(George Christo is a psychologist with doctorates in both clinical practice and treatment outcomes research. He has used these combined experiences to develop an evaluation tool which satisfies research requirements yet meets the limitations imposed by a busy practice.)

Substance misuse services are coming under increasing pressure from purchasers to demonstrate the effectiveness of their treatments. Although services generally have a wealth of qualitative data from detailed client notes and assessment interviews, these client descriptions are difficult to analyse and compare. It might be useful to convert detailed client information into a single score comparable across all clients. To be acceptable to busy workers, the process would have to be convenient, short and compatible with current procedures.

The usual areas measured in outcome questionnaires (e.g., The Opiate Treatment Index, the Addiction Severity Index, & the Maudsley Addiction Profile) are social functioning, general health, HIV risk behaviour, psychological well being, occupation, criminal involvement, and drug/alcohol use. Unfortunately the existing questionnaires take a while to complete, require the presence of the client in question, and cannot combine sub sections to produce a single total score for easy analysis. Many services do not have the time or research expertise to elicit, code, analyse and report on the complex multiple outcomes generated by these questionnaires; something simpler is required.

Clients are sometimes inaccessible or reluctant to fill in detailed questionnaires, a few may not be able to read in any case. Clients generally give valid self-reports unless they perceive some advantage to be gained from doing otherwise. They are thus more likely to give valid self-reports in confidential interviews with external researchers not perceived to a part of the treatment system. However where external researchers are not available, keyworkers are as likely to produce valid findings as clients filling out questionnaires which they know will be seen by treatment staff. One may assume that workers are familiar with their own clients and may be able to furnish the required information on their clients' behalf. Although the information would largely comprise of subjective impressions which may be difficult to validate, a competent worker should be expected to be able to produce a reasonably accurate impression of their client's status within the relevant outcome areas.

The Christo Inventory for Substance-misuse Services (CISS) was developed to elicit workers’ impressions of their clients in a quick, standardised and reliable way. Outcome areas are scored on a three point scale of problem severity (0 = none, 1 = moderate, 2 = severe), each point is illustrated with relevant examples for guidance. As well as the seven outcome variables mentioned earlier, the literature indicates that three further variables are relevant to outcome and should be included:

So the CISS assesses outcome over 10 different areas of clients’ functioning. A total score of 0 indicating no problems, and a maximum score of 20 indicating severe problems in all areas.

Use of a single outcome measure makes life easier for services that wish to produce a simple and readable DIY report without using a professional researcher / statistician. The process is further simplified now the CISS outcome score can be reduced to two or three categories e.g., ‘good / poor’ outcome or ‘low / average / high’ problem severity. The CISS is an evaluation tool and may not be suitable for some types of detailed research where separate measures of functioning in independent domains (e.g., drug use and health) may be required. Breakdowns showing the percentage of clients with none, moderate or severe problems may be produced from separate CISS items. However the individual item three point scales are not very sensitive to change, sensitivity is only gained when the 10 items are combined to form the 0 to 20 CISS outcome score.

In summary:

The CISS is a simple standard measure for outcome monitoring in a practice setting.

The CISS is a 10-item questionnaire producing a single score of 0 to 20 which is a general index of client problems.

It can be used to monitor client improvement over time, or to ensure that keyworkers / counsellors are carrying caseloads of approximately equal difficulty.

As well as the usual outcome measures (e.g., social, health, psychological, drug use, HIV risk, occupational, criminal), it also measures three important areas of client-support interaction: use of structured support, compliance, and working relationships. Research has shown these factors to be relevant to outcome and clinical audit.

It uses only a single page, is easy to photocopy and will not clutter clients' files.

It can be completed face to face or from client assessment notes, it does not necessarily require the presence of the client.

It is user friendly. A familiarised worker can complete it in three minutes during their admin time.

A single glance will tell you how the client is performing in 10 areas of outcome.

It works for either drug or alcohol users.

It works for either abstinence based or harm minimisation / prescribing services, comparison and cutoff scores are provided for both.

It appears to be quite popular with purchasers and providers alike.

Preliminary research shows the CISS to be easy to use, reliable and sensitive to change.

CISS forms and comparison scores can be currently obtained at no charge from Dr George Christo email: DrGeorgeChristo@tiscali.co.uk