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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
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,
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
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
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
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
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~.
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.
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
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
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
ASSESSMENT 253 drinkers. Other individuals drink constantly throughout the day, consuming remarkable quantities of alcohol but without exhibiting the least sign of intoxication (so-called "hollow gsn). That these phenomena are not mere folklore is well substantiated by research that, for example, documents that similar doses of alcohol differ widely in their effects on different individuals, or that even trained observers are unable to identify individuals with elevated blood alcohol levels in from more than a fifth to more than a half of all cases without the aid of such instruments as breathalyzers (Hartocollis, 1962; M. B. Sobell et al., 1979~. A study in adolescents found that use-related problems and intensity of drinking were to some degree correlated in the study population but that they were not sufficiently correlated to constitute a single dimension. Rather, they were most accurately viewed as separate dimensions (White, 1987~. There have been similar findings in adults (Sadava, 1985~. Indeed, a RAND Corporation study found that consequences from drinking were only weakly related either to the amount of alcohol consumed or to the symptomatology of alcohol use (Polich et al., 1981~. All three dimensions appear to contribute useful and independent information to the overall characterization of an alcohol problem. Taken together, they may be seen as illuminating the important question of the severity of the alcohol problem or problems experienced by a given individual. Therefore in assessing alcohol problems, the committee recommends that information be sought along three specific dimensions: (1) the use of alcohol; (2) the signs and symptoms of alcohol use; and (3) the consequences of alcohol use. This multidimensional classification is outlined in Table 10-1. One of the principal advantages of a multidimensional classification system of this type is that, by providing a more fine-grained, specific characterization of individuals with alcohol problems, it facilitates communication among workers in the field. To know where an individual stands on any one of these three proposed dimensions provides significant information. To know where an individual stands on all three provides a significantly greater degree of information. A more detailed example of a multidimensional classification system has been given elsewhere (H. ~ Skinner, 1985, 1988~. If all patients entering treatment were characterized according to a common multidimensional basis, enormous advantages would be realized. For example, the equivalence (or lack thereof) of patients in different treatment programs could readily be established. If the treatment provided then proved to be effective, it would be much more securely known for whom the treatment was effective. Should a program for whatever reason tend to deal exclusively with individuals manifesting only the most severe kinds of alcohol problems, its treatment outcomes would necessarily be viewed differently from those of a program that dealt largely with individuals manifesting problems that were not severe. An analogous multidimensional classification system has been in place in another field for some time. The tumor-node-metastasis (TNM) system, which was first proposed by P. F. Denoix in 1944, subsequently refined and accepted by the Union Internationale Centre de la Cancer (UICC), and widely implemented from about 1968 on, has been of great utility in dealing with cancer (Harmer, 1977), particularly in evaluating prognosis, planning therapy, and reporting results. It considers three significant events in the life history of a cancer: (1) tumor growth (T), (2) spread to primary lymph nodes (N), and (3) distant metastases (M). Cancers occurring in various regions of the body can be classified according to this system, and the effectiveness of differing modalities of treatment (e.g., surgery, radiation, chemotherapy) can be examined using the classification. Such examinations are predicated on the notion that the effects of treatment will vary depending on the classification of the cancer in the TNM system. Because of the widespread use of the TNM system, treatment results from multiple tumor registries can be aggregated to provide a vast body of information on which to base
254 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Table 10-1 Multidimensional Classification of Alcohol Problems Dimension Type of Information II III Use of alcohol Signs and symptoms of alcohol use Consequences of alcohol use judgments regarding optimal intervention. The National Cancer Institute offers a Physician Data Query (PDQ) system in which the TNM classification scheme is used to provide physicians with information on prognosis and with treatment protocols for different cancer sites and stages. The TNM system illustrates how a relatively simple but widely utilized multiaxial assessment scheme can greatly facilitate progress in research and treatment. The potential advantages of developing and using a similar scheme in the treatment of alcohol problems are substantial. Potentially, the enormous fund of clinical experience built up from the multitudes of cases seen every year can be directly brought to bear in a systematic manner upon the disposition of future cases (c£ the earlier discussion of clinical data bases). To some it will come as a surprise that the characterization of the alcohol problems of individuals seeking treatment is not regularly carried out along multiple dimensions. As has already been indicated, however, assessment itself is not commonly carried out in treatment programs. Even in research studies, which explicitly aim at widespread generalizability, characterization of the alcohol problem is often incomplete. For example, the much-publicized collaborative studies by Swedish and American investigators that have examined the contribution of genetic factors to alcohol problems (Bohman et al., 1981; Cloninger et al., 1981) have been criticized on these grounds: "[T]he data reflect only obvious and reportable instances of the consequences of insobriety. There are no measures of the quantity or frequency of drinking or of the social and personal consequences of private or unreported drunkenness . . . [I]t is quite likely that the obtained results are an artifact of the criteria of abuse" (Searles, 1988:159-160~. Further, in a review of 48 alcohol treatment outcome studies published in the period 1980-1984, it was found that reporting on all three dimensions was deficient: only 56.3 percent quantified pretreatment drinking levels; none reported whether the symptom of physical dependence was present or absent; only 18.8 percent reported on alcohol-related arrests; and only 33.3 percent reported on whether or not there had been prior treatment for alcohol problems (M. B. Sobell et al., 1987~. Although the need for a multidimensional approach has been discussed here largely in terms of the characterization of alcohol problems, multidimensionality is a broad structural principle that ideally should be applied to all stages of assessment. For example, a screening instrument such as the AUDIT, although brief, contains questions that cover all three of the axes suggested above for the problem assessment (Saunders and Aasland, 1987; Babor et al., 1989~. In like manner the personal stage of assessment requires that multiple aspects of the individual with the alcohol problem be assessed. Agreement on and consequent uniform adoption of a standard multidimensional problem assessment and personal assessment seem essential to progress in clinical services and in research. To review briefly, more than a single kind of information is required for adequate assessment at each stage of the assessment process. The dimensions along which problem assessments, for example, should proceed include aspects of the individual's use of alcohol,
ASSESSMENT 255 the signs and symptoms of alcohol use, and the consequences alcohol use. This is the principle of multidimensional assessment. The Content of Comprehensive Assessment An assessment process is comprehensive if it is designed to cover all stages and all dimensions as required. (Depending on the problem and the individual, the full assessment process may not be required.) In what follows the possible content of a comprehensive assessment for alcohol problems is described. The description is intended to be illustrative rather than definitive. Content of Screening Screening is by design a brief process (Saunders, 1988~. As noted earlier, it must answer two questions: (1) whether an alcohol problem is present and (2) if so, whether it is likely to require brief intervention or specialized treatment. Examples of instruments that accomplish these purposes are the Alcohol Clinical Index (ACI) (H. ~ Skinner et al., 1986; H. ~ Skinner and Holt, 1987), the CAGE questionnaire (Ewing, 1984), and the AUDIT (Saunders and Aasland, 1987; Babor et al., 1989~. Many alternative screening methods are available (Babor and Kadden, 1985; Babor et al., 1986~. The reader is referred to Chapter 9 for a more extensive discussion of screening and brief intervention. Content of the Problem Assessment In the problem assessment stage, content must address the three dimensions of the multidimensional characterization of alcohol problems. With respect to specifying the prospective client's use of alcohol, care must be taken to look broadly at a variety of aspects, including especially the level of use, the pattern of use, and the history of use. Various techniques have been developed for taking a drinking history. These techniques may be divided into three broad classes: (1) retrospective methods that gather information about drinking over a specified time interval in the past, using a self-report questionnaire or a structured interview; (2) prospective methods in which the individual is asked to monitor alcohol use and record it in a daily diary; and (3) laboratory determinations such as various tests performed on body fluids (blood, urine, saliva, sweat) and breath tests. Extensive reviews of these methods have been published (Babor et al., 1987; O'Farrell and Maisto, 1987; L. C. Sobell et al., 1987~; they will be discussed further below. Multiple methods are also available to survey the signs and symptoms of alcohol use. Signs and symptoms form the basis of both the 10th edition of the diagnostic manual of the International Classification of Diseases (ICD-10) and DSM-III-R. Methods of making diagnoses within the contexts of these systems, such as the DIS (Robins et al., 1981) or its computerized version (Blouin, 1986), may be useful. A number of self-report questionnaires have also been developed (Edwards, 1986; Davidson, 1987) that systematically review symptoms of alcohol use. The Severity of Alcohol Dependence Questionnaire (SADQ) (Hodgson et al., 1978; Stockwell et al., 1983) has been extensively used outside of North America, and a considerable amount of data on its measurement properties has been generated. The Alcohol Dependence Scale (ADS) has been widely used in North America (H. ~ Skinner and Allen, 1982; Horn et al., 1984~. Many treatment outcome studies and almost all epidemiological studies have included alternative scales of this kind.
256 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS With respect to the third axis, consequences of alcohol use, options abound in this arena as well. The Michigan Alcoholism Screening Test (MASK) (Seizer, 1971; Skinner, 1979), the Alcohol Use Inventory (AUI) (Wanberg et al., 1977; Skinner and Allen, 1983a; Horn et al., 1987) and the Addiction Severity Index (ASI) (McLellan et al., 1980; 1985) are largely concerned with the assessment of this axis. The ASI produces information in the areas of drug abuse, medical problems, psychiatric problems, legal problems, family and social problems, and employment and support problems. Beyond this, there are multiple direct ways of assessing all of these dimensions (e.g., routine medical and psychiatric examinations), as well as scores of psychometric instruments (cf. Lettieri et al., 1985b). Content of Personal Assessment Both the screening and problem assessment stages of the comprehensive assessment process may lead to the determination that a problem is present, that it requires a specialized intervention, and that it is of a particular kind. What remains to be specified in order to select the optimum treatment approach is the individual who presents the problem. Some of this information is needed to permit description of the individual and, through the aggregation of individual data, description of the program population. Additional information may be needed to gauge the prognosis, to assist in matching individuals to appropriate treatment, to determine whether prevalent comorbidities are present, to help plan living and working circumstances, to understand certain etiologic possibilities, and for other purposes. There may be some overlap between information gathered as part of the personal assessment and information gathered as part of the problem assessment when the consequences of alcohol use are being considered. For example, alcohol problems are often manifested in the vocational area. On the other hand, a person with alcohol problems may quite independently have vocational problems, which it may be important from a therapeutic perspective to know about. Fundamentally, the problem assessment looks at those problems that are reasonably attributable to alcohol consumption, while the personal assessmera looks a' those problems the individual has whether or not they are attributable to alcohol consumption. Whatever area of overlap exists is tolerable and ensures that all existing problems will come to light. Contingent dinero s in personal assessment As has been noted, personal assessment is a particularly complex area. Multiple dimensions that are descriptive of various aspects of the individual might be relevant. Unfortunately, the assessment of any one of these dimensions is often complex and time-consuming. Therefore (in keeping with the principle of sequential assessment), screening should be an important part of the personal assessment process. The purpose of such a screening is to identify which of the many potential dimensions of personal assessment require a more thorough investigation. For example, are there family problems, marital problems, vocational problems, sexual problems, personal problems (problems with assertiveness, with social skills, with particular situations), medical problems, or psychiatric problems? If screening indicates the presence of these problems, a more intensive assessment can be undertaken; if the problems are absent or minimal, no further evaluation may be necessary (and there is a considerable saving of time and effort over the routine administration of intensive assessment in all of these areas). An example was given earlier of screening for psychiatric problems with the GHQ or the ASI and administering the full DIS only when screening is positive. Noncor~tingent dimensions in personal assessment With regard to other dimensions of personal assessment, detailed examination should not be contingent on screening. For example, the collection of demographic information is important both to identify the
ASSESSMENT 257 individual and to help understand prognosis; age, marital status, and social class are exam- ples of such data. Demographics are also among the principal descriptors of populations; hence, there is a particular need for completeness and uniformity in their compilation. Yet experience suggests that the collection of demographic data is not as simple a matter as it may seem. Many programs collect age by category, and the categories may not be consistent from one program to another (e.g. persons aged 35-45 vs. persons aged 30-40~. Where there is an option to designate that a person is unmarried but living with someone in a stable relationship, this information will be recorded; if the option does not exist, however, the person will probably be designated as single. If data categories vary from program to program, data cannot be aggregated among different programs, nor can different programs be compared. The use of tobacco arid other drugs by persons seeking help for alcohol problems is another area of personal assessment that should be surveyed as a matter of routine rather than on the basis of contingent screening. Available data suggest that the correlations between use of alcohol and use of tobacco and other drugs are regularly impressive. With regard to tobacco, one study found that 80 percent of patients in an addiction treatment setting were daily cigarette smokers (Kozlowski et al., 1986~; another study of the same population by different means found that 78.3 percent of patients presenting for new episodes of service qualified for the DSM-III diagnosis of tobacco use disorder (Ross et al., 1988~. An earlier inpatient study on an alcohol and drug unit found a correlation of 0.74 between amount of alcohol drunk and number of cigarettes smoked for males and females diagnosed as "alcoholicsn; the correlation did not hold for individuals not so diagnosed (Maletzky and Klotter, 1974~. In an ambulatory medical care setting, 85.1 percent of new patients who answered five or more of the MAST questions affirmatively were smokers, whereas only 47 percent below this cutoff point were smokers (Cyr and Wartman, 1988~. In the large Epidemiologic Catchment Area survey, in which approximately 3,000 persons were diagnostically interviewed in each of five sites, almost one in every five persons (18 percent) who met criteria for alcohol problems also met diagnostic criteria for some type of drug problem (Helzer and Burnham, in press). In aggregate data from three of the five sites, the proportion was much higher (28 percent) among young men (Robins et al., 1984~. A study of all persons seeking help from a large alcohol and drug treatment center in Toronto found that exactly the same proportion as in the ECA study (18 percent) of individuals qualified for diagnoses of both alcohol and drug dependence (Ross et al., 1988~. A study of a large number of adult women admitted to inpatient treatment for alcohol and drug problems in the United States (N = 1,776) found that, although 61.1 percent of women over the age of 30 reported using only alcohol, the corresponding proportion for women under 30 was 31.2 percent (Harrison and Belille, 1987~. Thus, there is a great deal of evidence that persons with alcohol problems are highly likely to have problems with tobacco use arid quite like, to have problems with drug use. It also appears, from the data cited here and from the observations of clinicians in the field, that the concurrent use of alcohol and drugs is a more prevalent phenomenon among younger persons entering treatment. These findings suggest that the use of tobacco and of other drugs should be assessed routinely in those seeking treatment for alcohol problems. The personal stage of assessment should also examine data that are relevant to matching. For example, knowing what goad are seen as important by each individual entering treatment can be quite useful in the matching process. In one program that made consistent attempts to match, a treatment goals inventory was extensively utilized (Glaser and Skinner, 1984:76-77, see page 291~. Demographics are another dimension that have utility for matching purposes; information collected by AA, for example, suggests that it is a less attractive option for the young and for women (Ogborne and Glaser, 1981; J. K Jackson, 1988; but see Emrick, 1987~. Matching individuals to appropriate treatments is discussed in some detail in Chapter 11.
258 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Personality may be another area that should be routinely assessed. The intent is not to search for evidence of an "addictive personality" (i.e., the one personality pattern that characterizes persons with alcohol problems) because this population is heterogeneous in its personality characteristics (Syme, 1957; Mogar et al., 1970; Partington, 1970; H. A. Skinner et al., 1974; Stein et al., 1977; Barnes, 1979; Cloninger, 1987~. Rather, in keeping with the assessment goal of obtaining treatment-relevant information, the intent is to identify personality factors or patterns that may affect in a significant way which treatment programs individuals are likely to find suitable and which they are likely to reject. Certain pathological personality types, especially antisocial personality but also borderline personality, have been found to have prognostic value in this regard (Schuckit, 1973; Vaillant, 1983; Nace et al., 1986; Cloninger, 1987~. Normative factors or traits of personality may also have value in predicting appropriate matches and outcome (see the discussion earlier in this chapter and also Beutler [1979~. It is difficult to assess personality efficiently as a general construct, simply because the scope of the concept is extremely broad. However, potentially suitable structured instruments of reasonable length are available-for example, the Personality Research Form (PRF) (Jackson, 1974), and the Sixteen Personality Factors Inventory (16PF) (Institute for Personality and Ability Testing, 1986~. Intelligence has some influence both on matching and on outcome (Gibbs, 1980~. Fortunately, there is a high correlation between intelligence and some measures that can be efficiently administered, such as vocabulary tests. Full-scale intelligence testing with such standard instruments as the Wechsler Adult Intelligence Scales (WAIS) (Wechsler, 1981) is quite exacting, however, and if used at all should be used sparingly. CogrtitivefunctioJtiP-g is a related and important area to be assessed, because many kinds of treatment require the ability to process information at a high level of abstraction. Some persons with alcohol problems prove to be cognitively impaired (Wilkinson and Carlen, 1981; Wilkinson, 1987), and this information should enter into the process of treatment selection (Wilkinson and Sanchez-Craig, 1981~. The precise evaluation of cognitive functioning is complex and time-consuming, but it is possible to screen briefly for cognitive deficit before embarking on a full-scale evaluation (Barrett and Gleser, 1987; Kiernan et al., 1987; Wilkinson, 1988~. Some aspects of the assessment of the individual may be partly contingent and partly noncontingent. The area of the family is an example. Family circumstances may be an important determinant of alcohol problems and, even in instances in which they do not figure in the etiology of alcohol problems, they may nevertheless affect the outcome of treatment (Cronkhite and Moos, 1978, 1980; Moos et al., 1979~. Family history is also important. A significant minority of individuals with serious alcohol problems come from families in which a parent has a similar problem (Cotton, 1979~. In some samples potentially treatment-relevant differences have been found between individuals whose families do and do not have a history of alcohol problems (Penick et al., 1987~. Recent work in the genetics of alcohol problems (Cloninger, 1987) has enhanced interest in familial factors. Consequently, data on the family are relevant to the assessment of individuals with alcohol problems. It seems reasonable to recommend that a family history of alcohol problems be taken on all persons entering treatment. A full-scale family assessment process, on the other hand, is sufficiently complex (Jacob, 1988) that it should probably be contingent on the results of screening. Although it is often confidently asserted that, in cases in which a member of a family has an alcohol problem, the family itself has a problem, the assertion lacks strong empirical support. That drinking, and perhaps especially episodes of heavy drinking, may be related to specific life events (deaths, births, marriages, job losses, new jobs, etc.) is a matter of
ASSESSMENT TABLE 10-2 Comprehensive Assessment of Persons Seeking Treatment for Alcohol Problems . Stage of Dimension Assessment Dimension Label 259 Content of the Sample Methods and Dimension Instruments . Screening I Problem Is an alcohol Alcohol Clinical Index identification problem present? CAGE AUDIT Others II Indicated Is specialist Alcohol Clinical Index response treatment required? Others Problem I Use of alcohol Level of use Quantity-frequencyindices Assessment Pattern of use Time-line follow- back History of use Lifetime drinking history Other factors Diaries Laboratory tests (body fluids; markers) II Signs and Narrowing of SADQ symptoms of drinking repertoire ADS alcohol use Tolerance Relevant sections of the Withdrawal ICD-10 and DSM-III-R symptoms Others Neglect of alternative activities Subjective sense of impaired control Continuation despite consequences Relief drinking Reinstatement liability Sense of compulsion to drink Other signs and symptoms III Consequences Medical of alcohol use Psychiatric Family Employment/ educational Legal (incl. DWI) Financial Other consequences Personal I Screening for Key questions on Assessment contingent problem areas content MAST ASI AUI Others TABLE 10-2 continues
260 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Table 10-2 (continued) Stage of Dimension Assessment Dimension Label Content of the Sample Methods and Dimension Instruments II Contingent Medical status Multiphasic screening, content Psychiatric status medical consultation Vocational issues DIS; psychiatric Personal problems consultation Sexual problems Vocational assessment Social support Specific instruments Family structure (social skills inventories, Use of leisure time assertiveness scales, etc.) Others Others III Noncontingent Demographics Appropriate forms content Other drug and Vocabulary screen; WAIS tobacco use history Cognitive status Family history Examination; the Reitan Prior treatment battery history PRF, 16PF, or Intelligence other Appropriate Cognitive functioning inventories Personality Appropriate scale Treatment goals IDS Social stability Others Situational factors Others common knowledge. Yet individuals may not report these events unless they are specifically questioned about them. Moreover, it may be the combined weight of such events, whether positive or negative, rather than a specific event that acts as the trigger to particular coping behaviors, including the consumption of alcohol (Holmes and Rahe, 1967; Paykel et al., 1971; Holmes and Masuda, 1973~. A systematic attempt to assess the number and kinds of life events may therefore be useful, and a number of instruments have been developed for this purpose. Related to but different from life events are situationalfactors. These tend to be more complex constellations of individuals, feelings, and circumstances than are life events, but may also be closely related to individual variations in alcohol consumption. Recent studies (Marlatt and Gordon, 1985; Annis, 1986b; Annis and Davis, 1989) have provided both a theoretical and an empirical basis for understanding and dealing with situational factors, including the development of specific assessment devices. The ubiquity of situation- al stress suggests that careful consideration should be given to the inclusion of such instruments as the Inventory of Drinking Situations (IDS) (Annie, 1982; Annis, Graham, and Davis, 1987) as a noncontingent element of personal assessment. The preceding review of the potential content of assessment, which is intended to be more heuristic than exhaustive, nevertheless suggests an embarrassment of riches: many instruments are available to assess the relevant dimensions. The development of reliable and valid new instruments should in no way be discouraged, as the development of assessment must be an evolving process. But a pressing need already exists for shaping what is tow available into a reasonable and practical assessment procedure. To facilitate this development, an outline of the assessment discussed above may be helpful (Table 10-2~.
ASSESSMENT 261 The translation of such an outline into concrete reality-a fully specified comprehensive assessment battery in use across the universe of treatment programs has both scientific and political aspects. The publication of two monographs on assessment research (Lettieri et al., 1985a, 1985b) which summarize much of the literature to date and provide examples of instruments is a step in the right direction, and every effort should be made to secure the widespread distribution and serial updating of these useful compendia. A caution should be mentioned, however, that the standard means of conveying information (publication in journals and presentation at scientific conferences) will not suffice to bring about the development of comprehensive assessment batteries. Advantage should be taken in this effort of all that is known regarding the dissemination of innovations (cf. Backer et al., 1986~. Leadership of a high order will also be required to produce the desired result of Widely c,~h.~orih~1 consensus conferences devoted to the issue are a possible mechanism. The example of large and prestigious programs and of leaders in the field undoubtedly would have a positive influence. Ultimately, the financing of treatment could be made contingent upon the appropriate classification of individuals who are accepted for treatment; a reasonable aspect of accountability is to require a detailed documentation that a type of problem requiring treatment is being dealt with. The present practice of utilization management operations is directed in part toward this end. Surely it would be advisable for the alcohol treatment field itself to assume responsibility for such accountability. comprehensive and at least nartlv uniform assessment across all programs. Desirable Qualities of Assessment Content To be as useful as possible, the information gathered on individuals seeking treatment for alcohol problems should possess certain qualities. These qualities markedly enhance the value of assessment information and also facilitate the aggregation of individual information so that group information can be generated. Most of the data currently gathered on people seeking treatment have never been systematically evaluated to determine whether they possesses these qualities. Published research studies are deficient in this regard to a surprising degree, often making use, for example, of instruments for which reliability and validity have not been established or for which no standardized norms exist. Ideally, information gathered during an assessment will be quantitative, reliable, valid, standardized, and recordable. Numerical data are precise, easy to record, and amenable to statistical use. That information be reliable (reproducible) and that it measure what it purports to measure (valid) are obvious requirements, but they demand much in the way of effort to establish and certainly cannot be assumed. Information is much more useful if it can be compared to a previously established baseline (standardized); by itself, its meaningfulness may be unclear. In an era in which population mobility is so great, the importance of recordable data is considerable; the likelihood that multiple therapeutic personnel will encounter any given individual seeking treatment is much greater than ever before. The Administration of Assessment Obtaining Valid Assessment Data: Problems in Providing Information Validity, as discussed above, is a desirable property of information. Most of the information obtained during the assessment of an individual seeking assistance for an
262 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS alcohol problem comes from the individual himself. Although self-reports are a standard procedure in all human therapeutics, they take on a special coloring in the alcohol field. The use of alcohol may negatively affect the validity of self-reported information, especially regarding alcohol consumption. Contemporary research provides some reason for concern about this issue. Persons with elevated blood alcohol levels tend characteristically to underreport their alcohol consumption (M. B. Sobell et al., 1979~. Significant discrepancies have been noted in some recent studies between self-reports of alcohol consumption and alternative lines of evidence, such as laboratory tests or information obtained from collateral informants (spouses, relatives, and close friends) (Orrego et al., 1979; Watson et al., 1984; Peachey and Kapur, 1986; Fuller et al., 1988~. These findings have given additional impetus to ef- forts to find alternative or supplementary methods to self-reports for determining an individual's alcohol consumption. Methods of obtaining data on alcohol consumption were reviewed in Chapter 9 in relation to their potential use in screening. To recapitulate briefly, there is general agreement that in many circumstances screening questionnaires are significantly more accurate than physical examination findings and currently available laboratory measures (including body fluid examinations and biological markers). Questionnaires also have numerous practical advantages. On the other hand, the validity of the self-reports involved in questionnaire methods remains a matter of concern, and there is some indication that more recently proposed biological markers may possess significant advantages over those that are currently available. There are particular aspects of assessment that favor the use of laboratory methods in conjunction with other methods. One is the need for a validity check on the assessment process itself. Assessment is lengthy and complex, and its validity might be adversely affected by a high blood level of alcohol. For example, the validity of tests of cognitive functions could be confounded by alcohol intoxication. The use of a breathalyzer test as a preliminary to assessment, in recognition of the fact that high blood alcohol levels are not clinically apparent in a significant proportion of cases (M. B. Sobell et al., 1979), may be advisable. Because tolerance, physiological parameters (e.g., lean body mass), pharmaco- dynamic parameters (e.g., whether the blood alcohol curve is rising or falling) and other factors make the exact equation of a particular blood alcohol level with actual impairment in a particular individual quite difficult, an arbitrary level-often the legal limit for impaired driving in the jurisdiction of the assessment program-is generally used. Those achieving a level above the legal limit are not assessed but given a return appointment. If, as a matter of usual practice, persons given an assessment appointment are cautioned that they will be tested and that elevated blood alcohol levels will require a postponement, few individuals will need to be turned down. Breathalyzers are well suited for this role, as they are generally quite accurate and easy to use, do not require body fluid collection, are inexpensive to operate (although an initial investment is required), and provide immediate results. A second consideration is that, although their generally low sensitivity makes biological markers less useful than questionnaires for screening, they may be very useful for monitoring (Kristensen et al., 1983; Schuckit and Irwin, 1988~. Thus, establishing a baseline level for one or more markers may be a reasonable assessment procedure, although it should be entertained primarily if there is a specific intent to repeat the measure subsequently. Under these circumstances the time delay involved in a laboratory determination is not a significant problem, and the expense of the test may be quite justi- fiable. A sensitive, specific, responsive marker would be a most welcome supplement in assessing individuals with alcohol problems. Some of the newly proposed markers
ASSESSMENT 263 (desialated transferrin, hemoglobin adducts, etc.) are promising, and work continues. At present, however, there is no viable alternative to reliance on verbal self-report for the assessment of alcohol consumption in clinical settings. Fortunately, current research has shed some light on how the validity of self-reports may be enhanced. Such research (H. ~ Skinner, 1984; Babor et al., 1987; O'Farrell and Maisto, 1987; L. C. Sobell et al., 1987) suggests that the concern over whether verbal reports are either valid or invalid has been somewhat misleading. Verbal reports are inherer~t, neither valid nor invalid; rather, their validity varies, depending on circumstances. Table 10-3 contrasts those circumstances in which valid and invalid self-reports are likely to be forthcoming. Attention to the matter of accuracy is clearly of the greatest importance. Not only is an inaccurate assessment not worth doing but, insofar as treatment planning may be based on it, it is potentially harmful. A considerable amount of effort must be expended to ensure that assessment information is accurate and remains so over time. In many clinical settings minimal effort is currently expended toward this end, either because the information the patient gives is presumed to be completely accurate or because the opposite presumption is made. Neither of these presumptions is correct. Programs must come to see themselves as active collaborators with individuals seeking their services to produce the most accurate information possible. Obtaining Valid Assessment Data: Problems in Gathering Information Problems with the validity of assessment information can arise not only from those who provide the information but also from those who gather it. Two kinds of factors that operate on assessors, ideological factors and financial factors, have been identified as posing particular threats to the validity of assessment data. They arise from the circumstance, common because it is practically convenient, in which assessment data are obtained by therapists who also provide treatment in a given treatment program. Those who provide treatment often are, and perhaps ideally ought to be, enthusiastic about the services they provide. It is likely that their enthusiasm will both sustain them in the arduous task of providing treatment and will contribute to positive treatment outcomes. But their enthusiasm may at the same time adversely affect their ability to perceive other aspects of treatment objectively. One such aspect is treatment outcome. Therapists' perceptions of the results of their own efforts are traditionally considered suspect, and it is felt that obtaining objective data on outcome requires that such judgments be made by others. In technical language, this is referred to as the necessity for those who determine outcome to be "blind" to the treatment received by each individual. The enthusiasm that colors perceptions of treatment outcome may also color perceptions of the suitability of a given patient for a given treatment. Invested in their work, therapists may tend to perceive more individuals as suitable candidates for the treatments they provide than is actually the case. Thus they may not conduct valid assessments. In a pertinent study (Savitz et al., 1973), hypothetical patient profiles were constructed from actual patient data and were submitted to three groups of staff for disposition. One staff group was not connected with any particular treatment program but ordinarily made dispositional decisions on court-referred cases to a variety of treatment programs. This group assigned 45 percent of the hypothetical patients to treatment A and 35 percent to treatment B. But staff from treatment A assigned 93.8 percent of patients to treatment A, and staff from treatment B assigned 55 percent of patients to treatment B. That is, staff committed to a particular treatment program were significantly more likely to refer patients to that program than staff who were not so committed.
264 BROADENING IlIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS TABLE 10-3 Factors Influencing The Validity Of Self-Reports Situations Likely to Produce Invalid Self-Reports Situations Likely to Produce Valid Self-Reports Patient has positive blood alcohol concentration at time of assessment Patient is experiencing withdrawal symptoms or other acute distress Unstructured, general, or vague items are used to obtain information Patient is not aware that self-reports will be checked against other data Interaction with the patient is brief or minimal Patient shows poor compliance with the treatment regimen Patient has clear motive to distort information (e.g., abstinence is a condition of parole or continued employment) Patient doubts the confidentiality of the information provided to treatment personnel Staff has obvious expectations that certain behaviors (e.g., abstinence) will be reported Patient is alcohol free at the time of assessment Patient is stable and has no major symptoms Structured, carefully developed items are used Patient knows that self-reports will be checked against other sources of data (e.g., lab tests, collaterals, records) Good rapport is established with the patient Patient complies with other aspects of treatment Patient has no obvious reason for distorting self-reports Patient can be validly reassured about confidentiality Staff and the information-gathering process are obviously neutral and nonpunitive Another potential source of bias is the prospect of financial gain. Programs are often reimbursed on a fee-for-service basis. Under this arrangement the more service that is provided, the greater the profits of the provider. To refer a potential patient elsewhere under this type of reimbursement schedule is to turn away income. Financial incentives operating in the opposite direction may influence treatment provided under fixed-price prepayment schemes; here, the more service provided, the smaller the profits of the provider. Although many individuals involved in providing treatment do not deliberately base their treatment dispositions on financial considerations, it may be that such considerations influence them in subtle ways. An exception is the utilization management company, in which the influence of financial considerations upon the provision of services is explicit and paramount. Contracted to ensure that effective services are provided at the least cost, such companies are of increasing importance in alcohol treatment (Korcok, 1988; Lewis, 1988~. In a pertinent study of possible financial influences on assessment (Hansen and Emrick, 1983), five individuals were carefully trained to give histories about their use of alcohol and their concerns about that use; the levels of use and concern chosen by the investigators, although not negligible, did not objectively indicate either the presence of serious alcohol problems or a need for inpatient treatment. Each of these individuals then presented himself or herself to six local agencies that were selected on the basis of their aggressive recruitment practices.
ASSESSMENT 265 In 59 percent of the ensuing assessments, a diagnosis of "alcoholism" was made. In 100 percent of the diagnosed cases, total lifetime abstinence from alcohol was recommended, and in 53 percent inpatient treatment was recommended. The only agency that made consistently correct dispositional decisions was also the only not-for-profit agency of the six. The researchers concluded that People who seek out someone to evaluate their drinking behavior may be told they are 'alcoholic' when they are not and are subsequently influenced to receive very expensive, unnecessary, and perhaps harmful treatment" (Hansen and Emrick, 1983:177~. Other data corroborate the potential effect of financial considerations on the provision of treatment. A Citizens League study in Minnesota found that treatment selection was closely related to reimbursement arrangements. Even though inpatient treatment was more than 3.5 times more expensive than outpatient treatment, programs that were reimbursed on a fee-for-service basis treated the great majority of their patients in inpatient treatment programs. The one program that was reimbursed on a feed prepayment basis treated the majority of its patients in its outpatient treatment program. The Citizens League concluded that Treatment funding is an important factor affecting where people are referred to for treatment, and what services are provided them" (Boss, 1980:15). That financial or ideological biases may be reasonably widespread is suggested by data on the level of cross-referral among alcohol treatment programs. In two studies that looked at cross-referral in large numbers of persons seeking treatment, no instances could be documented among 600 persons in treatment (Pattison, 1974:640) nor among 6,805 persons in treatment (Glaser et al., 1978:209-210~. The reasons for the lack of cross-referral were not explored in either study on a systematic basis. Further studies are needed. Cross-referral probably does exist, but the rate of cross-referral may not be high. If the purpose of assessment is to provide objective data to serve as a basis for the appropriate referral of those seeking treatment to the variety of treatment programs that are available, the foregoing information is not encouraging. An obvious remedy for ideo- logical and financial biases would be to follow the lead proposed by the common practice in outcome determination and to ensure that assessment and treatment selection were not in the hands of therapists who might be ideologically or financially tied (or both) to particular treatment programs. In other words, perhaps the assessment (and consequent referral) process should be functionally independent of the treatment process. Experience with independent assessment has been limited but positive. Following its recommendation by Ontario's Addiction Research Foundation in 1978 (Marshman et al., 1978), the establishment of independent assessment/referral centers has been a policy of the province of Ontario in Canada. As of November 1987, 35 such centers were in operation. In comparison with treatment programs in which assessment is not independent of treatment, such centers: attract a younger population with less serious problems; attract clients from a wider array of referral sources; are more likely to attract persons with serious alcohol problems; are more likely to provide continuity of care; and are more likely to involve family members in the therapeutic process (Malta et al., 1985; Rush, 1987~. In the state of Minnesota, the financial independence of assessment from treatment is mandated by law. Partly as a result of the Citizens League report quoted earlier (Boss, 1980), Minnesota Statute 254B was enacted by the state legislature and went into effect on January 1, 1988. This law created a consolidated treatment fund for public assistance recipients, the monies of which were exempted from various federal and state entitlement
266 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS provisions. As a consequence these funds could follow the patient to whatever treatment was indicated, rather than their availability determining where and how treatment would be provided. From an assessment standpoint the law required that the county shall provide a chemical use assessment ". . . for all clients who seek treatment or for whom treatment is sought for chemical abuse or dependency. The assessor shall complete an assessment summary . . . for each client assessed for chemical dependency treatment services. The form shall be maintained in the client's case record . . . An assessor under contract with the coungy shall have no direct f Uncial interest or referral relationship resulting in shared f nar~czal gain with a treatment providers [emphasis supplied]. Although Minnesota's approach is of recent origin, the preliminary results are encouraging. There is already evidence that individuals seeking treatment are being directed more frequently to low-cost alternatives and that more treatment is being provided at less overall cost (Minnesota Chemical Dependency Program Division, 1989~. These findings are consistent with experience elsewhere in the provision of medical care (Feldstein et al., 1988~. In neither instance has it been determined that equivalent effectiveness necessarily accompanies a lower overall cost of treatment, but Minnesota has also mandated a uniform evaluation system and plans to address this question as well. Another state, Michigan, is moving toward a similar approach to treatment, involving independent pretreatment assessment and outcome monitoring (Alto et al., 1988~. The problems of financial and ideological bias are well known and at the very least require attention. At issue is whether the independence of the assessment process from the treatment process is required to prevent these biases from operating in a significant manner. The broadly accepted model of complete independence of outcome determination in efficacy studies suggests that such independence may be important, particularly if reassessment is used to determine outcome. On the other hand, objections have been raised on such practical grounds as the delays that may occur in entering treatment and the imposition of an additional structure (independent assessment) between the individual and the treatment he or she is seeking. Rather than settling the issue on a puma facile basis, a pilot study involving comparisons of referral patterns and of the results of treatment between independent and nonindependent assessment would be instructive. In the interim it seems possible that an administratively distinct assessment unit within an overall treatment program could provide some level of assurance that due protection is available from the effects of ideological and financial biases. This assurance would be more credible if the treatment program provided a multiplicity of treatments that were diverse in their treatment philosophies and costs. The arrangement could also provide built-in safeguards such as the regular and independent monitoring of disposition patterns and structural provision for cross-referral to other treatment programs. Methods of Obtaining Assessment Information In providing assessment information, individuals seeking treatment may interact with an interviewer, with a questionnaire or other assessment instrument, or with a suitably programmed computer. To some extent these methods represent alternatives; for example, computers are often used to obtain information that would otherwise have been obtained by interview or by questionnaire. The methods are not mutually exclusive: various mixtures of all three can be utilized and ideally should be available because some individuals are quite uncomfortable with particular methods (H. ~ Skinner and Allen, 1983b; H. ~ Skinner et al., 1985a, 1985b; Lucas et al., 1976; Lucas et al., 1977~. In addition, the assessment of sight- and hearing-impaired individuals or of persons not fluent in English poses problems for particular assessment methods.
ASSESSMENT 267 Face-to-face interviewing is probably the most common method of obtaining assessment information. Its principal advantage lies in the direct person-to-person interaction involved; as noted in Table 10-3, good rapport generally enhances the validity of self-reported data. Such interaction with a member of the staff of a treatment facility may be a prime factor in sustaining participation in treatment; conversely, a program that did not allow such interaction to occur would probably have a high drop-out rate. On the other hand, interpersonal interaction is not necessarily an unqualified good. Individuals vary widely in their comfort in interpersonal situations. Some of those seeking treatment may prefer a more distant method of interaction. Much of the information gath- ered during an assessment is of a sensitive nature, and the neutrality of test instruments or of computers may be advantageous in obtaining it. In one study, patients with alcohol problems reported higher levels of alcohol consumption to a computer, lower levels to a psychiatrist, and still lower levels to a higher status psychiatrist (Lucas et al., 1977~; both medical status and senior status apparently were intimidating. If assessment and treatment are carried out by different personnel, fostering a close personal relationship with assess- ment staff could become problematic (W. Skinner and Becks, 1988~. But (as noted) assessment is not an either/or situation with respect to method. Given a sufficiently flexible staff, combinations of interviewing, instruments, and computers can be utilized perhaps even a different mix of methods for different individuals, depending on preferences and circumstances (e.g., assessment should not have to cease when the computers are "downs). Nevertheless, some degree of face-to-face personal contact is clearly essential and should be part of any assessment process. To be effective, however, interpersonal interaction must be effectively carried out, and therein lies a possible problem. Potential assessors cannot automatically be assumed to possess the requisite interpersonal skills to conduct a comprehensive assessment. No at- tribute of an individual, including the possession of a particular academic qualification or the experience of dealing successfully with one's own alcohol problem, in itself guarantees such skills-or, for that matter, guarantees their absence. Even if assessment personnel do possess the requisite skills, it cannot be presumed they will use them consistently. In short, there is no substitute for the careful selection, thorough training, and close supervision of assessment staff. It should also be noted that, as commonly practiced even by individuals with abundant interpersonal skills, face-to-face interviewing as a method of obtaining assessment information often leaves much to be desired. Such interviewing is most frequently conducted in an unstructured way; that is to say, the content of the questions and the order in which they are asked are left to the interviewer to determine. The result of free-form assessment interviewing is all too frequently spotty and inconsistent data collection. One such interviewer might learn a great deal, for example, about the family history of one individual and nothing about that of the next. Moreover, the recording of data derived from unstructured interviews presents unusual challenges. Experience suggests that, even if the interview itself has been comprehensive, not everything that is discussed is recorded. Pressed as they often are for time, interviewers are sometimes content with summary statements. Yet the statement that a person has "a moderately severe alcohol problem" could mean just about anything. Finally, the legibility of notes recorded from unstructured interviewing is often a problem; because of the great variability in the structure and content of such interviews the notes are often written out in longhand. The structured face-to-face interview is another matter entirely. If carefully developed, it can be highly effective even in relatively inexperienced hands. It retains the interpersonal elements of the unstructured interview but substitutes predetermined for spontaneous content. Structure permits the interview to possess (at least potentially) the
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
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.
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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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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