- Email: [email protected]
Cognitive and behavioral dimensions of dysfunction in alcohol and polydrug abusers
Journal of Substance Abuse, 3, 415-426 (1991)
Cognitive and Behavioral Dimensions of Dysfunction in Alcohol and Polydrug Abusers Thomas H. Harrell L. Michael Honaker Elizabeth Davis Florida Institute of Technology
Development of a measure of parallel drmensions of cognuive and behavioral dysfunction related to substance abuse is descnbed Dimensions "ere assessed In alcohol and polydrug abusers entenng treatment and social drmkers Dimensions Included quanuty/trequency of use, physiological symptoms, Situational stressors, anusocial behav iors, Interpersonal problems, affective dysfunction, attitude toward treatment, degree of life impact, and three use expectancies Principal component analysis of the drmensrons and expectancies yielded three factors, behavioral/ physiological, SOCIal, and cognitive, Although the groups could be discriminated statistically, alcohol and polydrug abusers exhibited relauvely similar patterns of dysfunction across the dimensions and expectancies, WIth alcohol abusers demonstrating greater intensity or degree of dysfuncuon in several areas on admission to treatment. Implications of the findings WIth respect to multidimensional models of substance abuse and use of the dimensions In treatment matching and outcome research arc discussed
Theories of chemical dependency have evolved from an early focus on unitary concepts to a current emphasis on the multiplicity of factors associated with chemical abuse. The unitary-disease concept has a long history in the study of alcoholism. The advocates of this model have most often targeted quantity or frequency of use as the primary dimension that characterizes dependency (e.g., Jellinek, 1960). However, more recent approaches (e.g., Pattison, 1982; Wanberg & Horn, 1983) have adopted a multidimensional conceptualization in which dependency is recognized as a multi-level state that includes dysfunctions along physiological, interpersonal, behavioral, and cognitive dimensions. The focus also has shifted from a primary concern with alcohol abuse to consideration of abuse and dependency over a range of chemical substances. This change in emphasis has led to increasing interest in whether factors associated with other-drug abuse are similar to those found in alcohol abuse. In previous research, primarily in the area of alcohol abuse, a number of dimensions or domains of behavior relevant to substance abuse problems have We are grateful for the cooperation and assistance of the staff and management of Heritage Health Corporation, Melbourne, FL Correspondence and requests for reprints should be sent to Thomas H. Harrell, School of Psychology, Flonda Institute of Technology, 150 West University Blvd , Melbourne, FL 32901. 415
T.H. Harrell, L.M. Honaker, and E. Davis
416
been identified (see Ringer, Kufner, Antons, & Feuerlein, 1977; Wallace, 1986; Wanberg & Horn, 1983). A primary dimension involves the specific quantity and frequency of substance use. A second area of investigation has focused on the physiological symptoms and behavioral manifestations of substance abuse, including affective dysfunction, interpersonal conflict, and antisocial behaviors. Other researchers have emphasized the cognitive domain, examining expectancies, or reinforcement dimensions of substance use, as well as attitudes toward treatment and the user's perception of life stressors. Unfortunately, these areas have not been studied comparatively in alcohol and polydrug abuse populations. Examination of possible similarities across substance abuse populations has been impeded by the relative lack of availability of instruments that assess multiple factors associated with use in both alcohol and polydrug abuse samples. The Alcohol Use Inventory (AUI; Horn, Wanberg, & Foster, 1974) is a widely used instrument that was specifically developed to assess multidimensional concepts. However, the AUI was designed to assess only alcohol abuse. Early work in the area of alcohol and other-drug abuse assessment was done by Mcl.elland and his colleagues (Mcl.elland, Luborsky, Woody, & O'Brien, 1980). Their Addiction Severity Index (ASI) was designed to assess common elements of substance abuse across six major areas, irrespective of type of abuse. However, possibly due to the interview format, the ASI has seen limited use in subsequent research, and despite the conceptual emergence of polydrug abuse, many studies reveal a return to the earlier tendencies of assessing alcohol and polydrug abuse independently. In the present study, a paper-and-pencil questionnaire was developed to assess parallel cognitive and behavioral dimensions of problems in samples of alcohol-dependent and polydrug-dependent individuals entering treatment, and in a sample of social alcohol users. We delineated seven dimensions of substance abuse problems and three use expectancies, based on rationally derived categories of items. The dimensions and expectancies were conceptually meaningful, and indicated specific areas of dysfunction for the individual that could be directly related to intervention needs and treatment outcome evaluation. In this investigation we were particularly interested in examining the degree to which alcohol and polydrug abuse groups could be differentiated on the basis of the dimensions or expectancies, and whether common underlying factors related to chemical dependency could be identified. We hypothesized that both alcohol and polydrug abusers would demonstrate elevations across the dimensions relative to social drinkers, but that differential patterns of dysfunction would be obtained between the two abuse groups. We also hypothesized that commonalities in substance abuse factors could be identified among alcohol and other-drug abusers.
METHOD Subjects Participants in the study included 27 alcohol abusers, 31 polydrug abusers, and 28 social drinkers. All subjects participated on a volunteer basis, and were
Dimensions of Dysfunction
417
treated in accordance with APA standards for research with human subjects. The subjects in the substance abuse samples had been diagnosed as alcohol- or drug-dependent, based on DSM-III-R criteria. All alcohol and drug abuse subjects had acknowledged a problem with substance abuse, and were enrolled in an inpatient chemical dependency treatment program. Social drinkers were solicited from the community. Individuals with any history of substance abuse-related behaviors or any period of daily use were eliminated from this group. The total sample included 52 males and 34 females. Most of the subjects (93%) were caucasian, 4% were black, and 2% were hispanic. Average educationa I level was 13.2 years (SD = 2.76). Mean age of all subjects was 35.3 years (SD = 11.6). Subjects did not differ among the groups with respect to sex, race, educational level, or age. Within the alcohol abuse group, alcohol use had been problematic for a mean of 8.2 years (SD = 3.1), with 18.5% of the sample indicating infrequent use of other drugs. All subjects in the polydrug abuse group were included in the study on the basis of dependence on a drug other than alcohol (mean duration of use = 6.9 years, SD = 2.2), with cocaine (71%) and barbiturates (13%) as the principal drugs of choice. Amphetamines were the drug of choice in 10% of the polydrug subjects, while the remaining 6% preferred cannabis. Within this sample, 100% used combinations of drugs on a regular basis. Concurrent alcohol use was reported in 90% of these subjects, but was not indicated as the drug of choice or as a primary drug. Instruments Chemical Dependency Assessment Profile (CDAP) The CDAP (Davis, Harrell, & Honaker, 1989) is a 232-item clinical research questionnaire composed of multiple-choice, true-false, and open-ended questions. The profile specifically investigates alcohol use, use of non-alcohol drugs, and mixed or polydrug abuse. The questionnaire covers chemical use history, patterns of use, reinforcement dimensions of use, perception of situational stressors and attitudes about treatment, self-concept, and interpersonal relations. Adequate reliability and validity has been demonstrated (Davis et aI., 1989). A subset of the CDAP items, incorporating only mulitple-choice and truefalse items, were grouped into rationally derived dimensions that evaluated quantity/frequency of use, physiological symptoms associated with use, perceived situational influences or stressors, antisocial behaviors, interpersonal problems, affective dysfunction, attitude toward treatment, and the degree to which substance abuse is likely to have impacted on the individual's life circumstances. The dimensions were constructed from the questionnaire items to maximize both relative and operational independence (Horn, Wanberg, & Foster, 1985), with no item-overlap except on the degree of life impact dimension, which was based on critical items from the other dimensions and as such was conceptualized as a secondary dimension. Procedurally, multiplechoice and true-false items were independently sorted by two clinical psychologists and two senior doctoral students, all of whom were experienced in
418
T.H. Harrell, L.M. Honaker, and E. Davis
substance abuse assessment and treatment. The raters were asked to sort items into ten categories of their choice, based on their own conceptions of relevant dimensions of chemical dependency. Six categories demonstrated considerable item consistency across the raters. After eliminating items appearing in two or more categories, the categories were given dimension labels based on examination of item content, in much the same manner as statistically derived factors are evaluated. A seventh dimension was constructed by selecting those items believed to most significantly impact on the individual from the items in the six derived categories. Quantification of the dimension scores was adapted to the items and their response options, necessitating calculation by computer. Item response options were weighted on a scale of 0 to a maximum of 4, with 0 indicating that the endorsed response option did not constitute a problem and greater "eights indicating levels of severity or the number of difficulties present. For example, one item asks which of several feelings are problems for the individual. No endorsement is weighted 0, while each of the endorsed options describing an affect are weighted 1. On the item "I drink alone," the option "never" is weighted 0 and "frequently" is weighted 4, with the intermediate options weighted 2 and 3. Negative endorsements of true-false items were weighted 0 and positive endorsements weighted 4. Thus, the weightings were adapted to the nature of the item and response options. Sample items and response options are shown in Table 1. Actual scores for each dimension "ere calculated by dividing the sum of weights of the endorsed item options by the total possible weights and multiplying by 100. Increasing values denoted higher levels of dysfunction or symptomatology. Table 1. Sample Dimension and Expectancy Items from the Chemical Dependency Assessment Profile Antisocial Behaviors I get aggressive or violent "hen using alcohol I. ne'er 2. rarely 3. occasionally 4. frequently I have been arrested I. ne'er 2 for nUl 3 for more than one Dl.Il 4. for a crime committed when under the influence of alcohol Situational Stressors Employment Status I. employed 2 unemployed My Spouse or Roommate I. never had a problem with the use of alcohol or drugs 2. had or has a drinking problem 3. had or has a drug problem 4. had or has problems WIth drinking and drug use Attitude Toward Treatment I am here because 2 family or others wanted me to come I I chose to come 3 I was required to come by the court or other authorities
Dimensions of Dysfunction
419
Do )OU think )OU need trcatment? I. )CS 2 no Interpersonal Expectancies
I can be more assertive when I drink I. true 2. false Alcohol makes me feel less shy and more oUlgOlng I true 2 false Affective Dysfunction Select any of the followmg that are problems for )OU I. fears 2. guilt 3. depression 4. anger Physiological Symptoms
Whcn I stop dnnking for a penod of time I have the shakes or nausea I. never 2 rarely 3 occasionally 4. frequently I have been treated for a physical problem caused by my drinkmg I. never 2. once 3. repeatedly QuantitylFrequency of Use
In the last 6 months how frequently did )OU use alcohol? I. not at all 2. once a month 3. once a week 4 several times or more a week
Once I start uSing alcohol I continue until I'm completely intoxicated I. never 2. rarely 3 occasionally 4. frequently Tension Reduction Expectancy
I dnnk to relieve tension and stress I. true 2. false Drinking helps me get to sleep I true 2 false Social Facilitation Expectancy Drmkrng adds a certain warmth to SOCial occasions I. true 2. false
I prefer to dnnk with others I. true 2. false Mood Enhancement Expectancy
Dnnkmg makes me feel good 1. true 2 false Drmking makes me feel at peace wnh myself I. true 2. false
Items regarding use expectancies, or reinforcement dimensions of use, are included in the CDAP and also were utilized in the present study. These items were taken from the previously identified use expectancies of tension reduction, mood enhancement, and social facilitation, and are assessed via three lO-item
I.H. Harrell, L.M. Honaker, and E. Davis
420
true-false scales developed and validated by Farber, Khavari, & Douglas (1980) We derived expectancy scores from these scales based on the sum of affirmative responses to each scale. Comparability with the dimension scales was maintained by weighting affirmative responses 4 and negative responses O. For both dimension and expectancy scales, all original items were initially designed to measure alcohol abuse. A set of parallel items was developed for drug abuse, in most cases by replacing the terms alcohol and drinhing with drugs and USl1lg drugs. It was also necessary to repeat some drug items for each major type of drugs. Crowne-Marlowe Social Desirability Scale The Social Desirability Scale (Crowne & Marlowe, 1960) is designed to measure the degree to which subjects bias their responses by endorsing acceptable and approved behaviors. The Social Desirability Scale has demonstrated good reliability and validity, and is commonly used as a measure of response bias. Procedure All subjects completed the CDAP and the Crownc--Marlowe Scale. Substance abuse subjects completed the instruments within 3 to 9 days of entering treatment, depending on the length of detoxification. All subjects were retested approximately 1 week from the time of the first testing, with a mean test-retest interval of 6.4 days. Social drinkers completed the CDAP questionnaire based on their behavior and attitudes in the past 2 months. Substance abuse subjects completed the inventory based on the 2-month period prior to entering treatment. RESULTS
Social Desirability and Reliability Examination of the social desirability data indicated that all subjects responded with minimal concern for social desirability, demonstrating low Crown-Marlowe scores. There were no significant group differences on this measure, and social desirability scores were not significantly correlated with CDAP dimensions or expenctancy scores. Internal consistency of the dimensions and the expectancy scales was evaluated with Cronbachs alpha. Alpha values ranged from .78 to .88, all within an acceptable level for scales with varied items designed to increase validity (Kline, 1986). Test-retest correlations of the dimensions and expectancy scores yielded reliabilities exceeding .83 for all scores except attitude toward treatment (r = .65), which displayed an anticipated positive change in the abuse groups due to the subjects' participation in a treatment program. These findings were consistent with previous research indicating the relative reliability and validity
Dimcnsions of Dysfunction
421
of self-report regarding pretreatment use patterns and situational circumstances in alcohol-dependent populations. Factor Analysis
A preliminary factor analysis of the variables was conducted to determine whether common factors related to substance abuse would emerge. A principal component analysis. using a varimax rotation, was performed on the dimension scores (with the exclusion of the degree of impact secondary dimension) and the expectancy scores using the total sample. Table 2 displays the obtained factor loadings. Three clear factors emerged. The first factor was described as a behavioral/physiological component. This factor incorporated the dimension scores of physiological symptoms, affective dysfunction, antisocial behavioral, quantity/frequency of use, and the expectation of tension reduction. The behavioral/physiological factor accounted for 49.9% of the variance in the dimension and expectancy scores. The second factor was characterized as social in nature, including the interpersonal problems dimension along with social enhancement and mood facilitation expectancies. This factor accounted for 15.2% of the variance. The final factor, described as cognitive, involved the perceived influence of situational factors and attitude toward treatment. The cognitive factor accounted for 10.1 % of the variance. An independent maximum-likelihood factor analysis of the dimension and expectancy scores with varimax rotation also resulted in the extraction of three factors, with nearly identical factor loadings. Intercorrelations of Dimensions and Expectancy Scores
The CDAP dimensions and use expectancy scores were intercorrelated for the total sample and within each group. Because there were no significant Table 2. Factor Loadings from Principal Components Analysis with Varimax Rotation Factor I Varrable Physiological symptoms Affecuve dysfuncuon Tension reduction expectancy Antisocial behavior Usc quantity/frequency Interpersonal expectancy SOCial Iacilitauon expectancy Mood enhancement expectancy Treatment attitude Situational stressors 71
= 86
Behavioral/ Physiological
Factor 2
Factor 3
Social
Cognitive
85 .79 .78 .77 .77
92 .86 .85
.76 60
l.H. Hurell, L.M. HONker, and E. Da vis
422
differences in the intercorrelation matrices of the individ ual g roups, the tot al sample intercorrelation matrix is displayed in Table 3. Power for this sam ple, .81, was adequate for moderate effect sizes. Correlations were moderate, ranging from .25 to .87, for all variables except perceived situational stressors and attitude toward tre atment, which were not significantly correlated with the other di mensions or the expectancy scores. The relative correlational independence of th ese two dim ensions was found in each of the three groups. Group Differences in Dimensions and Expectancy Scores
Group differences in the dimensions and expecta ncies were evaluated via multi vari ate ANOVA . An overall group d ifference was obtai ned , Wllk's lambda = .056, multivariate F (32,136) = 13.7 2, P < .00 1, with pQ\\cr = .88. Table 4 presents the mean dimension and exp ectancy scores for the three groups. Social drinkers displayed significantly lower scores relative to abuse groups acros s all variables with the exception of social facilitation as an expectation of use . The alcohol and polydrug abuse groups differed significantly in the dimensions of perceived situational stressors, attitud e toward treat ment, and d egree of life impact, with the alcohol abuse group displaying higher (more dysfunction al) scores in each of these area s. Polydrug abusers ob tained a significantly higher Table 3.
Intercorrelations of CDAP Dimension and Use Expectancy Scores 2
Antisocial behaviors Situati on al st ressors Treatm en t attitude Interpersonal exp ectan cy Affective dysfu nction Physrolog ical s}mp toms Use qu antity! frequ ency Degree of hfe imp act Tension reduc tion exp ectancy SOCIal Iaciht ati on expe ctancy Mood enhancem ent exp ectancy
n
= 86.
3
4
5
6
7
8
9
10
(1) (2)
31
(3)
03
.06
(4)
44
.25
.20
(5)
.63
.29
02
.59
(6)
59
.31
.09
.38
.75
(7)
.61
.05
25
.29
63
.57
(8)
.72
.20
.07
040
.65
.7 1
46
(9)
60
.32
.0 1
047
.74
.70
.65
59
(10)
40
23
.06
80
.47
34
.38
36
.55
(11)
.52
.32
.16
87
.55
38
.47
.25
53
69
Dimensions of Dysfunction
423
Table 4. Means and Standard Deviations for the CDAP Dimensions and Use Expectancy Scores
Dimension
Antisocial beh aviors Situational stressors Treatment
Total POSSible 51 41 36
attitude
Interpersonal exp ect ancy Affective dysfunction Physiological symptoms Use qu anuty/ frequency Degree of life Impact Tension reduction SOCIal facrhtauon Mood enhancement
36 74 36 158 103 10 10 10
Alcohol Abusers (n
= 27)
73 (32) 15.2 (7.5) 66 (20) 177 (73) 35.9 (150) 96 (53) 17.2 (38) 358 (7.4) 7.8 (24) 63 (27) 6.6 (2.5)
Pol}drug Abusers (n
= 31) 7.6 (3.2) 82 (3 8) 40 (19) 14.2 (7.1) 367 (146) 90 (35) 30.7 (11.1) 22.0 (69) 7.5 (26) 5.6 (3.0) 52 (30)
SOCial Drinkers (n
= 28) 18 (2 0) 2,4 (1.9)
125 (69) 12.7 (8.0) 3 I (30) 88 (45) 68 (5.3) 3.1 (2.5) 46 (2.7) 39 (3.1)
score than alcohol abusers on the dimension related to quantity/frequency of use. Discriminant function classification analysis of the abuse groups using a linear combination of the var iables yielded correct classification of 100% of the subjects. Examination of the discriminant coefficients indicated that degree of life impact, quantity/frequency of usc, and perceived situational stressors most significantly contributed to discrimination between the two substance abuse groups. DISCUSSION The present findings suggest that our chemical dependency factors are reliable dimensions of substance abuse for both alcohol and polydrug abusers, and can be assessed in a questionnaire format with minimal concern regarding social desirability bias . Alcohol and polydrug abusers exhibited relatively parallel dimensions of dysfunction compared to social users, suggesting similarity in factors that are associated with or contribute to dependency for both abuse groups. The higher levels of dysfunction across several of the variables for the alcohol group, with greater quantity/frequency of use in the polydrug sample, led to some significant differences in dimensions between the two substance abuse groups.
424
T.H. Harrell, L.M. Honaker, and E. Davis
Although we hypothesized divergent patterns on the dimensions between the alcohol and polydrug samples, when considered individually the obtained differences primarily appear to reflect intensity or degree of dysfunction rather than qualitatively differential patterns of dysfunction specific to the nature of substance abuse. These differences most likely represent either sample or population differences between alcohol and polydrug abusers with respect to the level of dysfunction present before an individual seeks or is otherwise admitted to treatment. If the implications of these findings are more relevant to differences in the status of alcohol and polydrug abuse patients on admission to treatment, some interesting observations can be made. Relative to polydrug abusers, the alcohol abusers in our sample can be characterized as perceiving more situational life stressors and as having allowed alcohol to more significantly impact on their lives prior to entering treatment. Examination of specific items on these dimensions clarifies the implications of this finding. Alcohol abusers, prior to admission treatment, were more likely to be separated or experiencing marital conflicts and have been married more than once, have financial problems, be unemployed or have held ajob less than 1 year, and have a family member with a substance abuse problem. They also were more likely to have had occupational, family, legal, and memory problems due to substance abuse, to have sought treatment because others insisted, and to have experienced physical symptoms related to addiction. Polydrug abusers appeared to have engaged in an escalation of use over a relatively brief period prior to entering treatment, and had developed fewer long-term life complications. Overall, alcohol abusers had a somewhat greater duration of use, which was concomitant with more significant and chronic life problems relative to polydrug abusers, whose use patterns escalated more rapidly. Investigation of identified chemically dependent samples who are not seeking treatment is needed to clarify the relationship between entering treatment and our findings in this regard. Alcohol and polydrug abuse groups demonstrated dysfunctional use expectancies to a significant degree. Substance abusers endorsed an average of two thirds of the individual reasons for use, while social drinkers endorsed just over one third of the reasons. Reasons for use among the substance abusers emphasized tension reduction and negative mood avoidance, whereas social drinkers tended to have more moderate expectancies related to social facilitation and positive mood enhancement. Expectancies clearly operate to a significant degree in both alcohol and polydrug abusers. Although there were no significant differences between the two substance abuse samples, there was considerable individual variability in use expectancies, and examination of primary reasons for use on an individual basis would appear to be particularly relevant to treatment planning and relapse prevention. The principal component and factor analyses provide further support for a multidimensional model of substance abuse. Given that these analyses were based on small sample sizes, the relative consistency of the analyses is surprising, and increases the probability that the obtained factors will demonstrate stability
Dimensions of Dysfunction
425
and generalizability on replication. The extracted factors are similar to those identified previously in alcohol abuse populations (Scatero & Lesure, 1985; Schultz, Kelley, Overell, & Hollister, 1985) and are congruent with a multidimensional conceptualization of substance abuse, in which physiological, behavioral, social, and cognitive factors are necessary to adequately account for the patterns of dysfunction exhibited in chemically dependent individuals. Although the factors associated with substance abuse are clearly varied, they show a considerable degree of commonality across alcohol and polydrug abusers. The reliability and discriminant validity of the CDAP dimensions suggest their potential utility as treatment matching or outcome evaluation variables. Numerous investigators have advocated breadth in outcome evaluation, and noted that abstinence alone does not provide an adequate picture of the effects of treatment, especially with respect to overall psychosocial functioning (Emrick & Hansen, 1983; Maisto & McCollam, 1980; Pattison, 1966). Studies on patienttreatment matching have suggested that severity of life adjustment problems, affective dysfunctions, and self-concept are highly salient patient variables that may influence alcohol treatment effectiveness (see Mcl.ellan, Woody, Luborsky, O'Brien, & Druly, 1983). The CDAP dimensions assess several of the variables that have been recommended as potential matching measures, as well as patient factors noted as important in outcome evaluation (Emrick & Hansen, 1983). To facilitate further evaluation of the utility of the dimensions as outcome measures, a collateral version of the instrument is currently under development.
REFERENCES Crowne, D.P, & Marlowe, D (1960) A new scale of SOCIal dcsrrability independent of psychopathology journal ofCornullmg PSJchology, 24,349-354. DavIS, E , Harrell, T H , & Honaker, L M. (1989, November) Content domallls of dyfuncuon III alcoh ol and polydrugabusers The Chemical Dependency AssessmmlPrcfile. Paper presented at the meeting of the Association for the Advancement of Beha vior Therapy, Waslungton, DC Emrick, CD, & Hansen,] (1983) Assertions regarding effecuveness of treatment for alcoholism' Fact or fantasy? Amencan Psychologist, 38, 1078-1088. Farb er, P.D, Khavari, K A, & Dougl as, FM (1980) A factor analytic study of reasons for dunking: Empirical validauon of posuive and negative reinforcement dim ensions [ournal ofConsulting and Cluneal Psychology, 48, 780-781. Horn.] L., Wanberg, K.W, & Foster, F M. (1974). The Alcohol UseInventory, AUI Denver, CO Center for Alcohol-Abuse Research and Evaluation. I-lorn,] L , Wanberg, K W, & Foster, F M (1985) Guidelines for understanding alcohol use and abllSe The Alcohol UseInventory Baltim ore, MD. PsyclrSystems jellinek, E M (1960) The disease cconcept of alcoholism Highland Park, N] : Hill House Press Klme, P. (1986) A handbook of test construction New York Methuen Maisto , SA., & McCollam ,] B (1980) The use of multiple measures of hfe health to assess alcohol treatment outcome. A re view and cruique, In L C. Sobell, M B Sobell, & E. Ward (Eds .), Evaluatmg alcohol and drug abuse treatment efftclrt'elless: Recent ad t'a llces New York: Pergamon Mcl.clland, A.T, Luborsky, L, Wood)', G~E., & O'Brien, C P. (1980) An improved diagnostic evalu ation instrument for sub stance abuse pauents: The Addiction Severity Index.jouTllal of NeTt'OILS and Menial Disease, 168,232-239.
426
T.H. Harrell, L.M. Honaker, and E. Davis
Mcl.elland, AT, Wood)', G E, Luborsky, L , O'Brien, C P , & Druly, K A (1983) Predicting response to alcohol and drug abuse tre atments Archll'es oj General Psyduatry, 40, 620-625 Pattison, EM (1966). A cruique of alcoholism treatment concepts Wnh special reference to abstinence. Quarterly Journal oj Studies on Alcohol, 27, 49-71 Pattison, EM (1982). The concept of alcoholism as a syndrome. In E M Pattison (Ed), Selection oj treatment Jor alcoholics l'\e" Brunswick, N]: Rutgers Center of Alcohol Studies. Ringer, C., Kufner, H., Antons, K., & Fcuerlcm, W (1977) The N C A crueria for the dragnosis of alcoholism : A n empirical evaluation stud)'. Journal oj Studi es on Alcohol, 38, 1259-1273. Scatero, D] , & Lesure, K B. (1985) Syrnptornauc correlates of alcohol abuse as a presenting problem Journal oj Consulting Psychology, 41. 118-123. Schultz, H.T, Kelley, S , Overelk ] E., & Hollister, L.E. (1985) Factor structure of the Drinl..ing Behavior Interview in a prrvate mpauent treatrncnt program Journal oj Studies on Alcohol,46, 132-135. Wallace,] (1986) The other problems of alcoholics J oumal cfSubstance Abuse Treatment,3, 163-171. Wanberg, K.W , & Horn,] L (1983) Assessment of alcohol use \, IIh multidunensional concepts and measures Amencan Psychologist, 38, 1055-1069.
Cognitive and Behavioral Dimensions of Dysfunction in Alcohol and Polydrug Abusers Thomas H. Harrell L. Michael Honaker Elizabeth Davis Florida Institute of Technology
Development of a measure of parallel drmensions of cognuive and behavioral dysfunction related to substance abuse is descnbed Dimensions "ere assessed In alcohol and polydrug abusers entenng treatment and social drmkers Dimensions Included quanuty/trequency of use, physiological symptoms, Situational stressors, anusocial behav iors, Interpersonal problems, affective dysfunction, attitude toward treatment, degree of life impact, and three use expectancies Principal component analysis of the drmensrons and expectancies yielded three factors, behavioral/ physiological, SOCIal, and cognitive, Although the groups could be discriminated statistically, alcohol and polydrug abusers exhibited relauvely similar patterns of dysfunction across the dimensions and expectancies, WIth alcohol abusers demonstrating greater intensity or degree of dysfuncuon in several areas on admission to treatment. Implications of the findings WIth respect to multidimensional models of substance abuse and use of the dimensions In treatment matching and outcome research arc discussed
Theories of chemical dependency have evolved from an early focus on unitary concepts to a current emphasis on the multiplicity of factors associated with chemical abuse. The unitary-disease concept has a long history in the study of alcoholism. The advocates of this model have most often targeted quantity or frequency of use as the primary dimension that characterizes dependency (e.g., Jellinek, 1960). However, more recent approaches (e.g., Pattison, 1982; Wanberg & Horn, 1983) have adopted a multidimensional conceptualization in which dependency is recognized as a multi-level state that includes dysfunctions along physiological, interpersonal, behavioral, and cognitive dimensions. The focus also has shifted from a primary concern with alcohol abuse to consideration of abuse and dependency over a range of chemical substances. This change in emphasis has led to increasing interest in whether factors associated with other-drug abuse are similar to those found in alcohol abuse. In previous research, primarily in the area of alcohol abuse, a number of dimensions or domains of behavior relevant to substance abuse problems have We are grateful for the cooperation and assistance of the staff and management of Heritage Health Corporation, Melbourne, FL Correspondence and requests for reprints should be sent to Thomas H. Harrell, School of Psychology, Flonda Institute of Technology, 150 West University Blvd , Melbourne, FL 32901. 415
T.H. Harrell, L.M. Honaker, and E. Davis
416
been identified (see Ringer, Kufner, Antons, & Feuerlein, 1977; Wallace, 1986; Wanberg & Horn, 1983). A primary dimension involves the specific quantity and frequency of substance use. A second area of investigation has focused on the physiological symptoms and behavioral manifestations of substance abuse, including affective dysfunction, interpersonal conflict, and antisocial behaviors. Other researchers have emphasized the cognitive domain, examining expectancies, or reinforcement dimensions of substance use, as well as attitudes toward treatment and the user's perception of life stressors. Unfortunately, these areas have not been studied comparatively in alcohol and polydrug abuse populations. Examination of possible similarities across substance abuse populations has been impeded by the relative lack of availability of instruments that assess multiple factors associated with use in both alcohol and polydrug abuse samples. The Alcohol Use Inventory (AUI; Horn, Wanberg, & Foster, 1974) is a widely used instrument that was specifically developed to assess multidimensional concepts. However, the AUI was designed to assess only alcohol abuse. Early work in the area of alcohol and other-drug abuse assessment was done by Mcl.elland and his colleagues (Mcl.elland, Luborsky, Woody, & O'Brien, 1980). Their Addiction Severity Index (ASI) was designed to assess common elements of substance abuse across six major areas, irrespective of type of abuse. However, possibly due to the interview format, the ASI has seen limited use in subsequent research, and despite the conceptual emergence of polydrug abuse, many studies reveal a return to the earlier tendencies of assessing alcohol and polydrug abuse independently. In the present study, a paper-and-pencil questionnaire was developed to assess parallel cognitive and behavioral dimensions of problems in samples of alcohol-dependent and polydrug-dependent individuals entering treatment, and in a sample of social alcohol users. We delineated seven dimensions of substance abuse problems and three use expectancies, based on rationally derived categories of items. The dimensions and expectancies were conceptually meaningful, and indicated specific areas of dysfunction for the individual that could be directly related to intervention needs and treatment outcome evaluation. In this investigation we were particularly interested in examining the degree to which alcohol and polydrug abuse groups could be differentiated on the basis of the dimensions or expectancies, and whether common underlying factors related to chemical dependency could be identified. We hypothesized that both alcohol and polydrug abusers would demonstrate elevations across the dimensions relative to social drinkers, but that differential patterns of dysfunction would be obtained between the two abuse groups. We also hypothesized that commonalities in substance abuse factors could be identified among alcohol and other-drug abusers.
METHOD Subjects Participants in the study included 27 alcohol abusers, 31 polydrug abusers, and 28 social drinkers. All subjects participated on a volunteer basis, and were
Dimensions of Dysfunction
417
treated in accordance with APA standards for research with human subjects. The subjects in the substance abuse samples had been diagnosed as alcohol- or drug-dependent, based on DSM-III-R criteria. All alcohol and drug abuse subjects had acknowledged a problem with substance abuse, and were enrolled in an inpatient chemical dependency treatment program. Social drinkers were solicited from the community. Individuals with any history of substance abuse-related behaviors or any period of daily use were eliminated from this group. The total sample included 52 males and 34 females. Most of the subjects (93%) were caucasian, 4% were black, and 2% were hispanic. Average educationa I level was 13.2 years (SD = 2.76). Mean age of all subjects was 35.3 years (SD = 11.6). Subjects did not differ among the groups with respect to sex, race, educational level, or age. Within the alcohol abuse group, alcohol use had been problematic for a mean of 8.2 years (SD = 3.1), with 18.5% of the sample indicating infrequent use of other drugs. All subjects in the polydrug abuse group were included in the study on the basis of dependence on a drug other than alcohol (mean duration of use = 6.9 years, SD = 2.2), with cocaine (71%) and barbiturates (13%) as the principal drugs of choice. Amphetamines were the drug of choice in 10% of the polydrug subjects, while the remaining 6% preferred cannabis. Within this sample, 100% used combinations of drugs on a regular basis. Concurrent alcohol use was reported in 90% of these subjects, but was not indicated as the drug of choice or as a primary drug. Instruments Chemical Dependency Assessment Profile (CDAP) The CDAP (Davis, Harrell, & Honaker, 1989) is a 232-item clinical research questionnaire composed of multiple-choice, true-false, and open-ended questions. The profile specifically investigates alcohol use, use of non-alcohol drugs, and mixed or polydrug abuse. The questionnaire covers chemical use history, patterns of use, reinforcement dimensions of use, perception of situational stressors and attitudes about treatment, self-concept, and interpersonal relations. Adequate reliability and validity has been demonstrated (Davis et aI., 1989). A subset of the CDAP items, incorporating only mulitple-choice and truefalse items, were grouped into rationally derived dimensions that evaluated quantity/frequency of use, physiological symptoms associated with use, perceived situational influences or stressors, antisocial behaviors, interpersonal problems, affective dysfunction, attitude toward treatment, and the degree to which substance abuse is likely to have impacted on the individual's life circumstances. The dimensions were constructed from the questionnaire items to maximize both relative and operational independence (Horn, Wanberg, & Foster, 1985), with no item-overlap except on the degree of life impact dimension, which was based on critical items from the other dimensions and as such was conceptualized as a secondary dimension. Procedurally, multiplechoice and true-false items were independently sorted by two clinical psychologists and two senior doctoral students, all of whom were experienced in
418
T.H. Harrell, L.M. Honaker, and E. Davis
substance abuse assessment and treatment. The raters were asked to sort items into ten categories of their choice, based on their own conceptions of relevant dimensions of chemical dependency. Six categories demonstrated considerable item consistency across the raters. After eliminating items appearing in two or more categories, the categories were given dimension labels based on examination of item content, in much the same manner as statistically derived factors are evaluated. A seventh dimension was constructed by selecting those items believed to most significantly impact on the individual from the items in the six derived categories. Quantification of the dimension scores was adapted to the items and their response options, necessitating calculation by computer. Item response options were weighted on a scale of 0 to a maximum of 4, with 0 indicating that the endorsed response option did not constitute a problem and greater "eights indicating levels of severity or the number of difficulties present. For example, one item asks which of several feelings are problems for the individual. No endorsement is weighted 0, while each of the endorsed options describing an affect are weighted 1. On the item "I drink alone," the option "never" is weighted 0 and "frequently" is weighted 4, with the intermediate options weighted 2 and 3. Negative endorsements of true-false items were weighted 0 and positive endorsements weighted 4. Thus, the weightings were adapted to the nature of the item and response options. Sample items and response options are shown in Table 1. Actual scores for each dimension "ere calculated by dividing the sum of weights of the endorsed item options by the total possible weights and multiplying by 100. Increasing values denoted higher levels of dysfunction or symptomatology. Table 1. Sample Dimension and Expectancy Items from the Chemical Dependency Assessment Profile Antisocial Behaviors I get aggressive or violent "hen using alcohol I. ne'er 2. rarely 3. occasionally 4. frequently I have been arrested I. ne'er 2 for nUl 3 for more than one Dl.Il 4. for a crime committed when under the influence of alcohol Situational Stressors Employment Status I. employed 2 unemployed My Spouse or Roommate I. never had a problem with the use of alcohol or drugs 2. had or has a drinking problem 3. had or has a drug problem 4. had or has problems WIth drinking and drug use Attitude Toward Treatment I am here because 2 family or others wanted me to come I I chose to come 3 I was required to come by the court or other authorities
Dimensions of Dysfunction
419
Do )OU think )OU need trcatment? I. )CS 2 no Interpersonal Expectancies
I can be more assertive when I drink I. true 2. false Alcohol makes me feel less shy and more oUlgOlng I true 2 false Affective Dysfunction Select any of the followmg that are problems for )OU I. fears 2. guilt 3. depression 4. anger Physiological Symptoms
Whcn I stop dnnking for a penod of time I have the shakes or nausea I. never 2 rarely 3 occasionally 4. frequently I have been treated for a physical problem caused by my drinkmg I. never 2. once 3. repeatedly QuantitylFrequency of Use
In the last 6 months how frequently did )OU use alcohol? I. not at all 2. once a month 3. once a week 4 several times or more a week
Once I start uSing alcohol I continue until I'm completely intoxicated I. never 2. rarely 3 occasionally 4. frequently Tension Reduction Expectancy
I dnnk to relieve tension and stress I. true 2. false Drinking helps me get to sleep I true 2 false Social Facilitation Expectancy Drmkrng adds a certain warmth to SOCial occasions I. true 2. false
I prefer to dnnk with others I. true 2. false Mood Enhancement Expectancy
Dnnkmg makes me feel good 1. true 2 false Drmking makes me feel at peace wnh myself I. true 2. false
Items regarding use expectancies, or reinforcement dimensions of use, are included in the CDAP and also were utilized in the present study. These items were taken from the previously identified use expectancies of tension reduction, mood enhancement, and social facilitation, and are assessed via three lO-item
I.H. Harrell, L.M. Honaker, and E. Davis
420
true-false scales developed and validated by Farber, Khavari, & Douglas (1980) We derived expectancy scores from these scales based on the sum of affirmative responses to each scale. Comparability with the dimension scales was maintained by weighting affirmative responses 4 and negative responses O. For both dimension and expectancy scales, all original items were initially designed to measure alcohol abuse. A set of parallel items was developed for drug abuse, in most cases by replacing the terms alcohol and drinhing with drugs and USl1lg drugs. It was also necessary to repeat some drug items for each major type of drugs. Crowne-Marlowe Social Desirability Scale The Social Desirability Scale (Crowne & Marlowe, 1960) is designed to measure the degree to which subjects bias their responses by endorsing acceptable and approved behaviors. The Social Desirability Scale has demonstrated good reliability and validity, and is commonly used as a measure of response bias. Procedure All subjects completed the CDAP and the Crownc--Marlowe Scale. Substance abuse subjects completed the instruments within 3 to 9 days of entering treatment, depending on the length of detoxification. All subjects were retested approximately 1 week from the time of the first testing, with a mean test-retest interval of 6.4 days. Social drinkers completed the CDAP questionnaire based on their behavior and attitudes in the past 2 months. Substance abuse subjects completed the inventory based on the 2-month period prior to entering treatment. RESULTS
Social Desirability and Reliability Examination of the social desirability data indicated that all subjects responded with minimal concern for social desirability, demonstrating low Crown-Marlowe scores. There were no significant group differences on this measure, and social desirability scores were not significantly correlated with CDAP dimensions or expenctancy scores. Internal consistency of the dimensions and the expectancy scales was evaluated with Cronbachs alpha. Alpha values ranged from .78 to .88, all within an acceptable level for scales with varied items designed to increase validity (Kline, 1986). Test-retest correlations of the dimensions and expectancy scores yielded reliabilities exceeding .83 for all scores except attitude toward treatment (r = .65), which displayed an anticipated positive change in the abuse groups due to the subjects' participation in a treatment program. These findings were consistent with previous research indicating the relative reliability and validity
Dimcnsions of Dysfunction
421
of self-report regarding pretreatment use patterns and situational circumstances in alcohol-dependent populations. Factor Analysis
A preliminary factor analysis of the variables was conducted to determine whether common factors related to substance abuse would emerge. A principal component analysis. using a varimax rotation, was performed on the dimension scores (with the exclusion of the degree of impact secondary dimension) and the expectancy scores using the total sample. Table 2 displays the obtained factor loadings. Three clear factors emerged. The first factor was described as a behavioral/physiological component. This factor incorporated the dimension scores of physiological symptoms, affective dysfunction, antisocial behavioral, quantity/frequency of use, and the expectation of tension reduction. The behavioral/physiological factor accounted for 49.9% of the variance in the dimension and expectancy scores. The second factor was characterized as social in nature, including the interpersonal problems dimension along with social enhancement and mood facilitation expectancies. This factor accounted for 15.2% of the variance. The final factor, described as cognitive, involved the perceived influence of situational factors and attitude toward treatment. The cognitive factor accounted for 10.1 % of the variance. An independent maximum-likelihood factor analysis of the dimension and expectancy scores with varimax rotation also resulted in the extraction of three factors, with nearly identical factor loadings. Intercorrelations of Dimensions and Expectancy Scores
The CDAP dimensions and use expectancy scores were intercorrelated for the total sample and within each group. Because there were no significant Table 2. Factor Loadings from Principal Components Analysis with Varimax Rotation Factor I Varrable Physiological symptoms Affecuve dysfuncuon Tension reduction expectancy Antisocial behavior Usc quantity/frequency Interpersonal expectancy SOCial Iacilitauon expectancy Mood enhancement expectancy Treatment attitude Situational stressors 71
= 86
Behavioral/ Physiological
Factor 2
Factor 3
Social
Cognitive
85 .79 .78 .77 .77
92 .86 .85
.76 60
l.H. Hurell, L.M. HONker, and E. Da vis
422
differences in the intercorrelation matrices of the individ ual g roups, the tot al sample intercorrelation matrix is displayed in Table 3. Power for this sam ple, .81, was adequate for moderate effect sizes. Correlations were moderate, ranging from .25 to .87, for all variables except perceived situational stressors and attitude toward tre atment, which were not significantly correlated with the other di mensions or the expectancy scores. The relative correlational independence of th ese two dim ensions was found in each of the three groups. Group Differences in Dimensions and Expectancy Scores
Group differences in the dimensions and expecta ncies were evaluated via multi vari ate ANOVA . An overall group d ifference was obtai ned , Wllk's lambda = .056, multivariate F (32,136) = 13.7 2, P < .00 1, with pQ\\cr = .88. Table 4 presents the mean dimension and exp ectancy scores for the three groups. Social drinkers displayed significantly lower scores relative to abuse groups acros s all variables with the exception of social facilitation as an expectation of use . The alcohol and polydrug abuse groups differed significantly in the dimensions of perceived situational stressors, attitud e toward treat ment, and d egree of life impact, with the alcohol abuse group displaying higher (more dysfunction al) scores in each of these area s. Polydrug abusers ob tained a significantly higher Table 3.
Intercorrelations of CDAP Dimension and Use Expectancy Scores 2
Antisocial behaviors Situati on al st ressors Treatm en t attitude Interpersonal exp ectan cy Affective dysfu nction Physrolog ical s}mp toms Use qu antity! frequ ency Degree of hfe imp act Tension reduc tion exp ectancy SOCIal Iaciht ati on expe ctancy Mood enhancem ent exp ectancy
n
= 86.
3
4
5
6
7
8
9
10
(1) (2)
31
(3)
03
.06
(4)
44
.25
.20
(5)
.63
.29
02
.59
(6)
59
.31
.09
.38
.75
(7)
.61
.05
25
.29
63
.57
(8)
.72
.20
.07
040
.65
.7 1
46
(9)
60
.32
.0 1
047
.74
.70
.65
59
(10)
40
23
.06
80
.47
34
.38
36
.55
(11)
.52
.32
.16
87
.55
38
.47
.25
53
69
Dimensions of Dysfunction
423
Table 4. Means and Standard Deviations for the CDAP Dimensions and Use Expectancy Scores
Dimension
Antisocial beh aviors Situational stressors Treatment
Total POSSible 51 41 36
attitude
Interpersonal exp ect ancy Affective dysfunction Physiological symptoms Use qu anuty/ frequency Degree of life Impact Tension reduction SOCIal facrhtauon Mood enhancement
36 74 36 158 103 10 10 10
Alcohol Abusers (n
= 27)
73 (32) 15.2 (7.5) 66 (20) 177 (73) 35.9 (150) 96 (53) 17.2 (38) 358 (7.4) 7.8 (24) 63 (27) 6.6 (2.5)
Pol}drug Abusers (n
= 31) 7.6 (3.2) 82 (3 8) 40 (19) 14.2 (7.1) 367 (146) 90 (35) 30.7 (11.1) 22.0 (69) 7.5 (26) 5.6 (3.0) 52 (30)
SOCial Drinkers (n
= 28) 18 (2 0) 2,4 (1.9)
125 (69) 12.7 (8.0) 3 I (30) 88 (45) 68 (5.3) 3.1 (2.5) 46 (2.7) 39 (3.1)
score than alcohol abusers on the dimension related to quantity/frequency of use. Discriminant function classification analysis of the abuse groups using a linear combination of the var iables yielded correct classification of 100% of the subjects. Examination of the discriminant coefficients indicated that degree of life impact, quantity/frequency of usc, and perceived situational stressors most significantly contributed to discrimination between the two substance abuse groups. DISCUSSION The present findings suggest that our chemical dependency factors are reliable dimensions of substance abuse for both alcohol and polydrug abusers, and can be assessed in a questionnaire format with minimal concern regarding social desirability bias . Alcohol and polydrug abusers exhibited relatively parallel dimensions of dysfunction compared to social users, suggesting similarity in factors that are associated with or contribute to dependency for both abuse groups. The higher levels of dysfunction across several of the variables for the alcohol group, with greater quantity/frequency of use in the polydrug sample, led to some significant differences in dimensions between the two substance abuse groups.
424
T.H. Harrell, L.M. Honaker, and E. Davis
Although we hypothesized divergent patterns on the dimensions between the alcohol and polydrug samples, when considered individually the obtained differences primarily appear to reflect intensity or degree of dysfunction rather than qualitatively differential patterns of dysfunction specific to the nature of substance abuse. These differences most likely represent either sample or population differences between alcohol and polydrug abusers with respect to the level of dysfunction present before an individual seeks or is otherwise admitted to treatment. If the implications of these findings are more relevant to differences in the status of alcohol and polydrug abuse patients on admission to treatment, some interesting observations can be made. Relative to polydrug abusers, the alcohol abusers in our sample can be characterized as perceiving more situational life stressors and as having allowed alcohol to more significantly impact on their lives prior to entering treatment. Examination of specific items on these dimensions clarifies the implications of this finding. Alcohol abusers, prior to admission treatment, were more likely to be separated or experiencing marital conflicts and have been married more than once, have financial problems, be unemployed or have held ajob less than 1 year, and have a family member with a substance abuse problem. They also were more likely to have had occupational, family, legal, and memory problems due to substance abuse, to have sought treatment because others insisted, and to have experienced physical symptoms related to addiction. Polydrug abusers appeared to have engaged in an escalation of use over a relatively brief period prior to entering treatment, and had developed fewer long-term life complications. Overall, alcohol abusers had a somewhat greater duration of use, which was concomitant with more significant and chronic life problems relative to polydrug abusers, whose use patterns escalated more rapidly. Investigation of identified chemically dependent samples who are not seeking treatment is needed to clarify the relationship between entering treatment and our findings in this regard. Alcohol and polydrug abuse groups demonstrated dysfunctional use expectancies to a significant degree. Substance abusers endorsed an average of two thirds of the individual reasons for use, while social drinkers endorsed just over one third of the reasons. Reasons for use among the substance abusers emphasized tension reduction and negative mood avoidance, whereas social drinkers tended to have more moderate expectancies related to social facilitation and positive mood enhancement. Expectancies clearly operate to a significant degree in both alcohol and polydrug abusers. Although there were no significant differences between the two substance abuse samples, there was considerable individual variability in use expectancies, and examination of primary reasons for use on an individual basis would appear to be particularly relevant to treatment planning and relapse prevention. The principal component and factor analyses provide further support for a multidimensional model of substance abuse. Given that these analyses were based on small sample sizes, the relative consistency of the analyses is surprising, and increases the probability that the obtained factors will demonstrate stability
Dimensions of Dysfunction
425
and generalizability on replication. The extracted factors are similar to those identified previously in alcohol abuse populations (Scatero & Lesure, 1985; Schultz, Kelley, Overell, & Hollister, 1985) and are congruent with a multidimensional conceptualization of substance abuse, in which physiological, behavioral, social, and cognitive factors are necessary to adequately account for the patterns of dysfunction exhibited in chemically dependent individuals. Although the factors associated with substance abuse are clearly varied, they show a considerable degree of commonality across alcohol and polydrug abusers. The reliability and discriminant validity of the CDAP dimensions suggest their potential utility as treatment matching or outcome evaluation variables. Numerous investigators have advocated breadth in outcome evaluation, and noted that abstinence alone does not provide an adequate picture of the effects of treatment, especially with respect to overall psychosocial functioning (Emrick & Hansen, 1983; Maisto & McCollam, 1980; Pattison, 1966). Studies on patienttreatment matching have suggested that severity of life adjustment problems, affective dysfunctions, and self-concept are highly salient patient variables that may influence alcohol treatment effectiveness (see Mcl.ellan, Woody, Luborsky, O'Brien, & Druly, 1983). The CDAP dimensions assess several of the variables that have been recommended as potential matching measures, as well as patient factors noted as important in outcome evaluation (Emrick & Hansen, 1983). To facilitate further evaluation of the utility of the dimensions as outcome measures, a collateral version of the instrument is currently under development.
REFERENCES Crowne, D.P, & Marlowe, D (1960) A new scale of SOCIal dcsrrability independent of psychopathology journal ofCornullmg PSJchology, 24,349-354. DavIS, E , Harrell, T H , & Honaker, L M. (1989, November) Content domallls of dyfuncuon III alcoh ol and polydrugabusers The Chemical Dependency AssessmmlPrcfile. Paper presented at the meeting of the Association for the Advancement of Beha vior Therapy, Waslungton, DC Emrick, CD, & Hansen,] (1983) Assertions regarding effecuveness of treatment for alcoholism' Fact or fantasy? Amencan Psychologist, 38, 1078-1088. Farb er, P.D, Khavari, K A, & Dougl as, FM (1980) A factor analytic study of reasons for dunking: Empirical validauon of posuive and negative reinforcement dim ensions [ournal ofConsulting and Cluneal Psychology, 48, 780-781. Horn.] L., Wanberg, K.W, & Foster, F M. (1974). The Alcohol UseInventory, AUI Denver, CO Center for Alcohol-Abuse Research and Evaluation. I-lorn,] L , Wanberg, K W, & Foster, F M (1985) Guidelines for understanding alcohol use and abllSe The Alcohol UseInventory Baltim ore, MD. PsyclrSystems jellinek, E M (1960) The disease cconcept of alcoholism Highland Park, N] : Hill House Press Klme, P. (1986) A handbook of test construction New York Methuen Maisto , SA., & McCollam ,] B (1980) The use of multiple measures of hfe health to assess alcohol treatment outcome. A re view and cruique, In L C. Sobell, M B Sobell, & E. Ward (Eds .), Evaluatmg alcohol and drug abuse treatment efftclrt'elless: Recent ad t'a llces New York: Pergamon Mcl.clland, A.T, Luborsky, L, Wood)', G~E., & O'Brien, C P. (1980) An improved diagnostic evalu ation instrument for sub stance abuse pauents: The Addiction Severity Index.jouTllal of NeTt'OILS and Menial Disease, 168,232-239.
426
T.H. Harrell, L.M. Honaker, and E. Davis
Mcl.elland, AT, Wood)', G E, Luborsky, L , O'Brien, C P , & Druly, K A (1983) Predicting response to alcohol and drug abuse tre atments Archll'es oj General Psyduatry, 40, 620-625 Pattison, EM (1966). A cruique of alcoholism treatment concepts Wnh special reference to abstinence. Quarterly Journal oj Studies on Alcohol, 27, 49-71 Pattison, EM (1982). The concept of alcoholism as a syndrome. In E M Pattison (Ed), Selection oj treatment Jor alcoholics l'\e" Brunswick, N]: Rutgers Center of Alcohol Studies. Ringer, C., Kufner, H., Antons, K., & Fcuerlcm, W (1977) The N C A crueria for the dragnosis of alcoholism : A n empirical evaluation stud)'. Journal oj Studi es on Alcohol, 38, 1259-1273. Scatero, D] , & Lesure, K B. (1985) Syrnptornauc correlates of alcohol abuse as a presenting problem Journal oj Consulting Psychology, 41. 118-123. Schultz, H.T, Kelley, S , Overelk ] E., & Hollister, L.E. (1985) Factor structure of the Drinl..ing Behavior Interview in a prrvate mpauent treatrncnt program Journal oj Studies on Alcohol,46, 132-135. Wallace,] (1986) The other problems of alcoholics J oumal cfSubstance Abuse Treatment,3, 163-171. Wanberg, K.W , & Horn,] L (1983) Assessment of alcohol use \, IIh multidunensional concepts and measures Amencan Psychologist, 38, 1055-1069.