informasi terkait dengan etiologi dan derajat keparahan penyalahgunaan narkoba klien Dapat diterapkan pada seting klinis, untuk evaluasi program dan juga riset

The Addiction Severity Index

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Tujuan ASI

Menyediakan asesmen awal yang bersifat komprehensif Menyediakan informasi klinis yang dibutuhkan untuk rencana terapi Mengumpulkan data yang dibutuhkan untuk mengidentifikasi tren penggunaan narkoba dan menetapkan kebijakan yang sesuai

The Addiction Severity Index

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5.7 domain ASI 1. 3. 6. Medis Pekerjaan/ Faktor pendukung Napza Alkohol Legal Keluarga/ Sosial Psikiatrik The Addiction Severity Index 4 . 7. 4. 2.

Gali dan klarifikasi 3. Bulatkan 6 bulan ke atas menjadi 1 tahun. jangan lupa menuliskan nomor pertanyaan. X = Jika pertanyaan tidak dijawab / tdk adekuat 4. bulatkan 14 hari ke atas menjadi 1 bulan.7 1. N = Jika pertanyaan tidak aplikatif (tdk sesuai dg kondisi pertanyaan) 5. Aturan waktu setengah! Jika pertanyaan menyangkut jumlah bulan. Jangan ada yang kosong 2.Instruksi bagi pewawancara 1 . Buatlah catatan sebanyak mungkin. Pertanyaan yg diikuti dg tanda "“ adalah keterangan tambahan / klarifikasi 5 The Addiction Severity Index . 7. Akhiri pertanyaan jika klien tidak nyambung atau tidak paham atas dua atau lebih pertanyaan 6.

5. 4. Semua klien menerima interviu yang serupa ASI mencakup 7 domain Menghabiskan waktu 30-40 menit Masukan anda adalah penting –gunakan skala rating pasien Prinsip kerahasiaan Anda boleh tidak menjawab Ada dua kerangka waktu: dalam 30 hari terakhir dan sepanjang hidup The Addiction Severity Index 6 . 7.7 poin bagi klien/pasien 1. 6. 3. 2.

Skala rating klien / pasien 0 1 2 3 4 Tidak sama sekali Sedikit Sedang Lumayan Sangat The Addiction Severity Index 7 .

Pendahuluan dari bagian umum  Mengumpulkan informasi demografis klien Menentukan apakah klien tinggal pada situasi yang terkungkung dan bebas dari narkoba dalam 30 hari  The Addiction Severity Index 8 .

Institusi G2c.Negara G2a. Modalitas   G2b. Pasien ID_________________________________________ G2. Apakah program dijalankan pada fasilitas lapas / rutan? 0 = Tidak 1 = Ya The Addiction Severity Index 9 .G1 & G2 & G3: Versi Internasional  G1.Program  G3.

) Jelaskan____________________________________________ The Addiction Severity Index 10 . etc) 9=Lain2 (dokter praktek swasta. pesantren. Buprenorphine.G2c: Kode modalitas treatnet 1=Rawat jalan (<5 jam per minggu) 2=Rawat jalan intensif (≥ 5 jam per minggu) 3=Rawat inap 4=Therapeutic Community 5=Half-way house 6=Detox – rawat inap (biasanya 3 – 7 hari) 7=Detox rawat jalan 8=Pengganti Opioid (Methadone. etc.

Apakah program yang anda jalani berada pada fasilitas lapas/rutan? 0=Tidak 1=Ya The Addiction Severity Index 11 .G3: Terapi pada lapas/rutan G3.

G8 & G9: Tahap wawancara and Kode kontak G8. Telephone (Intake ASI must be in person)  G8:  Biasanya ASI digunakan pada tahap awal (intake)  ASI tahap follow-up (tindak lanjut) umumnya digunakan untuk penelitian outcome program G9:  Seluruh pengisian ASI pada tahap awal dijalankan secara tatap muka The Addiction Severity Index 12 . Intake 2. Contact Code:  1. Follow-up G9. In person 2. Class: 1.

catat alamat dimana klien berharap nantinya akan tinggal selepas program / pemenjaraan  Jika klien „homeless‟. teman atau saudara)  Buatlah catatan ttg homelessness ini pada kotak komentar The Addiction Severity Index 13 . rumah singgah.Informasi alamat  Jika saat wawancara klien ada di lapas/rutan/ rehab. catatlah alamat dimana dia dapat dijangkau (mis.

G14: Tempat tinggal G14. How long have you lived at this address? Years Months G14: Tujuan  Untuk mengevaluasi stabilitas situasi tempat tinggal klien Untuk menggali seberapa lama klien tinggal pada alamat ini The Addiction Severity Index 14  .

G19 & G20: Lingkungan terkontrol G19. Correctional Facility 3. without access to drugs/alcohol. catat jumlah waktunya The Addiction Severity Index 15 . 4. Have you been in a controlled environment in the past 30 days? 1. Refers to total number of days detained in the past 30 days. Medical Treatment 5. Alcohol/Drug Treat. No 2. Other: ______________ A place. How many days? "NN" if Question G19 is No. G19 dan G20: Tujuan   Untuk mencatat sejauhmana klien secara „teoritis‟ tidak memiliki akses terhadap narkoba selagi dalam proses perawatan Bila berada pd 2 lingkungan terkontrol. theoretically. G20. Psychiatric Treatment 6.

Bagian Medis Untuk menggali informasi tentang:  Riwayat medis klien  Riwayat perawatan sepanjang hidup  Masalah medis yang bersifat jangka panjang  Penyakit fisik terkini The Addiction Severity Index 16 .

T. Isu koding :      Harus dirawat minimal semalam Hanya diberi kode untuk masalah medis Termasuk overdosis dan delirium tremens Tidak termasuk detox. Enter the number of overnight hospitalizations for medical problems. perawatan psikiatrik dan kelahiran normal / spontan Jumlah episode. bukan jumlah hari The Addiction Severity Index 17 . Exclude detox.D. alcohol/drug.'s. psychiatric treatment and childbirth (if no complications). rawat inap napza.M1: Riwayat perawatan rumah sakit M1. How many times in your life have you been hospitalized for medical problems?  Include O.'s and D.

medication. dietary restriction) preventing full advantage of their abilities. (i.  A chronic medical condition is a serious physical condition that requires regular care. Do you have any chronic medical problems which continue to interfere with your life? 0=No 1=Yes  If "Yes".    Gambarkan problem kronik pada klien yang mengganggu kehidupannya atau membutuhkan perawatan berkesinambungan / jangka panjang Sediakan contoh seperti diabetes. hipertensi.e. asma Buatlah catatan & galilah The Addiction Severity Index 18 ..M3: Problem kronik M3. specify in comments.

 Tekankan obat yang diresepkan secara teratur (tidak termasuk resep sementara spt antibiotik) The Addiction Severity Index 19 .M4: Medikasi M4.  Include medicines prescribed whether or not the patient is currently taking them.  Must be for a medical condition. Has a health care provider recommended you take any medications on a regular basis for a physical problem?  Do not include various remedies given by a non-healthcare Provider. don’t include psychiatric medicines.  The intent is to verify chronic medical problems.

bukan psikiatrik Tidak termasuk dukungan yg diterima dari keluarga atau teman The Addiction Severity Index 20 . early retirement for medical disability ● Exclude psychiatric disability.M5: Dukungan cacat fisik M5. Do you receive financial support for a physical disability?  If Yes. specify in comments.  Include Workers' compensation.   Harus terkait dengan kecacatan fisik.

HCV. HIV.. colds. HBV abscesses from needles.M6: Hari dg masalah medis M6. cirrhosis of liver. Include serious ailments related to drugs/alcohol.M5.). etc. How many days have you experienced medical problems in the past 30 days?  Include flu.g. etc. which would continue even if the patient were abstinent (e. injuries. atau masalah lain yang belum disebutkan Tekankan pada lamanya hari dg masalah medis 21 The Addiction Severity Index .   Terkait masalah medis fisik yg didiskusikan pada M1 .

How troubled or bothered have you been by these medical problems in the past 30 days? • Restrict response to problem days of Question M6.    Terkait pada masalah M6 Tekankan masalah medik (bukan psikiatrik ataupun napza) Gunakan skala rating klien / pasien The Addiction Severity Index 22 .M7: Seberapa terganggu dg masalah medis M7.

M8: Need for treatment M8. Note: The patient is rating their need for additional medical services or referrals from your agency.    Merujuk pada kebutuhan terapi akan masalah yang tercatat di M6 Tekankan terapi pada masalah medis Gunakan skala rating pasien! The Addiction Severity Index 23 . above any services they may already be getting. How important to you now is treatment for these medical problems?  If client is currently receiving medical treatment. refer to the need for additional medical treatment by the patient.

Have you ever been tested for hepatitis? 0 = No. what was the result? 1 = Hep Negative (not infected) 2 = Hep positive (infected) 3 = Don’t Know  If M12 = No. anda bisa merujuk untuk melakukan tes The Addiction Severity Index 24 . M12a = “N” M12b.Hepatitis M12. If Yes. 1 = Yes M12a. Would you like help obtaining a Hepatitis test?   Item baru pada ASI versi Treatnet! M12b: Tidak berarti bahwa anda akan melakukan tes secara on site .M12: New question .

If Yes. Have you ever been tested for HIV? 0 = No.M13: New question – HIV/AIDS M13. Would you like help obtaining an HIV test?   Item baru pada ASI versi Treatnet! M13b: Tidak berarti bahwa anda akan melakukan tes secara on site . what was the result? 1 = HIV Negative (not infected) 2 = HIV positive (infected) 3 = Don’t Know  If M13 = No. 1 = Yes M12a. anda bisa merujuk untuk melakukan tes The Addiction Severity Index 25 . M13a = “N” M13b.

M14: New Questions – Pregnancy If patient is Male. do you have prenatal care? M14b. anda bisa merujuk untuk melakukan tes The Addiction Severity Index 26 . 1=Yes. would you like help obtaining a pregnancy test?  If M14= 0 or 2 (No or Unsure). Are you currently pregnant? M14a. 2=Unsure M14. M14b = N   Item baru pada ASI versi Treatnet! M13b: Tidak berarti bahwa anda akan melakukan tes secara on site . code all “N” 0=No. If unsure. M14a = N  If M14= 1 (Yes). If pregnant.

Transisi untuk pekerjaan dan seksi Dukungan .

* Training atau Pendidikan Lengkap:  Hanya pelatihan formal dan terorganisasi.* Pendidikan Lengkap: Kode: *Level 0 = Tidak sekolah * Level 1 = Sekolah Dasar 1 . Bln.A 10 . incl BS . MS ) * Level 6 = Pasca Sarjana (doctoral.M. OR Code Level #  Kode Tahun. Thn.M. Bulan The Addiction Severity Index 28 . Level # atau keduanya.E1 & E2: Education & training E1. E2.6 years. bulan.P 7.9 yrs * Level 3 = S.12 yrs * Level 4 = Akademi * Level 5 = Perguruan Tinggi (+ 4 .  Masukkan hanya pendidikan Formal.6 yrs * Level 2 = S. dll).

The Addiction Severity Index 29 .  E2. Masukkan tingkat pendidikan atau tahun dari pendidikan yang telah ditempuh atau keduanya. Masukkan jumlah bulan dari pelatihan teknis/ketrampilan. “Tingkat Pendidikan”telah ditambahkan untuk ASI versi Treatnet.E1 & E2: Education & training  E1.

E4a: International E4a. Apakah pilihan pekerjaan anda dibatasi dengan masalah transportasi ? 0 = No 1 = Yes Item ini digunakan untuk mengevaluasi jika ada masalah transportasi yang berkontribusi dalam masalah pekerjaan atau tidak mendapat pekerjaan The Addiction Severity Index 30 .

tidak perlu berkaitan dengan pekerjaan saat ini. E7. Kode pekerjaan“usual”. How long was your longest full time job?  Full time = 35+ hours weekly. does not necessarily mean most Years recent job. Months E7. Kode lama dari pekerjaan full time yang terlama.E6 & E7: Job & occupation E6. The Addiction Severity Index 31 . tidak perlu berkaitan dengan apa yang dikerjakan pasien saat ini.* Usual (or last) occupation? (specify) ___________________________________ (Use International Classification references page 1)   E6.

Legislatif. Teknisi / assoc. professionals 4. Pertanian / operator 9. Pekerja Kasar 0. Service & sales 6. Pengrajin & penjual 8. pegawai pemerintah 2. Juru tulis 5.E7 Codes: ISC0 Categories Standar Internasional Klasifikasi Pekerjaan 1. ABRI 32 The Addiction Severity Index . Profesional 3. Petani Tanaman/Ikan Terampil 7.

Include spouse's contribution.E17 The Addiction Severity Index 33 .     Tanyakan tentang dukungan (mis. “Housing” is considered the majority of someone’s support. perumahan) Harus berasal dari individu (termasuk pasangan) Harus dukungan yang sangat bermakna Cross-check dengan E12 .E9: Kontribusi dukungan E9 Does someone contribute the majority of your support? 0 .. exclude support by an institution.Yes  Is patient primarily financially supported on a regular basis from family/friends.No 1 . uang. makanan.

kode situasi saat ini The Addiction Severity Index 34 . Part time (irregular hours) 4. Retired/Disability 7. not just the most recent selection. Homemaker  Answer should represent the majority of the last 3 years. Part time (regular hours) 3. select category which best represents the current situation. Student 5. bukan yang paling sering Full time = >35 jam per minggu Part time = <35 jam per minggu Jika waktu/lama bekerja seimbang dalam kategori yang berbeda. Which of these represents how you spent the majority of the past three years? 1.E10: Pola pekerjaan secara umum E10. Military 6. If there are equal times. In controlled environment 9. Unemployed 8.     Pola pekerjaan yang biasanya dalam 3 tahun terakhir. Full time (35+ hours) 2.

Hari kerja reguler 5 hari/minggu = 20 hari Beberapa tempat kerja melaporkan membayar pekerja untuk 30 hari tiap bulan . paid sick days and paid vacation. beri kode disini Termasuk pembayaran pekerjaan pada akhir minggu The Addiction Severity Index 35 .     Termasuk hari absen sakit. How many days in the past 30 did you work for pay?  Include days actually worked. jika ini terjadi. liburan. dll.E11: Hari kerja yang dibayar E11.

social security?  Include disability.). family. benefits. Mate.  E15. Tujuan : catat berbagai jenis sumber dari pendapatan dalam 30 hari Gunakan mata uang lokal dan spesifikasikan dalam komentar E17. (Record cash payments only. Also code unreliable sources of income. windfalls (unexpected money) money from loans. E16. include any money earned except illegal income  E13. pensions. E12. Illegal? The Addiction Severity Index 36 . inheritance. etc. Employment?  Net or "take home" pay.E12 to E16: Sumber pendapatan For questions E12-17: How much money did you receive from the following sources in the past 30 days? * Use your local currency. Pensions. & workers' compensation and veterans benefits. Unemployment Compensation E14. Social Welfare  Money given by government to assist with living expenses. or friends?  Money for personal expenses. retirement.

Do not count estimated cash value of drugs or other items obtained illegally    Pertanyaan tentang uang yang diterima dari aktivitas ilegal. stealing. etc.E17: Uang ilegal yang diperoleh E17. bukan aktifitas ilegal secara sederhana/simple Termasuk uang yang diperoleh dari penjualan Napza. perjudian. Illegal gambling. prostitution. prostitusi Jangan mengkonversi nilai barang atau jasa yang ada ke dalam jumlah uang kontan. selling stolen goods. Illegal? Cash obtained from drug dealing. The Addiction Severity Index 37 . mencuri barang.

shelter. etc. etc.     Merupakan tanggungan yang biasanya ditanggung klien Gali bentuk dukungan dan jumlah uang yang dikeluarkan Buatlah catatan Cross-check dengan F4– lingkungan tempat tinggal The Addiction Severity Index 38 . How many people depend on you for the majority of their food. do not include the patient or selfsupporting spouse. do include alimony/child support.?  Must be regularly depending on patient.E18: Jumlah tanggungan E18.

kode E19 = “0” The Addiction Severity Index 39 . if they are actively looking for work. How many days have you experienced employment problems in the past 30 days?  Include inability to find work.  If the patient has been incarcerated or detained all of the past 30 days.E19: Hari-hari kerja yg bermasalah E19. they can’t have had problems    Termasuk ketidakmampuan untuk mendapatkan pekerjaan. code "NN". atau masalah yang membahayakan pekerjaan saat ini Refrase pertanyaan didasarkan pada informasi sebelumnya Jika klien tdk punya kesempatan kerja. or problems with present job in which that job is jeopardized.

E20. ask the patient to use the Patient Rating scale. not giving them a job. How troubled or bothered have you been by these employment problems in the past 30 days?  If E19=N. How important to you now is counseling for these employment problems?  Stress help in finding or preparing for a job. code N E21. etc from your agency. Note: The patient is rating their need for employment/support Services.   E20 –Merujuk pada masalah di E19 E21 – Tanyakan tentang bantuan bagaimana menyiapkan diri untuk mendapat pekerjaan atau mengatasi masalah pekerjaan. getting training for a job. bukan memberikan pekerjaan padaThe klien Addiction Severity Index 40 .E20 & E21: Rating pasien For Questions E20 & E21. referrals.

How troubled or bothered have you been by these employment problems in the past 30 days?  If E19=N.E19 – E21: Final 3 E19.  E19 & E20 are linked If E19 = “0”. then E20 = “0” E21 is coded independently of E19 & E20b  E20.  If the patient has been incarcerated or detained all of the past 30 days. they can’t have had problems For Questions E20 & E21. if they are actively looking for work. code N  E21. getting training for a job. referrals. ask the patient to use the Patient Rating scale. etc from your agency. How many days have you experienced employment problems in the past 30 days?  Include inability to find work. The Addiction Severity Index 41 . Note: The patient is rating their need for employment/support Services. or problems with present job in which that job is jeopardized. code "NN". How important to you now is counseling for these employment problems?  Stress help in finding or preparing for a job. not giving them a job.

Transition to Drug & Alcohol Sections .

2. The Addiction Severity Index 43 . 4. code the most severe and note the alternate route(s) in your comments. Oral Nasal Smoking Non-IV Injection IV Injection Least Severe Most Severe Jika klien mengaku menggunakan dengan 2 atau lebih cara secara rutinIf client reports routinely utilizing two or more ROAs. 5. 3.Routes of administration 1.

Alcohol and Drug Use Grid The Addiction Severity Index 44 .

Would you have used the alcohol and pot on the same days?” If so. The Addiction Severity Index 1 0 0 0 1 0 0 0 0 2 0 0 5 5 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 5 0 0 0 0 5 0 0 15 1 0 45 . For example: “I know you said you used alcohol 15 of the past 30 days and pot on 20 of the past 30 days. do not include the days/years in D13. If not. count these days / years in D13.Coding D13: >1 Substance Per Day     Start with the highest number of days / years.

D14a & D14b: Major Problems
D14a. Identify the primary substance of abuse: D14b. Identify the secondary substance of abuse:
 Interviewer should determine the primary and secondary drugs of abuse. Code the number next to the drug in questions 01-12

Interviewer determines problem substance (not client) Code the number next to drug on grid

(Example: Cocaine = 08 )
The Addiction Severity Index 46

D15 & D16: Abstinens
D15. How long was your most recent period of voluntary abstinence from these major substance(s)?
 Most recent sobriety lasting at least one month. Periods of hospitalization/incarceration do not count. Periods of antabuse, methadone, or naltrexone use do count.  Code 00 = never abstinent. Months

D16. How many months ago did this abstinence end?
 If D15 = 00, then D16 = NN.  Code 00 = still abstinent.
 

. Months


 

Merujuk pada problem zat/alkohol pada D14a & b Tanyakan “ berapa lama/” bukan “berapa lama yang lalu?” Merujuk pada kejadian saat ini, bukan periode abstinens terlama. Waktu dalam lingkungan terlindung tidak termasuk. Jika D15 = 00, maka D16 = NN. Jika masih abstinen,beri kode D16 = 00
The Addiction Severity Index 47

D17: DT‟s
D17.* How many times have you had: Alcohol DT's?
 Delirium Tremens (DT's): Occur 24-48 hours after last drink, Or significant decrease in alcohol intake, shaking, severe disorientation, fever, hallucinations, they usually require medical attention.

D17 – Jelaskan DT‟s – biasanya muncul 24-48 jam setelah minum terakhir atau pengurangan jumlah minum  Biasanya memerlukan perhatian medis  Bukan hanya “the shakes”  >5 DT episode bukan hal yang lazim

The Addiction Severity Index 48

D11 Route of Administration = 4 or 5 (injection) Past 30 days Lifetime D38. then D38a = N  Assess risiko medis yang berhubungan dengan penggunaan zat Beri kode setiap penggunaan dengan jarum. atau bahan lain yang memungkinkan transmisi virus The Addiction Severity Index 49  . Have you ever used needles or works after someone else had used them? D38a. How many times in the past 30 days?  If D38 past 30 days = 0. pekerjaan.D38 & 38a: Penggunaan Zat yang Berisiko If any item D3 .

maka dinilai sebagai satu periode perawatan. in/outpatient counseling. rumah singgah. and AA (if 3+ meetings within one month period).     Termasuk detox. How many times in your life have you been treated for Alcohol or Drug abuse? Include detoxification. halfway houses. dan konseling rawat inap dan konseling rawat jalan Termasuk AA atau NA jika klien menghadiri 3 atau lebih pertemuan/bulan Tidak termasuk program pertukaran jarum suntik Satu episode perawatan dihitung “01”  Contoh: jika pasien dari rawat inap dan dipindahkan cepat ke setting konseling rawat jalan.D19a: Treatment history D19a. The Addiction Severity Index 50 .

How many of these treatments were detox only:  If D19a = "00". then question D21a is "NN" or Not Applicable  Note: Code the number of treatments listed in D19a that consisted only of Detoxification and no other treatment. maka D21a = NN  Jika tidak ada terapi.  Jika D19a = 00.maka tidak ada detoks The Addiction Severity Index 51 .  “Hanya Detox” tidak berhubungan dengan terapi yang lain  Untuk bisa menentukan kemungkinan klien memperoleh terapi lain selain detoks.D21a: Terapi Detox D21a.

What is the financial burden caused by drugs?  Harus uang yang dikeluarkan secara nyata. What is the financial burden caused by alcohol? D24 How much would you say you spent during the past 30 days on drugs?  Only count actual money spent.  Secara umum dibatasi oleh pengeluaran uang untuk kebutuhan pribadi The Addiction Severity Index 52 .D23 & D24: Beban Keuangan D23. How much would you say you spent during the past 30 days on alcohol?  Only count actual money spent. bukan perdagangan/pertukaran  Tujuan dari pertanyaan adalah untuk menentukan jumlah uang yang benar-benar menjadi beban klien.

OP detox.D25: Terapi Rawat Jalan D25. etc. other support groups. methadone or treatment.   Tanyakan dalam 30 hari terakhir – jangan memasukkan jumlah lebih dari 30 Termasuk AA/NA  Jika menghadiri lebih dari satu pertemuan dalam sehari. How many days in the past 30 have you been treated in an outpatient setting for alcohol or drugs in the past 30 days?  Include days attended AA/NA.tetap diberi kode satu hari  Harus rawat jalan The Addiction Severity Index 53 .

D36: Berhenti tanpa terapi? D36. How many times have you tried to quit using substances without treatment?  Beri kode jumlah berapa kali pasien pernah berhenti dari penggunaan zat atau alkohol tanpa menggunakan terapi. The Addiction Severity Index  54 . Hal ini akan mencakup setiap perubahan perilaku dengan atau tanpa dukungan grup.

Nicotine Lifetime (years) Past 30 Days Route of Admin Cara kode sama seperti bagian Zat dan Alkohol. IV 55 The Addiction Severity Index .D37: Nikotin D37. Nasal 3. Injeksi bukan IV 5. Hisap 4. Oral / kunyah 2. 1.

I believe I can manage my drug use. Catatan : Pertanyaan ini tidak bertujuan untuk memotivasi pasien masuk dalam terapi. e. I am ready to decrease my drug use. I know I have a drinking or drug problem and I am motivated to work on it! Kaji motivasi untuk mengurangi penggunaan zat atau alkohol. c. The Addiction Severity Index 56 . d.D39a-e: Pertanyaan tentang motivasi D39. b. Using the patient rating scale. I believe I can manage my alcohol use. how would you rate your level of agreement with the following statements? a. I am ready to decrease my drinking.

Transition to Legal Section .

Need for Legal Counsel    The Addiction Severity Index 58 .Introduction to the Legal Section   Legal History Information About Probation & Parole Charges. & Incarcerations Illegal Activities Desire. Convictions.

Was this admission prompted or suggested by the criminal justice system? 0 .  Tujuan :  Untuk menentukan hubungan antara status terapi klien dan status kriminalitas klien.No 1 -Yes L2.No 1 .L1 & L2: Keterlibatan kasus kriminal saat ini LEGAL STATUS L1. Are you on parole or probation? 0 . The Addiction Severity Index 59 .Yes  Note duration and level in comments.

The Addiction Severity Index 60 .L3 – L16: Tuntutan kriminal  Klien harus ditahan dan resmi dituntut secara hukum.  Tuntutan pada usia remaja tidak termasuk.

probation.  Convictions include fines. The Addiction Severity Index 61 .  Do not include misdemeanor offenses from questions L18-20 below. masa percobaan. incarcerations. then question L17 = "NN". guilty pleas. penundaan masa tahanan. suspended sentences. and plea bargaining. Apakah yang termasuk vonis?   Termasuk pengakuan bersalah.L17: Vonis Hukuman L17* How many of these charges resulted in convictions?  If L3-16 = 00. pembelaan bersyarat/ masa percobaan Termasuk dalam bentuk denda.

no license. vagrancy. Disorderly conduct. public intoxication? L19. Driving while intoxicated? L20. Jelaskan “ pelanggaran lalu lintas yang berbahaya” dan berikan contoh. etc. reckless driving.    Berhubungan dengan kejahatan yang mengganggu masyarakat umum. Major driving violations?  Moving violations: speeding.L18 – L20: Tuntutan lain How many times in your life have you been charged with the following: L18. kode “0” The Addiction Severity Index 62 . Jika masalah yang berhubungan dengan mengemudi tidak dapat diterapkan di negara anda.

  Catat jumlah bulan yang dihabiskan dalam penjara sejak umur 18 tahun Masalah koding:  Jangan catat jumlah hari dalam tahanan The Addiction Severity Index 63 . List total number of months incarcerated. How many months were you incarcerated in your life?  If incarcerated 2 weeks or more. round this up Months to 1 month.L21: Lama Ditahan dalam Bulan L21.

code NN. If awaiting on more than one charge. or sentencing? 0 . trial. What for?  Use the number of the type of crime committed 03-16 and 18-20 in previous questions.No 1 . Are you presently awaiting charges. choose most severe.Yes L25. The Addiction Severity Index 64 . L24 & L25:  Evaluasi keterlibatan terakhir dengan sistem peradilan dan bagaimana kemungkinan kondisi ini mempengaruhi terapi saat ini. If L24=No. L24.  Refers to Q.L24 & L25: Keterlibatan dengan Sistem Peradilan saat ini L24.

etc. L26 & L27:  Evaluasi aktivitas ilegal terkini dan tahanan penjara. prostitution. The Addiction Severity Index 65 . L27. How many days in the past 30.L26 & L27: Tahanan dan aktivitas ilegal L26. selling stolen goods. How many days in the past 30 have you engaged in illegal activities for profit?  Exclude simple drug possession. were you detained or incarcerated?  Include being arrested and released on the same day. May be cross checked with Employment Question E17. Include drug dealing.

such as divorce. How important to you now is counseling or referral for these legal problems?  NOTE: Patient is rating need for referral (or services) from your agency to legal counsel for defense against criminal charges. L28.L 28 & L29: Client ratings of legal problems For Questions L28-29. How serious do you feel your present legal problems are?  Exclude civil problems. Rating pasien : ingat. L29. rating biasanya rendah kecuali ada kebutuhan untuk konseling legal! The Addiction Severity Index 66 . ask the patient to use the Patient Rating scale. etc.

Transition to Family/Social Status .

Marital Status: 1-Married 3-Widowed 5-Divorced 2-Remarried 4-Separated 6-Never Married  Common-law marriage = 1. 0-No 1-Indifferent 2-Yes Contoh:  “Apakah status pernikahan saat ini?”  “Apakah saat ini sudah menikah?”  “Apakah ini pernikahan pertama?” The Addiction Severity Index 68 . F3. Are you satisfied with this situation?  Satisfied = generally liking the situation.  Refers to Questions F1 & F2.F1 – F3: Status Pernikahan FAMILY/SOCIAL STATUS F1. Specify in comments.

Usual living arrangements (past 3 years): 1-With partner & children 6-With friends 2-With partner alone 7-Alone 3-With children alone 8-Controlled Environment 4-With parents 9-No stable arrangement 5-With family  Choose arrangements most representative of the past 3 years F6. The Addiction Severity Index 69 . Are/were you satisfied with these arrangements? 0-No 1-Indifferent 2-Yes   F6 menanyakan apakah klien merasa nyaman selama tinggal di tempat yang sudah disebut ( meski bukan tempat saat ini ) Jika F4 berbeda-beda. maka beri kode pada tempat tinggal utama saat ini dalam 3 tahun terakhir.F4 & F6: Tempat Tinggal F4.

F4a: Tempat tinggal F4a. Living arrangements past 30 days? (Use codes above)   F4a mencatat tempat tinggal utama saat ini Gunakan kode dari F4 The Addiction Severity Index 70 .

F7 & F8: Tinggal bersama pengguna yang lain
Do you live with anyone who: Has a current alcohol problem? Uses non-prescribed drugs?
(or abuses prescribed drugs)

F7. F8

0-No 1-Yes 0-No 1-Yes

Beri kode kemana klien akan pulang, ( jika klien dalam rawat inap) atau situasi tinggal saat ini ( jika dalam rawat jalan) Tidak termasuk institusi

The Addiction Severity Index

71

F9 & F10: Waktu Senggang
F9. With whom do you spend most of your free time?
1-Family 2-Friends 3-Alone

F10. Are you satisfied with spending your free time this way ? 0-No 1-Indifferent 2-Yes
 A satisfied response must indicate that the person generally likes the situation. Refers to Question F9.

Tandai pandangan klien tentang bagian dari keluarga sebagai “Keluarga”. Tidak harus berarti ada hubungan darah atau pasangan.
The Addiction Severity Index 72

F11a: Teman Dekat
F11a. How many of your close friends use drugs or abuse alcohol? Note: If patient has no close friends, code “N”

F11a. Tekankan artinya dekat. Kecuali anggota keluarga.  Hal ini adalah hubungan timbal balik atau saling menguntungkan/mendukung. “Mereka akan menolongmu, memperoleh terapi,dan anda harus membantu mereka. Anda dapat menceritakan hal-hal yang pribadi tentang diri Anda dan mereka The Addiction Severity juga akan melakukan hal Index yang sama.dll.”

73

Co-workers  "Serious problems" mean those that endangered the relationship. Brother/Sister F21. If no contact code “N” If no relative (ex: no children) Code N. either by telephone or in person. Neighbors F26. Close Friends F25.F18 – F26: Hubungan keluarga/sosial Have you had significant periods in which you have experienced serious problems getting along with: 0 – No. Other Significant Family (specify)_________________________ F24. Partner/Spouse F22. Mother F19. 1 . Children F23.Yes Past 30 days In Your Life F18. Father F20.  A "problem" requires contact of some sort. The Addiction Severity Index 74 .

jika klien tidak kontak tapi ada riwayat sepanjang hidup mempunyai problem dengan mereka. The Addiction Severity Index 75 . Jika F11a = 0. Sepanjang hidup = “1.” Kontak dalam 30 hari terakhir dengan telefon.” F23. maka F24 = 0. kode “N. Harus memiliki hubungan yang bermakna dengan orang tersebut dan khusus! F24. surat. Maka 30 hari terakhir = “N”. email. F26. F26 = N.F18 – F26: Instruksi kode       Periode sepanjang hidup yang “signifikan” ! Dalam 30 hari terakhir . Jika tidak bekerja dalam 30 hari terakhir . atau langsung. Jika tidak ada kontak.

76 The Addiction Severity Index . 0. Beri penekanan pertanyaan yang diberi tanda “. Physically?  Caused you physical harm.F28 – F29: Riwayat Pelecehan FAMILY/SOCIAL (cont.No 1-Yes Past 30 days In Your Life Sexually?  Forced any sexual advances/acts. tidak hanya keluarga atau teman Harus sensitif.) Has anyone ever abused you? F28.    Pernahkah seseorang melakukan pelecehan pada anda.” Jangan penekanan terlalu dalam bila anda bukan klinisi yang menangani klien. F29.

32. “Days of conflict” refers to more immediate confrontational actions. Family problems  Patient is rating his/her need for counseling for family problems. fighting. or verbal abuse and loss of control. not whether they would be willing to attend . 34: “Final 3” problem keluarga How many days in the past 30 have you had serious conflicts: F30. The Addiction Severity Index 77 .F30. Note: The patient is rating their need for you/your program to provide or refer them to family services. physical. Penilaian anda penting untuk terapi masalah keluarga. above and beyond any services they may already be getting. With your family? Ask the patient to use the Patient Rating scale:  How troubled or bothered have you been in the past 30 days by: F32. tidak harus keluarga akan hadir. Family problems? How important to you now is treatment or counseling for these: F34. yelling.

F31-F35. Social problems? How important to you now is treatment or counseling for these: F35. conflicts. physical/verbal abuse. Social problems  Include patient's need to seek treatment for such social problems as loneliness. F33. and dissatisfaction with friends. and loss of control. or other serious problems. 33. 35: “Final 3” masalah sosial  How many days in the past 30 have you had serious conflicts: F31.  “Days of conflict” also refers to confrontational actions.F31. fighting. dissatisfaction with friends. Refers to social problems that are defined by ASI questions not related to family. inability to socialize. above and beyond treatment they may already be getting somewhere else. Patient rating should refer to dissatisfaction. such as yelling. Include feelings of loneliness. etc.  Note: The patient is rating their need for you/your program to provide or r efer them to these types of services. With other people (excluding family)? Ask the patient to use the Patient Rating scale: How troubled or bothered have you been in the past 30 days by: F33. 78 The Addiction Severity Index .

F39 & F39a: Anak Living with you Living outside your home F39. How many of these are under age 18   F39 bertujuan menentukan jumlah anak dan situasi kehidupannya. The Addiction Severity Index 79 . Dampingi mengevaluasi hal keluarga dan masalah dukungan. How many children do you have? F39a.

Transition to Psychiatric Section .

Gejala berhubungan secara eksklusif akibat menghirup zat (mis halusinasi) atau detoksifikasi (“ saya merasa cemas selama masa detoks.Status Psikiatrik  Bagian ini untuk menentukan gejala psikologis dan distres emosional.  The Addiction Severity Index 81 .”) jangan dicatat. tidak membuat diagnosis.

Tidak termasuk penyalahgunaan zat. not the number of visits. or family counseling. employment.  Treatment episode = a series of continuous visits or treatment days.  Termasuk terapi untuk setiap masalah psikiatrik.P1–P2: Terapi Psikologis Sebelumnya PSYCHIATRIC STATUS How many times have you been treated for any psychological or emotional problems: P1* In a hospital or inpatient setting? P2* Outpatient/private patient?  Do not include substance abuse. pekerjaan atau konseling keluarga The Addiction Severity Index 82 .

P3: Dukungan keuangan untuk masalah psikiatrik P3. santunan untuk penyakit seperti kondisi jantung masuk dalam Status Medis  Jika klien tidak tahu penyakit yang diderita yang diberikan santunan. Do you receive financial support for a psychiatric disability? Can be from government or employer. etc. 0-No 1-Yes  Masalah koding: Hanya mencatat santunan yang diterima gangguan psikologis/keterbatasan. kode “X” The Addiction Severity Index 83 .

or remembering? P5. hopelessness. inability to feel relaxed? Experienced hallucinations-saw things/ heard voices that others didn’t see/hear? Code other psychotic symptoms here also. Experienced serious depressionsadness. P7. The Addiction Severity Index 84 . Experienced trouble understanding. loss of interest? Experienced serious anxiety/tension uptight. concentrating.P4 – P7: Gejala Psikologis Have you had a significant period of time (that was not a direct result of alcohol/drug use) in which you have: 0-No 1-Yes Past 30 Days Lifetime P4. unreasonably worried. P6.

setelah itu tanyakan dalam 30 hari terakhir Kode sepanjang hidup bila gejala > 2 minggu   Note: P6 cukup penting meski hanya pengalaman singkat/sesaat tetap di catat.  30 hari terakhir kode “1-ya” jika klien mengalami gejala menyeluruh Kode gejala psikotik yang lain di P6 The Addiction Severity Index 85  .P4 – P7: Gejala Psikologis   Uraikan gejalanya Tanyakan gejala yang serius sepanjang hidup dulu.

kode jika pasien dibawah pengaruh zat dan/atau alkohol.P8: Gejala Psikologis Have you had a significant period of time (regardless of alcohol and drug use) in which you have: 0-No 1-Yes Past 30 Days Lifetime P8. Experienced trouble controlling violent behavior including episodes of rage. beri kode meski hanya terjadi satu kali sepanjang hidup Selanjutnya. atau melewati masa putus zat pada saat gejala muncul. or violence?  Masalah koding:   Berhubungan dengan beratnya gejala. The Addiction Severity Index 86 .

Attempted suicide?  Jika klien dikuasai pikiran serius tentang bunuh diri :   Tanya bagaimana seringnya klien merasa ingin bunuh diri .  Include actual suicidal gestures or attempts. P10. bagaimana cara anda melaksanakan keinginan bunuh diri?”) The Addiction Severity Index 87 . Experienced serious thoughts of suicide?  Patient seriously considered a plan for taking his/her life.P9 & P10: Ide Bunuh Diri P9. atau melakukan upaya bunuh diri Tanyakan secara rinci rencana bunuh diri (mis.

  Tidak termasuk medikasi sementara Tekankan “diresepkan untuk anda” The Addiction Severity Index 88 . Record "Yes" if a medication was recommended even if the patient is not taking it.P11: Peresepan Obat P11. Has a health care provider recommended you take any medications for psychological or emotional problems?  Recommended for the patient by a physician or other health care provider as appropriate.

anda menyebutkan anda mengalami depresi. Smith. dapatkah anda menceritakan berapa hari dalam 30 hari terakhir anda merasakan tertekan?” The Addiction Severity Index 89 .P12: Masalah sehari-hari P12. tidak hanya sekedar menyebutkan “masalah psikologis” Sebagai contoh: “Mr. How many days in the past 30 have you experienced these psychological or emotional problems?  This refers to problems noted in Questions P4-P10. Catatan: Gunakan contoh gejala yang diceritakan pasien dengan memiliki masalah dengan.

How important to you now is treatment for these psychological or emotional problems? Note: The patient is rating their need for you/your program to provide or refer them to psychological/psychiatric services. For Questions P13-P14. above and beyond treatment they may already be getting somewhere else. P14. ask the patient to use the Patient Rating scale P13.  P12 merujuk pada gejala yang disebutkan di dalam P4-P10  P12 harus >0 jika tiap item dalam 30 hari terakhir dalam P4-P10 > 0.P12 – P14: Psikiatrik Final 3 P12. How troubled or bothered have you been by these psychological or emotional problems in the past 30 days?  Patient should be rating the problem days from Question P12. How many days in the past 30 have you experienced these psychological or emotional problems?  This refers to problems noted in Questions P4-P10. The Addiction Severity Index 90 .

The Addiction Severity Index 91 . P14. above and beyond treatment they may already be getting somewhere else.P12 – P14: Psikiatrik Final 3 P12. How troubled or bothered have you been by these psychological or emotional problems in the past 30 days?  Patient should be rating the problem days from Question P12. tekankan bahwa “treatment” tidak harus berarti dirawat di bagian psikiatrik atau masuk dalam perawatan. How important to you now is treatment for these psychological or emotional problems? Note: The patient is rating their need for you/your program to provide or refer them to psychological/psychiatric services. ask the patient to use the Patient Rating scale P13. How many days in the past 30 have you experienced these psychological or emotional problems?  This refers to problems noted in Questions P4-P10.  Untuk P14. For Questions P13-P14.

OP (Methadone.) Jelaskan________________________________________ The Addiction Severity Index 92 .G50: Modalitas Terapi yang diharapkan G50. dll) 9=Lain ( DU. Buprenorphine. penyembuh spiritual . dll. Modalitas Terapi Yang Diharapkan: 1=Rawat Jalan (<5 jam per minggu) 2=Rawat Jalan Intensive (≥ 5 jam per minggu) 3=Rawat Inap/residensial 4=Therapeutic Community 5=Rumah Singgah 6=Detox – Rawat inap (biasanya 3 – 7 hari) 7=Detox Rawat Jalan 8=Opioid Replacement.

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