|
Items in cart [4] |
Questions? Call 888-624-8373 |
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 242
10 Assessment
In Chapter 9 the committee proposed a broadening of the base of treatment
through a wide dissemination of the capability to identify and briefly intervene with persons
manifesting mild or moderate alcohol problems. This strategy is intended for
implementation in settings other than specialized treatment programs for alcohol problems
to which persons identified as having substantial or severe alcohol problems would be
referred. In the next three chapters of this section of the report the committee discusses
strategies for enhancing the specialized treatment of alcohol problems. Three areas are
emphasized: (1) assessment prior to treatment, (2) matching to optimal treatment, and (3)
determining treatment outcome.
Considering assessment, matching, and outcome determination in separate chapters
is an arbitrary division of material for the purposes of discussion. In practice, each function
is related to the others, and all are parts of a unified whole. For example, the treatment
modalities that are available influence the content of assessment, and to match individuals
to the most appropriate treatments requires pretreatment assessment. Treatment outcomes
become increasingly meaningful with assessment and can be utilized to increase the accuracy
of matching. How accurate matching has been is, in turn, evaluated by determining
treatment outcome. Because the committee wishes to emphasize the importance of a close
integration of assessment, matching, and outcome determination, it has elected to discuss
how they might be fitted together both at the outset of this report (Chapter 1) and at the
close of Section II, Aspects of Treatment" (Chapter 13~. However, because all three of
these processes raise particular issues that need to be discussed, the committee has devoted
a separate chapter to each.
A key purpose of assessment is to determine which of the available treatment
options is likely to be most appropriate for the individual being assessed. Hence,
assessment must occur prior to any commitment of the individual to a particular kind of
treatment, and its utility is contingent upon the availability of multiple treatment options.
"When clinicians apply the same general [treatment] approach to most clients, assessment
data can have few treatment implications. With the arrival of more specific interventions,
however, the need for guidance by assessment data becomes more obvious" (Hayes et al.,
1987:964).
This general principle is particularly pertinent to the treatment of alcohol problems.
A major conclusion from the substantial body of research on treatment outcome in this
field is that there is no single treatment approach that is effective for all persons with
alcohol problems (see Chapter 5~. This being so, for optimal treatment matching is not
optional but is required (see Chapter 11~. Assessment provides the basis for matching.
What Is Assessment?
Assessment is the systematic process of interaction with an individual to observe,
elicit, and subsequently assemble the relevant information required to deal with his or her
case, both immediately and for the foreseeable future. In general, the collection of de-
tailed initial information is a feature of all human service settings. In particular, alcohol
problems are known to affect, and to be affected by, multiple aspects of an individual's life;
they frequently manifest themselves as physical problems, psychological problems, social
problems, and vocational problems simultaneously. Thus, the initial effort to collect
information might be expected to be at least as extended if not more extended than in
other service settings.
242
OCR for page 243
ASSESSMENT
243
Yet despite the logic and the pervasiveness of this approach, a comprehensive
assessment of each individual entering specialized treatment for alcohol problems is a
principle honored more in the breach than in the observance. Many specialized treatment
settings offer only a single modality of treatment (Glaser et al., 1978~. Thus, there is no
reason (from the program's standpoint) to develop information that might suggest
alternatives, and there may be strong financial incentives not to do so, a point discussed
later in this chapter. Although a certain amount of data is usually gathered, it is often
simply demographic information and, increasingly these days, information regarding available
reimbursement mechanisms. The data are gathered after admission to the treatment
program and therefore after a commitment has been made to a particular form of
treatment; hence, they have little or no bearing on treatment selection.
A sample statement from the literature documenting the general lack of
comprehensive assessment is that Patients were assigned to treatment methods without a
thorough evaluation of their problems and without a recorded assessment of severity and
were allowed to progress without follow-up or reassessments (S. Miller et al., 1974:213~.
In the province of Ontario, where the Addiction Research Foundation has advocated
pretreatment assessment for almost a decade, a 1986 survey of 181 programs found that
"although there was a very high endorsement of the systematic assessment of clients, only
about 20-25% of programs include state-of-the-art diagnostic instruments in their
assessment protocol. Assessment typically involved a structured or unstructured questioning
of the client, without the use of further diagnostic aids" (Rush, 1987:3~.
Even if one looks only at the treatment outcome research literature, in which
knowledge of pretreatment status is essential to determine whether treatment has affected
outcome, what one sees is less than satisfactory. "The failure to provide more
comprehensive pretreatment data, reports one group of investigators, ". . . is distressing
and is a problem that has not lessened with passage Of time Pr`~.tre.ntm`~.nt `1ntn for
~ . ..,,, _ . . . ~ , _ _ _ _
variables such as severity of dependence, chronicity of drinking problems, and quantitative
assessment of pretreatment drinking were reported in only about one-half of the studies"
(L. C. Sobell et al., 1988:117~.
The committee's general charge was to study the process of treatment and make
recommendations for its improvement, and it considers a comprehensive pretreatment
assessment to be crucial to such improvement. The "basic justification for assessment is
that it provides information of value to the planning, execution, and evaluation of
treatment" (Korchin and Schuldberg, 1981~. Yet assessment can serve multiple purposes,
and an appreciation of the need for assessment should arise from an understanding of all
of them.
The Purposes of Assessment for Alcohol Problems
Characterizing the Problem
If alcohol problems differ from one person to another, whether in degree or in
kind, it is crucial to document the differences. Otherwise, any changes subsequent to
treatment cannot be compared with the individual's pretreatment status. Some persons
coming for treatment, for example, will have high alcohol consumption levels, and others
will not. Some will be binge drinkers, and others will be steady drinkers. Some will have
experienced many symptoms in connection with their use of alcohol, and others will have
experienced few symptoms. Some will have accrued a great many adverse consequences of
alcohol consumption, and others will have accrued few consequences. As with other drugs,
OCR for page 244
244 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
those who have lower levels of consumption will probably exhibit more variety in the
problems they manifest than will individuals with higher levels of consumption (Edwards,
1974~.
But even among those with many signs and symptoms, the specific manifestations
will differ from one person to the next. For example, DSM-III-R lists nine signs and
symptoms of "psychoactive substance use disorders, of which any combination of three will
qualify for a diagnosis (American Psychiatric Association, 1987~. Thus, among those
qualifying for this diagnosis on the basis of their alcohol use, many alternative combinations
of manifestations will occur. In this spirit physicians have been cautioned to "be aware that
not every patient that drinks too much (for whatever reason) will be dependent on alco-
hol, and different patients need different help and treatment" (Edwards and Gross,
1976:1061).
As this warning suggests, the correspondence between level of consumption, pattern
of consumption, signs and symptoms, and consequences is not invariably a close one. Some
people with high consumption levels will drink steadily, have many signs and symptoms, and
experience many consequences, but others will not. The evidence for the relative
independence of these dimensions of alcohol problems will be discussed later in this
chapter. That they are not necessarily highly correlated with each other, particularly in
younger persons (Fillmore and Midanik, 1984; Fillmore, 1987), introduces still more
variance into the clinical picture of alcohol problems.
What should emerge from a comprehensive assessment is a detailed picture of the
particular kind of alcohol problem manifested by a particular individual at a particular
point in time. Of major importance is to describe the person and the problem in terms
that are clear and unambiguous. Not only is precision valuable in itself but, if assessment
is to be maximally useful, its terms must be clearly understandable to a variety of
individuals. The evolving treatment system is complex. Particularly in cases in which the
problem is a chronic one (and many alcohol problems will be), a large number of different
treatment personnel will encounter particular persons with alcohol problems over time.
In the absence of a clear and unambiguous picture at initial contact it may not
prove possible to understand the evolution of an individual's alcohol problem over time,
or to make appropriate decisions regarding care for the present and the future. Let us
consider a common clinical situation: a patient reports that he "had a problem before, but
it got better; now he has developed a problem again, only this time it is a little different."
What sort of problem did he have before? In what sense and to what degree did it
improve? In what way is the problem he has now different from the problem he had previ-
ously? Skillful interviewing can help to clarify some of these issues, but a comprehensive,
understandable, quantitative, recorded account of the patient's earlier status and of his
course would be invaluable in providing solid answers.
Precise information regarding the parameters of an alcohol problem is of interest
not only to therapists but also to those who manifest the problems. The feedback of
assessment data in an understandable form to those from whom it has been obtained is a
common and useful practice. Not only does it seem a reasonable courtesy, but there is
evidence that feedback can contribute significantly to treatment-seeking behavior.
Thus, in one study, half again as many individuals seeking help for alcohol
problems appeared in treatment after receiving a comprehensive assessment compared with
those who were not assessed (Annie and Skinner, 1984~. In another study, 95 percent of
a random sample of such individuals who were given an assessment battery returned for
their second appointment, compared with only 56 percent of those who were not given the
assessment (Sutherland et al., 1985~. General practice patients who completed a brief
assessment of their use of alcohol, tobacco, caffeine, medication, and nonmedical drugs
during which Feedback was given on how the patient's consumption levels compared with
OCR for page 245
ASSESSMENT
245
others of the same sex and ages were significantly more likely than those who were not so
assessed to query their doctors regarding all of these substances (H. ~ Skinner et al.,
1985b).
"Taking these [assessment] tests," commented one group of observers, "could have
predisposed patients to attend a second session either because they may have expected to
obtain some information about the test's results . . . or because they may have been
impressed by the amount of care devoted to them" (Sutherland et al., 1985:212~. In
confirmation, one patient in an assessment program commented that "it helps you to get
a hold of yourself and use your mind to sort out what makes you feel [the way you do]
about life" (Segal, 1984~. Another said that "it slowed down my thinking process and
allowed me to have a good, long look at myself. I now know what I am and what I have
to do to improve myself."
Characterizing the Individual
Alcohol problems do not occur in a vacuum. The individuals who manifest them
are at least as different from one another as are ordinary people (Chapter 2~. Or perhaps,
more different: Keller's law is that "the investigation of any trait in alcoholics will show
that they have either more or less of its (Keller, 1972~. A precise and systematic knowledge
of the differing characteristics that each individual exhibits at the time he or she is seen for
an alcohol problem, as well as a characterization of the problem, is another purpose of
assessment.
Eventually, such information will help to unravel which individual characteristics
may predispose people to alcohol problems and which are the result of alcohol problems.
Beyond these benefits for future research, however, lies the immediate therapeutic utility
of such information. Individual characteristics have much to do with a person's acceptance
(and, in consequence, the eventual outcome) of various forms of treatment (see the review
by Ogborne, 1978~. Thus, detailed knowledge of these characteristics is extremely useful
in selecting an appropriate treatment.
For example, persons who are well organized and of quite decided opinions may
tend to prefer relatively unstructured forms of therapy, whereas those who are disorganized
and at a loss may prefer more structured approaches (McLachlan, 1972; McLachlan, 1974;
Witkin and Goodenough, 1977; Hartman et al., 1988~. Those who prefer structure are
more likely to affiliate with programs that provide it, such as Alcoholics Anonymous
(Canter, 1966; Reilly and Sugerman, 1967~. Those who prefer unstructured settings, on the
other hand, may prefer an approach like client-centered or insight-oriented counseling, in
which the patient takes the lead and the therapist is relatively inactive. Persons with
positive views of themselves may be able to tolerate and benefit from therapeutic
approaches that are highly confrontational; those who view themselves negatively may be
harmed by such approaches (Annie and Chan, 1983~. Persons whose views of the locus of
responsibility for alcohol problems (both for developing and for dealing with them) are
congruent with the views of program staff may be more likely to sustain treatment
(Brickman et al., 1982~.
Another aspect of characterizing individuals has to do with their medical and
psychiatric status. People with alcohol problems often have medical and psychiatric
problems as well (Wilkinson and Carlen, 1981; Ashley, 1982; Popham et al., 1984;
Mendelson et al., 1986; Ross et al., 1988~. Some of these problems may be the result of
alcohol consumption; some may result in drinking (for example, for symptomatic relief);
still others may be independent problems. Yet all are important in themselves, requiring
clarification and, often, therapeutic attention. To concentrate solely on an individual's
alcohol problem and fail to recognize or to deal with a significant medical or psychiatric
OCR for page 246
246 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
problem in the same individual is not only poor therapeutic practice but a potential cause
for legal action.
There is also evidence that the coexistence of particular problems (e.g., depression,
anxiety or panic states, schizophrenia, antisocial personality, drug dependence) may directly
affect the outcome of treatment for alcohol problems (Woody et al., 1984; Strayvinski et
al., 1986; Rounsaville et al., 1987; Kadden et al., 1990~. The effective management of
alcohol problems, in other words, may in some instances be contingent upon the effective
management of intercurrent problems. Thus, an assessment of medical and psychiatric
status should be a standard element of comprehensive assessment. When one considers
that alcohol affects both the body and the mind directly, this is hardly a surprising
conclusion.
The point that alcohol problems do not occur in a vacuum is paralleled by the
point that "no man is an island. It is important during the assessment process to
characterize the person's social context as well as the person. A turbulent social context
may entirely negate any attempts at individual treatment and may need to be directly
addressed as the initial order of business. Individuals with problematic family or home
situations or both are unlikely to sustain participation in outpatient treatment programs
(H. ~ Skinner, 1981c). If there is a history of marital troubles, some attention may be
required in this area. If there have been job-related difficulties, vocational evaluation and
training may be prudent. If there has been difficulty in allocating leisure time, or a social
support network is lacking, social or recreational counseling may be in order. Thus,
obtaining an adequate picture of the social context of the individual who has the alcohol
problem is an important purpose of assessment.
Characterizing the manifold aspects of individuality is a highly complex matter, and
an exhaustive discussion of all of the parameters that may require address during assessment
is not possible here. The committee envisions such a discussion as more appropriately part
of a consensus exercise that would consider both the relevance of various parameters and
the means whereby they can be effectively measured (see below). What the committee
hopes will arise from the foregoing discussion is an appreciation of the necessity to
characterize individuals as part of a comprehensive assessment process.
Characterizing the Treatment Population
If each individual in the treatment population were characterized in a similar
manner, individual data could be aggregated; with aggregation it becomes possible to
characterize the treatment population as a whole. As will be discussed further below,
accomplishing such a characterization does not mean that the assessment of each individual
must be identical in every particular, a practice that would fail to give due recognition to
the diversity of individuals and of the problems for which they are seeking treatment. It
does suggest, however, that there should be common data elements in the assessment of all
individuals. Common data would permit not only the characterization of the population
of a given program but the comparison of one program population with another.
O 1 ~ ~ ~ · ~ _ ~ ~ ~ A ~ ~ 1 1 _ .
While it is easy to see that the population cnaracterlstlcs of programs especially
targeted for particular population groups-women, youth, or ethnic minorities, for
example-are likely to differ, it is less apparent that the populations of treatment programs
with a more general orientation may differ as well (Pattison et al., 1969; Pattison et al.,
1973; Bromet et al., 1976; Bromet et al., 1977; H. ~ Skinner and Shoffner, 1978; Kern
et al., 1978; Finney and Moos, 1979; H. A. Skinner, 1981c). Location, history, reputation,
publicity, accessibility, treatment orientation, cost, staff composition, funding, and other
factors undoubtedly enter into the determination of such differences. They are not stable
determinants, and so the characteristics of a treatment program population may change over
OCR for page 247
ASSESSMENT
247
time. For this reason the occasional assessment of program population characteristics is
less useful than their ongoing assessment.
If the characteristics of a program population are known, and the characteristics
of the general population from which it is drawn are also known, it is possible to estimate
the effectiveness of the program in recruiting its target population. For example, a
community assessment service in London, Ontario, saw 14.1 percent of the persons with
serious alcohol problems in its catchment area over a three-year period (Malla et al., 1985~.
A household survey in that area of the province had found that only 3.2 percent of
individuals classified as problem or dependent drinkers during the past year had ever
received treatment for alcohol problems in their lifetimes (Smart et al., 1980~. The authors
concluded that "the assessment centre may, over a period of time, increase the penetration
rate of a treatment system into the local alcoholic population" (Malta et al., 1985:41~.
If comparable data exist for more than one treatment program, between-program
comparisons are possible. Two programs may have similar proportions of positive
outcomes, but if it is known that the two populations differ on Such pretreatment
characteristics as, for example, severity of alcohol problems or level of employment, a more
exact understanding of the two programs and their relative efficacy is possible. The
assessment center noted above (Malta et al., 1985) had a high rate of referral from
physicians and employers, while other area programs had high rates of self-referrals and
referrals from family and friends; this pattern speaks to differential, and possibly
complementary, recruiting from the overall population. Comparable data from all treatment
programs would be invaluable in revealing which segments of the community were being
served and in planning further services for those who are not entering existing programs.
Planning Treatment for the Individual
, , ,
~. ~ . ^^
-
Full characterization of a given individual, combined with knowledge of available
treatment options, facilitates appropriate, prompt, and effective management of the
-individual's problem. For example, there is evidence (cf. reviews by Annis, 1986a; W. R.
Miller and Hester, 1986) that the results from inpatient and outpatient treatment do not
differ for heterogeneous groups of patients. Some (W. R. Miller and Hester, 1986; Saxe
et al., 1983) accordingly have advocated that outpatient treatment should be tried first
because it is less expensive and that inpatient treatment should be undertaken only if
outpatient treatment fails.
But it is well known that individuals with low social stability (as well as other
characteristics) are unlikely to sustain participation in outpatient treatment (e.g., H. ~
Skinner, 1981c). Thus, rather than a wholesale embargo on inpatient programs for all
persons seeking treatment, the more discriminating use of inpatient programs might be
envisioned. Those with low social stability, as well as a profile of other indicative features
(severe withdrawal symptoms, major medical or psychiatric complications, a markedly
noxious environment, crucially aversive temporary circumstances, etc.), might be referred
initially to inpatient or residential programs. Others, in more favorable circumstances and
with less severe problems, might be referred to outpatient programs (cf. Hoffmann et al.,
1987~.
To provide another example of the potential utility of pretreatment assessment in
assigning individuals to treatment, let us consider a controlled trial in which no advantage
was found in the use of a particular treatment (highly confrontational group therapy, or
so-called "attack" therapy) in a heterogeneous correctional population (Annie, 1979~.
Retrospective reanalysis of the data extended these findings. Although there had been no
net benefit in the treatment group, in fact some individuals had benefitted and others (in
OCR for page 248
248 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
approximately equal numbers) had not. Moreover, data were available to show that these
two groups were systematically different.
Those who had benefitted were characterized on initial assessment by positive
self-images (determined objectively with appropriate psychometric instruments). Those who
failed to benefit indeed, who appeared to have been harmed by the treatment were
characterized by negative self-images (Annie and Chan, 1983~. In future, it is to be hoped
that the self-image of persons seeking treatment could be determined in advance, and that
only those with positive self-images would be assigned to "attacks therapy.
In other words, assessment prier to treat forms the basis on which individual
patients are matched to particular treatment programs. This point was stressed earlier, but is
repeated here for emphasis. Matching is the subject of the next chapter in this report
(Chapter 11~; the implications of assessment for matching are more fully discussed there.
It is worthwhile to point out that additional information on the individual will need
to be gathered by program staff following the selection of treatment in order to plan the
individual's ongoing treatment course. In some respects, indeed, treatment involves a
continual and ongoing gathering of information on the individual. Pretreatment assessment
initiates this aspect of treatment, but information gathering continues throughout treatment.
Guiding Treatment for the Population
Assessment provides information that can be used to develop a clinical data base.
HA clinical data base is created when well-defined, discrete, and continuous data elements
concerning patients are routinely recorded and coupled with outcome descriptors" (Pryor
et al., 1985:623~. Given knowledge of pretreatment characteristics and knowledge of the
outcome of treatment, a comprehensive picture of individual responses to treatment can be
elaborated. This information can then be used to estimate the probable responses of future
patients to particular treatments. Their characteristics can be documented during the
assessment process, and treatment can be selected on the basis of information about how
individuals with similar characteristics have previously responded to the available alter-
natives.
speed.
Ah ~ cvct`~m he hP.P.n rP.~.nmmended as the basis for medical care generally
(Ellwood, 1988~. To manage the large amount of information involved and to provide
rapid access to that information, computerization of the clinical data base is logical. Yet
it is worth noting that the fundamental model is the human clinician. "The ability of a
practitioner to couple the process of patient care to the outcome of a disease is the
underlying principle enabling physicians to learn from their previous experience" (Pryor et
al., 1985:623~. Computerized data bases seem foreign or even outlandish to many. Yet
they simply imitate and extend a familiar model, formalizing what is done by good clinicians
in the management of patients but doing it with greater scope, capacity, accuracy, and
~ ~e ~ ~ ~ ~ ,.. .. ~ ~
Such data bases are already in existence for many particular kinds of problems.
Tumor registries are perhaps the most familiar example (Laszlo, 1985), but clinical data
bases exist for such prevalent problems as cardiovascular disease (Hlatky et al., 1984) and
such uncommon problems as systemic lupus erythematosus (Fries, 1976), a severe disease
that involves the destruction of connective tissue throughout the body. There is at least
one extensive clinical data base for alcohol problems that includes outcome information,
that of the Chemical Abuse/Addiction Treatment Outcome Registry (CATOR) (Belille, n.d.
[ca.19873; Harrison and Belille, 1987; Harrison and Hoffmann, 1987~.
OCR for page 249
ASSESSMENT
249
At present, existing data bases are for the most part not used to guide treatment
for populations (but see Fries, 1976~. Given the increasing availability of computers there
is every prospect that they could be so used. In fact, treatment programs offering different
treatments could assemble around--a shared clinical data base and use the information
contained in it to guide the selection of treatment for all individuals presenting to the
programs collectively (see Chapter 13~. For this proposal to be feasible, however, a
comprehensive pretreatment assessment must be an integral part of the clinical process.
To summarize: assessment is a comprehensive gathering of information about each
individual who is being considered for specialized treatment for alcohol problems. Its
purposes include the characterization of the presenting alcohol problem, the individual who
has the problem, and the population seeking treatment, and the facilitation of appropriate
treatment for all. Although widely advocated, comprehensive assessment prior to treatment
is the exception rather than the rule. To facilitate its more general use, the committee in
the next three sections discusses its structure, its content, and its administration.
The Structure of Comprehensive Assessment
There are two important guidelines for structuring comprehensive assessment in the
alcohol treatment field. Both are consequences of the heterogeneity of alcohol problems
(see Chapter 2~. One is that assessment should be sequentu~l; the other is that assessment
should be mul~idimer~sional.
Sequential Assessment
Gathering information, and the attendant processes of recording, storing, and
retrieving it for various uses, should not be lightly undertaken. Such activities are costly
in terms of time, money, and effort. One wants to be certain, therefore, that all of the
information gathered is necessary and that no more information is gathered than is required
for the purposes at hand. Accordingly, it is advisable to divide the process of assessment
into a series of stages, each of which may or may not lead into the next stage (H. ~
Skinner, 1981a; 1981b). This approach, which is called sequential assessment, is graphically
portrayed in Figure 10-1.
The initial stage in the assessment sequence for those seeking specialized treatment
for alcohol problems is screening. In common with the process of identification in the
community sector of treatment (see Chapter 9), the basic questions asked here are (1)
whether an alcohol Problem is present and (2) whether it requires specialized treatment.
. ~ ~
This duplication of what may occur in the community is necessary in a specialized
assessment setting for alcohol problems because some individuals-those who did not first
attend a primary care physician, social agency, or another community setting in which the
identification process is available-will seek specialized treatment directly. Of those who do
present for treatment, many will prove to have alcohol problems, but some will not.
Hence, screening as the first order of business makes practical sense and, in at least some
instances, will suggest that the remainder of the comprehensive assessment process is not
necessary.
Even if a problem is present, it may prove to be one that can readily be dealt with
through brief intervention. Referral to a community setting rather than to specialized
treatment can in such instances be made on the basis of screening alone. Although the
yield again will be small, the saving of time and effort devoted to subsequent assessment
stages even in a small number of cases will be worthwhile.
OCR for page 250
250 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
EXTENT OF INFORMATION
it_
-SCREENING
_
PROBLEM
ASSESSMENT
-
-
PERSONAL
ASSESSMENT
COST
Ch
_ ~
FIGURE 10-1 Sequential Assessment. As one moves from screening to problem assessment to personal
ae~P~:~:mPnt the `~rt`~nt Of infnrrn~tir~n t1f~v~1r~nt~.~1 in arbiter hilt the costs of assessment are also greater. Performing
~ ~ all_ In_ ~^ - - r D
an assessment sequentially ensures that further information is necessary and justifies its increased cost (adapted
from Skinner, 1981a:30; 1981b:330~.
If screening suggests that the individual probably does have a problem that is likely
to require specialized treatment, the next step in the sequence may be thought of as the
problem assessment. This stage of assessment represents a major increment over screening
in the extent and variety of the information it yields (as well as in the effort and time
required to implement it). Because screening has indicated the likelihood that an alcohol
problem is present, this next stage of assessment both tests and extends that observation.
Many instruments have been developed which may be utilized for problem
assessment (cf. Lettieri et al., 1985b). As discussed in the previous chapter, a single scale
instrument is often used for screening purposes. It may be appropriate in the next stage
of assessment to utilize a multiscale instrument, such as the Alcohol Use Inventory (AUI)
(Wanberg et al., 1977; H. ~ Skinner and Allen, 1983a; Horn, Wanberg & Foster, 1987~.
With its extensive item pool and multiple scales, the AUI, together with other elements of
the problem assessment, can provide confirmation or disconfirmation of the screening
finding that an alcohol problem exists; moreover, it can help to determine what kind of
alcohol problem it might be. Additional effort is expended, but additional information is
gained. As is discussed later in the chapter, other measures at this stage of assessment can
also be used to provide similarly extensive data on other aspects of the presenting alcohol
problem.
Ideally, both the screening stage and the problem assessment stage are uniform in
their content for all persons seeking treatment. Such uniformity is desirable because all
such persons may or may not have alcohol problems. If no alcohol problem is present, or
OCR for page 251
ASSESSMENT
251
the problem that is present is appropriate for brief intervention rather than specialized
treatment, the assessment process can end.
Alternatively, once the presence of a problem appropriate for specialized treatment
has been confirmed, and the nature of that problem has been fully characterized during the
problem assessment stage, it is appropriate to move on to the next stage of assessment.
As discussed earlier, to determine the most appropriate treatment one must take into
consideration not only the characteristics of the problem but those of the individual
manifesting the problem. Thus, the third stage of a comprehensive assessment, following
screening and the problem assessment, is the personal assessment.
Before beginning this stage of the assessment, however, it is advisable to undertake
a specific screening process as the first order of business. Some of the procedures that
must be implemented to gather a full complement of data during the course of a personal
assessment are among the most extensive and time-consuming in the assessment repertoire.
They therefore should not be deployed unless there is preliminary evidence that it is
necessary to do so.
For example, confirmation of the presence of a psychiatric disorder may involve the
administration of a structured instrument such as the Diagnostic Interview Schedule (DIS)
(Robins et al., 1981), or a psychiatric consultation, or both. Before engaging in these
complex procedures, it would be appropriate first to screen as quickly and as accurately as
possible for the presence or absence of psychiatric problems. The screening could be
accomplished by the use of a brief instrument such as the General Health Questionnaire
(GHQ) (Goldberg, 1972, 1978; Ross and Glaser, 1989) or the psychiatric scale of the
Addiction Severity Index (ASI) (McLellan et al., 1980; McLellan et al., 1985~.
Screening for this and the many other substantive areas one might wish to explore
during the personal assessment is essential to ensure that the assessment process is
parsimonious; that is, that only those dimensions of the individual that require an extensive
assessment receive it. There should be variability in the procedures of the personal
assessments of specific individuals because there will be variability in the personal areas
in which they have problems. With the exception of certain individual attributes that are
sufficiently relevant in all cases to merit routine assessment (e.g., personality), the highly
specialized measures would only be utilized if screening indicated a reasonable probability
that treatment-relevant information would be gained.
To summarize, the committee views comprehensive assessment as a seque~ialprocess that
proceeds from one stage to the revert if such a progressions is indicated. Three stages are
proposed. The first is a screening stage, in which the presence or absence of a problem and
the likelihood that specialized treatment may be required are determined; this stage is
similar to the identification process in the community setting discussed in Chapter 9. The
second stage comprises the problem assessment, that is, the characterization of the alcohol
problem that screening has indicated is present. The third stage is the personal assessment
stage, in which the nature of the individual who is experiencing the problem is fully and
uniquely characterized; the emphasis in this stage is on areas in which personal problems
are being experienced. The overall goal of the assessment is to produce sufficient
information to make treatment-relevant decisions.
Multidimensional Assessment
In the previous section of this chapter, it was suggested that assessment be divided
into stages. Each of these stages, however, ideally involves the eliciting of information
along several important dimensions rather than along a single dimension. Alcohol
problems are complex; the people who manifest them are complex; and these complexi
OCR for page 252
252 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
ties defy simple characterization.
mult~idimens~on~al.
To illustrate the principle of multidimensional assessment, let us concentrate for
the moment on the problem assessment. The task of problem assessment is to describe as
fully (and yet as parsimoniously) as possible the problem or problems with alcohol that an
individual may have. From the standpoint of multidimensionality, the relevant question is
the following: how many different dimensions are required to provide a reasonable
description of a given alcohol problem?
There has been a tendency to rely on only a single dimension, a measure of the
individual's use of alcohol, to characterize his or her alcohol problem. This measure can
be taken, for example, by a tally of the average number of standard drinks the individual
consumes per day. Certainly, this is important information, but such a measure of a
person's level of use does not even fully characterize alcohol use. Of additional importance
is the pattern of use. If an individual consumes four drinks per day on average, it will
make a considerable difference (at least in the clinical picture) whether he consumes them
in an hour or two or whether they are spaced out over the course of the entire day. With
the former pattern, the individual is likely to become intoxicated; with the latter pattern,
intoxication is unlikely.
The pattern of alcohol use in turn can make a difference in the consequences the
individual experiences. In a recent study (Kranzler et al., 1990) it was found that both an
increased level of consumption and a pattern of consumption likely to result in intoxica-
tion independently increased the risk of consequences. Interestingly, it was found that an
increased level of consumption was more likely to contribute to consequences in males,
while an intoxication pattern of consumption was more likely to contribute to consequences
in females. The authors concluded that "these variables, though related, require
independent consideration."
Beyond the daily pattern of use, it is important to have information about the
pattern of use over longer periods of time. Some persons do drink at the same level and
in the same daily pattern over prolonged periods of time. Others, however, vary both their
level and their daily pattern of use quite considerably. Binge drinking is a well-known
long-term pattern of alcohol use. It is likely that such long-term patterns have important
implications for consequences as well as prognosis; hence what can be termed a history of
use is an important element in the characterization of an individual's use of alcohol. Such
a history would include information as to the time in life the individual began to drink and
the length and circumstances of periods of nonuse, as well as the pattern of use over the
last few years prior to seeking treatment.
Thus, an adequate assessment of an individual's use of alcohol would include
information on the level of use, the pattern of use, and the history of use. It might be felt
that such a comprehensive consideration of alcohol use might suffice to characterize an
alcohol problem because there is a general and positive correlation between the use of
alcohol, signs and symptoms, and consequences, a correlation that becomes most evident
when aggregate data from large groups of individuals are explored and when the problems
themselves are longstanding and severe. But treatment is a clinical process that deals with
single individuals, one at a time; among individuals, wide variations may be found in the
relationship between' use, signs and symptoms, and consequences. The vignettes at the beginning
of Chapter 2 of this report include individuals (George, Gregory) with low levels of
consumption and serious consequences, as well as one individual (Elizabeth) in whom a
high level of consumption was associated for a long period of time with no apparent
consequences at all.
Disparities between the level of alcohol consumption and the effects of alcohol are
also matters of common experience. Some individuals "can't hold their liquors and become
thoroughly intoxicated on small amounts of alcohol which would not faze most social
Thus, the assessment of alcohol problems should be
OCR for page 268
268 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
desired qualities of quantifiability, reliability, validity, standardization, and recordability (see
above).
An example of a structured interview from the alcohol field is the time-line (TL)
interview, which measures past lifetime alcohol consumption.
Its reliability has been
examined (L. C. Sobell et al., 1988) and it has been found that individuals given the
instrument at different times will come up with consistent estimates of levels of alcohol
consumption in past periods of their lives. Whether it is valid, however whether these
estimates are correct-cannot be established because there is no adequate criterion, that is,
a certain and alternative method of determining past consumption. Research on biological
markers may one day provide the needed criterion. Meanwhile, a reliable means of
determining retrospective consumption is to be preferred to one that lacks demonstrated
reliability.
The chief disadvantage of structured interviewing as a means of gathering
assessment information has to do with personnel time and training. The constant
attendance of extensively trained personnel is required to administer a structured interview.
In a time of resource constraints on the one hand and increased demand for services on
the other, this disadvantage can be considerable. Attention has accordingly been given to
the self-administration of assessment. The savings from self-administration can be
considerable, even if small amounts of information are concerned. The MAST takes
approximately 10 minutes to administer; if 20 patients a day are assessed, the total saving
is more than three hours of personnel time.
A common form of self-administration is the use of paper-and- pencil tests. The
use of such tests does involve personnel time but of another sort. More than a single test
is usually given. Tests must be selected from storage; then each test must be presented to
the individual with the appropriate instructions, proofed for completeness, scored,
standardized, and recorded. Because different individuals are given different tests and work
at different speeds, a one-on-one assessment staffing pattern may be required. In short,
although there are resource advantages to self-administration, resource requirements are still
apparent.
Computers can be utilized effectively to limit further the resource requirements of
assessment. An initial capital investment is needed, but the ultimate saving on resources
through the reduced cost of each assessment performed thereafter more than compensates
for the original expenditure (Klingler et al., 1977~. Although computers can be used in a
rather peripheral manner to perform such tasks as the automated scoring of
self-administered tests, they truly come into their own when they are used as
self-administration devices. For staff, this use involves providing the individuals being
assessed with adequate instructions, sitting them down in front of a computer and keyboard
(often modified for the sake of simplicity), and being available to provide help and answer
questions.
The various instruments or interview schedules to be used for the assessment are
held in the capacious and accurate memory banks of the computer. An appropriate
program presents the instruments in predesignated order. Responses to individual items
can be checked for appropriateness and completeness, ensuring that each response given
falls within the designated range for each item and that all questions are completed. If the
responses are faulty or incomplete, the computer can (given adroit programming) prompt
the individual to make appropriate corrections. In a sequential assessment process, the
computer can be programmed to indicate automatically whether it is necessary to proceed
from one stage to the next, and to select the requisite instruments to provide in-depth
assessment on the basis of scores from the screenings of the prior stage, which it has
automatically calculated and compared with the standardized norms in its memory. In
addition, the computer can be programmed to integrate multiple assessment results into
OCR for page 269
ASSESSMENT
269
an understandable and comprehensive assessment report (see an example in H. ~ Skinner
[1981a:359~.
To some readers the prospect of computerized assessment will sound like magic at
best and science fiction at worst. But to others it will be commonplace. Interactive
computer games were the best-selling gift item during the 198$ holiday season. The use
of computers not only has a high level of initial acceptance in assessment situations but an
increasing level of enthusiasm following first exposure, as well as equivalent or superior
results to paper-and pencil tests and face-to-face interviewing (H. ~ Skinner, 1981; H. ~
Skinner and Allen, 1983b; H. ~ Skinner et al., 1985a, 1985b). Computer technology has
advanced rapidly since the introduction of microcomputers, with the result that equipment
of great capability is now available at reasonable cost. Although most frequently criticized
as impersonal, the computer can instead increase the interpersonal ambience of assessment.
By performing many of the tasks that would ordinarily be required of the assessor it frees
time for interpersonal interaction (cf. Levitt, 1972~.
Nevertheless, even if assessment is largely automated it may be prudent to design
an assessment that is a mixture of face-to-face interviewing, self-administered testing, and
computerized testing. None of the methods is foolproof, and some may be precluded by
the specialized disabilities or preferences of individual patients. Those carrying out the
assessment might optimally be trained to administer the entire process in either of the
three options. In that way staff would have a more complete understanding of the process,
and maximum flexibility would be assured.
. ~ ,
Conclusions and Recommendations
This chapter has made the case that all individuals seeking specialized treatment for
Alcohol problems should receive a comprehensive assessment prior to treatment. The assessment
should be carried out in a sequential manner, proceeding in a logical and carefully
articulated manner from one stage to the next as needed to produce sufficient information
for relevant treatment decisions. The stages of assessment recommended by the committee
i~zc~de a screening stage, a problem assessment stage, awl a personal assessment stage.
Assessment should also be multidimensional; that is, it should include several different
kinds of information within each stage of assessment content. For example, the committee
recommends that the problem assessment stage include information on the individual's use of
alcohol, on the signs arid symptoms of alcohol use, and on the consequences of alcohol use. In
many instances each of these elements should also be multidimensional; for example, with
respect to the use of alcohol, it is important to obtain information on the level of use. the
pattern of use, and the history of use. .._ lo
The nrnhlPm assessment stage is highly
multidimensional (see Table 10-2~. Finally, assessment should be uniform to a significant
degree for all persons seeking treatment, so that data from different subjects can be pooled
and data from different programs can be compared.
Information gathered during the ideal assessment should be of demonstrated
reliability and validity; it should be quantitative and standardized; and it should be readily
recordable. Appropriate techniques should be employed to ensure that self-reported
assessment information is maximally accurate. Assessments should be administered by a
carefully selected, specifically trained, and continuously supervised staff that is adept at
using a variety of assessment methods. Due precautions should be taken to assure that
assessment staff operated independently of any significant biases, including and especially
those that can arise from the prospect of financial gain or from commitment to a specific
form of treatment.
OCR for page 270
270 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
The principal purpose of gathering assessment information Is to provide a basis for the
selection of the most appropriate treatment for the individual being assessed. However, the
information also serves a number of other purposes. It constitutes a baseline for
subsequent outcome determinations; permits the characterization of treatment populations
and facilitates their comparison with one another; and (if analyzed together with outcome
data) can be used to guide the future treatment of others with similar problems.
Implementation of a program of comprehensive assessment of this kind will require
vigorous and polycentric leadership, adequate funding, and a stepw~se developmental
process. The committee believes it is of the essence to foster a consensus within the treatment f eld
both on the general notion of assessment and on all aspects of its content and administration. To
this end, demonstration models of various kinds of comprehensive assessment should be set up and
carefully studied; such a process would be helpful to those who are not fully persuaded of
the need for comprehensive assessment. Those who have already been persuaded should
provide information on all aspects of their experience to enrich and accelerate the
development of a broad response.
REFERENCES
Allo, C. D., B. Mintzes, and R. C. Brook. 1988. What purchasers of treatment services want from evaluation.
Alcohol Health and Research World 12:162-167.
American Psychiatric Association (APA). 1987. DSM III-R: Diagnostic and Statistical Manual of Mental Disorders,
3rd edition, revised. Washington, D.C.: American Psychiatric Association.
Annis, H. M. 1979. Group treatment of incarcerated offenders with alcohol and drug problems: A controlled
evaluation. Canadian Journal of Criminology 21:3-15.
Annis, H. M. 1982. Inventory of Drinking Situations. Toronto: Addiction Research Foundation.
Annis, H. M. 1986a. Is inpatient rehabilitation of the alcoholic cost effective? Con position. Advances in Alcohol
and Substance Abuse 5:175-190.
Annis, H. M. 1986b. A relapse prevention model for treatment of alcoholics. Pp. 407433 in Treating Addictive
Behaviors, W. R. Miller and N. Heather, eds. New York: Plenum Press.
Annis, H. M., and D. Chan. 1983. The differential treatment model: Empirical evidence from a personality typology
of adult offenders. Criminal Justice and Behavior 10:159-173.
Annis, H. M., and C. Davis. 1989. Relapse prevention. Pp. 170-182 in Handbook of Alcoholism Treatment
Approaches: Effective Alternatives, R. K. Hester and W. R. Miller, eds. New York: Pergamon Press.
Annis, H. M., J. M. Graham, and C. S. Davis. 1987. Inventory of Drinking Situations User's Guide. Toronto:
Addiction Research Foundation.
Annis, H. M., and H. A. Skinner. 1984. Early experiences with assessment. Pp. 107-145 in A System of Health Care
Delivery, vol. 2, F. B. Glaser, H. M. Annis, H. A. Skinner, S. Pearlman, R. L. Segal, B. Sisson, A. C. Ogborne,
E. Bohnen, P. Gazda, and T. Zimmerman. Toronto: The Addiction Research Foundation.
Ashley, M. J. 1982. Alcohol, tobacco, and drugs: An audit of mortality and morbidity. Pp. 350-366 in Man, Drugs,
and Society: Current Perspectives, L. R. H. Drew, P. Stolz, and W. A. Barclay, eds. Canberra: Australian
Federation on Alcoholism and Drug Dependence.
Babor, T. F., and R. Kadden. 1985. Screening for alcohol problems: Conceptual issues and practical considerations.
Pp. 1-30 in Early Identification of Alcohol Abuse, N. C. Chang and H. M. Chao, eds. Washington, D.C.: U. S.
Government Printing Office.
Babor, T. F., E. B. Ritson, and R. J. Hodgson. 1986. Alcohol-related problems in the primary health care setting:
A review of early intervention strategies. British Journal of Addiction 81:23-46.
OCR for page 271
ASSESSMENT
271
Babor, T. F., R. S. Stephens, and G. A. Marlatt. 1987. Verbal report methods in clinical research on alcoholism:
Response bias and its minimization. Journal of Studies on Alcohol 48:410-24.
Babor, T. F., R. de la Fuente, J. Saunders, and M. Grant. 1989. Manual for the Alcohol Use Disorders
Identification Test (AUDIT). Geneva: World Health Organization.
Backer, T. E., R. P. Liberman, and T. G. Kuehnel. 1986. Dissemination and adoption of innovative psychosocial
interventions. Journal of Consulting and Clinical Psychology 54:111-118.
Barnes, G. E. 1979. The alcoholic personality: A reanalysis of the literature. Journal of Studies on Alcohol
40:571-634.
Barrett, E. T., and G. C. Gleser. 1987. Development and validation of the Cognitive Status Examination. Journal
of Consulting and Clinical Psychology 55:877-882.
Belille, C. N.d. (ca. 1987~. Bringing Definition to a Soft Science. Saint Paul, Minn.: Chemical Abuse/Addiction
Treatment Outcome Registry (CATOR), Ramsey Clinic.
Beutler, L. E. 1979. Toward specific psychological therapies for specific conditions. Journal of Consulting and
Clinical Psychology 47:882-897.
Blouin, A. G. 1986. The computerized Diagnostic Interview Schedule. DIS Newsletter 3(Fall):4-8.
Bohman, M., S. Sigvardsson, and C. R. Cloninger. 1981. Cross fostering analysis of adopted women. Archives of
General Psychiatry 38:965-969.
Boss, W. A. 1980. Next Steps in the Evolution of Chemical Dependency Care in Minnesota. Minneapolis: The
Citizens League.
Brickman, P., V. C. Rabinowitz, J. Karuza, Jr., D. Coates, E. Cohen, and L. Kidder. 1982. Models of helping and
coping. American Psychologist 37:368-384.
Bromet, E., R. H. Moos, and F. Bliss. 1976. The social climate of alcoholism treatment programs. Archives of
General Psychiatry 33:910-916.
Bromet, E., R. Moos, F. Bliss, and C. Wuthmann. 1977. Posttreatment functioning of alcoholic patients: Its
relationship to program participation. Journal of Consulting and Clinical Psychology 45:829-842.
Canter, F. M. 1966. Personality factors related to participation in treatment by hospitalized male alcoholics. Journal
of Clinical Psychology 22:114-116.
Cloninger, C. R. 1987. Neurogenetic adaptive mechanisms in alcoholism. Science 236:410-416.
Cloninger, C. R., M. Bohman, and S. Sigvardsson. 1981. Inheritance of alcohol abuse: Cross fostering analysis of
adopted men. Archives of General Psychiatry 38:861-868.
Cotton, N. S. 1979. The familial incidence of alcoholism: A review. Journal of Studies on Alcohol 40:89-116.
Cronkite, R. C., and R. H. Moos. 1978. Evaluating alcoholism treatment programs: An integrated approach. Journal
of Consulting and Clinical Psychology 46:1105-1119.
Cronkite, R. C., and R. H. Moos. 1980. Determinants of the posttreatment functioning of alcoholic patients: A
conceptual framework. Journal of Consulting and Clinical Psychology 48:305-316.
Cyr, M. G., and S. A. Wartman. 1988. The effectiveness of routine screening questions in the detection of
alcoholism. Journal of the American Medical Association 259:51-54.
Davidson, R. 1987. Assessment of the alcohol dependence syndrome: A review of self-report screening
questionnaires. British Journal of Clinical Psychology 26:243-255.
Edwards, G. 1974. Drugs, drug dependence, and the concept of plasticity. Quarterly Journal of Studies on Alcohol
35:176-195.
OCR for page 272
272 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Edwards, G. 1986. The alcohol dependence syndrome: A concept as stimulus to enquiry. British Journal of
Addiction 81:171-183.
Edwards, G., and M. M. Gross. 1976. Alcohol dependence: Provisional description of a clinical syndrome. British
Medical Journal 1:1058-1061.
Ellwood, P. 1988. Outcomes management: A technology of patient experience. New England Journal of Medicine
318:1549-1556.
Emrick, C. D. 1987. Alcoholics Anonymous: Affiliation processes and effectiveness as treatment. Alcoholism:
Clinical and Experimental Research 11:416-423.
Ewing, J. A. 1984. Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association
252:1905-1097.
Feldstein, P. J., T. M. Wickizer, and J. R. C. Wheeler. 1988. Private cost containment: The effects of utilization
review programs on health care use and expenditures. New England Journal of Medicine 318:1310-1314.
Fillmore, K M. 1987. Women's drinking across the life course as compared to men's. British Journal of Addiction
82:801-811.
Fillmore, K M., and L. Midanik. 1984. Chronicity of drinking problems among men: A longitudinal study. Journal
of Studies on Alcohol 45:228-236.
Finney, J. W., and R. H. Moos. 1979. Treatment and outcome for empirical subtypes of alcoholic patients. Journal
of Consulting and Clinical Psychology 47:25-38.
Fries, J. F. 1976. A data bank for clinicians? New England Journal of Medicine 294:1400-1402.
Fuller, R. K, K K Lee, and E. Gordis. 1988. Validity of self report in alcoholism research: Results of a Veterans
Administration cooperative study. Alcoholism: Clinical and Experimental Research 12:201-205.
Gibbs, L. E. 1980. A classification of alcoholics relevant to type-specific treatment. International Journal of the
Addictions 15:461488.
Glaser, F. B., and H. A. Skinner. 1984. Matching in the real world. Pp. 61-98 in A System of Health Care Delivery,
vol. 3, F. B. Glaser, H. M. Annis, H. A. Skinner, S. Pearlman, R. L. Segal, B. Sisson, A. C. Ogborne, E. Bohnen,
P. Gazda, and T. Zimmerman. Toronto: Addiction Research Foundation.
Glaser, F. B., S. W. Greenberg, and M. Barrett. 1978. A Systems Approach to Alcohol Treatment. Toronto: ARE
Books.
Goldberg, D. P. 1972. The Detection of Psychiatric Illness by Questionnaire: A Technique for the Identification
and Assessment of Nonpsychotic Illness. London: Oxford University Press.
Goldberg, D. P. 1978. Manual of the General Health Questionnaire. Windsor. NFER Publishing Company.
Hansen, J., and C. D. Emrick. 1983. Whom are we calling "alcoholic?" Bulletin of the Society of Psychologists in
Addictive Behaviors 2:164-178.
Harmer, M. H. 1977. The case for TNM. Clinical Oncology 3:131-135.
Harrison, P. A., and C. A. Belille. 1987. Women in treatment: Beyond the stereotype. Journal of Studies on
Alcohol 48:574-578.
Harrison, P. A., and N. G. Hoffmann. 1987. CATOR 1987 Report: Adolescent Residential Treatment: Intake and
Follow-Up Findings. Saint Paul, Minn.: Chemical Abuse/Addiction Treatment Outcome Registry (CATOR), Ramsey
Clinic.
Hanman, L., M. K'ywonis, and E. Morrison. 1988. Psychological factors and health-related behavior change:
Preliminary findings from a controlled clinical trial. Canadian Family Physician 34:1045-1050.
Hanocollis, P. 1962. Drunkenness and suggestion: An experiment with intravenous alcohol. Quarterly Journal of
Studies on Alcohol 23:376-389.
OCR for page 273
ASSESSMENT
273
Hayes, S. C., R. O. Nelson, and R. B. Jarrett. 1987. The treatment utility of assessment: A functional approach
for evaluating assessment quality. American Psychologist 42:963-974.
Helzer, J. E., and ~ Burnham. In press. Alcohol abuse and dependence. In Psychiatric Disorders in America, L.
N. Robins and D. ~ Regier, eds. New York: The Free Press.
Hlatky, M. As, K L. Lee, F. E. Harrel, Jr., R. M. Califf, D. B. Poor, D. B. Mark, and R. A. Rosati. 1984. Tying
clinical research to patient care by use of an observational data base. Statistics in Medicine 3:375-384.
Hodgson, R., T. Stockwell, H. RanWn, and G. Edwards. 1978. Alcohol dependence: The concept, its utility and
measurement. British Journal of Addiction 73:339-342.
Hoffmann, N. G., J. ~ Halikas, and D. Mee-Lee. 1987. The Cleveland Admission, Discharge, and Transfer Criteria:
Model for Chemical Dependency Treatment Programs. Cleveland, Ohio: The Greater Cleveland Hospital
Association.
Holmes, T. H., and M. Masuda. 1973. Psychosomatic syndrome: When mothers-in-law or other disasters visit, a
person can develop a bad, bad cold. Psychology Today 5(11):71-72, 106.
Holmes, T. H., and R. H. Rahe. 1967. The Social Readjustment Rating Scale. Journal of Psychosomatic Research
11:213-218.
Horn, J. L., H. A. Skinner, K Wanberg, and F. M. Foster. 1984. Alcohol Dependence Scale. Toronto: Addiction
Research Foundation.
Horn, J. L., K W. Wanberg, and F. M. Foster. 1987. Guide to the Alcohol Use Inventory (AUI). Minneapolis,
Minn.: National Computer Systems, Incorporated.
Institute for Personality and Ability Testing. 1986. 16PF Manual. Savoy, Ill.: Institute for Personality and Ability
Testing.
Jackson, D. N. 1974. Personality Research Form Manual. Goshen, N.Y.: Research Psychologists Press.
Jackson, J. K 1988. Testimony presented before the U.S. Senate Governmental Affairs Committee hearing
regarding the causes of and governmental responses to alcohol abuse and alcoholism, Washington, D.C., June 16.
Jacob, T. 1988. Executive summary: Approaches to the assessment of family/marital functioning. Prepared for the
IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse.
Kadden, R. M., N. L. Cooney, H. Getter, and M. D. Litt. 1990. Matching alcoholics to coping skills or interactional
therapies: Posttreatment results. Journal of Consulting and Clinical Psychology 698-704.
Keller, M. 1972. The oddities of alcoholics. Quarterly Journal of Studies on Alcohol 33:1147-1148.
Kern, J. C., W. Schmelter, and M. Fanelli. 1978. A comparison of three alcoholism treatment populations:
Implications for treatment. Journal of Studies on Alcohol 39:785-792.
Kiernan, R. J., J. Mueller, J. W. Langston, and C. van Dyke. 1987. The Neurobehavioral Cognitive Status
Examination: A br~ef but differentiated approach to cognitive assessment. Annals of Internal Medicine 107:481-485.
Klingler, D. E., D. ~ Miller, J. H. Johnson, and T. A. Williams. 1977. Process evaluation of an on-line computer
assisted unit for intake assessment of mental health patients. Behavioral Research Methods and Instrumentation
9:110-116.
Korchin, S. J., and D. Schuldberg. 1981. The [uture of clinical assessment. American Psychologist 36:1147-1158.
Korcok, M. 1988. Managed Care and Chemical Dependency: A Troubled Relationship. Providence, R.I.: Manisses
Communications Group, Inc.
Kozlowski, L. T., L. C. Jellinek, and M. ~ Pope. 1986. Cigarette smoking among alcohol abusers: A continuing
and neglected problem. Canadian Journal of Public Health 77:205-207.
OCR for page 274
274 BROADENING MIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Kranzler, H. R., T. F. Babor, and R. J. Lauerman. 1990. Problems associated with average alcohol consumption
and frequency of intoxication in a medical population. Alcoholism Experimental and Clinical Research 14(1~:119-
126.
Kristensen, H., H. Ohlin, M.-B. Hulten-Nosslin, E. Trell, and B. Hood. 1983. Identification and intervention of
heavy drinking in middle-aged men: Results and follow-up of 24~0 months of long-term study with randomized
controls. Alcoholism: Clinical and Experimental Research 7:203-209.
Laszlo, J. 1985. Health registry and clinical data base technology: With special emphasis on cancer registries.
Journal of Chronic Disease 38:67-78.
Lettieri, D. J., M. ~ Sayers, and J. E. Nelson, eds. 1985a. Summaries of Alcoholism Treatment Assessment
Research. Washington, D.C.: U.S. Government Printing Office.
Lettieri, D. J., M. ~ Sayers, and J. E. Nelson, eds. 1985b. Alcoholism Treatment Assessment Research Instruments.
Washington, D.C.: U.S. Government Printing Office.
Levitt, T. 1972. Production-line approach to service. Harvard Business Review 50:41-52.
Lewis, J. 1988. Growth in managed care forcing providers to adjust. Alcoholism Report 16(24):1.
Lucas, R. W., W. I. Card, R. P. Knill-Jones, G. Watkinson, and G. P. Crean. 1976. Computer interrogation of
patients. British Medical Journal 2:623-625.
Lucas, R. W., P. J. Mullin, C. B. X. Luna, and D. C. McInroy. 1977. Psychiatrists and a computer as interrogators
of patients with alcohol-related illness: A comparison. British Journal of Psychiatry 131:160-167.
Maletzky, B. M., and J. Klotter. 1974. Smoking and alcoholism. American Journal of Psychiatry 131:445-447.
Malta, ~ K, B. Rush, M. Gavin, and G. Cooper. 1985. A community-centred alcoholism assessment/treatment
service: A descriptive study. Canadian Journal of Psychiatry 30:35-43.
Marlatt, G. A, and J. R. Gordon, eds. 1985. Relapse Prevention. New York: Guilford Press.
Marshman, J., R. D. Fraser, C. Lambert, A. C. Ogborne, S. J. Saunders, P. W. Humphries, D. W. Macdonald, J.
G. Rankin, and W. Schmidt. 1978. The Treatment of Alcoholics: An Ontario Perspective. Toronto: Addiction
Research Foundation.
McLachlan, J. F. C. 1972. Benefit from group therapy as a function of patient-therapist match on conceptual level.
Psychotherapy: Theory, Research, and Practice 9:317-323.
McLachlan, J. F. C. 1974. Therapy strategies, personality orientation, and recovery from alcoholism. Canadian
Psychiatric Association Journal 19:25-30.
McLellan, ~ T., L. Luborsky, G. E. Woody, and C. P. O'Brien. 1980. An improved diagnostic evaluation
instrument for substance abuse patients: The Addiction Severity Index. Journal of Nenrous and Mental Diseases
168:26-33.
McLellan, A. T., L. Luborsky, J. Cacciola, J. Griffith, P. McGahan, and C. P. O'Brien. 1985. Guide to the
Addiction Severity Index. Washington, D.C.: U. S. Government Printing Office.
Mendelson, J. H., T. F. Babor, N. K Mello, and H. Pratt. 1986. Alcoholism and prevalence of medical and
psychiatric disorders. Journal of Studies on Alcohol 47:361-366.
Miller, S., E. Helmick, L. Berg, P. Nutting, and G. Shorr. 1974. Alcoholism: A statewide program evaluation.
American Journal of Psychiatry 131:210-214.
Miller, W. R., and R. K Hester. 1986. Inpatient alcoholism treatment: Who benefits? American Psychologist
41:794-805.
Minnesota Chemical Dependency Program Division. 1989. Report on the Status of the Consolidated Chemical
Dependency Treatment Fund. Saint Paul: Minnesota l:)epartment of Human Services.
OCR for page 275
ASSESSMENT
275
Mogar, R. E., W. W. Wilson, and S. T. Helm. 1970. Personality subtypes of male and female alcoholic patients.
International Journal of the Addictions 5:99-113.
Moos, R. H., E. Bromet, V. Tsu, and B. Moos. 1979. Family characteristics and the outcome of treatment for
alcoholism. Journal of Studies on Alcohol 40:78~.
Nace, E. P., J. J. Saxon, Jr., and N. Shore. 1986. Borderline personality disorder and alcoholism treatment: A
one-year follow-up study. Journal of Studies on Alcohol 47:196-200.
O'Farrell, T. J., and S. A. Maisto. 1987. The utility of self-report and biological measures of alcohol consumption
in alcoholism treatment outcome studies. Advances in Behavioral Research and Therapy 9:91-125.
Ogborne, A. C. 1978. Patient characteristics as predictors of treatment outcomes for alcohol and drug abusers. Pp.
177-223 in Research Advances in Alcohol and Drug Problems, vol. 4, Y. Israel, F. B. Glaser, H. Kalant, R. E.
Popham, W. Schmidt, and R. G. Smart, eds. New York: Plenum Press.
Ogborne, A. C., and F. B. Glaser. 1981. Characteristics of affiliates of Alcoholics Anonymous: A review of the
literature. Journal of Studies on Alcohol 42:661-675.
Orrego, H., L. M. Blendis, J. E. Blake, B. M. Kapur, and Y. Israel. 1979. Reliability of assessment of alcohol intake
based on personal interviews in a liver clinic. Lancet 2:1354-1356.
Partington, J. T. 1970. Dr. Jekyll and Mr. High: Multidimensional scaling of alcoholics' self-evaluations. Journal
of Abnormal Psychology 75:131-138.
Pattison, E. M. 1974. Rehabilitation of the chronic alcoholic. Pp. 587-658 in Clinical Pathology, Vol. 3 of The
Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum Press.
Pattison, E. M., R. Coe, and R. J. Rhodes. 1969. Evaluation of alcoholism treatment: A comparison of three
facilities. Archives of General Psychiatry 20:478-488.
Pattison, E. M., R. Coo, and H. O. Doerr. 1973. Population variation among alcoholism treatment facilities.
International Journal of the Addictions 8:199-229.
Paykel, E. S., B. S. Prusoff, and E. H. Uhlenhuth. 1971. Scaling of life events. Archives of General Psychiatry
25:340-347.
Peachey, J. E., and B. M. Kapur. 1986. Monitoring drinking behavior with the alcohol dipstick during treatment.
Alcoholism: Clinical and Experimental Research 10:663-666.
Penick, E. C., B. J. Powell, S. F. gingham, B. I. Liskow, N. S. Miller, and M. R. Read. 1987. A comparative study
of familial alcoholism. Journal of Studies on Alcohol 48:136-146.
Polich, J. M., D. J. Armor, and H. B. Braiker. 1981. The Course of Alcoholism: Four Years After Treatment. New
York: John Wiley and Sons.
Popham, R. E., W. Schmidt, and S. Israelstam. 1984. Heavy alcohol consumption and physical health problems:
A review of the epidemiologic evidence. Pp. 148-182 in Research Advances in Alcohol and Drug Problems, vol.
8, R. G. Smart, H. D. Cappell, F. B. Glaser, Y. Israel, H. Kalant, R. E. Popham, W. Schmidt, and E. M. Sellers,
eds. New York: Plenum Press.
Pryor, D. B., R. M. Califf, F. E. Harrell, Jr., M. ~ Hlatky, K L. Lee, D. B. Mark, and R. ~ Rosati. 1985. Clinical
data bases: Accomplishments and unrealized potential. Medical Care 23:623-647.
Reilly, D. H., and A. A Sugerman. 1967. Conceptual complexity and psychological differentiation in alcoholics.
Journal of Nervous and Mental Disease 144:14-17.
Robins, L. N., J. E. Helzer, J. Croughan, and K S. Ratcliff. 1981. National Institute of Mental Health Diagnostic
Intewiew Schedule: Its history, characteristics, and validity. Archives of General Psychiatry 38:381-389.
Robins, L. N., J. E. Helzer, M. M. Weissman, H. Orvaschel, E. Gruenberg, J. D. Burke, Jr., and D. A. Regier.
1984. Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psychiatry 41:949-958.
OCR for page 276
276 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Ross, H. E., and F. B. Glaser. 1989. Psychiatric screening of alcohol and drug patients: The validity of the
GHQ-60. American Journal of Drug and Alcohol Abuse. 15:429-442.
Ross, H. E., F. B. Glaser, and T. Germanson. 1988. The prevalence of psychiatric disorders in patients with alcohol
and other drug problems. Archives of General Psychiatry 45:1023-1031.
Rounsaville, B. J., Z. S. Dolinsky, T. F. Babor, and R. E. Meyer. 1987. Psychopathology as a predictor of treatment
outcome in alcoholics. Archives of General Psychiatry 44:505-513.
Rush, B. 1987. Executive summary: Assessment procedures and specialized assessment in Ontario. Prepared for
the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse.
Sadava, S. 1985. Problem behavior theory and consumption and consequences of alcohol use. Journal of Studies
on Alcohol 46:392-397.
Saunders, J. B. 1988. Executive summary: Screening techniques for alcohol and drug problems. Prepared for the
IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse.
Saunders, J. B., and O. G. Aasland. 1987. World Health Organization Collaborative Project on Identification and
Treatment of Persons with Harmful Alcohol Consumption: Report on Phase I Development of a Screening
Instrument. Geneva: World Health Organization, Division of Mental Health.
Savitz, L. D., K File, and T. W. McCahill. 1973. Referral decision-making in a multi-modality system. Pp. 158-168
in Proceedings of the Fifth National Conference on Methadone Treatment. New York: NAPAN.
Saxe, L., D. Dougherty, K Esty, and M. Fine. 1983. The Effectiveness and Costs of Alcoholism Treatment.
Washington, D.C.: U. S. Congress, Office of Technology Assessment.
Schuckit, M. A. 1973. Alcoholism and sociopathy-diagnostic confusion. Quarterly Journal of Studies on Alcohol
34:157-164.
Schuckit, M. A., and M. Irwin. 1988. Diagnosis of alcoholism. Medical Clinics of North America 72:1133-1153.
Searles, J. S. 1988. The role of genetics in the pathogenesis of alcoholism. Journal of Abnormal Psychology
97:153-167.
Segal, R. L. 1984. The administration of the Assessment Unit. Pp. 198-214 in A System of Health Care Delivery,
vol. 2, F. B. Glaser, H. M. Annis, H. A. Skinner, S. Pearlman, R. L. Segal, B. Sisson, A. C. Ogborne, E. Bohnen,
P. Gazda, and T. Zimmerman. Toronto: Addiction Research Foundation.
Seizer, M. L. 1971. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American
Journal of Psychiatry 127:1653-1658.
Skinner, H. A. 1979. A multivariate evaluation of the MAST. Journal of Studies on Alcohol 40:831-834.
Skinner, H. A. 1981a. Assessment of alcohol problems: Basic principles, critical issues, and future trends. Pp.
316-369 in Research Advances in Alcohol and Drug Problems, vol. 6., Y. Israel, F. B. Glaser, H. Kalant, R. E.
Popham, W. Schmidt, and R. G. Smart, eds. New York: Plenum Press.
Skinner, H. A. 1981b. Benefits of sequential assessment. Social Work Research and Abstracts 17:21-28.
Skinner, H. A. 1981c. Comparison of clients assigned to in-patient and out-patient treatment for alcoholism and
drug addiction. British Journal of Psychiatry 138:312-320.
Skinner, H. A. 1984. Instruments for assessing alcohol and drug problems. Bulletin of the Society of Psychologists
in Addictive Behaviors 3:21-33.
Skinner, H. A. 1985. The clinical spectrum of alcoholism: Implications for new drug therapies. Pp. 123-135 in
Research Advanees in New Psychopharmacological Treatments for Aleoholism, C. A. Naranjo and E. M. Sellers,
eds. Amsterdam: Elsevier.
Skinner, H. A. 1988. Exeeutive summary: Toward a multiaxial framework for the elassifieation of alcohol problems.
Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Aleoholism and
Alcohol Abuse.
OCR for page 277
ASSESSMENT
277
Skinner, H. A., and B. ~ Allen. 1982. Aleohol dependence syndrome: Measurement and validation. Journal of
Abnormal Psyehology 91:199-209.
Skinner, H. As, and B. A. Allen. 1983a. Differential assessment of alcoholism. Journal of Studies on Alcohol
44:852-862.
Skinner, H. A., and B. A. Allen. 1983b. Does the computer make a difference? Computerized versus faee-to-faee
versus self-report assessment of alcohol, drug, and tobacco use. Journal of Consulting and Clinieal Psychology
51:267-275.
Skinner, H. A., and S. Holt. 1987. The Aleohol Clinieal Index: Strategies for Identifying Patients with Aleohol
Problems. Toronto: Addiction Research Foundation.
Skinner, H. A, and H. Lei. 1980. The multidimensional assessment of stressful life events. Journal of Nervous and
Mental Disease 168:535-541.
Skinner, H. A., and K R. Shoffner. 1978. Sex differences and addiction: A comparison of male and female clients
at the Clinieal Institute. Substudy No. 983. Toronto: Addiction Research Foundation.
Skinner, H. A., D. N. Jackson, and H. Hoffmann. 1974. Alcoholic personality types: Identification and correlates.
Journal of Abnormal Psychology 83:658 666, 1974.
Skinner, H. A., B. A. Allen, M. C. McIntosh, and W. H. Palmer. 1985a. Lifestyle assessment: Applying
microcomputers in family praetiee. British Medieal Journal 290:212-14.
Skinner, H. A., B. A. Allen, M. C. McIntosh, and W. H. Palmer. 1985b. Lifestyle assessment: Just asking makes
a difference. British Medieal Journal 290:214-216.
Skinner, H. A., S. Holt, W.-J. Sheu, and Y. Israel. 1986. Clinieal versus laboratory detection of alcohol abuse: The
alcohol clinical index. British Medieal Journal 292:1703-1708.
Skinner, W., and W. Becks. 1988. Executive summary: The assessment setting: Should assessment/referral centers
be independent of treatment programs? Prepared for the IOM Committee for the Study of Treatment and
Rehabilitation Services for Alcoholism and Alcohol Abuse.
Smart, R. G., M. Gillies, G. Brown, and N. L. Blair. 1980. A survey of alcohol-related problems and their
treatment. Canadian Journal of Psychiatry 25:220-227.
Sobell, L. C., M. B. Sobell, and T. D. Nirenberg. 1987. Behavioral assessment and treatment planning with alcohol
and drug abusers: A review with emphasis on clinical application. Clinieal Psychology Review 8:19-54.
Sobell, L. C., M. B. Sobell, G. Leo, and A. Caneilla. 1988. Reliability of a timeline method: assessing normal
drinkers' reports of recent drinking and comparative evaluation across several populations. British Journal of
Addiction 83:393~02.
Sobell, M. B., L. C. Sobell, and R. VanderSpek. 1979. Relationships among clinical judgment, self-report, and
breath-analysis measures of intoxication in alcoholics. Journal of Consulting and Clinical Psychology 47:204-206.
Sobell, M. B., S. Broehu, L. C. Sobell, J. Roy, and J. A. Stevens. 1987. Alcohol treatment outcome evaluation
methodology: State of the art 1980-84. Addictive Behaviors 12:113-128.
Stein, K B., V. Rozynko, and L. A. Pugh. 1977. The heterogeneity of personality among alcoholics. British Journal
of Social and Clinieal Psyehology 10:253-259.
Stoekwell, T., D. Murphy, and R. Hodgson. 1983. The Severity of Alcohol Dependence Questionnaire: Its use,
reliability, and validity. British Journal of Addiction 78:145-155.
Strayvinski, A, Y. Lamontagne, and Y.-J. Lavallee. 1986. Clinical phobias and avoidant personality disorder among
alcoholics admitted to an alcoholism rehabilitation setting. Canadian Journal of Psychiatry 31:714-719.
Sutherland, G., T. Stockwell, and G. Edwards. 1985. The impact of a research interview on clinical re-attendance:
A happy finding. British Journal of Addiction 80:211-212.
OCR for page 278
278 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Syme, L. 1957. Personality characteristics and the alcoholic: A critique of current studies. Quarterly Journal of
Studies on Alcohol 18:288-302.
Vaillant, G. E. 1983. The Natural History of Alcoholism: Causes, Patterns, and Paths to Recovery. Cambridge,
Mass.: Harvard University Press.
Wanberg, K W., J. L. Horn, and F. M. Foster. 1977. A differential assessment model for alcoholism: The scales
of the Alcohol Use Inventory. Journal of Studies on Alcohol 38:512-543.
Watson, C. G., C. Tilleskjor, E. A. Hoodecheck-Schow, J. Pucel, and L. Jacobs. 1984. Do alcoholics give valid
self-reports? Journal of Studies on Alcohol 45:344-348.
Wechsler, D. 1981. Wechsler Adult Intelligence Scale. New York: Psychological Corporation.
White, H. R. 1987. Longitudinal stability and dimensional structure of problem drinking in adolescents. Journal
of Studies on Alcohol 48:541-50.
Wilkinson, D. A. 1987. C. T. scan and neuropsychological assessments of alcoholism. Pp. 76-102 in
Neuropsychology of Alcoholism, O. ~ Parsons, N. Butters, and P. E. Nathan, eds. New York: Guilford Press.
Wilkinson, D. A. 1988. Executive summary: Neuropsychological screening. Prepared for the IOM Committee for
the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse.
Wilkinson, D. A., and P. L. Carlen. 1981. Chronic organic brain syndromes associated with alcoholism:
Neuropsychological and other aspects. Pp. 107-145 in Research Advances in Alcohol and Drug Problems, vol. 6,
Y. Israel, F. B. Glaser, H. Kalant, R. E. Popham, and R. G. Smart, eds. New York: Plenum Press.
Wilkinson, D. A., and M. Sanchez-Craig. 1981. Relevance of brain dysfunction to treatment objectives: Should
alcohol-related cognitive deficits influence the way we think about treatment? Addictive Behaviors 6:253-260.
Witkin, H. As, and D. R. Goodenough. 1977. Field dependence and interpersonal behavior. Psychological Bulletin
84:661~89.
Woody, G. E., ~ T. McLellan, L. Luborsky, C. P. O'Brien, J. Blaine, S. Fox, I. Herman, and A. T. Beck. 1984.
Severity of psychiatric symptoms as a predictor of benefits from psychotherapy: The Veterans Administration-Penn
Study. American Journal of Psychiatry 141:1172-1177.
Representative terms from entire chapter:
treatment programs
