Clinically useful, research validated assessment of persons with alcohol problems

Behaviour Research and Therapy 40 (2002) 1425–1441 www.elsevier.com/locate/brat

Clinically useful, research validated assessment of persons with alcohol problems Frederick Rotgers ∗ Department of Psychology, Philadelphia College of Osteopathic Medicine, 4190 City Avenue, Philadelphia, PA 19131-1693, USA Accepted 14 March 2002

Abstract Advances in treatment approaches available for persons with alcohol problems, particularly the advent of cognitive behavioral and motivational approaches, have made systematic assessment of these problems more important than ever for clinicians. There is a plethora of assessment instruments available, and it is a difficult task for clinicians to conceptualize, select and use these instruments in a coherent fashion. Particularly important in this task is the identification of research validated instruments that provide both clinically useful and psychometrically sound data. This paper presents a model of alcohol assessment and reviews selected research validated instruments that can be assembled into an assessment battery that provides useful data to guide treatment of alcohol problems while also addressing practical concerns encountered by clinicians in practice.  2002 Elsevier Science Ltd. All rights reserved. Keywords: Alcohol assessment; Test selection

1. Introduction A sea change is occurring in the treatment of alcohol problems in the US. The results of more than three decades of research detailing the components of effective treatments for alcohol problems (Miller, Brown, Simpson, Handmaker, Bien, Luckie et al., 1985) have led to a greater emphasis on assessment as the basis for planning, conducting and evaluating treatment. Traditionally, especially in the US, we have used an approach to treat alcohol problems that has little scientific evidence for its efficacy, and which often relies on a one-size-fits-all philosophy that prescribes ∗

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essentially the same treatment approaches and tasks for all persons seeking treatment. As our knowledge of the range and diversity of alcohol-related problems has expanded, it has become clear that using a single approach with all clients is ineffective (Institute of Medicine, 1990). Treatments based in cognitive-behavioral and motivational frameworks have been developed that rely heavily on ascertaining and addressing individual factors and problem parameters that can vary significantly between clients (Donovan, 1988). Unlike traditional approaches, these treatments rely heavily on assessment of a variety of client characteristics and alcohol-related consequences for their success. For example, one of the earliest motivational approaches to grow out of research, the ‘drinker’s check up’ (Miller & Sovereign, 1989) relies heavily on a pre-intervention assessment to provide the clinician with client-specific, and treatment relevant information that can used as the focus of a motivational feedback interview aimed at prompting movement toward changes in drinking behavior. Other, similar approaches, such as the BASICS (Dimeff, Baer, Kivlahan, & Marlatt, 1999) intervention for heavy drinking college students rely heavily on assessment-based normative feedback that assists the client in comparing his/her own drinking patterns and associated consequences with those of peers. Cognitive-behavioral approaches also rely heavily on assessment of client drinking, skills and skill deficits that may have an impact on whether and how clients are able to effect lasting changes in drinking. In addition, the emergence of moderate drinking approaches, still quite controversial in the US, places an ethical burden on clinicians to properly assess clients with respect to the advisability of attempting to reduce their drinking as opposed to stopping altogether. Assessment-based research data are available in the research literature (Heather et al., 2000; Miller, Leckman, Delaney, & Tinkcom, 1992) that can help guide clinicians in providing appropriate informed consent to clients regarding the potential risks and benefits of attempting to moderate their drinking. At the core of all of these research-validated treatment approaches, is assessment of a variety of client characteristics that are likely to be either targets of behavior change efforts, or can help inform both clinician and client of the most reasonable starting point and potential course treatment might take. Yet, despite the heavy emphasis on assessment in these new, effective treatment approaches, many clinicians do little, if any formal assessment of clients, other than what is required in order to establish a diagnosis and obtain third-party reimbursement. Certainly, few treatment programs provide systematic, ongoing assessment of clients over the course of treatment, despite the emphasis by the Joint Commission on accreditation of healthcare organizations (JCAHO) on assessment as a cornerstone of well-delivered treatment (JCAHO, 2001). A recent JCAHO audit of a program with which the author was formerly associated, lauded that program as one of the best the auditor had ever seen for doing what amounts to a minimal, but systematic, assessment of all new clients using the Addiction Severity Index (McLellan et al., 1992). Even in this highly praised (by JCAHO) program, no formal, systematic follow-up assessment was done during the process of treatment. This paper is an attempt to partially remedy this lacuna in clinical practice. In it, I will present a model that can help clinicians design assessment batteries that will be useful in their own practice settings, to guide treatment with their particular clients. In order to accomplish this task, I will first contrast research and clinical assessment. I will then present an overview of critical assessment domains and suggest a model assessment package that uses empirically validated

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assessment instruments to address those domains. I will focus minimally on assessments to establish a diagnosis (i.e. alcohol abuse, alcohol dependence) as such assessment often serves more to provide the basis for obtaining third party reimbursement for treatment than for guiding treatment itself. It is also no longer clear that diagnosis, at least DSM-IV diagnosis (Hasin, Payken, Meydan, & Grant, 2000; Heather et al., 2000) has clinical relevance beyond suggesting a starting point for treatment. Data are accumulating to suggest that a diagnosis of alcohol dependence, for example, may not necessarily predict whether or not a person can moderate their drinking (Heather et al., 2000). For these reasons, my focus will be on instruments that can be of assistance to both clinicians and clients in understanding the parameters of the individual’s problems with alcohol, and how treatment might be designed to address those parameters effectively. This paper is not intended to be an exhaustive review. There are currently nearly 200 published instruments available to clinicians that have been used to assess alcohol problems, and have some degree of research-based validity (many of these are reviewed in publications by the National Institute on Alcohol and Abuse and Alcoholism (NIAAA, 1995); and the Center for Addiction and Mental Health (CAMH, 1993). To review all of them, is far beyond the space limitations of this paper. What will be presented is a guide to selecting and using research validated instruments in clinical practice. There are many sources for research-validated assessment instruments, some of which are listed in the Appendix at the end of this paper. The recommendations I will make should be followed up by each clinician with a bit of homework that focuses on reviewing both the instruments I suggest and others that are available, and making an informed decision as to which instruments will be most useful given the context and limitations of each clinician’s practice. This paper is directed at clinicians, therefore, I will begin by addressing practical issues such as cost, time requirements and ‘user-friendliness’ that are often ignored by researchers in the interest of obtaining the most reliable and valid research data. That discussion will be followed by an overview of the types of assessment procedures that have reasonable research validation. Next, I will review a number of critical domains of assessment that clinicians should address in designing a research validated assessment process. For each domain I will suggest one or more research validated instruments that might be included in such an assessment process. 2. Assessment in the context of clinical practice The contexts and aims of clinical and research assessments, while sharing some characteristics (i.e. a need to reliably define client problems and characteristics at treatment entry, and measure changes in client behavior/characteristics over time), contrast in several significant ways. Researchers, who often provide incentives for persons to enroll and become research subjects, typically have much more time and latitude for assessment than do practicing clinicians. Large scale studies such as Project MATCH often collect massive amounts of data from subjects using batteries that can last several hours, and require specially trained assessors to administer (Project MATCH Research Group, 1997). Few clinicians or clinics have the resources to conduct such assessments, even if clients would agree to complete them or third party payers reimburse for them. Research assessments are designed to reliably describe subject sample characteristics, and to

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measure changes in groups of people in ways that are easily amenable to statistical analysis. As with initial assessments, research studies typically have dedicated, specifically trained staff whose primary task is to re-administer assessment instruments at periodic follow-up intervals following the research treatment intervention. Few clinicians or clinics have the fiscal resources to conduct such systematic follow-up assessment. Researchers budget specific amounts for commercial assessment instruments and assessment technician time into their projects, and know in advance that they will have the resources available to purchase instruments and complete assessments and follow-ups proposed in the research proposal. Clinicians, and particularly publicly supported clinics, often must operate on shoestring budgets, or are dependent upon client-generated revenues for their operational survival. Frequently they lack the sophisticated computer administration capabilities that researchers often have available, and they often are unable to afford the cost of purchasing commercial instruments. Furthermore, many clinics rely upon clinicians who have little formal training in test administration, scoring and interpretation to provide the bulk of direct services to clients. Some assessment instruments, particularly commercially marketed ones, often require a relatively higher level of professional training and experience (i.e. that one be a licensed psychologist) to use, than the staff at many clinics possess. Clinical assessments are primarily idiographic. While group data collection may be one use to which clinical assessments may be put (i.e. program evaluators may collect systematic data on all clients in a clinic and use that to describe site-specific population characteristics) most clinical data is used in an n ⫽ 1 study aimed at understanding and intervening with a single individual. In this regard, clinical assessments often have, as a primary goal, matching of appropriate interventions to client motivation and treatment needs. Although large scale research studies, such as Project MATCH have frequently failed to identify many matching variables upon which to base intervention to client need matching, a number of empirically validated approaches, particularly cognitive-behavioral and motivational ones, are particularly geared toward matching. Approaches based on the stages of change model, developed and validated by Prochaska, DiClemente and their colleagues (Prochaska, DiClemente, & Norcross, 1992), are particularly assessment driven in that particular types of interventions are presumed to be most useful to clients in a particular stage of change (Connors, Donovan, & DiClemente, 2001). Other matching parameters that require assessment include matching skills training approaches to client skill deficits, matching treatment goals to client goals, and identifying and matching coping strategies to high relapse risk situations. These differences between the demands of clinical and research practice and assessment suggest, in part, that in order for an assessment procedure or battery of procedures to be clinically useful several criteria must be met. These criteria are summarized in Table 1. To be most clinically useful to the broadest range of clinicians and agencies assessment instruments must be: (1) Clinically relevant to the specific types of clients seen in the practice setting, but easy and brief to administer. For example, assessment instruments that are highly sensitive to low levels of alcohol problems, but blur distinctions among clients at higher levels will probably be less useful in an inner city alcoholism clinic than in a moderation training program. (2) Low cost, and easy to obtain and score. Commercially published instruments, while often quite good and clinically useful, are often very costly to both obtain and score, placing them beyond the reach of clinicians/agencies that work with low income clients or rely on scarce government funding for

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Table 1 Criteria for selecting clinically useful assessment instruments 1. 2. 3. 4. 5. 6. 7.

Brief and easy to administer. Low cost and easy to obtain and score. Written in non-technical language. Easy to interpret and explain to patients. Psychometric reliability and criterion/content validity. Predictive validity. Sensitive to change.

their operational budgets. Commercial publishers also place restrictions on the availability of their products based on clinician credentials, often placing excellent instruments beyond the reach of many clinicians working in agencies. (3) Written in easily understandable language i.e. readable by clients with poorer reading skills or who have some degree of cognitive impairment. In many publicly funded treatment settings, clients are often poorly educated and unable to read at a sophisticated level. Assessment instruments that contain sophisticated or technical vocabulary will often baffle these clients, and render them less likely to complete the assessment adequately. (4) Easy to interpret and explain to clients in terms the client can understand. Particularly with the advent of motivational approaches based on individualized feedback (Miller & Rollnick, 1991) the degree to which assessment data can be readily translated into normative feedback and clearly made personally relevant to an individual client assumes greater import. (5) Have reasonable psychometric reliability and criterion/content validity. Clinicians (and researchers!) need some assurance that the instruments they are using are both reliable (measuring consistently and not changing based on anything other than changes in the object of measurement) and are measuring what they purport to measure. Choosing instruments that have demonstrated reliability and criterion/content validity helps insure this. It also allows for data to be pooled across clients for program evaluation and other research purposes with some assurance that data gathered on one individual will be comparable in quality to data gathered on others. (6) Have reasonable predictive validity in that initial scores/results of assessment have demonstrated in empirical studies some consistent relationship with such clinically relevant variables as treatment adherence and completion, relapse potential, and coping skills, among others. (7) Sensitive to changes in client drinking status and treatment-relevant skills and abilities. Many of the most widely used assessment instruments used in clinical assessments are measures of static characteristics of clients that change little, even when treatment is successful. For example, the Michigan Alcoholism Screening Test (MAST) (Selzer, 1971), while useful in a variety of ways, taps into life-time consequences of drinking that will not change, even if the individual has been abstinent for years. In fact, for clients undergoing their very first treatment for an alcohol problem, the MAST score may actually appear to worsen as a result of treatment in that the individual may endorse the item referring to attendance at Alcoholics Anonymous (AA) after treatment, a clinically positive sign, but not before! If a clinician is using a treatment approach that focuses on, for example, skill enhancement, an assessment indicating the client’s skill levels at treatment entry and that is sensitive to changes in skill levels across treatment is essential if progress is to be assessed. To the extent that a research-validated battery of assessment instruments can be assembled that meets these criteria, incorporation of systematic, routine assessments into clinical practice will be

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facilitated. In addition, because assessment will no longer represent a time and resource consuming endeavor that provides minimal reimbursement, agencies will begin to view assessment as less of a costly extra and more of an aide to effective treatment. Such a battery will also provide a useful guide, beyond clinical and subjective impression, to how well the client is doing and whether or not treatment is proceeding in a helpful direction, or the direction needs to be re-evaluated.

3. Types of research validated assessment instruments and criteria for choosing suggested instruments There are four basic types of assessment instruments that have been used in clinical research on the treatment of alcohol problems: (1) direct behavioral assessments using role-plays (Monti et al., 1993); (2) psychometrically validated questionnaires consisting of multiple choice items or rating scales in which client responses are summed, often along empirically derived dimensions or factors to produce a useful description of client characteristics; (3) simple linear or Likert-type rating scales used as stand-alone indicators of client characteristics; and (4) standardized, structured interviews that require the clinician to ask a series of questions in a specified format and particular order. From the perspective of behavior therapy, the more closely assessment instruments come to direct sampling and psychometrically reliable and valid quantification of behavior, the more adequate they are likely to be. In the area of coping skills and strategies, direct behavioral assessment of client skills has been used effectively in research. Extensive batteries that sample behaviors have also been used to assess cognitive co-occurring pathology and impairment. The ‘ideal’ assessment process would directly sample client behaviors in each of the domains to be reviewed below. However, this type of assessment is typically time consuming and often requires extensive training in order to reliably score and interpret results. For some of the domains direct behavior sampling is ethically and practically impossible (for example, in assessing withdrawal risk, direct behavior sampling simply is not possible as the purpose of the assessment is, in part, to prevent the critical behavior/process from occurring). Lastly, direct behavioral assessments are often impractical in clinical settings where staff training may not be feasible, and where resources do not permit hours of pre-treatment assessment. For these reasons I have focused almost exclusively on questionnaire and rating scale procedures in my suggestions for instruments to assess each of the critical domains. My recommendations focus on assessment tools that, in addition to being research-validated, share the following characteristics: (1) They are brief and take only a short amount of time to administer. (2) Scoring and interpretation require minimal formal training. (3) They are available either via the general research literature or sources such as the NIAAA or CAMH compendia of assessment instruments or the worldwide web, and are thus either free for clinicians to reproduce and use, or are obtainable for clinical use at minimal cost. If the instrument is commercially published it is inexpensive and can be hand-scored as well as computer scored.

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4. Domains of clinically useful assessment In assessing persons who come for help with alcohol-related problems, a number of content domains need to be addressed. All of these domains should be assessed with every client. Depending on the complexity and severity of a given client’s problems, an assessment battery that taps into these domains can be completed in well under two hours. Even this time frame may be daunting in some clinical settings, so it is possible to select out several critical domains that should be assessed if the setting forces a truncation of a full assessment. These critical domains will be identified below, and are marked with an asterisk in Table 2, which summarizes the assessment domains to be discussed below, and contains suggestions for instruments to address each domain. Table 2 Selected clinical useful assessment instruments by domain of assessment Domain

Withdrawal risk Drinking quantity/frequency

Instrument

CIWA Form 90-AQ drinking assessment interview TLFB Motivation/commitment URICA SOCRATES RCQ ADCQ Commitment to goal rating scale Severity of dependence ADS SADD SADQ Consequences of DrInC drinking Co-occurring BDI-2 psychopathology BSI High risk IDS situations/expectancies AEQ/EAQ DEQ NAEQ Coping skills/strategies CBI ECBI Self-efficacy SCQ BSCQ DASES

Stage of assessment

Time to administer (min)

Charge for use (Y/N)?

Computerized version?

IE IE, DT, PT

2 5–10

N N

N N

IE, IE, IE IE IE, IE,

~15 ~10 ~10 ~5 5 1

N N N N N N

Y N N N N N

IE IE, DT, PT IE, DT. PT IE, DT, PT

5 5 5 10

Y N N N

Y N N N

IE, DT, PT

5

Y

Y

IE, DT, PT IE, DT, PT

10 10

Y Y

Y Y

IE, IE, IE, IE, IE, IE, IE, IE,

10 10 10 10 10 15 2 5

N N N N N Y N N

N N Y N N Y N N

DT, PT DT, PT

DT, PT DT, PT

DT, DT, DT, DT, DT, DT, DT, DT,

PT PT PT PT PT PT PT PT

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For each of the domains discussed, one or two research validated assessment instruments will be suggested. As indicated above, these instruments have been chosen because they have been used in research and have demonstrated reliability and validity in research settings. Due to space limitations, this will not be an exhaustive list of possible instruments for each domain, and clinicians are urged to go to one of the many sources of instruments, review them and select others that may meet local needs. Each instrument will be briefly outlined in the discussion that follows. Assessment is done at several stages of the clinical process: intake/initial evaluation (IE), during treatment (DT) to monitor progress, and post-treatment (PT) to monitor maintenance of changes. Intake/initial evaluation instruments provide data that can serve as a baseline against which to measure changes in client behavior and characteristics over the course of treatment, while instruments useful in the other stages are ones that are sensitive to changes in client behavior and characteristics over time. For each of the instruments suggested in Table 2, the stage of assessment in which the instrument can be useful is indicated. 4.1. Withdrawal risk The most directly life-threatening consequence of alcohol problems is often the risk associated with withdrawal when the client stops drinking. Assessment of withdrawal risk is thus a critical component of the IE stage of assessment. Perhaps the best validated single instrument for assessing withdrawal risk is the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-R) (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989). The CIWA-R is a structured interview and clinical evaluation guide that takes about 5 min to administer. It can be augmented by breath testing or other biological measures of blood alcohol concentration to ascertain the need for medically managed detoxification. 4.2. Drinking quantity/frequency A clear picture of a client’s drinking behavior in terms of how much and how often is critical to an initial understanding of the severity of the problem to be addressed clinically, and thus is an important part of IE assessment. Understanding a client’s drinking behavior is also important in ongoing monitoring of progress during treatment (DT stage of assessment) and in determining the degree to which changes in drinking behavior have been maintained after treatment (PT stage of assessment). Initial and ongoing assessment of drinking itself is particularly important when the client’s treatment goal is one of moderation of alcohol intake, rather than complete abstinence. A number of methods of gathering drinking behavior data have been developed and used in both research and clinical settings. Most assessments of drinking quantity frequency have been constructed as part of clinical interviewing procedures. The Form 90 approach, a structured interview developed and validated for Project MATCH (Miller, 1996) is one such approach that provides both long and short forms of a structured interview that helps in quantifying and understanding a client’s drinking patterns, and can be administered at multiple points during the IE, DT and PT stages of assessment, if necessary. The short form consists of only six questions, and thus can be administered quickly when time is at a premium.The long forms of the Form 90 ask detailed questions about a recent

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typical week of drinking, about periods of abstinence, and about fluctuations in drinking intensity over time. A different approach to quantification of drinking that provides a somewhat more detailed picture of the client’s drinking, and which can also be transformed into a concurrent diary method for self-monitoring of drinking is the Time Line Follow Back (TLFB) procedure (Sobell & Sobell, 1995). The TLFB has the advantage that it can be used, with appropriate brief explanation of the procedure to the client, as a self-administered assessment. It is also available in a computer administered version. The TLFB provides day by day quantification of client drinking for a time frame specified by the clinician. Research using the TLFB has shown it to be capable of reliable and valid assessment of drinking quantity and frequency for periods of up to a year pre-treatment. 4.3. Motivation/commitment With the advent of motivational interviewing and other treatments aimed at enhancing client motivation to change, and the growing clinical popularity of Prochaska and DiClemente’s stages of change model (Prochaska et al., 1992) in matching interventions to client stage of change, the assessment of client motivation for change at all three stages of the assessment process has become much more important. In addition, research (Morgenstern, Frey, McCrady, Labouvie, & Neighbors, 1996; Sanchez-Craig, & Lei, 1986) has shown that client commitment to a treatment goal is a good predictor of treatment outcome. As the assessment of motivation has become more sophisticated it has become clear that there are four variables related to motivation and commitment that need to be assessed in order to guide the clinician in developing an effective treatment program for any given client. These motivational variables are: (1) motivation to change drinking behavior (Miller & Tonigan, 1996); (2) motivation to change drinking behavior using treatment as one method of change (Heather, Luce, Peck, Dunbar, & James, 1999); (3) treatment goals sought by the client (Sanchez-Craig, & Lei, 1986; Sobell, Sobell, Bogardis, Leo, and Skinner, 1992); and (4) degree of commitment to reaching the sought after goals and to maintaining them (Morgenstern et al., 1996). A number of instruments have been developed that measure motivation to change including the University of Rhode Island Change Assessment (URICA) (McConnaughy, DiClemente, Prochaska, & Velicer, 1989), Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) (Miller & Tonigan, 1996) and Readiness to Change Questionnaire (RCQ) (Heather et al., 1999), all of which have been validated in previous research studies and are psychometrically sound. The URICA has the advantage of having both long and brief forms, as does the SOCRATES, and also can be tailored to problems other than alcohol problems as the items are worded using a more generic change language. The URICA allows for assignment of clients to stage of change for each behavior that is the target of the questionnaire. The SOCRATES is similar in function to the URICA, but is drinking-behavior specific. Factor analytic studies of the SOCRATES suggest that it taps into three factors that correspond roughly to precontemplation/contemplation (problem recognition), preparation/action (taking steps) and maintenance stages of change. The RCQ is a brief (12 items) scale that also categorizes clients according to stage of change. Two forms are available, one that focuses on readiness to change drinking behavior, the other on readiness to change drinking behavior using treatment.

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The URICA, SOCRATES and RCQ all are brief and easy to score and interpret. All three of these questionnaires function to place clients in a particular readiness category, but do not specifically address the content of the client’s readiness, i.e. the degree to which the client sees various costs and benefits to changing his/her drinking. Research on movement through the stages of change suggests that shifts in relative perceived costs and benefits of change is a predictor of movement from precontemplation/contemplation stages into action to change behavior. The Alcohol and Drug Consequences Questionnaire (ADCQ) (Cunningham, Sobell, Gavin, Sobell, & Breslin, 1997) is an attempt to measure this important theoretical factor in motivation to change. Using 29-Likert response items, the ADCQ asks clients to rate the importance of various behavioral, cognitive and emotional outcomes that might occur if the client stopped or cut down on drinking (and/or drug use). The ADCQ is available free of charge, and has been shown to correlate with drinking at one year post-treatment. Assessing motivation to change from this somewhat different perspective can provide clinicians and clients with information on both initial motivational targets and help track changes in motivation as treatment progresses. The measurement of goal choice and commitment in ways that have predictive validity with respect to treatment outcome has been done using very simple processes. The assessment of goal choice requires merely asking the client whether his/her goal is quit altogether or to cut-down. This is typically followed up with a simple Likert rating scale of commitment to the stated goal. Such ratings, on a 1–10 scale, have been shown to predict abstinence post-treatment (Morgenstern et al., 1996), while client goal choice vs. goal imposition has been shown to be associated with better outcomes for alcohol treatment, regardless of the goal chosen (Sanchez-Craig and Lei, 1986). There are also studies that suggest that repeated assessment of goal choice in the context of treatment progress can facilitate treatment adherence, and perhaps outcome (Ojehagen & Berglund, 1989). 4.4. Severity of dependence Severity of dependence is a critical factor in helping clients decide on their choice of treatment goal, and enhancing motivation for pursuing the chosen goal. An objective measure of severity of dependence can also be helpful as part of an assessment feedback or motivational intervention in helping clients who may be in the earlier stages of change begin to understand the impact of their drinking, and move toward taking action. There have been a number studies that have suggested that measures of severity of dependence are predictive of success in pursuit of moderation goals (Heather et al., 2000; Miller et al., 1992). For the clinician, knowledge of severity of dependence can serve as a guide for working with clients, and making clinical recommendations as part an initial IE assessment. There are three brief, but well validated questionnaires that are available to assess severity of dependence. All three scales are sensitive to the degree of physical dependence that can result from prolonged alcohol consumption, however they vary somewhat in their sensitivity to lower levels of dependence. The Alcohol Dependence Scale (ADS) is a 25 item, commercially published scale that has been widely used in research, and has demonstrated good reliability and validity (Skinner & Allen, 1982). As with the other two scales to be discussed, the ADS is normed, facilitating comparison of individual clients with larger groups of clients, and thus providing a

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powerful piece of feedback about how the client’s own experience with drinking and dependence compares with those of others. The two other scales, the Short Alcohol Dependence Questionnaire (SADQ) (Stockwell, Murphy, & Hodgson, 1983) and Short Alcohol Dependence Data (SADD) questionnaire (Davidson & Raistrick, 1986) are both available free of charge in the research literature or the NIAAA assessment reference volume. Both are brief (SADQ has 20 items that factor into five subscales, SADD has 15 items) and can be self-administered. The SADD has the advantage that it is somewhat more sensitive to inter-client variability at lower levels of dependence than either the ADS or SADQ, but all three questionnaires provide useful clinical data. 4.5. Consequences of drinking Understanding both past and ongoing negative consequences of drinking can be helpful in both motivating clients for change and in assessing ongoing progress both during and after treatment. In order for a measure of consequences to be most useful clinically it must not only tap into the severity of experienced consequences in the past, but also be sensitive to changes in consequences. Until recently, most measures of consequences associated with drinking, such as the MAST (Selzer, 1971) were lifetime, cumulative measures, i.e. the client was asked if the consequence ‘ever’ occurred, and the score was a cumulative, weighted sum of the number of consequences ever reported. While useful for IE assessment to provide data for use in a motivational feedback intervention, such instruments are insensitive to changes in levels of consequences over time. Recent research has led to the development of instruments that are sensitive to both lifetime and ongoing consequences of drinking, and can be used both for IE and DT and PT assessments. The instrument that appears to be the most useful clinically among those currently available is the Drinker Inventory of Consequences (DrInC) (Miller, Tonigan, & Longabaugh, 1995) developed as part of the assessment package for Project MATCH, the DrInC has the advantage of tapping into both lifetime and circumscribed timeframe consequences, and has both long (DrInC) and short (Short Inventory of Problems (SIP)) forms that are available for use free of charge from NIAAA. Both forms of the DrInC have good psychometric properties, normative data based on the Project MATCH sample, and are easily scored and interpreted by clinicians with minimal training in psychological assessment. 4.6. Co-occurring psychopathology Co-occurring psychopathology is a significant complicating variable in the treatment of alcohol problems. The co-occurrence of anxiety, depression, bipolar disorder, schizophrenia, as well as personality disorders has been shown to significantly affect both viable treatment goals (i.e. persons with severe co-occurring psychopathology appear less likely to be able to moderate drinking successfully (Rosenberg, 1993)), and the degree to which clients are able to effectively pursue them in treatment. While the assessment of various types of co-occurring psychopathology is complicated by the fact that alcohol problems can be both a cause and a symptom of such psychopathology (Rosenthal & Westreich, 1999), the assessment of co-occurring depression, anxiety and psychosis at both IE and DT assessment stages is essential in helping to map out effective treatment.

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While there are any number of psychometric tools for assessing co-occurring psychopathology, most of these are commercially published and subject to copyright restrictions, require a significant level of education and training to obtain and administer, and are often complicated to interpret. In addition, the most widely used of such instruments are quite lengthy, taking an hour or more for many clients to complete. While they provide excellent data, they are impractical for use in most clinical settings. There are, however, clinically useful, though commercially published, instruments that are brief and can provide both clinicians and clients with good information that can be used in both the IE and DT stages of assessment. It is particularly important in the IE stage of assessment to ascertain the presence of suicidality, significant depression and psychosis. Two commercial instruments, the Beck Depression Inventory-II (BDI-II) (Beck, Steer, & Brown, 1996) and the Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983) are brief, low-cost, available in hand scored versions, and are useful in tracking changes in reported psychopathology over time. The BDI-II is a widely used and validated measure of clinical depression that has the advantage of specifically asking about suicidal thoughts and intent. It is sensitive to changes, asking the client to report symptoms and symptom severity for a one or two week time window. The BSI is a brief, 53-item questionnaire that employs a Likert scale response system to assess the degree to which clients have experienced symptoms of various forms of psychopathology within a specified preceding time frame, usually two weeks. It yields specific indicators for a variety of forms of psychopathology, as well as a general severity index that can provide information about the overall relative severity of psychopathology the client is reporting. Both the BDI and BSI are useful in the IE and DT stages of treatment to monitor changes in psychopathology, and thus help resolve the co-occurring pathology ‘chicken–egg’ problemwhether drinking is a cause or result of the co-occurring psychopathology. 4.7. High risk situations Understanding situations in which a client presently is very likely to drink, gives both the clinician and client clues as to situations in which the client is likely to be at high risk for relapse as treatment progresses. High risk situations can be both external contexts in which drinking has occurred with high frequency in the past, and internal cognitive and emotional states that occur frequently prior to the onset of a drinking episode. The Inventory of Drinking Situations (IDS) (Annis, Graham, & Davis, 1987) is one of the few standardized questionnaire measures of high risk situations that samples both internal and external high risk situations. The IDS is available in research validated short and long forms which can take from a few minutes to nearly an hour for the average client to complete. The IDS is a commercially published instrument, in both hand and computer scored versions. For IE assessments, the IDS helps the clinician and client identify those situations that should probably become the immediate focus of change efforts and skills training, i.e. the ones associated with greatest risk for drinking in the past. As treatment progresses, the IDS can be helpful in planning for relapse prevention, and in assessing progress in conjunction with its parallel companion measure of self-efficacy, the situational confidence questionnaire, discussed below. While the IDS is probably the choice for a broad assessment of external and internal drinking situations, another aspect of risk for drinking is the set of expectations the client holds for the

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benefits he/she will obtain from drinking, as well as the degree to which the client holds negative expectations for drinking, i.e. believes that negative consequences will result in he/she drinks. Both positive and negative expectancies and changes therein have been associated with treatment outcome (Jones & McMahon, 1998). For the clinician and client, a clear understanding of the benefits a client seeks from drinking can point the way toward treatments aimed at achieving those effects through alternate means. An understanding of the negative expectancies a particular client holds (or does not hold) can also guide treatment toward helping clients develop a realistic expectation of the possible consequences of continued, unchanged drinking. There are a number of excellent instruments available that assess both positive expectancies for drinking alcohol including the Alcohol Expectancy Questionnaire (AEQ) (Brown, Christiansen, & Goldman, 1987) and the shorter version of the same instrument, the Alcohol Effects Questionnaire (AEFQ) (Brown, Goldman, Inn, & Anderson, 1980). The Drinking Expectancy Questionnaire (DEQ) (Young & Knight, 1989) can both discriminate problem from non-problem drinkers and track treatment progress. To date, only one measure of negative alcohol expectancies has appeared in the literature, the Negative Alcohol Expectancy Questionnaire (NAEQ) (McMahon & Jones, 1993). This measure has, nonetheless, been well validated and has been shown to be sensitive to changes in negative expectancies that are associated with positive treatment outcome. All of these expectancy measures are available free of charge with the exception of the NAEQ which can be purchased for a nominal cost from the authors. The NAEQ also has a computer scoring program available for which there is a licensing charge. 4.8. Coping skills/strategies These are important to assess both at IE and throughout treatment. In most research settings that have assessed coping skills and strategies, the means of doing so has been to have subjects respond orally or behaviorally to set roleplay scenarios, the audio or videotapes of which are then rated for adequacy by trained raters. This procedure is obviously much more time and cost intensive than is practical in most clinical settings. Fortunately, there is a more cost-efficient questionnaire measure of coping skills and behaviors in the Coping Behaviors Inventory (CBI) (Litman, Stapleton, Oppenheim, & Peleg, 1983) and its alternate form the Effectiveness of Coping Behavior Inventory (ECBI) (Litman, Stapleton, Oppenheim, Peleg & Jackson, 1984). The CBI uses a Likert scale response format to assess the degree to which clients use a variety of coping strategies in response to high risk situations generally. Both cognitive and behavioral coping strategies are assessed. The ECBI asks, for the same set of coping behaviors, whether or not the client has found them to be effective. The CBI is available free of charge in both long (60 item) and short (36 item) versions, which appear to share the same factor structure (Litman et al., 1984). 4.9. Self-efficacy Research in social learning theory suggests a relationship between whether or not a client believes he/she can carry out a coping behavior effectively (self-efficacy) and whether that behavior is likely to actually be performed in a high risk situation (Bandura, 1977). Many clients possess basic coping skills at treatment entry, but lack a sense of self-efficacy with respect to

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performance of those skills ‘under fire’. For example, clients often know how to say ‘no’ to an offer of a drink, but have little sense of self-efficacy with respect to actually saying no when a drink is offered. Assessment of drinking-related self-efficacy can be helpful both at IE for initial treatment planning, and throughout treatment as a means of tracking client progress. Several measures of drinking related self-efficacy are available. The Situational Confidence Questionnaire (SCQ) (Annis & Graham, 1988) is a companion to the short form of the IDS which uses the same item stems but asks the client to rate his/her confidence in the ability to resist drinking in that situation. Like its companion, the IDS, the SCQ is a commercially published instrument for which there is a charge. Both computerized and hand scoring are available. Breslin and colleagues (Breslin, Sobell, Sobell, & Agrawal, 2000) have recently validated a brief version of the SCQ (BSCQ) that consists of eight items, compared with the 120 items in the original instrument. Their data indicate that the BSCQ provides information comparable to the longer form, and this, combined with its brevity, make the BSCQ an attractive choice for measuring self-efficacy. The Drinking Refusal Self-Efficacy questionnaire (DRSEQ) (Young, Oei, & Crook, 1991) is another, brief instrument (31 items) that uses a Likert item format to assess self-efficacy at avoiding drinking in three types of situations involving social pressure to drink, drinking to alleviate negative affect, and what the authors call ‘opportunistic’ drinking, i.e. drinking in situations that are habitual ones for the client. The DRSEQ is available free of charge. A third instrument to assess self-efficacy is the Drug Avoidance Self-Efficacy Scale (DASES) (Martin, Wilkinson, & Poulos, 1995). Despite it’s name, the DASES consists of 16 Likert response items that assess the degree to which the client believes he/she would actually use alcohol or drugs in the target situation. The DASES is also available free of charge, and is the briefest of these measures of self-efficacy. 5. Conclusion In this review I have provided a model of clinically useful assessment using research based instruments, as well as suggestions for instruments that can be used to assess the various domains that are important to effective treatment for alcohol problems. This review has been necessarily incomplete due to the large number of assessment instruments for various aspects of alcohol problems currently available. The assembly of an effective assessment battery always needs to be done with local needs in mind. A practice or agency that treats primarily multi-problem inner city alcohol dependent people who are under significant pressure from welfare or other legal authorities to be completely abstinent will have different assessment requirements than one that focuses, for example, primarily on moderation training with middle class suburbanites. In assembling an assessment battery, clinicians need to be aware of the extent to which the domains that have been discussed here are important to the understanding and treatment of their particular client populations. There are, of course, other treatment relevant domains that might be assessed, among them beliefs about treatment, the extent of family/environmental support available, attitudes towards 12-step support groups, beliefs about the nature of drinking problems, and a number of others. In any assessment domain the principal of attempting to link clinical assessment with research

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findings that has guided the discussion here still applies. Clinicians should strive to use assessment instruments that have demonstrated good psychometric properties, and that have also demonstrated some degree of construct or predictive validity. Doing so, can increase the clinician’s confidence that the assessment instruments used will provide more than just more data—they will serve as a useful guide to treatment initiation and process for both clinician and client.

Appendix The instruments referred to in this paper are available from several sources both in print and on the worldwide web. Available from NIAAA website at http://www.niaaa.nih.gov are several sources including the NIAAA treatment handbook series No. 4: Assessing alcohol problems: A guide for clinicians and researchers, a compendium of more than 130 research instruments that includes many of the instruments cited abve. Also available from NIAAA via their website are the manuals for the FORM-90 and DrInC assessment tools. Available from the Center for Addiction and Mental Health of Toronto, Canada website at http://www.camh.net is the Directory of client outcome measures for addictions treatment programs in which can be found several instruments. Also available through the CAMH website are the IDS, SCQ, ADS and TLFB computer programs. The BDI-II is available from the Psychological Corporation, 19500 Bulverde,San Antonio, TX 78259. It can also be ordered from their website at http://www.psychcorp.com. The Brief Symptom Inventory is available from NCS Pearson, Inc. 5605 Green Circle Drive, Minnetonka, Minnesota 55343-4400, or via their website at http://assessments.ncs.com.

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