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10 Assessment In Chapter 9 the committee proposed a broadening of the base of treatment through a wide dissemination of the capability to identify and briefly intervene with persons manifesting mild or moderate alcohol problems. This strategy is intended for implementation in settings other than specialized treatment programs for alcohol problems to which persons identified as having substantial or severe alcohol problems would be referred. In the next three chapters of this section of the report the committee discusses strategies for enhancing the specialized treatment of alcohol problems. Three areas are emphasized: (1) assessment prior to treatment, (2) matching to optimal treatment, and (3) determining treatment outcome. Considering assessment, matching, and outcome determination in separate chapters is an arbitrary division of material for the purposes of discussion. In practice, each function is related to the others, and all are parts of a unified whole. For example, the treatment modalities that are available influence the content of assessment, and to match individuals to the most appropriate treatments requires pretreatment assessment. Treatment outcomes become increasingly meaningful with assessment and can be utilized to increase the accuracy of matching. How accurate matching has been is, in turn, evaluated by determining treatment outcome. Because the committee wishes to emphasize the importance of a close integration of assessment, matching, and outcome determination, it has elected to discuss how they might be fitted together both at the outset of this report (Chapter 1) and at the close of Section II, Aspects of Treatment" (Chapter 13~. However, because all three of these processes raise particular issues that need to be discussed, the committee has devoted a separate chapter to each. A key purpose of assessment is to determine which of the available treatment options is likely to be most appropriate for the individual being assessed. Hence, assessment must occur prior to any commitment of the individual to a particular kind of treatment, and its utility is contingent upon the availability of multiple treatment options. "When clinicians apply the same general [treatment] approach to most clients, assessment data can have few treatment implications. With the arrival of more specific interventions, however, the need for guidance by assessment data becomes more obvious" (Hayes et al., 1987:964). This general principle is particularly pertinent to the treatment of alcohol problems. A major conclusion from the substantial body of research on treatment outcome in this field is that there is no single treatment approach that is effective for all persons with alcohol problems (see Chapter 5~. This being so, for optimal treatment matching is not optional but is required (see Chapter 11~. Assessment provides the basis for matching. What Is Assessment? Assessment is the systematic process of interaction with an individual to observe, elicit, and subsequently assemble the relevant information required to deal with his or her case, both immediately and for the foreseeable future. In general, the collection of de- tailed initial information is a feature of all human service settings. In particular, alcohol problems are known to affect, and to be affected by, multiple aspects of an individual's life; they frequently manifest themselves as physical problems, psychological problems, social problems, and vocational problems simultaneously. Thus, the initial effort to collect information might be expected to be at least as extended if not more extended than in other service settings. 242
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ASSESSMENT 243 Yet despite the logic and the pervasiveness of this approach, a comprehensive assessment of each individual entering specialized treatment for alcohol problems is a principle honored more in the breach than in the observance. Many specialized treatment settings offer only a single modality of treatment (Glaser et al., 1978~. Thus, there is no reason (from the program's standpoint) to develop information that might suggest alternatives, and there may be strong financial incentives not to do so, a point discussed later in this chapter. Although a certain amount of data is usually gathered, it is often simply demographic information and, increasingly these days, information regarding available reimbursement mechanisms. The data are gathered after admission to the treatment program and therefore after a commitment has been made to a particular form of treatment; hence, they have little or no bearing on treatment selection. A sample statement from the literature documenting the general lack of comprehensive assessment is that Patients were assigned to treatment methods without a thorough evaluation of their problems and without a recorded assessment of severity and were allowed to progress without follow-up or reassessments (S. Miller et al., 1974:213~. In the province of Ontario, where the Addiction Research Foundation has advocated pretreatment assessment for almost a decade, a 1986 survey of 181 programs found that "although there was a very high endorsement of the systematic assessment of clients, only about 20-25% of programs include state-of-the-art diagnostic instruments in their assessment protocol. Assessment typically involved a structured or unstructured questioning of the client, without the use of further diagnostic aids" (Rush, 1987:3~. Even if one looks only at the treatment outcome research literature, in which knowledge of pretreatment status is essential to determine whether treatment has affected outcome, what one sees is less than satisfactory. "The failure to provide more comprehensive pretreatment data, reports one group of investigators, ". . . is distressing and is a problem that has not lessened with passage Of time Pr`~.tre.ntm`~.nt `1ntn for ~ . ..,,, _ . . . ~ , _ _ _ _ variables such as severity of dependence, chronicity of drinking problems, and quantitative assessment of pretreatment drinking were reported in only about one-half of the studies" (L. C. Sobell et al., 1988:117~. The committee's general charge was to study the process of treatment and make recommendations for its improvement, and it considers a comprehensive pretreatment assessment to be crucial to such improvement. The "basic justification for assessment is that it provides information of value to the planning, execution, and evaluation of treatment" (Korchin and Schuldberg, 1981~. Yet assessment can serve multiple purposes, and an appreciation of the need for assessment should arise from an understanding of all of them. The Purposes of Assessment for Alcohol Problems Characterizing the Problem If alcohol problems differ from one person to another, whether in degree or in kind, it is crucial to document the differences. Otherwise, any changes subsequent to treatment cannot be compared with the individual's pretreatment status. Some persons coming for treatment, for example, will have high alcohol consumption levels, and others will not. Some will be binge drinkers, and others will be steady drinkers. Some will have experienced many symptoms in connection with their use of alcohol, and others will have experienced few symptoms. Some will have accrued a great many adverse consequences of alcohol consumption, and others will have accrued few consequences. As with other drugs,
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244 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS those who have lower levels of consumption will probably exhibit more variety in the problems they manifest than will individuals with higher levels of consumption (Edwards, 1974~. But even among those with many signs and symptoms, the specific manifestations will differ from one person to the next. For example, DSM-III-R lists nine signs and symptoms of "psychoactive substance use disorders, of which any combination of three will qualify for a diagnosis (American Psychiatric Association, 1987~. Thus, among those qualifying for this diagnosis on the basis of their alcohol use, many alternative combinations of manifestations will occur. In this spirit physicians have been cautioned to "be aware that not every patient that drinks too much (for whatever reason) will be dependent on alco- hol, and different patients need different help and treatment" (Edwards and Gross, 1976:1061). As this warning suggests, the correspondence between level of consumption, pattern of consumption, signs and symptoms, and consequences is not invariably a close one. Some people with high consumption levels will drink steadily, have many signs and symptoms, and experience many consequences, but others will not. The evidence for the relative independence of these dimensions of alcohol problems will be discussed later in this chapter. That they are not necessarily highly correlated with each other, particularly in younger persons (Fillmore and Midanik, 1984; Fillmore, 1987), introduces still more variance into the clinical picture of alcohol problems. What should emerge from a comprehensive assessment is a detailed picture of the particular kind of alcohol problem manifested by a particular individual at a particular point in time. Of major importance is to describe the person and the problem in terms that are clear and unambiguous. Not only is precision valuable in itself but, if assessment is to be maximally useful, its terms must be clearly understandable to a variety of individuals. The evolving treatment system is complex. Particularly in cases in which the problem is a chronic one (and many alcohol problems will be), a large number of different treatment personnel will encounter particular persons with alcohol problems over time. In the absence of a clear and unambiguous picture at initial contact it may not prove possible to understand the evolution of an individual's alcohol problem over time, or to make appropriate decisions regarding care for the present and the future. Let us consider a common clinical situation: a patient reports that he "had a problem before, but it got better; now he has developed a problem again, only this time it is a little different." What sort of problem did he have before? In what sense and to what degree did it improve? In what way is the problem he has now different from the problem he had previ- ously? Skillful interviewing can help to clarify some of these issues, but a comprehensive, understandable, quantitative, recorded account of the patient's earlier status and of his course would be invaluable in providing solid answers. Precise information regarding the parameters of an alcohol problem is of interest not only to therapists but also to those who manifest the problems. The feedback of assessment data in an understandable form to those from whom it has been obtained is a common and useful practice. Not only does it seem a reasonable courtesy, but there is evidence that feedback can contribute significantly to treatment-seeking behavior. Thus, in one study, half again as many individuals seeking help for alcohol problems appeared in treatment after receiving a comprehensive assessment compared with those who were not assessed (Annie and Skinner, 1984~. In another study, 95 percent of a random sample of such individuals who were given an assessment battery returned for their second appointment, compared with only 56 percent of those who were not given the assessment (Sutherland et al., 1985~. General practice patients who completed a brief assessment of their use of alcohol, tobacco, caffeine, medication, and nonmedical drugs during which Feedback was given on how the patient's consumption levels compared with
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ASSESSMENT 245 others of the same sex and ages were significantly more likely than those who were not so assessed to query their doctors regarding all of these substances (H. ~ Skinner et al., 1985b). "Taking these [assessment] tests," commented one group of observers, "could have predisposed patients to attend a second session either because they may have expected to obtain some information about the test's results . . . or because they may have been impressed by the amount of care devoted to them" (Sutherland et al., 1985:212~. In confirmation, one patient in an assessment program commented that "it helps you to get a hold of yourself and use your mind to sort out what makes you feel [the way you do] about life" (Segal, 1984~. Another said that "it slowed down my thinking process and allowed me to have a good, long look at myself. I now know what I am and what I have to do to improve myself." Characterizing the Individual Alcohol problems do not occur in a vacuum. The individuals who manifest them are at least as different from one another as are ordinary people (Chapter 2~. Or perhaps, more different: Keller's law is that "the investigation of any trait in alcoholics will show that they have either more or less of its (Keller, 1972~. A precise and systematic knowledge of the differing characteristics that each individual exhibits at the time he or she is seen for an alcohol problem, as well as a characterization of the problem, is another purpose of assessment. Eventually, such information will help to unravel which individual characteristics may predispose people to alcohol problems and which are the result of alcohol problems. Beyond these benefits for future research, however, lies the immediate therapeutic utility of such information. Individual characteristics have much to do with a person's acceptance (and, in consequence, the eventual outcome) of various forms of treatment (see the review by Ogborne, 1978~. Thus, detailed knowledge of these characteristics is extremely useful in selecting an appropriate treatment. For example, persons who are well organized and of quite decided opinions may tend to prefer relatively unstructured forms of therapy, whereas those who are disorganized and at a loss may prefer more structured approaches (McLachlan, 1972; McLachlan, 1974; Witkin and Goodenough, 1977; Hartman et al., 1988~. Those who prefer structure are more likely to affiliate with programs that provide it, such as Alcoholics Anonymous (Canter, 1966; Reilly and Sugerman, 1967~. Those who prefer unstructured settings, on the other hand, may prefer an approach like client-centered or insight-oriented counseling, in which the patient takes the lead and the therapist is relatively inactive. Persons with positive views of themselves may be able to tolerate and benefit from therapeutic approaches that are highly confrontational; those who view themselves negatively may be harmed by such approaches (Annie and Chan, 1983~. Persons whose views of the locus of responsibility for alcohol problems (both for developing and for dealing with them) are congruent with the views of program staff may be more likely to sustain treatment (Brickman et al., 1982~. Another aspect of characterizing individuals has to do with their medical and psychiatric status. People with alcohol problems often have medical and psychiatric problems as well (Wilkinson and Carlen, 1981; Ashley, 1982; Popham et al., 1984; Mendelson et al., 1986; Ross et al., 1988~. Some of these problems may be the result of alcohol consumption; some may result in drinking (for example, for symptomatic relief); still others may be independent problems. Yet all are important in themselves, requiring clarification and, often, therapeutic attention. To concentrate solely on an individual's alcohol problem and fail to recognize or to deal with a significant medical or psychiatric
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246 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS problem in the same individual is not only poor therapeutic practice but a potential cause for legal action. There is also evidence that the coexistence of particular problems (e.g., depression, anxiety or panic states, schizophrenia, antisocial personality, drug dependence) may directly affect the outcome of treatment for alcohol problems (Woody et al., 1984; Strayvinski et al., 1986; Rounsaville et al., 1987; Kadden et al., 1990~. The effective management of alcohol problems, in other words, may in some instances be contingent upon the effective management of intercurrent problems. Thus, an assessment of medical and psychiatric status should be a standard element of comprehensive assessment. When one considers that alcohol affects both the body and the mind directly, this is hardly a surprising conclusion. The point that alcohol problems do not occur in a vacuum is paralleled by the point that "no man is an island. It is important during the assessment process to characterize the person's social context as well as the person. A turbulent social context may entirely negate any attempts at individual treatment and may need to be directly addressed as the initial order of business. Individuals with problematic family or home situations or both are unlikely to sustain participation in outpatient treatment programs (H. ~ Skinner, 1981c). If there is a history of marital troubles, some attention may be required in this area. If there have been job-related difficulties, vocational evaluation and training may be prudent. If there has been difficulty in allocating leisure time, or a social support network is lacking, social or recreational counseling may be in order. Thus, obtaining an adequate picture of the social context of the individual who has the alcohol problem is an important purpose of assessment. Characterizing the manifold aspects of individuality is a highly complex matter, and an exhaustive discussion of all of the parameters that may require address during assessment is not possible here. The committee envisions such a discussion as more appropriately part of a consensus exercise that would consider both the relevance of various parameters and the means whereby they can be effectively measured (see below). What the committee hopes will arise from the foregoing discussion is an appreciation of the necessity to characterize individuals as part of a comprehensive assessment process. Characterizing the Treatment Population If each individual in the treatment population were characterized in a similar manner, individual data could be aggregated; with aggregation it becomes possible to characterize the treatment population as a whole. As will be discussed further below, accomplishing such a characterization does not mean that the assessment of each individual must be identical in every particular, a practice that would fail to give due recognition to the diversity of individuals and of the problems for which they are seeking treatment. It does suggest, however, that there should be common data elements in the assessment of all individuals. Common data would permit not only the characterization of the population of a given program but the comparison of one program population with another. O 1 ~ ~ ~ · ~ _ ~ ~ ~ A ~ ~ 1 1 _ . While it is easy to see that the population cnaracterlstlcs of programs especially targeted for particular population groups-women, youth, or ethnic minorities, for example-are likely to differ, it is less apparent that the populations of treatment programs with a more general orientation may differ as well (Pattison et al., 1969; Pattison et al., 1973; Bromet et al., 1976; Bromet et al., 1977; H. ~ Skinner and Shoffner, 1978; Kern et al., 1978; Finney and Moos, 1979; H. A. Skinner, 1981c). Location, history, reputation, publicity, accessibility, treatment orientation, cost, staff composition, funding, and other factors undoubtedly enter into the determination of such differences. They are not stable determinants, and so the characteristics of a treatment program population may change over
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ASSESSMENT 247 time. For this reason the occasional assessment of program population characteristics is less useful than their ongoing assessment. If the characteristics of a program population are known, and the characteristics of the general population from which it is drawn are also known, it is possible to estimate the effectiveness of the program in recruiting its target population. For example, a community assessment service in London, Ontario, saw 14.1 percent of the persons with serious alcohol problems in its catchment area over a three-year period (Malla et al., 1985~. A household survey in that area of the province had found that only 3.2 percent of individuals classified as problem or dependent drinkers during the past year had ever received treatment for alcohol problems in their lifetimes (Smart et al., 1980~. The authors concluded that "the assessment centre may, over a period of time, increase the penetration rate of a treatment system into the local alcoholic population" (Malta et al., 1985:41~. If comparable data exist for more than one treatment program, between-program comparisons are possible. Two programs may have similar proportions of positive outcomes, but if it is known that the two populations differ on Such pretreatment characteristics as, for example, severity of alcohol problems or level of employment, a more exact understanding of the two programs and their relative efficacy is possible. The assessment center noted above (Malta et al., 1985) had a high rate of referral from physicians and employers, while other area programs had high rates of self-referrals and referrals from family and friends; this pattern speaks to differential, and possibly complementary, recruiting from the overall population. Comparable data from all treatment programs would be invaluable in revealing which segments of the community were being served and in planning further services for those who are not entering existing programs. Planning Treatment for the Individual , , , ~. ~ . ^^ - Full characterization of a given individual, combined with knowledge of available treatment options, facilitates appropriate, prompt, and effective management of the -individual's problem. For example, there is evidence (cf. reviews by Annis, 1986a; W. R. Miller and Hester, 1986) that the results from inpatient and outpatient treatment do not differ for heterogeneous groups of patients. Some (W. R. Miller and Hester, 1986; Saxe et al., 1983) accordingly have advocated that outpatient treatment should be tried first because it is less expensive and that inpatient treatment should be undertaken only if outpatient treatment fails. But it is well known that individuals with low social stability (as well as other characteristics) are unlikely to sustain participation in outpatient treatment (e.g., H. ~ Skinner, 1981c). Thus, rather than a wholesale embargo on inpatient programs for all persons seeking treatment, the more discriminating use of inpatient programs might be envisioned. Those with low social stability, as well as a profile of other indicative features (severe withdrawal symptoms, major medical or psychiatric complications, a markedly noxious environment, crucially aversive temporary circumstances, etc.), might be referred initially to inpatient or residential programs. Others, in more favorable circumstances and with less severe problems, might be referred to outpatient programs (cf. Hoffmann et al., 1987~. To provide another example of the potential utility of pretreatment assessment in assigning individuals to treatment, let us consider a controlled trial in which no advantage was found in the use of a particular treatment (highly confrontational group therapy, or so-called "attack" therapy) in a heterogeneous correctional population (Annie, 1979~. Retrospective reanalysis of the data extended these findings. Although there had been no net benefit in the treatment group, in fact some individuals had benefitted and others (in
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248 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS approximately equal numbers) had not. Moreover, data were available to show that these two groups were systematically different. Those who had benefitted were characterized on initial assessment by positive self-images (determined objectively with appropriate psychometric instruments). Those who failed to benefit indeed, who appeared to have been harmed by the treatment were characterized by negative self-images (Annie and Chan, 1983~. In future, it is to be hoped that the self-image of persons seeking treatment could be determined in advance, and that only those with positive self-images would be assigned to "attacks therapy. In other words, assessment prier to treat forms the basis on which individual patients are matched to particular treatment programs. This point was stressed earlier, but is repeated here for emphasis. Matching is the subject of the next chapter in this report (Chapter 11~; the implications of assessment for matching are more fully discussed there. It is worthwhile to point out that additional information on the individual will need to be gathered by program staff following the selection of treatment in order to plan the individual's ongoing treatment course. In some respects, indeed, treatment involves a continual and ongoing gathering of information on the individual. Pretreatment assessment initiates this aspect of treatment, but information gathering continues throughout treatment. Guiding Treatment for the Population Assessment provides information that can be used to develop a clinical data base. HA clinical data base is created when well-defined, discrete, and continuous data elements concerning patients are routinely recorded and coupled with outcome descriptors" (Pryor et al., 1985:623~. Given knowledge of pretreatment characteristics and knowledge of the outcome of treatment, a comprehensive picture of individual responses to treatment can be elaborated. This information can then be used to estimate the probable responses of future patients to particular treatments. Their characteristics can be documented during the assessment process, and treatment can be selected on the basis of information about how individuals with similar characteristics have previously responded to the available alter- natives. speed. Ah ~ cvct`~m he hP.P.n rP.~.nmmended as the basis for medical care generally (Ellwood, 1988~. To manage the large amount of information involved and to provide rapid access to that information, computerization of the clinical data base is logical. Yet it is worth noting that the fundamental model is the human clinician. "The ability of a practitioner to couple the process of patient care to the outcome of a disease is the underlying principle enabling physicians to learn from their previous experience" (Pryor et al., 1985:623~. Computerized data bases seem foreign or even outlandish to many. Yet they simply imitate and extend a familiar model, formalizing what is done by good clinicians in the management of patients but doing it with greater scope, capacity, accuracy, and ~ ~e ~ ~ ~ ~ ,.. .. ~ ~ Such data bases are already in existence for many particular kinds of problems. Tumor registries are perhaps the most familiar example (Laszlo, 1985), but clinical data bases exist for such prevalent problems as cardiovascular disease (Hlatky et al., 1984) and such uncommon problems as systemic lupus erythematosus (Fries, 1976), a severe disease that involves the destruction of connective tissue throughout the body. There is at least one extensive clinical data base for alcohol problems that includes outcome information, that of the Chemical Abuse/Addiction Treatment Outcome Registry (CATOR) (Belille, n.d. [ca.19873; Harrison and Belille, 1987; Harrison and Hoffmann, 1987~.
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ASSESSMENT 249 At present, existing data bases are for the most part not used to guide treatment for populations (but see Fries, 1976~. Given the increasing availability of computers there is every prospect that they could be so used. In fact, treatment programs offering different treatments could assemble around--a shared clinical data base and use the information contained in it to guide the selection of treatment for all individuals presenting to the programs collectively (see Chapter 13~. For this proposal to be feasible, however, a comprehensive pretreatment assessment must be an integral part of the clinical process. To summarize: assessment is a comprehensive gathering of information about each individual who is being considered for specialized treatment for alcohol problems. Its purposes include the characterization of the presenting alcohol problem, the individual who has the problem, and the population seeking treatment, and the facilitation of appropriate treatment for all. Although widely advocated, comprehensive assessment prior to treatment is the exception rather than the rule. To facilitate its more general use, the committee in the next three sections discusses its structure, its content, and its administration. The Structure of Comprehensive Assessment There are two important guidelines for structuring comprehensive assessment in the alcohol treatment field. Both are consequences of the heterogeneity of alcohol problems (see Chapter 2~. One is that assessment should be sequentu~l; the other is that assessment should be mul~idimer~sional. Sequential Assessment Gathering information, and the attendant processes of recording, storing, and retrieving it for various uses, should not be lightly undertaken. Such activities are costly in terms of time, money, and effort. One wants to be certain, therefore, that all of the information gathered is necessary and that no more information is gathered than is required for the purposes at hand. Accordingly, it is advisable to divide the process of assessment into a series of stages, each of which may or may not lead into the next stage (H. ~ Skinner, 1981a; 1981b). This approach, which is called sequential assessment, is graphically portrayed in Figure 10-1. The initial stage in the assessment sequence for those seeking specialized treatment for alcohol problems is screening. In common with the process of identification in the community sector of treatment (see Chapter 9), the basic questions asked here are (1) whether an alcohol Problem is present and (2) whether it requires specialized treatment. . ~ ~ This duplication of what may occur in the community is necessary in a specialized assessment setting for alcohol problems because some individuals-those who did not first attend a primary care physician, social agency, or another community setting in which the identification process is available-will seek specialized treatment directly. Of those who do present for treatment, many will prove to have alcohol problems, but some will not. Hence, screening as the first order of business makes practical sense and, in at least some instances, will suggest that the remainder of the comprehensive assessment process is not necessary. Even if a problem is present, it may prove to be one that can readily be dealt with through brief intervention. Referral to a community setting rather than to specialized treatment can in such instances be made on the basis of screening alone. Although the yield again will be small, the saving of time and effort devoted to subsequent assessment stages even in a small number of cases will be worthwhile.
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250 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS EXTENT OF INFORMATION it_ -SCREENING _ PROBLEM ASSESSMENT - - PERSONAL ASSESSMENT COST Ch _ ~ FIGURE 10-1 Sequential Assessment. As one moves from screening to problem assessment to personal ae~P~:~:mPnt the `~rt`~nt Of infnrrn~tir~n t1f~v~1r~nt~.~1 in arbiter hilt the costs of assessment are also greater. Performing ~ ~ all_ In_ ~^ - - r D an assessment sequentially ensures that further information is necessary and justifies its increased cost (adapted from Skinner, 1981a:30; 1981b:330~. If screening suggests that the individual probably does have a problem that is likely to require specialized treatment, the next step in the sequence may be thought of as the problem assessment. This stage of assessment represents a major increment over screening in the extent and variety of the information it yields (as well as in the effort and time required to implement it). Because screening has indicated the likelihood that an alcohol problem is present, this next stage of assessment both tests and extends that observation. Many instruments have been developed which may be utilized for problem assessment (cf. Lettieri et al., 1985b). As discussed in the previous chapter, a single scale instrument is often used for screening purposes. It may be appropriate in the next stage of assessment to utilize a multiscale instrument, such as the Alcohol Use Inventory (AUI) (Wanberg et al., 1977; H. ~ Skinner and Allen, 1983a; Horn, Wanberg & Foster, 1987~. With its extensive item pool and multiple scales, the AUI, together with other elements of the problem assessment, can provide confirmation or disconfirmation of the screening finding that an alcohol problem exists; moreover, it can help to determine what kind of alcohol problem it might be. Additional effort is expended, but additional information is gained. As is discussed later in the chapter, other measures at this stage of assessment can also be used to provide similarly extensive data on other aspects of the presenting alcohol problem. Ideally, both the screening stage and the problem assessment stage are uniform in their content for all persons seeking treatment. Such uniformity is desirable because all such persons may or may not have alcohol problems. If no alcohol problem is present, or
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ASSESSMENT 251 the problem that is present is appropriate for brief intervention rather than specialized treatment, the assessment process can end. Alternatively, once the presence of a problem appropriate for specialized treatment has been confirmed, and the nature of that problem has been fully characterized during the problem assessment stage, it is appropriate to move on to the next stage of assessment. As discussed earlier, to determine the most appropriate treatment one must take into consideration not only the characteristics of the problem but those of the individual manifesting the problem. Thus, the third stage of a comprehensive assessment, following screening and the problem assessment, is the personal assessment. Before beginning this stage of the assessment, however, it is advisable to undertake a specific screening process as the first order of business. Some of the procedures that must be implemented to gather a full complement of data during the course of a personal assessment are among the most extensive and time-consuming in the assessment repertoire. They therefore should not be deployed unless there is preliminary evidence that it is necessary to do so. For example, confirmation of the presence of a psychiatric disorder may involve the administration of a structured instrument such as the Diagnostic Interview Schedule (DIS) (Robins et al., 1981), or a psychiatric consultation, or both. Before engaging in these complex procedures, it would be appropriate first to screen as quickly and as accurately as possible for the presence or absence of psychiatric problems. The screening could be accomplished by the use of a brief instrument such as the General Health Questionnaire (GHQ) (Goldberg, 1972, 1978; Ross and Glaser, 1989) or the psychiatric scale of the Addiction Severity Index (ASI) (McLellan et al., 1980; McLellan et al., 1985~. Screening for this and the many other substantive areas one might wish to explore during the personal assessment is essential to ensure that the assessment process is parsimonious; that is, that only those dimensions of the individual that require an extensive assessment receive it. There should be variability in the procedures of the personal assessments of specific individuals because there will be variability in the personal areas in which they have problems. With the exception of certain individual attributes that are sufficiently relevant in all cases to merit routine assessment (e.g., personality), the highly specialized measures would only be utilized if screening indicated a reasonable probability that treatment-relevant information would be gained. To summarize, the committee views comprehensive assessment as a seque~ialprocess that proceeds from one stage to the revert if such a progressions is indicated. Three stages are proposed. The first is a screening stage, in which the presence or absence of a problem and the likelihood that specialized treatment may be required are determined; this stage is similar to the identification process in the community setting discussed in Chapter 9. The second stage comprises the problem assessment, that is, the characterization of the alcohol problem that screening has indicated is present. The third stage is the personal assessment stage, in which the nature of the individual who is experiencing the problem is fully and uniquely characterized; the emphasis in this stage is on areas in which personal problems are being experienced. The overall goal of the assessment is to produce sufficient information to make treatment-relevant decisions. Multidimensional Assessment In the previous section of this chapter, it was suggested that assessment be divided into stages. Each of these stages, however, ideally involves the eliciting of information along several important dimensions rather than along a single dimension. Alcohol problems are complex; the people who manifest them are complex; and these complexi
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252 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS ties defy simple characterization. mult~idimens~on~al. To illustrate the principle of multidimensional assessment, let us concentrate for the moment on the problem assessment. The task of problem assessment is to describe as fully (and yet as parsimoniously) as possible the problem or problems with alcohol that an individual may have. From the standpoint of multidimensionality, the relevant question is the following: how many different dimensions are required to provide a reasonable description of a given alcohol problem? There has been a tendency to rely on only a single dimension, a measure of the individual's use of alcohol, to characterize his or her alcohol problem. This measure can be taken, for example, by a tally of the average number of standard drinks the individual consumes per day. Certainly, this is important information, but such a measure of a person's level of use does not even fully characterize alcohol use. Of additional importance is the pattern of use. If an individual consumes four drinks per day on average, it will make a considerable difference (at least in the clinical picture) whether he consumes them in an hour or two or whether they are spaced out over the course of the entire day. With the former pattern, the individual is likely to become intoxicated; with the latter pattern, intoxication is unlikely. The pattern of alcohol use in turn can make a difference in the consequences the individual experiences. In a recent study (Kranzler et al., 1990) it was found that both an increased level of consumption and a pattern of consumption likely to result in intoxica- tion independently increased the risk of consequences. Interestingly, it was found that an increased level of consumption was more likely to contribute to consequences in males, while an intoxication pattern of consumption was more likely to contribute to consequences in females. The authors concluded that "these variables, though related, require independent consideration." Beyond the daily pattern of use, it is important to have information about the pattern of use over longer periods of time. Some persons do drink at the same level and in the same daily pattern over prolonged periods of time. Others, however, vary both their level and their daily pattern of use quite considerably. Binge drinking is a well-known long-term pattern of alcohol use. It is likely that such long-term patterns have important implications for consequences as well as prognosis; hence what can be termed a history of use is an important element in the characterization of an individual's use of alcohol. Such a history would include information as to the time in life the individual began to drink and the length and circumstances of periods of nonuse, as well as the pattern of use over the last few years prior to seeking treatment. Thus, an adequate assessment of an individual's use of alcohol would include information on the level of use, the pattern of use, and the history of use. It might be felt that such a comprehensive consideration of alcohol use might suffice to characterize an alcohol problem because there is a general and positive correlation between the use of alcohol, signs and symptoms, and consequences, a correlation that becomes most evident when aggregate data from large groups of individuals are explored and when the problems themselves are longstanding and severe. But treatment is a clinical process that deals with single individuals, one at a time; among individuals, wide variations may be found in the relationship between' use, signs and symptoms, and consequences. The vignettes at the beginning of Chapter 2 of this report include individuals (George, Gregory) with low levels of consumption and serious consequences, as well as one individual (Elizabeth) in whom a high level of consumption was associated for a long period of time with no apparent consequences at all. Disparities between the level of alcohol consumption and the effects of alcohol are also matters of common experience. Some individuals "can't hold their liquors and become thoroughly intoxicated on small amounts of alcohol which would not faze most social Thus, the assessment of alcohol problems should be
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268 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS desired qualities of quantifiability, reliability, validity, standardization, and recordability (see above). An example of a structured interview from the alcohol field is the time-line (TL) interview, which measures past lifetime alcohol consumption. Its reliability has been examined (L. C. Sobell et al., 1988) and it has been found that individuals given the instrument at different times will come up with consistent estimates of levels of alcohol consumption in past periods of their lives. Whether it is valid, however whether these estimates are correct-cannot be established because there is no adequate criterion, that is, a certain and alternative method of determining past consumption. Research on biological markers may one day provide the needed criterion. Meanwhile, a reliable means of determining retrospective consumption is to be preferred to one that lacks demonstrated reliability. The chief disadvantage of structured interviewing as a means of gathering assessment information has to do with personnel time and training. The constant attendance of extensively trained personnel is required to administer a structured interview. In a time of resource constraints on the one hand and increased demand for services on the other, this disadvantage can be considerable. Attention has accordingly been given to the self-administration of assessment. The savings from self-administration can be considerable, even if small amounts of information are concerned. The MAST takes approximately 10 minutes to administer; if 20 patients a day are assessed, the total saving is more than three hours of personnel time. A common form of self-administration is the use of paper-and- pencil tests. The use of such tests does involve personnel time but of another sort. More than a single test is usually given. Tests must be selected from storage; then each test must be presented to the individual with the appropriate instructions, proofed for completeness, scored, standardized, and recorded. Because different individuals are given different tests and work at different speeds, a one-on-one assessment staffing pattern may be required. In short, although there are resource advantages to self-administration, resource requirements are still apparent. Computers can be utilized effectively to limit further the resource requirements of assessment. An initial capital investment is needed, but the ultimate saving on resources through the reduced cost of each assessment performed thereafter more than compensates for the original expenditure (Klingler et al., 1977~. Although computers can be used in a rather peripheral manner to perform such tasks as the automated scoring of self-administered tests, they truly come into their own when they are used as self-administration devices. For staff, this use involves providing the individuals being assessed with adequate instructions, sitting them down in front of a computer and keyboard (often modified for the sake of simplicity), and being available to provide help and answer questions. The various instruments or interview schedules to be used for the assessment are held in the capacious and accurate memory banks of the computer. An appropriate program presents the instruments in predesignated order. Responses to individual items can be checked for appropriateness and completeness, ensuring that each response given falls within the designated range for each item and that all questions are completed. If the responses are faulty or incomplete, the computer can (given adroit programming) prompt the individual to make appropriate corrections. In a sequential assessment process, the computer can be programmed to indicate automatically whether it is necessary to proceed from one stage to the next, and to select the requisite instruments to provide in-depth assessment on the basis of scores from the screenings of the prior stage, which it has automatically calculated and compared with the standardized norms in its memory. In addition, the computer can be programmed to integrate multiple assessment results into
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ASSESSMENT 269 an understandable and comprehensive assessment report (see an example in H. ~ Skinner [1981a:359~. To some readers the prospect of computerized assessment will sound like magic at best and science fiction at worst. But to others it will be commonplace. Interactive computer games were the best-selling gift item during the 198$ holiday season. The use of computers not only has a high level of initial acceptance in assessment situations but an increasing level of enthusiasm following first exposure, as well as equivalent or superior results to paper-and pencil tests and face-to-face interviewing (H. ~ Skinner, 1981; H. ~ Skinner and Allen, 1983b; H. ~ Skinner et al., 1985a, 1985b). Computer technology has advanced rapidly since the introduction of microcomputers, with the result that equipment of great capability is now available at reasonable cost. Although most frequently criticized as impersonal, the computer can instead increase the interpersonal ambience of assessment. By performing many of the tasks that would ordinarily be required of the assessor it frees time for interpersonal interaction (cf. Levitt, 1972~. Nevertheless, even if assessment is largely automated it may be prudent to design an assessment that is a mixture of face-to-face interviewing, self-administered testing, and computerized testing. None of the methods is foolproof, and some may be precluded by the specialized disabilities or preferences of individual patients. Those carrying out the assessment might optimally be trained to administer the entire process in either of the three options. In that way staff would have a more complete understanding of the process, and maximum flexibility would be assured. . ~ , Conclusions and Recommendations This chapter has made the case that all individuals seeking specialized treatment for Alcohol problems should receive a comprehensive assessment prior to treatment. The assessment should be carried out in a sequential manner, proceeding in a logical and carefully articulated manner from one stage to the next as needed to produce sufficient information for relevant treatment decisions. The stages of assessment recommended by the committee i~zc~de a screening stage, a problem assessment stage, awl a personal assessment stage. Assessment should also be multidimensional; that is, it should include several different kinds of information within each stage of assessment content. For example, the committee recommends that the problem assessment stage include information on the individual's use of alcohol, on the signs arid symptoms of alcohol use, and on the consequences of alcohol use. In many instances each of these elements should also be multidimensional; for example, with respect to the use of alcohol, it is important to obtain information on the level of use. the pattern of use, and the history of use. .._ lo The nrnhlPm assessment stage is highly multidimensional (see Table 10-2~. Finally, assessment should be uniform to a significant degree for all persons seeking treatment, so that data from different subjects can be pooled and data from different programs can be compared. Information gathered during the ideal assessment should be of demonstrated reliability and validity; it should be quantitative and standardized; and it should be readily recordable. Appropriate techniques should be employed to ensure that self-reported assessment information is maximally accurate. Assessments should be administered by a carefully selected, specifically trained, and continuously supervised staff that is adept at using a variety of assessment methods. Due precautions should be taken to assure that assessment staff operated independently of any significant biases, including and especially those that can arise from the prospect of financial gain or from commitment to a specific form of treatment.
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270 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS The principal purpose of gathering assessment information Is to provide a basis for the selection of the most appropriate treatment for the individual being assessed. However, the information also serves a number of other purposes. It constitutes a baseline for subsequent outcome determinations; permits the characterization of treatment populations and facilitates their comparison with one another; and (if analyzed together with outcome data) can be used to guide the future treatment of others with similar problems. Implementation of a program of comprehensive assessment of this kind will require vigorous and polycentric leadership, adequate funding, and a stepw~se developmental process. The committee believes it is of the essence to foster a consensus within the treatment f eld both on the general notion of assessment and on all aspects of its content and administration. To this end, demonstration models of various kinds of comprehensive assessment should be set up and carefully studied; such a process would be helpful to those who are not fully persuaded of the need for comprehensive assessment. Those who have already been persuaded should provide information on all aspects of their experience to enrich and accelerate the development of a broad response. REFERENCES Allo, C. D., B. Mintzes, and R. C. Brook. 1988. What purchasers of treatment services want from evaluation. Alcohol Health and Research World 12:162-167. American Psychiatric Association (APA). 1987. DSM III-R: Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised. Washington, D.C.: American Psychiatric Association. Annis, H. M. 1979. Group treatment of incarcerated offenders with alcohol and drug problems: A controlled evaluation. Canadian Journal of Criminology 21:3-15. Annis, H. M. 1982. Inventory of Drinking Situations. Toronto: Addiction Research Foundation. Annis, H. M. 1986a. Is inpatient rehabilitation of the alcoholic cost effective? Con position. Advances in Alcohol and Substance Abuse 5:175-190. Annis, H. M. 1986b. A relapse prevention model for treatment of alcoholics. Pp. 407433 in Treating Addictive Behaviors, W. R. Miller and N. Heather, eds. New York: Plenum Press. Annis, H. M., and D. Chan. 1983. The differential treatment model: Empirical evidence from a personality typology of adult offenders. Criminal Justice and Behavior 10:159-173. Annis, H. M., and C. Davis. 1989. Relapse prevention. Pp. 170-182 in Handbook of Alcoholism Treatment Approaches: Effective Alternatives, R. K. Hester and W. R. Miller, eds. New York: Pergamon Press. Annis, H. M., J. M. Graham, and C. S. Davis. 1987. Inventory of Drinking Situations User's Guide. Toronto: Addiction Research Foundation. Annis, H. M., and H. A. Skinner. 1984. Early experiences with assessment. Pp. 107-145 in A System of Health Care Delivery, vol. 2, F. B. Glaser, H. M. Annis, H. A. Skinner, S. Pearlman, R. L. Segal, B. Sisson, A. C. Ogborne, E. Bohnen, P. Gazda, and T. Zimmerman. Toronto: The Addiction Research Foundation. Ashley, M. J. 1982. Alcohol, tobacco, and drugs: An audit of mortality and morbidity. Pp. 350-366 in Man, Drugs, and Society: Current Perspectives, L. R. H. Drew, P. Stolz, and W. A. Barclay, eds. Canberra: Australian Federation on Alcoholism and Drug Dependence. Babor, T. F., and R. Kadden. 1985. Screening for alcohol problems: Conceptual issues and practical considerations. Pp. 1-30 in Early Identification of Alcohol Abuse, N. C. Chang and H. M. Chao, eds. Washington, D.C.: U. S. Government Printing Office. Babor, T. F., E. B. Ritson, and R. J. Hodgson. 1986. Alcohol-related problems in the primary health care setting: A review of early intervention strategies. British Journal of Addiction 81:23-46.
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ASSESSMENT 273 Hayes, S. C., R. O. Nelson, and R. B. Jarrett. 1987. The treatment utility of assessment: A functional approach for evaluating assessment quality. American Psychologist 42:963-974. Helzer, J. E., and ~ Burnham. In press. Alcohol abuse and dependence. In Psychiatric Disorders in America, L. N. Robins and D. ~ Regier, eds. New York: The Free Press. Hlatky, M. As, K L. Lee, F. E. Harrel, Jr., R. M. Califf, D. B. Poor, D. B. Mark, and R. A. Rosati. 1984. Tying clinical research to patient care by use of an observational data base. Statistics in Medicine 3:375-384. Hodgson, R., T. Stockwell, H. RanWn, and G. Edwards. 1978. Alcohol dependence: The concept, its utility and measurement. British Journal of Addiction 73:339-342. Hoffmann, N. G., J. ~ Halikas, and D. Mee-Lee. 1987. The Cleveland Admission, Discharge, and Transfer Criteria: Model for Chemical Dependency Treatment Programs. Cleveland, Ohio: The Greater Cleveland Hospital Association. Holmes, T. H., and M. Masuda. 1973. Psychosomatic syndrome: When mothers-in-law or other disasters visit, a person can develop a bad, bad cold. Psychology Today 5(11):71-72, 106. Holmes, T. H., and R. H. Rahe. 1967. The Social Readjustment Rating Scale. Journal of Psychosomatic Research 11:213-218. Horn, J. L., H. A. Skinner, K Wanberg, and F. M. Foster. 1984. Alcohol Dependence Scale. Toronto: Addiction Research Foundation. Horn, J. L., K W. Wanberg, and F. M. Foster. 1987. Guide to the Alcohol Use Inventory (AUI). Minneapolis, Minn.: National Computer Systems, Incorporated. Institute for Personality and Ability Testing. 1986. 16PF Manual. Savoy, Ill.: Institute for Personality and Ability Testing. Jackson, D. N. 1974. Personality Research Form Manual. Goshen, N.Y.: Research Psychologists Press. Jackson, J. K 1988. Testimony presented before the U.S. Senate Governmental Affairs Committee hearing regarding the causes of and governmental responses to alcohol abuse and alcoholism, Washington, D.C., June 16. Jacob, T. 1988. Executive summary: Approaches to the assessment of family/marital functioning. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Kadden, R. M., N. L. Cooney, H. Getter, and M. D. Litt. 1990. Matching alcoholics to coping skills or interactional therapies: Posttreatment results. Journal of Consulting and Clinical Psychology 698-704. Keller, M. 1972. The oddities of alcoholics. Quarterly Journal of Studies on Alcohol 33:1147-1148. Kern, J. C., W. Schmelter, and M. Fanelli. 1978. A comparison of three alcoholism treatment populations: Implications for treatment. Journal of Studies on Alcohol 39:785-792. Kiernan, R. J., J. Mueller, J. W. Langston, and C. van Dyke. 1987. The Neurobehavioral Cognitive Status Examination: A br~ef but differentiated approach to cognitive assessment. Annals of Internal Medicine 107:481-485. Klingler, D. E., D. ~ Miller, J. H. Johnson, and T. A. Williams. 1977. Process evaluation of an on-line computer assisted unit for intake assessment of mental health patients. Behavioral Research Methods and Instrumentation 9:110-116. Korchin, S. J., and D. Schuldberg. 1981. The [uture of clinical assessment. American Psychologist 36:1147-1158. Korcok, M. 1988. Managed Care and Chemical Dependency: A Troubled Relationship. Providence, R.I.: Manisses Communications Group, Inc. Kozlowski, L. T., L. C. Jellinek, and M. ~ Pope. 1986. Cigarette smoking among alcohol abusers: A continuing and neglected problem. Canadian Journal of Public Health 77:205-207.
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274 BROADENING MIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Kranzler, H. R., T. F. Babor, and R. J. Lauerman. 1990. Problems associated with average alcohol consumption and frequency of intoxication in a medical population. Alcoholism Experimental and Clinical Research 14(1~:119- 126. Kristensen, H., H. Ohlin, M.-B. Hulten-Nosslin, E. Trell, and B. Hood. 1983. Identification and intervention of heavy drinking in middle-aged men: Results and follow-up of 24~0 months of long-term study with randomized controls. Alcoholism: Clinical and Experimental Research 7:203-209. Laszlo, J. 1985. Health registry and clinical data base technology: With special emphasis on cancer registries. Journal of Chronic Disease 38:67-78. Lettieri, D. J., M. ~ Sayers, and J. E. Nelson, eds. 1985a. Summaries of Alcoholism Treatment Assessment Research. Washington, D.C.: U.S. Government Printing Office. Lettieri, D. J., M. ~ Sayers, and J. E. Nelson, eds. 1985b. Alcoholism Treatment Assessment Research Instruments. Washington, D.C.: U.S. Government Printing Office. Levitt, T. 1972. Production-line approach to service. Harvard Business Review 50:41-52. Lewis, J. 1988. Growth in managed care forcing providers to adjust. Alcoholism Report 16(24):1. Lucas, R. W., W. I. Card, R. P. Knill-Jones, G. Watkinson, and G. P. Crean. 1976. Computer interrogation of patients. British Medical Journal 2:623-625. Lucas, R. W., P. J. Mullin, C. B. X. Luna, and D. C. McInroy. 1977. Psychiatrists and a computer as interrogators of patients with alcohol-related illness: A comparison. British Journal of Psychiatry 131:160-167. Maletzky, B. M., and J. Klotter. 1974. Smoking and alcoholism. American Journal of Psychiatry 131:445-447. Malta, ~ K, B. Rush, M. Gavin, and G. Cooper. 1985. A community-centred alcoholism assessment/treatment service: A descriptive study. Canadian Journal of Psychiatry 30:35-43. Marlatt, G. A, and J. R. Gordon, eds. 1985. Relapse Prevention. New York: Guilford Press. Marshman, J., R. D. Fraser, C. Lambert, A. C. Ogborne, S. J. Saunders, P. W. Humphries, D. W. Macdonald, J. G. Rankin, and W. Schmidt. 1978. The Treatment of Alcoholics: An Ontario Perspective. Toronto: Addiction Research Foundation. McLachlan, J. F. C. 1972. Benefit from group therapy as a function of patient-therapist match on conceptual level. Psychotherapy: Theory, Research, and Practice 9:317-323. McLachlan, J. F. C. 1974. Therapy strategies, personality orientation, and recovery from alcoholism. Canadian Psychiatric Association Journal 19:25-30. McLellan, ~ T., L. Luborsky, G. E. Woody, and C. P. O'Brien. 1980. An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nenrous and Mental Diseases 168:26-33. McLellan, A. T., L. Luborsky, J. Cacciola, J. Griffith, P. McGahan, and C. P. O'Brien. 1985. Guide to the Addiction Severity Index. Washington, D.C.: U. S. Government Printing Office. Mendelson, J. H., T. F. Babor, N. K Mello, and H. Pratt. 1986. Alcoholism and prevalence of medical and psychiatric disorders. Journal of Studies on Alcohol 47:361-366. Miller, S., E. Helmick, L. Berg, P. Nutting, and G. Shorr. 1974. Alcoholism: A statewide program evaluation. American Journal of Psychiatry 131:210-214. Miller, W. R., and R. K Hester. 1986. Inpatient alcoholism treatment: Who benefits? American Psychologist 41:794-805. Minnesota Chemical Dependency Program Division. 1989. Report on the Status of the Consolidated Chemical Dependency Treatment Fund. Saint Paul: Minnesota l:)epartment of Human Services.
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276 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Ross, H. E., and F. B. Glaser. 1989. Psychiatric screening of alcohol and drug patients: The validity of the GHQ-60. American Journal of Drug and Alcohol Abuse. 15:429-442. Ross, H. E., F. B. Glaser, and T. Germanson. 1988. The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Archives of General Psychiatry 45:1023-1031. Rounsaville, B. J., Z. S. Dolinsky, T. F. Babor, and R. E. Meyer. 1987. Psychopathology as a predictor of treatment outcome in alcoholics. Archives of General Psychiatry 44:505-513. Rush, B. 1987. Executive summary: Assessment procedures and specialized assessment in Ontario. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Sadava, S. 1985. Problem behavior theory and consumption and consequences of alcohol use. Journal of Studies on Alcohol 46:392-397. Saunders, J. B. 1988. Executive summary: Screening techniques for alcohol and drug problems. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Saunders, J. B., and O. G. Aasland. 1987. World Health Organization Collaborative Project on Identification and Treatment of Persons with Harmful Alcohol Consumption: Report on Phase I Development of a Screening Instrument. Geneva: World Health Organization, Division of Mental Health. Savitz, L. D., K File, and T. W. McCahill. 1973. Referral decision-making in a multi-modality system. Pp. 158-168 in Proceedings of the Fifth National Conference on Methadone Treatment. New York: NAPAN. Saxe, L., D. Dougherty, K Esty, and M. Fine. 1983. The Effectiveness and Costs of Alcoholism Treatment. Washington, D.C.: U. S. Congress, Office of Technology Assessment. Schuckit, M. A. 1973. Alcoholism and sociopathy-diagnostic confusion. Quarterly Journal of Studies on Alcohol 34:157-164. Schuckit, M. A., and M. Irwin. 1988. Diagnosis of alcoholism. Medical Clinics of North America 72:1133-1153. Searles, J. S. 1988. The role of genetics in the pathogenesis of alcoholism. Journal of Abnormal Psychology 97:153-167. Segal, R. L. 1984. The administration of the Assessment Unit. Pp. 198-214 in A System of Health Care Delivery, vol. 2, F. B. Glaser, H. M. Annis, H. A. Skinner, S. Pearlman, R. L. Segal, B. Sisson, A. C. Ogborne, E. Bohnen, P. Gazda, and T. Zimmerman. Toronto: Addiction Research Foundation. Seizer, M. L. 1971. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry 127:1653-1658. Skinner, H. A. 1979. A multivariate evaluation of the MAST. Journal of Studies on Alcohol 40:831-834. Skinner, H. A. 1981a. Assessment of alcohol problems: Basic principles, critical issues, and future trends. Pp. 316-369 in Research Advances in Alcohol and Drug Problems, vol. 6., Y. Israel, F. B. Glaser, H. Kalant, R. E. Popham, W. Schmidt, and R. G. Smart, eds. New York: Plenum Press. Skinner, H. A. 1981b. Benefits of sequential assessment. Social Work Research and Abstracts 17:21-28. Skinner, H. A. 1981c. Comparison of clients assigned to in-patient and out-patient treatment for alcoholism and drug addiction. British Journal of Psychiatry 138:312-320. Skinner, H. A. 1984. Instruments for assessing alcohol and drug problems. Bulletin of the Society of Psychologists in Addictive Behaviors 3:21-33. Skinner, H. A. 1985. The clinical spectrum of alcoholism: Implications for new drug therapies. Pp. 123-135 in Research Advanees in New Psychopharmacological Treatments for Aleoholism, C. A. Naranjo and E. M. Sellers, eds. Amsterdam: Elsevier. Skinner, H. A. 1988. Exeeutive summary: Toward a multiaxial framework for the elassifieation of alcohol problems. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Aleoholism and Alcohol Abuse.
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