Assessment To Aid in the Treatment Planning Process

Full text

Assessment T
o Aid in the
Treatment Planning Process
Dennis M. Dono
van, Ph.D.
Alcohol and Dr
ug Abuse Institute, and
Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle, WA
Assessment of alcohol and other dr
ug (AOD) use
problems serves multiple functions (e.g., Shaffer
and Kauffman 1985; Jacobson 1989
a, 1989b;
Allen and Mattson 1993; Carroll 1995; Donovan
1995; Carey and Teitelbaum 1996; Donovan
1998). The Institute of Medicine (1990) and
others (e.g., Carroll 1995) have suggested three
stages of a comprehensive assessment for all indi-
viduals seeking specialized treatment for alcohol
problems: a screening stage, a problem assess-
ment stage, and a personal assessment stage. The
first two stages involve screening, case finding,
and identification of a substance use disorder; an
evaluation of the parameters of drinking behavior,
signs, symptoms, and severity of alcohol depen-
dence, and negative consequences of use; and
formal diagnosis of alcohol abuse or dependence.
Each of these aspects of the assessment process is
covered in detail in other chapters in this
Guide.
Although these drinking-related parameters are
important in defining the person’s treatment needs,
a broader range of factors must be considered in
the treatment planning process because alcohol use
both affects and is affected by a number of other
areas of life function (Donovan 1988; Institute of
Medicine 1990; Donovan 1992, 1998). The
personal assessment stage recommended by the
Institute of Medicine focuses on this broader array
of personal problems being experienced by the
individual. Carroll (1995) suggested that this stage
involves a comprehensive description of the indi-
vidual and his or her circumstances (e.g., demo-
graphic characteristics, concurrent problems,
comorbid psychiatric disorders, family history).
The process should focus on clients’ strengths as
well as weaknesses, problems, and needs. Some of
the identified problems may be fairly directly
related to alcohol use (contingent problems), while
others may not be at all attributable to alcohol use
(noncontingent problems). Examples may include
psychological, social, and vocational problems,
each of which may involve an interactive relation-
ship with drinking. The provision of a comprehen-
sive assessment is consistent with the
recommendations derived from a biopsychosocial
model of addictions and the process of assessment
(Donovan 1988) and is a requirement of a number
of accrediting bodies such as the Joint
Commission on Accreditation of Healthcare
Organizations or the Commission on Accreditation
of Rehabilitation Facilities.
Within the clinical context, the primary goal of
assessment is to determine those characteristics of
the client and his or her life situation that may influ-
ence treatment decisions and contribute to the
success of treatment (Allen 1991). Additionally,
assessment procedures are crucial to the treatment
planning process. Treatment planning involves the
integration of assessment information concerning
the person’s drinking behavior, alcohol-related
problems, and other areas of psychological and
social functioning to assist the client and clinician to
develop and prioritize short- and long-term goals for
treatment, select the most appropriate interventions
125

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
to ad
dress the identified problems, determine and
address perceived barriers to treatment engage-
ment and compliance, and monitor progress
toward the specified goals, which will typically
include abstinence and/or harm reduction and
improved psychosocial functioning (P.M. Miller
and Mastria 1977; L.C. Sobell et al. 1982;
Washousky et al. 1984; L.C. Sobell et al. 1988;
Bois and Graham 1993).
The assessment and treatment planning
process should lead to the individualization of
treatment, appropriate client-treatment matching,
and the monitoring of goal attainment (Allen and
Mattson 1993). The Institute of Medicine (1990)
noted that treatment outcomes may be improved
significantly by matching individuals to treat-
ments based on variables assessed in the problem
assessment and personal assessment stages of the
comprehensive assessment process. Although the
results of Project MATCH have raised questions
about the viability of matching treatments to client
attributes (Project MATCH Research Group
1997
a), ther
e was evidence on a number of vari-
ables, including anger, severity of concomitant
psychiatric problems, and social support for drink-
ing, that was sufficient to warrant continued
attempts to identify potential matches between
client characteristics and types of treatment
(Project MATCH Research Group 1997
b, 1998).
Similarly, there is evidence that matching thera-
peutic services to the presence, nature, and sever-
ity of problems clients present at treatment entry
leads to improved outcomes (McLellan et al.
1997). Assessment at intake will continue to be
instrumental in attempting to match clients to the
most appropriate available treatment options;
however, assessment also should be viewed as a
continuous process that allows monitoring of
treatment progress, refocusing and reprioritizing
of treatment goals and interventions across time,
and determination of outcome (Donovan 1988;
Institute of Medicine 1990; L.C. Sobell et al.
1994
a; Dono
van 1998).
This chapter reviews a number of instruments
that are available to assist the clinician and clini-
cal researcher in the personal assessment stage
and in the development of appropriate treatment
plans. This review attempts to provide information
that has clinical utility and that can assist in the
planning and conduct of treatment in clinical
settings. The instruments include those assessing
the areas of readiness to change, expectations
about alcohol’s effects, self-efficacy expectancies,
drinking-related locus of control, family history of
alcoholism, and extra-treatment social support for
abstinence. A number of multidimensional
measures and those developed specifically for
treatment placement are also reviewed.
Tables 1A and 1B provide descriptive informa-
tion on these instruments, and table 2 summarizes
available information concerning the reliability
and validity of these instruments. The information
in these tables has been derived primarily from the
fact sheets in the appendix and from the published
literature. A number of other instruments that may
be of assistance to the treatment planning process
but that did not meet the inclusion criteria are also
discussed in the text. Also, several reviews provide
more detailed information about the assessment
process in addictive behaviors and about specific
assessment instruments and procedures (e.g.,
Donovan and Marlatt 1988; L.C. Sobell et al.
1988; Jacobson 1989
a, 1989b; Institute of
Medicine 1990; Allen 1991; Donovan 1992;
Addiction Research Foundation 1993; Allen and
Mattson 1993; Connors et al. 1994; Longabaugh et
al. 1994; L.C. Sobell et al. 1994
a, 1994b; Car
roll
1995; Carey and Teitelbaum 1996; Donovan
1998).
P
ROBLEM RECOGNITION, MOTIVATION,
AND READINESS TO CHANGE
An impor
tant construct within the alcoholism
field is the degree to which drinkers are aware of
the extent of their drinking patterns, such as quan-
tity and frequency of drinking, the negative physi-
cal and psychosocial consequences of their
drinking, and their perception of these patterns
and consequences as problematic. The goal of
using screening instruments is, in fact, to increase
126

T
ABLE 1A.—Assessment instruments for treatment planning: Descriptive information
Groups used Norms
Instr
ument Purpose Clinical utility population with Normed groups
F-SMAST/
M-SMAST
Aids in determining
Adults and Non-problem
No
NA
parental history of
adolescents
alcoholics
ASI
Adults Adults seeking
Males and females;
on recent (past 30 days)
areas in need of
treatment for
alcohol, opiate,
and lifetime medical,
and cocaine treat-
aids in treatment
problems;
ment groups; psy-
planning and outcome
psychiatrically ill,
chiatrically ill
substance users;
psychiatric problems
and prisoner
populations
users; gamblers;
homeless persons;
probationers; and
assistance clients
AASE
Adults
Outpatient
concerning alcohol
situations in which
alcoholics in
substance
treatment
terms of temptation to
about not drinking in
high-risk situations
ADCQ
associated with changing
Adults
?
?
alcoholics in
treatment
Target
avail.?
To provide a structured
measure of mother’s
and father’s lifetime
alcohol abuse
drinkers, prob-
alcohol abuse
lem drinkers,
To provide information
Identifies problem
Yes
targeted intervention;
substance abuse
employment and
support, AOD use,
legal, family/social, and
evaluation
homeless, pregnant,
pregnant substance
related to AOD use
employee
To measure self-efficacy
Identifies high-risk
Problem drinkers,
Yes
abstinence, defined in
the individual is highly
abusers
tempted and has low
drink and confidence
levels of confidence; aids
in developing relapse
prevention interventions
To measure perceived
Measures relative
costs and benefits
motivation to change
drinking behavior
drinking behavior
Problem drinkers,
Assessment To Aid in the Treatment Planning Process
127

128
T
ABLE 1A.—Assessment instruments for treatment planning: Descriptive information
(contin
ued)
Assessing Alcohol Problems: A Guide for Clinicians and Researchers
Groups used Norms Normed
Instr
ument Purpose Clinical utility population with groups
ABS
Adults Non-problem
No
NA
three amounts of
and feelings, the use-
alcoholic clients in
and the utility of
fulness of alcohol for
treatment
drinking in producing
desired outcomes, and
emotional outcomes
amount of alcohol
AEQ-S
Adults
?
?
measure of both
desired from alcohol
alcoholics
alcohol-related
AEQ
Adults
Clinical and
nonclinical
alcoholics
samples of
initiation and mainte-
nance of, and relapse to,
alcohol
ADRS
Adults Alcoholics in ?
Alcoholics
of problems and
treatment
in treatment
minimization of
alcohol-related
problems
Target
avail.?
To measure beliefs
Identifies expectancies
about the effects of
about alcohol’s effects
drinkers, problem
on different behaviors
drinkers, and
alcohol on behavior
different reasons or
desired behavioral or
how these expectan-
cies vary with the
To provide a brief
Assesses the effects
College student
drinkers and
positive and negative
expectancies
To assess positive
Assesses alcohol’s
College student
Yes
expectancies adults
perceived reinforcing
drinkers and
hold about alcohol’s
effects related to
effects
drinkers
To measure level of
Measures awareness
awareness or
perceived need or
motivation to change
drinking behavior

T
ABLE 1A.—Assessment instruments for treatment planning: Descriptive information
(contin
ued)
Groups used Norms Normed
Instr
ument Purpose Clinical utility population with groups
Adults and
Alcoholics in
?
sional assessment of
treatment assignment
adolescents
alcohol use, styles,
based on drinking
> 16 years
patterns and styles
Adults Alcoholics in No
Alcoholics in
signs” or high-risk
relapse risk and
treatment
treatment
situation potentially
precipitants
Adults and
Adults and
Alcohol
in format useful for
adolescents
adolescents with
case conceptualiza-
>16 years
chemical depen-
polydrug
tion and treatment
cies, symptoms, self-
planning
concept, and interpersonal
relationships
CDP
Adults Adults entering
Alcohol
sional assessment of
and consistent data
alcohol treatment
drinking history and
programs, problem
males and
treatment planning
females
treatment, demographics,
Target
avail.?
AUI To provide a multidimen-
Aids in differential
Yes
treatment, DWI
offenders
patterns, and perceived
benefits of drinking
AWARE
To measure “warning
Identifies potential
predictive of relapse
CDAP To provide a multidimen-
Provides information
Yes
sional assessment of AOD
abusers,
use history, patterns of
use, beliefs and expectan-
dency problems
abusers, social
drinkers
To provide a multidimen-
Provides a systematic
Yes
abusers,
set at intake for
behavior, motivation for
drinkers
and self-efficacy
Assessment To Aid in the Treatment Planning Process
129

T
ABLE 1A.—Assessment instruments for treatment planning: Descriptive information
(contin
ued)
Assessing Alcohol Problems: A Guide for Clinicians and Researchers
Groups used Norms Normed
Instr
ument Purpose Clinical utility population with groups
DEQ
and tension reduction
Adults Community
Adult
clinical
patients,
ized alcoholics
adult com-
munity
students
DRSEQ
dimensional assessment
drink refusal ability in
of the strength of self-
social pressure,
opportunistic, and
emotional relief
situations
Adults Adult non-problem
Adult
clinical
patients,
clients in treatment
adult com-
munity
students
DRIE
Adults
No
NA
dimensional assess-
adults entering
control of drinking
alcohol treatment
perception of locus of
programs
control related to
Target
avail.?
To assess positive and
Assesses alcohol’s
negative expectancies
perceived reinforcing
about alcohol’s effects
effects related to
assertion, affective
change, sexual enhance-
ment, cognitive change,
Yes
drinkers, problem
drinkers, hospital-
drinkers,
university
To provide a multi-
Identifies efficacy in
efficacy to refuse
drinking in various
situations, targeting
them for interventions
Yes
drinkers, problem
drinkers, alcoholic
drinkers,
university
To provide a multi-
Assesses relative
Problem drinkers,
degree of personal
ment of an individual’s
behavior and for
recovery; can be used
drinking behavior
to target expectancies
for intervention
130

T
ABLE 1A.—Assessment instruments for treatment planning: Descriptive information
(contin
ued)
Groups used Norms
Normed
Instr
ument Purpose Clinical utility population with
groups
FTQ
Aids in determining
Adults General population,
NA
NA
alcohol problems in
risk for more serious
alcohol problems and
alcoholics
relapse vulnerability
among those with
support for sobriety and
for continued drinking
and friends for sobriety
vs. continued drinking
Adults and Alcoholics in
Alcoholics
adolescents treatment
in outpatient
and aftercare
treatment
IDS
Adults Clients seeking or in
Age groups,
treatment for an
males and
alcohol problem
females
the past year
relapse, to aid in
planning relapse
MSAPS
Assesses presence
Adults No
NA
dimensional measure
in treatment
of problems related to
social problems
Target
avail.?
To assess history of
problem drinkers,
first- and second-
degree relatives
positive family history
IPA
To assess level of social
Determines relative
support from family
Yes
To measure degree of
Develops a client
Yes
heavy drinking in
profile of those situa-
different situations over
tions having greatest risk
of heavy drinking and/or
prevention
To provide a multi-
Substance abusers
and severity of psycho-
logical, behavioral, and
AOD use
Assessment To Aid in the Treatment Planning Process
131

T
ABLE 1A.—Assessment instruments for treatment planning: Descriptive information
(contin
ued)
Assessing Alcohol Problems: A Guide for Clinicians and Researchers
Groups used Norms Normed
Instrument Purpose Clinical utility population with groups
MSQ
T
o identify problem
Identif
ies clients’
Adults and
concerns in major
adolescents
students,
patterns that underlie
life areas, their
chemically
relationship to
a wide range of
dependent
drinking alcohol
counselees
alcoholic
for systematic
inpatients,
traumatically
ing to change
brain-injured
rehabilitation
patients
Adults
Non-problem
which immediate,
about to enter or
abstainers;
short-term, and long-
currently in
light,
and represent
treatment
moderate,
occur if one were to
restrain drinking
social
drink
posttreatment
relapsers and
abstainers
PEI-A
dimensional measure of
associated psycho-
and psychosocial
social problems
problems
Adults
in treatment,
seeking and
normal
community
samples
Target
avail.?
Substance abusers,
Yes
College
drinkers’ maladaptive
cases of work
inhibition/burnout,
their motivations for
motivations for
veterans,
drinking, and targets
motivational counsel-
motivational patterns
NAEQ
To assess the extent to
Identifies negative
Problem drinkers
Yes
expectancies that may
serve as a deterrent
term negative conse-
quences are expected to
motivation to stop or
and heavy
drinkers;
To provide a multi-
Identifies substance
abuse patterns and
AOD problem severity
Substance abusers Yes
Treatment-
criminal offenders
132

T
ABLE 1A.—Assessment instruments for treatment planning: Descriptive information
(contin
ued)
Groups used Norms Normed
Instr
ument
Purpose
Clinical utility
population with groups
Assesses readiness to
Adults and
Outpatients in
readiness for change
change drinking
adolescents;
general medical
among substance
hazardous
settings, head
treatment planning
and harmful
trauma and spinal
general
cord injury
medical
are not
practice at
seeking
psychiatric patients
general
treatment
hospital
Assesses readiness to
Adults and
Alcohol
readiness for change
change drinking
adolescents alcohol treatment
dependents
among substance
treatment planning
in treatment
treatment
RFDQ
Adults Alcoholics in No
NA
and potential relapse
treatment
drinking after a period
of abstinence
emotions, social
dimensions
Aids in assigning
Adults
Ethnic
and
about to enter or
groups;
currently in
middle-class
to current and long-term
treatment, in making
treatment
continued stay or
socioeco-
biomedical and psy-
transfer decisions
nomic status
chiatric or psychologi-
during treatment, and
groups
cal problems, and social
in documenting
appropriateness of
support
Target
avail.?
RTCQ
To determine stage of
Yes
Excessive
drinkers
behaviors; may aid in
identified in
abusers
drinkers who
individuals,
RTCQ-TV
To determine stage of
Individuals in Yes
behaviors; may aid in
and abusers
abusers seeking or in
To measure reasons
Identifies relapse risk
given for returning to
precipitants in negative
pressure, and craving
RAATE-CE
To provide a multidimen-
Problem drinkers
Yes
sional assessment of mo-
individuals to
RAATE-QI
tivation for and resistance
appropriate level of
and lower
treatment, severity of
and environmental
discharge
Assessment To Aid in the Treatment Planning Process
133

T
ABLE 1A.—Assessment instruments for treatment planning: Descriptive information
(contin
ued)
Assessing Alcohol Problems: A Guide for Clinicians and Researchers
Purpose Clinical utility population
Groups used
with
Normed
groups
Norms
SCQ
she will be able to
potential high-risk
situations
drinking and/or relapse,
to aid in planning
Adults
treatment
Age and
gender
readiness to change
readiness to change,
helping to determine
stage-appropriate
Adults
alcohol-dependent
Alcoholics
in treatment
YWP
performance, support
for drinking, and
support for abstinence
of social support in the
risk of relapse
Adults
treatment for
alcohol problems;
programs
in alcohol
treatment
URICA
readiness to change
readiness to change,
helping to determine
stage-appropriate
Adults
alcohol-dependent
Adult
outpatient
alcoholism
treatment
population
Instrument
Target
avail.?
To assess self-efficacy,
or how confident an
individual is that he or
resist the urge to drink
or drink heavily in
Develops a client
profile of the degree of
confidence in resisting
urges to drink in those
situations having the
greatest risk of heavy
relapse prevention
Problem drinkers in Yes
SOCRATES To assess stage of
drinking behavior
Identifies stage of
interventions
Alcohol abusers and
individuals
Yes
To assess alcohol-
related workplace
activities, particularly
adverse effects of
drinking on work
Determines the level
workplace that would
either facilitate
recovery or increase
Individuals in
employee assistance
Yes
Individuals
To assess stage of
drinking behavior
Identifies stage of
interventions
Alcohol abusers and
individuals
Yes
Note: Instruments are listed in alphabetical order by full name; see the text for the full names. A question mark in a table cell indicates that no information is
available. AOD = alcohol and other drug; NA = not applicable.
134

T
ABLE 1B.—Assessment instruments for treatment planning: Administrative information
Assessment To Aid in the Treatment Planning Process
Computer
No. of items score/ scoring Fee for
Instrument (no. of subscales) options administer needed? interpret use?
F-SMAST/ 13 P&P 5 min No 5 min No No
M-SMAST
ASI ~200 (7) 50–60 min 5–10 min No
AASE P&P No No No
ADCQ 29 (2) P&P 10–15 min No 5–10 min ?
ABS 48 (7) P&P No No No
AEQ-S 40 (8) P&P 5–10 min No ?
AEQ 120 (90 scored) (6) No ? ? No
ADRS 8 10–15 min ? No ?
a decision tree
228 (24)
28 (1) P&P 10–15 min No 5–10 min ? ?
232 (10) No
CDP 88 1–2 h 30 min
DEQ 43 (6) P&P No No No
DRSEQ 31 (3) P&P 10 min No 10 min No No
DRIE 25 (3) P&P No No No
FTQ No 2–3 min
No No
IDS 42 or 100 (8) 15–20 min No 5 min
MSAPS 37 (3) No ?
MSQ P&P 2–3 h
(1 h for the depending on
22 or 60 (5) 15–20 min No 5 min
PEI-A 270 45 min No 2 min
10 min 5–10 min
No
15 min 15 min
No No
10–15 min
35–60 min 3–5/10 min
45 min 5 min
15 min 15–20 min
10 min 5–10 min
5 min No No
19 20–30 min 30 min
30 min 15 min
135
Time to
Format Time to Training
avail.?
P&P, computer, interview Yes Yes
20 Efficacy,
20 Temptation (4)
P&P, computer
Interview guided by Yes
AUI P&P, computer Yes Yes Yes
AWARE
CDAP P&P, computer Yes Yes
Interview Yes Yes Yes
NA P&P, interview
IPA Interview Yes
P&P, computer Yes Yes
Interview Yes
NA Yes Highly variable Yes Yes
briefer version) objectives
NAEQ P&P, computer, interview Yes Yes
P&P, computer Yes Yes

T
ABLE 1B.—Assessment instruments for treatment planning: Administrative information
(contin
ued)
Assessing Alcohol Problems: A Guide for Clinicians and Researchers
Computer
No. of items score/ scoring Fee for
Instrument (no. of subscales) options administer needed? interpret use?
12 (3) P&P No 1–2 min No No
15 (3) P&P No No No
RFDQ 16 (3) P&P 5 min No 3–5 min No ?
35 (5) in CE 20–30 min for CE, No
and 94 (5) in QI P&P (QI)
SCQ 39 (8) 8–10 min No 5 min
19 or 39 (3) P&P No No No
URICA 28 or 32 (4) P&P 5–10 min No 5–10 min
YWP 13 (3) P&P No No No
2–3 min 1 min
5 min
30–45 min for QI
5–10 min
No No
5 min 5 min
2–3 min
Time to
Format Time to Training
avail.?
RTCQ
RTCQ-TV
RAATE-CE Interview (CE), Yes Yes
RAATE-QI
P&P, computer Yes Yes
SOCRATES 10–15 min for
39-item version
Note: Instruments are listed in alphabetical order by full name; see the text for the full names. A question mark in a table ce
ll indicates that no information is
available. NA = not applicable; P&P = pencil and paper.
136

Assessment To Aid in the Treatment Planning Process
T
ABLE 2.—Availability of psychometric data on treatment planning measures
Internal
Measure Split-half Content Criterion Construct
F-SMAST/M-SMAST • • • • • •
ASI • • • • • •
AASE • • •
ADCQ • • •
ABS • •
AEQ-S • • •
AEQ • • • • •
ADRS •
1
• •
• • • • •
• • • •
• • • •
CDP • • •
DEQ • • • • •
DRSEQ • • • • •
DRIE • • • •
FTQ • •
• • •
IDS • • • • •
MSAPS • • •
MSQ • • • •
• • • • •
PEI-A • • • • •
• • • • •
• • • •
RFDQ • • •
• • • •
SCQ • • • • •
• • • •
URICA • • •
YWP • • •
Reliability Validity
Test-Retest consistency
AUI
AWARE
CDAP
IPA
NAEQ
RTCQ
RTCQ-TV
RAATE
SOCRATES
Note: Measures are listed in the same order as in table 1; see the text for the full names.
1
Reliability estimates based on interrater reliability.
137

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
the indi
vidual’s awareness and increase problem
recognition. Such awareness is an important step
in the process to initiate behavior change and
treatment-seeking behavior (Donovan and
Rosengren 1999; Tucker and King 1999).
There have been two prominent views about
the alcoholic’s “inability to recognize” or “lack of
awareness” of his or her problems. One view is
that this is part of a defensive process of “denial,”
or the tendency of heavy drinkers to minimize or
deny that they have a “drinking problem.” This
stance, thought to be unconscious and protective
of the individual’s perception of self, has contin-
ued to exert an important influence both in defini-
tions of alcoholism (e.g., Morse and Flavin 1992)
and in the development of patient placement crite-
ria (e.g., Mee-Lee et al. 1996).
An alternative model of behavior change
presented by Prochaska and DiClemente is applic-
able to addictive behaviors and has come to serve
as the frame of reference for assessing motivation
or readiness to change (Prochaska and
DiClemente 1986; Prochaska et al. 1992). They
suggest that individuals go through a series of
stages in this decisionmaking process, ranging
from precontemplation to taking positive steps to
initiate change. Each stage reflects an increased
level of problem recognition and commitment to
change the addictive behavior. Many individuals
have gone for years without perceiving that they
have a problem, seemingly oblivious to the nega-
tive consequences that others are able to observe.
This behavior, characteristic of the precontempla-
tion phase, has often been thought of as denial.
Other individuals have contemplated the need for
changing their drinking for some time but have
not been sufficiently committed to take action.
Others may have attempted action in the past but
have since resumed use, raising questions in their
minds about the efficacy of treatment and their
ability to reach their goals. Others, acknowledging
the need to change, may still be influenced by
their perceptions of the positive benefits derived
from drinking and are unable to make a firm
commitment to take action.
Each of these two views of denial and readi-
ness has generated assessment measures and
procedures meant to determine “where the client
is” with respect to problem recognition and readi-
ness for behavior change. Clinical lore has
suggested that one of the most important steps in
the counseling and recovery process is to identify
and “break through” the individual’s denial, often
through the use of confrontational therapeutic
approaches, so that he or she can take steps neces-
sary to seek treatment. The importance of this task
led Goldsmith and Green (1988) to develop the
Alcoholism Denial Rating Scale (ADRS). They
define alcoholic denial as “the alcoholic’s inability
to connect his drinking with its resulting conse-
quences” (Breuer and Goldsmith 1995, p. 171).
The intent of the scale is to quantify denial, in
order to aid counselors in enhancing treatment and
its outcome. An 8-point scale is used to define a
continuum from denial to awareness. The individ-
ual reporting that he or she has no problem at all
and has no awareness of alcohol-related problems
is at one end of the continuum. The midpoint
represents an awareness of some alcohol-related
problems but with none of them viewed as being
out of control. The other end of the continuum is
the individual who indicates that he or she has
pervasive alcohol-related problems and that his or
her life is out of control because of drinking.
These ratings are made by clinicians following an
interview with the individual that focuses on AOD
use and his or her perception of the use pattern.
The rating process is aided by the use of a deci-
sion tree model and descriptions of behavior and
life circumstances at each of the eight levels.
Preliminary and subsequent reports suggest
that the ADRS has a good to relatively high level
of interrater reliability, and the level of agreement
is increased by using a semi-structured interview
format and the decision tree (Goldsmith and
Green 1988; Breuer and Goldsmith 1995).
Newsome and Ditzler (1993) also found the scale
to be useful clinically by providing a heuristic tool
that can be used (1) to determine issues, decisions,
and prioritization regarding admission to treat-
ment among those seeking treatment; (2) to iden-
138

Assessment To Aid in the Treatment Planning Process
tify and inter
vene preventively with individuals
who are at high risk of early discharge; and (3) to
assess treatment progress.
Assessment is often the first step in the formal
process of treatment for an addictive disorder.
Choosing to change one’s drinking pattern or give
up alcohol or other drugs is not a decision arrived
at easily. Individuals vary widely in their readiness
to change, being more or less ready to stop drink-
ing or other drug use. The level of motivation for
change or for treatment will vary across individuals
seeking treatment and will fluctuate within each
individual across time. Even presenting for treat-
ment intake does not reliably gauge the client’s
level or locus (e.g., intrinsic vs. extrinsic) of moti-
vation. One task of the assessment process is to
evaluate and attempt to enhance the individual’s
motivation and readiness to change and to engage
in treatment (Donovan 1988; W.R. Miller 1989
a;
W.R. Miller and Rollnick 1991; Horvath 1993).
Clearly, knowing the stage of readiness to
change drinking behavior is an important compo-
nent in the treatment planning process (Connors et
al. 2001). A number of assessment instruments
have been developed to assist the clinician in deter-
mining the stage of readiness for change among
problem drinkers or alcoholics. All are based on
Prochaska and DiClemente’s stages of change
model. The Readiness To Change Questionnaire
(RTCQ), developed by Rollnick and colleagues
(1992), is a 12-item questionnaire consisting of
three subscales that correspond to the precontem-
plation, contemplation, and action stages as
reflected in the factor structure derived from princi-
pal components analysis. Each of these scales
consists of 4 items presented as 5-point rating
scales ranging from strongly agree to strongly
disagree. Despite the relative brevity of the scales,
Rollnick and colleagues found that Cronbach alpha
levels, reflecting their internal consistency, ranged
from 0.73 for precontemplation to 0.85 for action
in a sample of excessive drinkers (i.e., harmful and
hazardous drinkers) identified in a general medical
setting. A similar range was found for the test-
retest reliability coefficients.
Two methods have been developed to assign
drinkers to one of the three stages. The first
involves assigning the individual to the stage
having the highest raw score; in the event of tied
scores, the person is assigned to the more
advanced stage. The second method is a pattern or
profile analysis of either the raw scale scores or
standardized scale scores across the three scales.
Both methods have been shown to have predictive
validity. The stages to which excessive drinkers
identified from general medical wards of a hospi-
tal were assigned, using either method, were asso-
ciated with changes in drinking behavior at
8-week and 6-month followup points; those in the
action stage consistently showed the greatest
reduction in drinking (Heather et al. 1993).
However, some have argued that the RTCQ does
not measure distinct stages but rather represents a
higher order measure of readiness that can be
scaled along a continuum with a high level of
internal consistency and predictive power (Budd
and Rollnick 1997).
The RTCQ thus appears to provide a brief
assessment instrument that can be used to identify
readiness to change, predict subsequent drinking,
direct the selection of interventions, and serve as an
outcome or process measure to evaluate brief inter-
ventions among individuals identified as having
drinking problems but who are not actively seeking
specialized alcoholism treatment. The scale has
been used with a variety of such groups, including
outpatients in general medical settings (e.g., Hapke
et al. 1998; Samet and O’Connor 1998), head
trauma and spinal cord injury individuals (e.g.,
Bombardier et al. 1997; Bombardier and Rimmele
1998), and psychiatric patients (e.g., Blume and
Schmaling 1997; Blume and Marlatt 2000).
The authors emphasize that the RTCQ was
developed primarily for use with hazardous or
harmful drinkers in general medical settings who
are
not seeking tr
eatment for alcohol problems. Its
use with problem drinkers in treatment has led to
considerably lower estimates of reliability and
different factor structures (Gavin et al. 1998); this
was particularly true for the precontemplation
(alpha = 0.30) and contemplation (alpha = 0.52)
139

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
scales. T
hese low internal consistency estimates
raise a question about the utility of the RTCQ in
treatment settings (Gavin et al. 1998). This has led
to subsequent work to develop measures more
appropriate to individuals in treatment. One such
measure is the Readiness To Change
Questionnaire Treatment Version (RTCQ-TV)
(Heather et al. 1999). Through a series of factor
analyses a 15-item scale was derived. It includes 5
items each for the precontemplation, contempla-
tion, and action stages. Of these, the internal
consistency reliability of the contemplation scale
was the lowest (alpha = 0.60), with that of the
precontemplation (alpha = 0.68) and action (alpha
= 0.77) scales somewhat higher. As an index of
concurrent validity the RTCQ-TV scale scores
were correlated with those from the University of
Rhode Island Change Assessment (URICA)
(McConnaughy et al. 1983). The RTCQ-TV
scales were significantly and most highly corre-
lated with the corresponding scales on the
URICA. It was also found that a significantly
higher percentage of clients who at followup (an
average of 7.4 months after the initial assessment)
were classified as having “good” outcomes (either
abstinent or drinking below recommended levels)
were in the action stage at intake (57 percent),
compared with the rate of clients having good
outcomes who were in the contemplation stage
(35 percent). Although Heather and colleagues
indicated that additional research is necessary to
determine the psychometric properties of the
RTCQ-TV with different populations, they
suggested that it is preferable for clinicians
dealing with clients in treatment settings to shift
from the original RTCQ to the new version specif-
ically developed for use with clinical populations
(Heather et al. 1999).
Another relatively new scale focused on use
within a clinical setting is the Alcohol and Drug
Consequences Questionnaire (ADCQ) (Cunning-
ham et al. 1997). This scale derives from the
general theoretical notion, and from related clini-
cal interventions, that represent a form of deci-
sional balance. A number of such measures have
been developed previously and have explored the
“pros” and “cons” of continued alcohol use (e.g.,
Migneault et al. 1999). However, the ADCQ
focuses on the costs and benefits of stopping or
changing one’s drinking. The ADCQ consists of
two subscales. A 14-item subscale asks individuals
to endorse those negative consequences or
perceived costs involved in choosing to change
their substance use pattern. A complementary 15-
item subscale asks them to endorse the positive
outcomes or perceived benefits derived from
making such a change. Each of these subscales has
an internal consistency index above 0.90. It was
found that individuals who rated the perceived
benefits of change higher at intake or those who
rated the perceived costs of change as lower at
intake were less likely to drink and drank on fewer
days during a 1-year followup. Although the
ADCQ appears to be a promising measure, further
psychometric evaluations, such as those reported
by Carey and colleagues (2001), are needed.
Two measures have been increasingly used to
determine the readiness for change among
problem drinkers who are seeking treatment. The
first is the URICA, mentioned earlier in this
chapter. This scale was originally developed as
part of the evaluation of the change process in
psychotherapy (McConnaughy et al. 1983). It has
become a primary measure used in the context of
Prochaska and DiClemente’s stages of change
model and has had its greatest application in the
area of smoking cessation (e.g., DiClemente et al.
1991). More recently it has been applied in the
evaluation of individuals having drinking prob-
lems (DiClemente and Hughes 1990) and other
drug problems (Abellanas and McLellan 1993).
The scale originally consisted of 32 items
presented with a 5-point response scale (from
strong disagreement to strong agreement). The
items are worded so that individuals respond to
their perception of a general “problem” that they
define themselves; the initial instruction set is
used to focus the respondent’s attention to drink-
ing as the problem to be considered.
The URICA scale operationally defines four
theoretical stages of change, each assessed by
eight items: precontemplation, contemplation,
140

Assessment To Aid in the Treatment Planning Process
action, and maintenance
. However, subsequent
factor analyses with alcoholic subjects in an
outpatient treatment program led to a reduction of
the items to 28, with 7 per subscale (DiClemente
and Hughes 1990). Cluster analysis yielded five
patterns of respondents. Those in the precontem-
plation group view themselves as not having a
problem. Those in the ambivalent group appear to
be reluctant or ambivalent about changing their
behavior. Those in the participation group appear
to be highly invested and involved in change.
Those in the uninvolved or discouraged group
appear to have given up on the prospect of change
and are not involved in attempting to do so. Those
in the contemplation group appear to be interested
in making changes, are thinking about it, but have
not yet begun to take action. The subtypes were
found to differ significantly with respect to the
pattern of alcohol use, the perceived benefits of
drinking, and the incidence of negative alcohol-
related consequences. The validity of these
typologies has been largely corroborated in subse-
quent cluster analyses of AOD clients seeking
treatment (Carney and Kivlahan 1995; el-Bassel et
al. 1998).
Willoughby and Edens (1996; Edens and
Willoughby 2000) derived and replicated a two-
cluster solution on the URICA in evaluating
alcohol-dependent veterans in a residential
setting. The two clusters appeared to resemble the
precontemplation and contemplation/action
stages. Their findings suggest that those individu-
als classified as members of the precontemplation
group were less worried about their drinking and
were less interested in receiving help than those in
the contemplation/action group. Individuals clas-
sified as members of the precontemplation group
were also found to be less likely to complete treat-
ment (Edens and Willoughby 2000). Carbonari
and DiClemente (2000) also found that profiles
derived from the URICA, self-efficacy (confi-
dence of remaining abstinent and temptation to
drink), and the use of cognitive and behavioral
change strategies were related to drinking
outcomes in both outpatient and aftercare samples
from Project MATCH. This body of results
suggests that the URICA can be used to identify
clinically meaningful motivational subtypes of
treatment-seeking alcoholics.
The second measure receiving increased atten-
tion in the determination of readiness for change
among problem drinkers seeking treatment is the
Stages of Change Readiness and Treatment
Eagerness Scale (SOCRATES) (W.R. Miller et al.
1990; W.R. Miller and Tonigan 1996). This scale
is available in either a 39-item version or an abbre-
viated 19-item version. Like the RTCQ, but unlike
the URICA, the SOCRATES items are worded
specifically in reference to changing drinking
behavior. These items are responded to along a 5-
point Likert scale (from strong agreement to strong
disagreement). The measure has been shown to
have adequate levels of internal and test-retest reli-
ability as well as construct and criterion validity
(W.R. Miller and Tonigan 1996). Conceptually, the
SOCRATES assesses the stage of readiness
expressed by the individual within the theoretical
framework proposed by Prochaska and DiClemente,
namely, precontemplation, contemplation, determi-
nation or preparation, action, and maintenance.
Factor analytic studies by Miller and colleagues,
however, indicate three empirically derived scales:
Readiness for Change, Taking Steps for Change,
and Contemplation (W.R. Miller and Tonigan
1996). Isenhart (1994) similarly found three
factors on the SOCRATES, labeled Determination,
Action, and Contemplation. Subsequent factor
analyses with heavy-drinking college students (Vik
et al. 2000) were generally consistent with the
three factors. Also, the results of cluster analyses
(Isenhart 1994) suggest three groups based on the
pattern of their factor scores. These were similar in
nature to those obtained by DiClemente and
Hughes (1990) using the URICA, namely the
ambivalent, uninvolved, and active groups. These
groups were found to differ significantly with
respect to the pattern and styles of drinking and
drinking-related consequences as measured by the
Alcohol Use Inventory (AUI), which is discussed
later in this chapter.
Despite the general consistency in the findings
concerning the factor structure of the SOCRATES,
141

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
Maisto and collea
gues (1999) found only two prin-
cipal factors among a sample of “at risk” drinkers
recruited from primary care medical clinics: a
pr
oblem recognition
f
actor and a
taking action
f
actor. The first factor was based on a scale that
appeared to measure reliably the perceived degree
of severity of an existing alcohol problem (nine
items, Cronbach alpha = 0.91) using items from
Miller and Tonigan’s Ambivalence and
Recognition scales; the second factor was based on
a scale composed of items that focus on taking
action to change or to maintain changes that have
already been made (six items, Cronbach alpha =
0.89). These two factors also were found through
confirmatory factor analysis to best fit the
SOCRATES data when compared with the three-
factor solution derived by Miller and Tonigan
(1996). At the initial assessment the problem
recognition factor was most highly correlated with
measures of alcohol problems and symptoms of
dependence (e.g., Alcohol Dependence Scale,
Alcohol Use Disorders Identification Test, Drinker
Inventory of Consequences, Short Michigan
Alcoholism Screening Test [SMAST; see the
discussion later in this chapter]); while also signifi-
cantly correlated with these measures, the magni-
tude of the relationships was considerably lower
for the taking action factor. It was also found that
the problem recognition factor at baseline signifi-
cantly predicted the number of drinks, drinks per
drinking day, number of heavy-drinking days, and
number of negative consequences at a 6-month
followup, even after age, gender, race, severity of
dependence, baseline measures of each of the
outcome criterion variables, and the two
SOCRATES baseline factor scores were taken into
account. In each case, higher scores on the
problem recognition factor were associated with
heavier drinking and more negative consequences.
The taking action factor at baseline, however, did
predict these outcome measures.
Carey and colleagues (2001) found significant
correlations between the ADCQ subscales and
subscales from the SOCRATES among psychiatric
patients. The taking steps factor was negatively
associated with the perceived costs of quitting
(–0.28) and positively (0.64) with the anticipated
benefits of quitting. The problem recognition factor
from the SOCRATES was positively related (0.70)
to the anticipated benefits of quitting. The taking
steps factor was also found to be negatively related
to the perceived benefits of drinking/substance use
(–0.45) and positively related to the perceived
negative consequences of drinking/use (0.47).
Although the stages of change model has been
critiqued on methodological and conceptual
grounds (e.g., Sutton 1996; Whitehead 1997;
Joseph et al. 1999), the assessed stage of a client’s
readiness to change has direct implications for the
development of initial interventions meant to
enhance the likelihood of the client engaging in
and complying with treatment (Annis et al. 1996;
Sutton 1996; Connors et al. 2001). Carey and
colleagues (1999) provided a thorough review of a
number of measures of readiness to change among
substance abusers and some comparative informa-
tion that may help the clinician choose which of
these measures to use. The approach taken by the
clinician in attempting to accomplish this task will
differ depending on the client’s stage of readiness
to change (Prochaska and DiClemente 1986;
Prochaska et al. 1992; Connors et al. 2001). For
example, a client who is in the early stages of the
behavior change process, in which he or she is
contemplating change and moving toward making
a commitment and taking action, will likely
benefit most from approaches that increase one’s
information and awareness about oneself and the
nature of the problem, lead to self-assessment
about how one feels and thinks about oneself in
light of a problem, increase one’s belief in the
ability to change, and reaffirm one’s commitment
to take active steps to change (Prochaska et al.
1992; Horvath 1993).
In addition to being consistent with “practice
wisdom” and theoretical approaches to change,
the proposed focus on such awareness-raising
factors for those in the precontemplation and
contemplation phases is also consistent with
evidence from individuals who had resolved an
alcohol problem on their own without the aid of
formal treatment. L.C. Sobell and colleagues
142

Assessment To Aid in the Treatment Planning Process
(1993) f
ound that over half of the recoveries of
such individuals could be characterized by a
cognitive evaluation of the pros and cons of
continued drinking.
For some individuals, the events that led them
to contemplate the need for change or to take
steps to seek help may be sufficient for them to
stop drinking or modify their alcohol use patterns
without more formal treatment (L.C. Sobell et al.
1993; Marlatt et al. 1997; Donovan and
Rosengren 1999; Tucker and King 1999). For
others, brief interventions based on a comprehen-
sive assessment of their addictive behaviors and
related life areas, the provision of feedback and
advice to the client, and a focus on increasing
motivation for change have been found to increase
the likelihood of clients following through on
referrals to seek and enter treatment (e.g.,
Heather 1989; W.R. Miller 1989
a; Bien et al.
1993; Wilk et al. 1997).
In a review of measures of readiness to
change, Carey and colleagues (1999) indicated
that despite their common theoretical background,
their high popularity among clinicians, and their
heuristic value in working with clients, each
measure has psychometric limitations of one sort
or another. Because of this they caution that these
scales should be viewed as experimental in nature
and should not be used in isolation to make
important clinical decisions.
A
LCOHOL-RELATED EXPECTANCIES AND
SELF-EFFICACY
Clinicians and c
linical researchers have increas-
ingly focused on the role of cognitive factors in
decisions to drink and in drinkers’ responses to
alcohol (Oei and Jones 1986; Young and Oei
1993; Oei and Baldwin 1994; Oei and Burrow
2000; B.T. Jones et al. 2001). Two broad cate-
gories of such cognitive factors having implica-
tions for the development and maintenance of
drinking problems and for potential relapse
following treatment are (1) the individual’s expec-
tations about drinking and the anticipated effects
of alcohol and (2) the individual’s expectations
about one’s ability to cope adequately with prob-
lems (self-efficacy expectations). These categories
and related instruments are discussed in the
following sections.
Alcohol-Rela
ted Expectancy Measures and
Reasons for Drinking
Alcohol-r
elated expectancies typically refer to the
beliefs or cognitive representations held by the
individual concerning the anticipated effects or
outcomes expected to occur after consuming
alcohol. These expectancies are shaped by an
individual’s past direct or indirect experience with
alcohol and drinking behavior (Connors and
Maisto 1988
a). T
o the extent that these represen-
tations are activated and accessible to the individ-
ual in drinking-related situations, they are
hypothesized to determine the anticipated
outcomes in using alcohol and to mediate subse-
quent drinking behavior (Rather and Goldman
1994; Stacy et al. 1994; Palfai and Wood 2001).
It is often presumed that individuals drink in
order to achieve or enhance the emotional or
behavioral outcomes that they expect; thus, these
expectancies are often viewed as being reflective
of the individual’s possible “reasons for drinking”
(Cronin 1997; Galen et al. 2001). Individuals
differ with respect to both their experiences with
alcohol and drinking and with the resultant beliefs
and expectations they hold about alcohol’s antici-
pated effects. To the extent that individuals are
found to hold expectancies that serve a functional
role in maintaining problematic drinking behavior,
they may be assigned to treatment strategies
designed to challenge or modify their beliefs
about alcohol’s effects on mood and behavior and
to substitute more adaptive or realistic expecta-
tions, with the prediction that decreases in positive
expectancies associated with alcohol would be
associated with a decrease in drinking behavior
(Oei and Jones 1986; S.A. Brown et al. 1988;
Connors and Maisto 1988
a; Connor
s et al. 1992;
Darkes and Goldman 1993; Oei and Baldwin
1994; Darkes and Goldman 1998).
143

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
A n
umber of measures of alcohol-related
beliefs and expectancies have been developed and
are available to help the clinician determine the
nature, strength, and valence of these beliefs. The
Alcohol Expectancy Questionnaire (AEQ) (S.A.
Brown et al. 1980, 1987
a) contin
ues to be the most
widely used alcohol expectancy measure in both
research and clinical settings. The AEQ is a 90-
item self-report form, presented with a forced
choice (i.e., agree/disagree) response format that
assesses a diverse array of anticipated experiences
associated with alcohol use. It was developed
empirically by refining a larger pool of verbatim
statements of adult men and women ages 15–60
years, with diverse ethnic backgrounds and drink-
ing histories (from nondrinkers to chronic alco-
holics). The adult version is designed to assess the
domain of alcohol reinforcement expectancies and
consists of six factor-analytically derived
subscales: positive global changes in experience,
sexual enhancement, social and physical pleasure,
social assertiveness, relaxation/tension reduction,
and arousal/interpersonal power. The scale has
been shown to have a high level of internal consis-
tency, test-retest reliability, and concurrent validity.
A recent factor analytic study identified a
number of meaningful dimensions derived from
the AEQ (Vik et al. 1999). The authors suggested
that the AEQ content could be considered to fall
along two dimensions, namely the valence of the
anticipated alcohol-related effects (positive/nega-
tive) and the degree of personal versus more
social context of the expected outcomes. The
authors described four resultant hypothetical
factors: social enhancement, social coping,
personal enhancement, and personal coping. The
results of a confirmatory factor analysis supported
the presence of the hypothesized four factors.
These factors were found to have a high degree of
concurrent, convergent, and discriminant validity.
The AEQ has been evaluated in clinical and
nonclinical populations. As an example in a
nonclinical sample, Williams and Ricciardelli
(1996) found that scores on the AEQ were related
to alcohol dependence symptoms among heavy-
drinking young adults. More specifically, high
scores among young men on the social assertive-
ness, sexual enhancement, and arousal/interper-
sonal power scales were predictive of higher
symptoms of loss of control over drinking. The
pattern of findings among females was much
more complex. With respect to clinical popula-
tions, the AEQ total score and subscale scores
have been found to differentiate alcoholic from
nonalcoholic respondents and to be predictive of
current and future drinking practices, persistence
and participation in treatment, and relapse follow-
ing treatment (S.A. Brown 1985
a, 1985b; S
.A.
Brown et al. 1987
a).
Despite the systematization brought to the
assessment of alcohol expectancies by the AEQ,
investigators and clinicians have noted a number
of theoretical and practical limitations in its
utility. These include its reliance on a forced-
choice response format that does not allow deter-
mination of the strength of the expectancies; a
confounding of global or general beliefs with
personal ones; its focus on positive outcome
expectancies without assessing expectancies
concerning anticipated negative outcomes; its
restriction to a single “dose” or level of alcohol in
the instruction set to reference expectancies (e.g.,
a “few drinks”), thus precluding examination of
variation in expectancies over different dose
levels; and the lack of a measure of frequency of
occurrence or personal importance associated with
each of the expectancies (e.g., Southwick et al.
1981; Leigh 1989
a, 1989b, 1989c; Collins et al.
1990; Oei et al. 1990; Adams and McNeil 1991;
Leigh and Stacy 1991; Connors et al. 1992; Leigh
and Stacy 1993). These concerns have led to the
development of a number of subsequent
expectancy measures, each of which attempts to
address one or more of the noted limitations.
The Alcohol Effects Questionnaire-Self (AEQ-S)
(Rohsenow 1983), a revision and extension of the
AEQ, was developed as a brief method of assessing
both the positive and negative effects people expect
alcohol to have on them. It was intended to have
several advantages over the earlier AEQ. It is
briefer (40 true/false items); it assesses undesirable
effects of alcohol (impairment and irresponsibility)
144

Assessment To Aid in the Treatment Planning Process
as w
ell as positive reinforcing effects; and it
assesses only personal beliefs (beliefs about the
effects of alcohol on the individual) rather than
mixing personal beliefs with general beliefs (beliefs
about the effects of alcohol on people in general).
The AEQ-S was developed by taking the 5 items
that loaded most highly on the six factors of AEQ,
adding 2 items assessing verbal aggression and
deleting from the arousal/interpersonal power scale
1 item that had loaded on two factors, and adding 5
items assessing cognitive and physical impairment
and 4 items assessing carelessness or lack of
concern about consequences. All items were then
reworded to reflect personal beliefs. The AEQ-S
consists of eight rational scales: Global Positive,
Social and Physical Pleasure, Sexual Enhancement,
Power and Aggression, Social Expressiveness,
Relaxation and Tension Reduction, Cognitive and
Physical Impairment, and Careless Unconcern.
Internal consistency indices across subscales
ranged from 0.49 to 0.74 for college student
drinkers and from 0.37 to 0.85 among alcoholics in
treatment. Factor analysis of the AEQ-S on college
students (Rohsenow 1983) largely supported the
first six rationally derived factors and combined the
two negative scales into one factor. The AEQ-S has
been used largely as a research instrument to
explain or predict behaviors or responses of indi-
viduals in other areas, such as aggression after
drinking (Rohsenow and Bachorowski 1984) and
cue reactivity (Rohsenow et al. 1992).
George and colleagues (1995) modified and
extended the AEQ-S in an attempt to maintain the
benefits of this instrument (e.g., brevity and nega-
tive expectancies) while shifting the response
format to a 6-point rating scale (from strongly
agree to strongly disagree) to allow information
about strength of endorsement. This measure is
called the AEQ-3 (i.e., third revision of the
Alcohol Expectancy Questionnaire). The structure
derived from confirmatory factor analysis of the
AEQ-3 was found to be relatively consistent with
that proposed by Rohsenow (1983) and was rela-
tively invariant across gender and ethnic groups.
It appears that neither the AEQ-S nor the AEQ-
3 has been used in clinical applications to date,
and neither appears to have been used in recent
research.
Another measure of expectancies is the
Drinking Expectancy Questionnaire (DEQ)
(Young and Knight 1989; Young et al. 1991
a). It
also attempts to improve on the AEQ by phrasing
items consistently in the first person, measuring
both positive and negative expectancies, and
balancing the valence of items selected for the
questionnaire by providing a multiple-response
format (Young and Knight 1989). The DEQ
consists of 43 items developed using both commu-
nity and clinical populations. Each item is rated on
a 5-point rating scale from strongly disagree to
strongly agree. Five subscales, derived from factor
analysis, relate to specific alcohol expectancies of
assertion, affective change, sexual enhancement,
cognitive change, and tension reduction. A sixth
factor, dependence, is more general and relates to
perceived level of alcohol involvement. Analyses
suggest that the alcohol-related beliefs assessed by
the DEQ are relatively stable and traitlike, being
relatively unaffected by drinking (Young et al.
1989). The total score and the subscale scores of
the DEQ have been found to correlate with
measures of frequency of drinking, but not quan-
tity consumed, in a community sample (N. Lee
and Oei 1993
a). As an e
xample, those who
expected greater negative affective states when
drinking reported that they drank both their usual
and maximum amounts of alcohol less often.
The Alcohol Beliefs Scale (ABS) (Connors et
al. 1987; Connors and Maisto 1988
b; Connor
s et
al. 1992) is a two-part, 48-item questionnaire. It
attempts to incorporate information concerning
strength of endorsement, dose-related changes in
the anticipated effects of alcohol, and the
perceived utility of alcohol in inducing a number
of emotions or behaviors. On part A of the scale
(26 items), subjects indicate the extent to which
each of three different amounts of alcohol (one to
three standard drinks, four to six standard drinks,
and “when drunk”) increases or decreases behav-
iors and feelings such as judgment, problem
solving, depression, aggression, stress, and group
interaction. The ratings are made on an 11-point
145

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
scale r
anging from a “strong decrease in behavior
or feeling” to a “strong increase in behavior or
feeling”; a rating of zero is used to indicate no
change in the behavior or feeling as a result of
drinking. Four domains have been derived from
the items contained in part A: control issues,
sensations, capability issues, and social issues. On
part B of the scale (22 items), drinkers rate how
useful the consumption of each of the three doses
of alcohol would be for a variety of reasons (e.g.,
to relax, to become more popular, to become unin-
hibited, to relieve depression, and to forget
worries). These estimates are also made on an 11-
point scale ranging from “not at all useful” to
“very useful.” The factors derived from part B
have been labeled as useful in feeling better,
useful for being in charge, and useful for alleviat-
ing aversive states.
Results suggest that alcoholics differ from
problem drinkers and non-problem drinkers with
respect to the expected effects of alcohol and its
anticipated utility. In general, alcoholics antici-
pated less impairment on the control and capability
factors. A dose-response relationship was noted,
with all drinkers expecting increased impairment
with increasing doses. An interaction between
drinker group and dose was found on a number of
subscales of part B, suggesting differences in the
perceived utility to induce moods and behaviors as
a function of severity of drinking problem and
amount consumed. As an example, higher doses of
alcohol were perceived as increasingly useful in
reducing emotional distress, with the magnitude of
the increases in this perceived utility being greatest
for alcoholics. There also appears to be an interac-
tion with respect to perceived effects and utility
across doses as a function of gender and ethnicity
(Connors et al. 1988).
Fromme, Stroot, and Kaplan (1993) developed
the Comprehensive Effects of Alcohol (CEOA)
scale. The scale was developed initially through
exploratory factor analysis. This process identified
four positive expectancy factors, consisting of 22
items: sociability, tension reduction, “liquid
courage,” and sexuality. Three negative
expectancy factors were also derived, consisting
of 19 items: cognitive and behavioral impairment,
risk and aggression, and self-perception. All items
focus on discrete rather than global effects of
alcohol and all are worded to focus on the
person’s own expectations rather than those of
people in general. The scale has two parts. In the
first part, the individual indicates the level of
agreement with the expectancy statement on a 4-
point scale from “disagree” to “agree.” In the
second part, the individual is asked to provide a
subjective evaluation of the expected effects on a
5-point scale from “bad” through “neutral” to
“good.” The latter scale was developed because
there is considerable individual difference in the
perceived desirability of a given effect of alcohol,
and as such it is preferable to assess the person’s
evaluation rather than make inferences about it.
Individuals are also asked to estimate the number
of standard drinks that they would need to
consume to experience each of the anticipated
effects. The CEOA scale was demonstrated to
have adequate levels of internal consistency,
temporal stability, and construct validity. The
positive and negative expectancy and evaluation
scale scores were also related to measures of
quantity and frequency of drinking and weekly
alcohol consumption among college students.
Guarna and Rosenberg (2000) explored the
situational specificity of expectancies measured
by the CEOA scale. Driving under the influence
(DUI) offenders were asked to complete the scale
under a number of different response sets. They
were asked to respond as if they had consumed
either small or large amounts of alcohol, beer,
wine, mixed drinks, or straight liquor.
Respondents’ expectancies were found to vary
across both the quantity and the beverage cate-
gories. The greatest number of negative expectan-
cies was associated with drinking straight liquor,
with the highest level of positive expectancies
associated with drinking beer. Of interest,
consuming a large amount of alcohol was associ-
ated with both more positive and more negative
expectancies than drinking small amounts.
Leigh (Critchlow 1987; Leigh 1987, 1989
b,
1989
c) de
veloped the Effects of Drinking Alcohol
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Assessment To Aid in the Treatment Planning Process
(ED
A) scale as a measure of both expectations
about the consequences of drinking and subjective
evaluations of the relative desirability of these
consequences as part of a utility analysis of drink-
ing behavior. The utility of a behavior is viewed
as a function of the perceived probability of its
occurrence and the desirability of the anticipated
consequences if the behavior does occur. This
general principle guided the development of this
questionnaire, which lists 20 possible effects of
alcohol, both positive and negative. Individuals
are asked to rate the probability of experiencing
each of the effects on a 5-point rating scale from
“very unlikely” to “very likely.” They are
instructed to use as a reference for their ratings the
consumption of enough alcohol to “be under the
influence.” Individuals are also asked to evaluate
each effect based on their personal experience
along a 5-point scale from “very good” to “very
bad.” Utility scores have been found to be posi-
tively related to drinking; this appears to be partic-
ularly due to the increased expectations of positive
consequences of drinking and more positive eval-
uation of all consequences by heavier drinkers
(Critchlow 1987; Leigh 1987). Also, individuals
tend to believe that alcohol effects, particularly for
socially undesirable behaviors, are more likely to
happen to others than to themselves (Leigh 1987).
The EDA scale has been found to be comparable
to the AEQ in its ability to predict drinking behav-
ior among college students (Leigh 1989
a). T
he
EDA scale has recently served as one of the crite-
rion measures used to determine the convergent
and divergent validity of the newly derived four-
factor subscales of the AEQ (Vik et al. 1999).
Leigh and Stacy (1993) subsequently devel-
oped another measure of expectancies through a
series of factor and structural equation analytic
techniques. The resultant untitled 34-item scale
consists of two broad categories of positive and
negative alcohol effects. The positive effects cate-
gory has four subscales: social facilitation, fun,
sexual enhancement, and tension reduction/nega-
tive reinforcement. The negative effects category
also has four subscales: social, emotional, physi-
cal, and cognitive/performance. Using a 5-point
scale from “no chance/very unlikely” to “certain
to happen,” individuals are asked to rate the likeli-
hood that each of the consequences would happen
to them if they drank. The structural equation
modeling suggested that although negative
expectancy was significantly related to alcohol
use, positive expectancy was a stronger predictor
of drinking behavior, and as such may represent a
more powerful motivator of drinking.
One of the expectancy measures that has been
used the most over the recent past is the Negative
Alcohol Expectancy Questionnaire (NAEQ) (B.T.
Jones and McMahon 1992, 1993; McMahon and
Jones 1993
a, 1993b). Unlik
e the AEQ, which
focused exclusively on anticipated positive effects
of alcohol, the NAEQ assesses the extent to which
an individual expects negative consequences to
occur if he or she were to drink. There is no speci-
fication in the instruction set to indicate the
amount of alcohol that is to serve as a reference
for judging the likely occurrence of these negative
consequences. The expected negative conse-
quences may serve as a behavioral deterrent and
represent motivation to stop or restrain drinking
(rather than motivation to drink, as expected posi-
tive consequences might measure) (McMahon and
Jones 1993
b). T
he potential negative conse-
quences are measured over three consecutive time
contexts: on the same day as the drinking, the next
day following drinking, and continued drinking at
the current level over a prolonged period. Each
item consists of a statement about a negative
consequence of drinking alcohol that could
conceivably occur; responses are measured in
terms of how likely each consequence would be
expected to occur, on a 5-point scale from “highly
unlikely” to “highly likely.” The standard NAEQ
has a total of 60 items; a short version (22 items)
is also available. Five subscales have been devel-
oped. The first three correspond to the three time-
frames (same day, next day, and long term);
proximal (same day) and distal (next day + long
term) subscales are also included.
In a study comparing the NAEQ and the AEQ
assessed at intake to a nonresidential alcohol treat-
ment program, the NAEQ was found to predict
147

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
time to f
irst drink following treatment; positive
expectancies, as measured by the AEQ, were not
predictive (B.T. Jones and McMahon 1994
a). T
he
total score of the NAEQ was predictive of alcohol
consumption at a 3-month followup; the total
score of the AEQ was not predictive (B.T. Jones
and McMahon 1994
b). Ho
wever, the positive
global changes subscale of the AEQ was found to
be positively related to posttreatment drinking,
while the distal subscale of the NAEQ (reflecting
expected negative consequences with continued
long-term drinking) was negatively related to
posttreatment drinking.
These results reflect the differential motiva-
tional factors represented by positive and negative
expectancies in relationship to drinking behavior
(McMahon and Jones 1993
c). N
.K. Lee and
colleagues (1999), in a general community sample,
found that negative expectancies were most promi-
nently associated with the frequency of drinking
and positive expectancies were associated primarily
with the quantity of alcohol consumed. Also, both
the NAEQ and the RTCQ were found to predict
time to first drink following treatment. However,
the RTCQ and NAEQ were uncorrelated, suggest-
ing that they measure different aspects of client
motivation (McMahon and Jones 1996).
Devine and Rosenberg (2000) evaluated the
relative contribution of both negative expectan-
cies, measured by the NAEQ, and positive
expectancies, measured by the AEQ, on self-
reported alcohol use among DUI offenders.
Baseline measures of expectancies were related to
the self-reported number of drinking days at a 3-
month followup assessment. They also looked at
subgroups that were defined by being either high
or low on the two expectancy measures. What was
of note was that those in the low positive/high
negative group drank considerably less frequently
than those in the high positive/high negative
group. The authors suggest that the apparent inhi-
bition of drinking previously found associated
with high levels of negative expectancies may be
lessened when the person also has high levels of
positive expectancies.
Clearly, there is a wide variety of measures of
alcohol-related expectancies from which to choose,
many with a number of features in common as well
as common variance in assessing aspects of the
expectancy domain (Leigh 1989
b; B
.T. Jones et al.
2001). From a clinical perspective, an important
limitation of many of the scales is that they have
been used more with college students and/or
general population samples than with alcoholics in
treatment. The decision of which of these scales to
use in a clinical or research setting should thus be
guided by the empirically determined or hypothe-
sized relationship between a particular measure of
beliefs and the prediction of specific drinking
behaviors or treatment outcomes. The evolution of
the available expectancy scales, however, suggests
that it is important to consider both positive and
negative consequences, to ask about both the likeli-
hood of occurrence of these consequences and the
subjective appraisal of the relative desirability of
each if it does occur, and to assess changes in these
expectancies as a function of differing levels of
alcohol intake.
Leigh and Stacy (1994) suggested that there
may be an important artifact involved in the many
alcohol expectancy scales that have been devel-
oped to date. That is, by providing the individual
with a structured questionnaire that provides a
listing of a number of possible consequences, the
individual’s responses are likely to be cued. As
such, these responses actually may not be repre-
sentative of those expected effects that are the
most salient for the person. They suggest and
demonstrate the potential benefit of eliciting
expectancy responses from an open-ended ques-
tionnaire. Individuals were asked to “list all the
good or pleasant things that might happen to you
as a result of drinking alcohol.” A similar method
was used to elicit a listing of bad or unpleasant
outcomes. Although the resultant categories of
responses appear consistent with those obtained
using more structured questionnaires, the percent-
age of responses in each category differed consid-
erably across subgroups of drinkers. Thus, it may
be important to consider the benefits derived from
both the more structured questionnaire and the
148

Assessment To Aid in the Treatment Planning Process
mor
e open-ended approaches in attempting to
assess both a broad range of and more personally
salient alcohol-related expectancies.
Cox and Klinger (1988) proposed a motiva-
tional model of drinking behavior that has led to
the development of an assessment of individuals’
expectancies in relationship to a number of treatment-
relevant goals using a mixed ideographic and
nomothetic method (Klinger 1987). People who
drink alcohol excessively are assumed to do so
because drinking serves some function in their
lives (Cox and Klinger 1988, 1990). Although a
wide range of biological, psychological, and social
factors may influence drinking, the final common
pathway to alcohol use is motivational in nature.
An individual is assumed to choose to take a drink
or not based on the belief that the anticipated posi-
tive affective consequences of drinking outweigh
those of not drinking. An important factor in this
balance is the individual’s current incentives. To
the extent that individuals do not have other non-
alcohol-related sources of satisfaction, are not
making progress toward reaching positive goals, or
are burdened by a number of negative life activi-
ties, the greater the likelihood of expecting that
alcohol will counteract negative emotions and lead
to or enhance positive emotions.
This motivational model of drinking provides
the framework within which the Motivational
Structure Questionnaire (MSQ)
(Kling
er and Cox
1985, 1986) was developed. The MSQ identifies
those maladaptive motivational patterns that under-
lie the consumption of alcohol by problem
drinkers. It is a self-administered semi-structured
questionnaire that requires approximately 2–3
hours to complete; a briefer version is also avail-
able, requiring about 1 hour to complete (Cox et al.
1991
a). Indi
viduals are asked to identify their
current concerns in major life areas such as their
interests, activities that they are engaged in, prob-
lems, general and specific concerns, goals, joys,
disappointments, hopes, and fears. They then are
asked to make judgments about the pursuit of goals
associated with each area of concern along dimen-
sions that will reveal the structure of their motiva-
tion. These judgments include factors such as the
degree of commitment to pursuing each goal; the
amount of positive affect expected by achieving a
particular goal and the amount of negative affect
associated with not attaining it; the perceived prob-
ability of success and time urgency associated with
pursuing a goal; and the perceived impact of
continued alcohol use on attaining the goal. A
computer program scores the MSQ and generates
quantitative indices that include the value,
perceived accessibility, and imminence of the alco-
holic’s goals; the pattern of commitment to these
goals; and the nature of the individual’s desires and
roles regarding them (Cox et al. 1991
b). A moti
va-
tional profile is then derived to depict the signifi-
cant features of the individual’s motivational
structure and to identify problematic motivational
patterns. Thus, the MSQ can be used at the begin-
ning of treatment to identify and specify patients’
motivational problems and their impact on the
motivation to drink alcohol. The information
derived from the MSQ can also provide the basis
for initiating Systematic Motivational Counseling
(Cox et al. 1991
b), an a
pproach developed to facili-
tate changing drinkers’ maladaptive motivational
patterns. A detailed manual to guide the counseling
technique is available (Cox et al. 1993).
Recently Cox and colleagues (2000) explored
the relationship between the MSQ and a measure of
readiness to change in a group of alcoholics enter-
ing inpatient treatment. Factor analysis derived two
factors on the MSQ, adaptive motivation and
maladaptive motivation. The nature of patients’
motivational structure was related to readiness to
change. High scores on the adaptive motivation
factor, reflecting a commitment to pursue goals
having emotionally satisfying outcomes, were posi-
tively related to determination to change and nega-
tively related to denial of one’s alcohol problem.
Dr
inking Relapse Risk and Self-Efficacy
A second major co
gnitive factor to be incorpo-
rated into the assessment of alcohol abusers is that
of self-efficacy (DiClemente 1986; Wilson 1987
a,
1987
b). W
hile this construct plays a prominent
role in cognitive-behavioral models of problem
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Assessing Alcohol Problems: A Guide for Clinicians and Researchers
dr
inking, considerably less research attention has
been focused on its assessment and its relationship
to drinking behavior than has been given to
alcohol-related outcome expectancies (Young et
al. 1991
b; Oei and Bald
win 1994). The concept of
self-efficacy, originally developed by Bandura
(1977, 1986), has been adapted and expanded to
be applied in the area of addictive behaviors
(Rollnick and Heather 1982; Baer and
Lichtenstein 1988). Within the context of alcohol
problems, this construct has been defined in terms
of the beliefs that individuals hold or their level of
confidence concerning their ability to resist
engaging in drinking behavior (Young et al.
1991
b; Oei and Bald
win 1994). The adaptation of
the self-efficacy construct to the addictions has
also led to modifications in its assessment (Young
et al. 1991
b). Str
ength of self-efficacy is typically
defined as the mean self-efficacy ratings across
situations, and generality of self-efficacy is
usually estimated as the variability of these ratings
across situations. Additionally, Sitharthan and
Kavanagh (1991) recommended a measure of the
level of self-efficacy, defined as the number of
situations in which the individual had the
maximum rating of confidence about not drinking.
The cognitive-behavioral model of relapse
developed by Marlatt and colleagues (Marlatt and
Gordon 1980, 1985) has served as a heuristic
framework to guide the development of measures
of self-efficacy in substance abuse. Although there
have been challenges to the reliability and validity
of Marlatt’s original taxonomy of relapse precipi-
tants (Marlatt and Gordon 1980; Zywiak et al.
1996), this taxonomy has led to the generation of
categories of situations having high relapse poten-
tial. Implicit in the operational definition of self-
efficacy, and explicit in Marlatt’s model of
relapse, is the assumption that the strength of effi-
cacy is dependent on the availability and accessi-
bility of emotional and behavioral skills necessary
to cope with situations that are appraised as a
challenge to one’s perception of control and
which, therefore, may precipitate a relapse. It is
assumed that the greater the individual’s available
repertoire of coping skills, the greater the strength
of self-efficacy, and the lower the probability of
relapse or drinking in a given situation.
The instruments developed by Annis and
colleagues are probably the most widely used
methods to date for assessing self-efficacy in rela-
tionship to drinking (e.g., Annis and Davis 1988
a,
1988
b, 1991). T
wo parallel measures, administered
either as self-report forms or via computer, are typi-
cally used in combination in the assessment
process. Each scale takes approximately 15–20
minutes to complete. The first is the Inventory of
Drinking Situations (IDS) (Annis 1982; Annis et al.
1987). The original version of the IDS was a 100-
item self-report questionnaire designed to assess
situations in which the client drank heavily over the
past year. A 42-item version is also available
(Isenhart 1991, 1993). Eight general categories of
drinking situations, based on Marlatt’s classifica-
tion system (Marlatt and Gordon 1980, 1985), are
assessed: unpleasant emotions, physical discom-
fort, pleasant emotions, testing personal control,
urges and temptations, conflict with others, social
pressure to drink, and pleasant times with others.
Clients are instructed to rate on a 4-point rating
scale (from “never” to “almost always”) their
frequency of heavy drinking in each of 100 situa-
tions during the past year. Clients define “heavy
drinking” in terms of their own consumption
pattern and their perception of what constitutes
“heavy” for them. M.B. Sobell and Sobell (1993)
suggested that at the start of the questionnaire clini-
cians might ask clients to note the number of stan-
dard drinks they would consider to constitute
“drinking heavily” as a way to provide a reference
point for their responses to the IDS.
From the client’s responses on the IDS, a problem
index score, ranging from 1 to 100, can be calculated
for each of the eight categories of drinking situations.
By plotting the eight problem index scores, a client
profile can be constructed to show the client’s areas of
greatest risk for heavy drinking and to help target and
guide interventions. Profiles that show variability
across situations, or differentiated profiles, are more
helpful in the identification of specific intervention
targets than are generalized or flat profiles that have
little variation across situations. Evidence also suggests
150

Assessment To Aid in the Treatment Planning Process
tha
t clients with differentiated profiles may have better
outcomes in relapse prevention treatment than those
with generalized profiles (Annis and Davis 1991).
Annis and Graham (1995) also described the
use of a profile method in which clients are cate-
gorized into one of four categories based on their
responses on the IDS: high negative profile, high
positive profile, low physical discomfort profile,
and low-testing personal control profile.
Differences were found across the profiles on a
number of measures. Clients with high negative
profiles, compared with those with high positive
profiles, tended to drink alone, to have high levels
of alcohol dependence, and to be women. Those
with high positive profiles, compared with clients
having low physical discomfort profiles, appeared
to have less serious or chronic alcohol problems.
Studies of the psychometric properties of the
IDS suggest that the 42-item version has adequate
levels of reliability and is comparable with the
100-item version (Cannon et al. 1990; Isenhart
1991, 1993; Victorio et al. 1996; Carrigan et al.
1998; Breslin et al. 2000; Stewart et al. 2000).
However, initial factor analyses of the 100-item
version at the item level failed to support the pres-
ence of the eight rationally derived Marlatt drink-
ing relapse categories. Rather, a smaller number
of factors were obtained. On the 100-item IDS,
Cannon et al. (1990) found three primary factors
representing categories of situations in which
alcoholics are likely to drink: negative affective
states, positive affective states combined with
social cues to drink, and attempts to test one’s
ability to control one’s drinking. Isenhart (1991)
found five factors, having some conceptual
overlap with those obtained by Cannon et al.:
negative emotions, social pressure, testing
personal control, physical distress, and positive
emotions. An item-level principal components
analysis replicated this factor structure with the
42-item version of the IDS, although a second-
order principal components analysis at the scale
level suggested a single-factor solution (Isenhart
1993). More recent factor analytic investigations
of the IDS have fairly consistently found three
higher order factors corresponding to positively
reinforcing situations, negatively reinforcing situ-
ations, and temptation or testing personal control,
with a number of lower order factors correspond-
ing to the more specific relapse situations
(Victorio et al. 1996; Carrigan et al. 1998; Stewart
et al. 2000). The level of specificity in the drink-
ing categories used will vary based on clinical
needs; however, Annis and colleagues (1987)
recommended the use of the full IDS-100 and the
eight relapse risk categories of the original scale
for maximal utility in treatment planning and
intervention targeting.
The second instrument developed by Annis
and colleagues is the Situational Confidence
Questionnaire (SCQ, or SCQ-39) (Annis 1987;
Annis and Graham 1988). This is a 39-item self-
report questionnaire designed to assess the
concept of self-efficacy for alcohol-related situa-
tions. Whereas the IDS attempts to determine the
relative cue strength for drinking in each of the
situations, the SCQ attempts to determine the
individual’s current level of confidence or strength
of self-efficacy that he or she can encounter each
of these situations without drinking heavily.
Clients are asked to imagine themselves in the
same set of drinking situations as presented in the
IDS and for each situation to rate on a 6-point
scale how confident (ranging from “not at all
confident” to “very confident”) they are that they
will be able to resist the urge to drink heavily in
each situation.
As was found with the IDS, it appears that
there are fewer than eight meaningful categories
of drinking situations assessed by the SCQ based
on the results of factor analysis. Sandahl, Linberg,
and Ronnberg (1990), for instance, found four
factors at the item level of analysis. As would be
expected, these factors parallel those that have
been found on the IDS: unpleasant emotions,
social pressure, testing personal control, and posi-
tive emotions.
Higher levels of drinking and/or severity of
alcohol dependence appear to be inversely related
to an individual’s level of drinking-related self-
efficacy; further, lower levels of self-efficacy are
associated with greater expectancies about the
151

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
potential positi
ve benefits of drinking (e.g., belief
that drinking will improve social involvement and
reduce depression and tension) (Skutle 1999).
An individual may be at the lowest level of self-
efficacy when he or she enters treatment. A client’s
responses on the SCQ-39 can be used to monitor
the development of the client’s self-efficacy in rela-
tion to coping with specific drinking situations
(identified and prioritized by use of the IDS) over
the course of treatment or with increasing sobriety.
It would be expected that self-efficacy would
increase across treatment, and this appears to be the
case (e.g., Burling et al. 1989; P.J. Miller et al.
1989; Sitharthan and Kavanagh 1991; Rychtarik et
al. 1992; S.A. Brown et al. 1998; Long et al. 1999).
Burling et al. (1989), for example, found that self-
efficacy increased during the course of inpatient
treatment and was higher for those individuals who
were abstainers at a 6-month followup than for
those who had relapsed. Presumably, one would
expect a relative increase in efficacy in those situa-
tions that have been the focus of intervention
(Annis and Davis 1988
b). Also, S
.A. Brown et al.
(1998) found not only that self-efficacy increased
across the course of treatment but also that positive
drinking-related outcome expectancies decreased.
The greatest decrease in positive expectancies
about the anticipated effects of alcohol was among
patients who entered treatment with less confidence
to resist drinking when compared with those having
higher initial levels of self-efficacy. The assumption
that higher levels of self-efficacy would be associ-
ated with lower levels of relapse or posttreatment
drinking has also been supported (e.g., Solomon
and Annis 1990; Sitharthan and Kavanagh 1991;
Rychtarik et al. 1992), although this has not been a
universal result (e.g., Mayer and Koeningsmark
1992). Greenfield and colleagues (2000) found
that a cutoff score of 45 on the SCQ during inpa-
tient treatment quite accurately differentiated alco-
holics who relapsed early and drank more heavily
at a 12-month followup than those having scores
less than 45. Those with scores less than 45 had a
median of 30 days to relapse following treatment
compared with the 135 days to relapse for those
with scores above 45. However, the level of effi-
cacy at the beginning or end of treatment has not
been consistently related to outcome (e.g.,
Langenbucher et al. 1996).
DiClemente et al. (1994) noted that the SCQ
may not be an appropriate measure to use when
attempting to assess self-efficacy in abstinence-
oriented treatment programs. The SCQ focuses on
measuring the individual’s ability to resist the
urge to drink heavily, not necessarily to refrain
from drinking completely. They suggested that the
goals of treatment (e.g., abstinence or harm reduc-
tion) should correspond to the type of efficacy
being assessed. As such, they expressed some
concern that the efficacy to avoid drinking heavily
as manifested on the SCQ may miss some impor-
tant aspects of the efficacy to remain abstinent. To
this end, DiClemente et al. (1983, 1994) devel-
oped a measure that focuses on the individual’s
efficacy or confidence to abstain from alcohol
across a range of situations also derived from
Marlatt’s eight primary relapse categories and
from surveys of drinkers in treatment.
The resultant scale, the Alcohol Abstinence
Self-Efficacy (AASE) Scale, consisted of 49
items. Each item was rated on two separate 5-
point rating scales (from “not at all” to
“extremely”) to reflect both the temptation to
drink and the confidence or efficacy to abstain in
each of the situations. The AASE Scale has been
used in conjunction with the evaluation of treat-
ment for alcohol-dependent individuals (Ito et al.
1988). Following an inpatient hospitalization,
individuals involved in a relapse prevention after-
care group showed a significant decrease in their
level of temptation and an increased level of self-
efficacy over the 8-week course of aftercare.
However, subjects involved in an interpersonally
based aftercare group therapy program demon-
strated no significant changes in either temptation
or confidence across the corresponding 8-week
treatment phase. DiClemente and Hughes (1990)
also found that alcoholics entering outpatient
treatment who were discouraged, less motivated,
and less ready to engage in behavior change
activities demonstrated the highest level of temp-
152

Assessment To Aid in the Treatment Planning Process
ta
tion and the lowest level of confidence
compared with those closer to action.
The original AASE Scale was shortened
through a series of empirical steps to 20 items in
an attempt to increase its ease of inclusion in
assessment batteries and to improve on its psycho-
metric properties (DiClemente et al. 1994). Based
on a sample of alcoholics involved in outpatient
treatment, 9 of the original 49 items were initially
eliminated due to poor item statistics in prelimi-
nary analyses; the remaining 40-item self-efficacy
(confidence) scale was subjected to an oblique
factor analysis. A four-factor solution was chosen
as the best fit for the data. A large negative affect
factor included items that measured both intraper-
sonal (“When I am feeling depressed”) and inter-
personal (“When I feel like blowing up because of
frustration”) negative affect. Items from these two
potential subscales were highly correlated,
producing a single first factor. Social situations
(“When I am being offered a drink in a social situ-
ation”) and the use of alcohol to enhance positive
states (“When I am excited or celebrating with
others”) represented a social/positive emotion
factor. The third factor, physical and other
concerns, consisted of varied items representing
physical discomfort or pain (“When I am experi-
encing some physical pain or injury”), concerns
about others (“When I am concerned about
someone”), and dreams about drinking (“When I
dream about taking a drink”). The final factor,
withdrawal and urges, represented withdrawal
(“When I am in agony because of stopping or
withdrawing from alcohol use”), craving (“When
I am feeling a physical need or craving for
alcohol”), and testing willpower (“When I want to
test my willpower over drinking”). These four
factors have been replicated among drug-abusing
probationers (Hiller et al. 2000).
Those five items having the highest and clear-
est factor loading on each of the four factors were
then assessed for internal consistency. The
Cronbach alpha coefficients ranged from 0.81 for
the withdrawal and urges factor to 0.88 for the
negative affect factor; the total scale had an alpha
of 0.92. A similar pattern of results was found in
subsequent analyses of the temptation items. The
Cronbach alphas ranged from 0.60 for the physi-
cal and other concerns factor to 0.99 for the nega-
tive affect factor. A moderate inverse relationship
was found between temptation and efficacy scales.
That is, temptation appears to be a separate
construct but related to efficacy, with higher levels
of efficacy associated with less temptation). There
was evidence of construct validity, convergent
validity, and divergent validity when examining
the relationships of the self-efficacy scales and
measures of motivation and of alcohol use
patterns on the AUI. There were no apparent
differences in self-efficacy between men and
women (DiClemente et al. 1994).
Carbonari and DiClemente (2000) investigated
the utility of client profiles based on the combina-
tion of the stage of readiness to change and self-
efficacy. The derived profiles differentiated among
both aftercare and outpatient clients with respect
to both their 1-year posttreatment drinking cate-
gories (i.e., abstinent, moderate, and heavier
drinking) and their use of cognitive and behavioral
change processes.
The Drinking Refusal Self-Efficacy Question-
naire (DRSEQ) (Young et al. 1991
b) is a self-r
eport
questionnaire developed initially on a sample of
predominantly female young adults from colleges
and a community youth group; it was subsequently
evaluated in a general adult sample from a large
government agency. It assesses the individual’s
confidence that he or she will not drink in a number
of situations. An initial item pool was developed
from other self-efficacy questionnaires, from
Marlatt’s interpersonal and intrapersonal precipi-
tants of relapse, and from interviews with young
problem drinkers. Individuals were to rate each
item on a 6-point scale ranging from “I am very
sure I would drink” to “I am very sure I would not
drink.” The 31 items that met final inclusion criteria
were subjected to principal axis factor analysis.
Three factors were derived: self-efficacy in situa-
tions of social pressure (“When friends are drink-
ing”), self-efficacy in situations of opportunistic
drinking (“When you are listening to music or
reading”), and self-efficacy in situations character-
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Assessing Alcohol Problems: A Guide for Clinicians and Researchers
iz
ed by a need for emotional relief (“When you feel
frustrated”). High degrees of internal consistency
and test-retest reliability were found for each of
these three subscales.
In the college sample, the measures of self-
efficacy were found to contribute significantly to
the prediction of alcohol consumption (particu-
larly self-efficacy in social pressure situations)
and to the discrimination of problem drinkers
from non-problem drinkers (all three subscales
were significant discriminators). However, self-
efficacy did not emerge as a significant predictor
of alcohol consumption in an independent sample
of individuals manifesting alcohol-related prob-
lems. In the adult sample of government employ-
ees, a single self-efficacy summary score
accounted for the greatest amount of variance
(26.3 percent) in the prediction of alcohol
consumption, even when other variables such as
age, gender, alcohol-related expectancies (the
DEQ), and alcohol problems (the Michigan
Alcoholism Screening Test [see the chapter by
Connors in this
Guide]) w
ere included in the
regression analysis. Recent studies have explored
the relationship between drink refusal self-efficacy
and alcohol-related expectancies in predicting
drinking behavior in general and clinical popula-
tions (Oei et al. 1998; Connor et al. 2000; Oei and
Burrow 2000; Young and Oei 2000).
Litman and colleagues developed the Relapse
Precipitants Inventory (RPI), the Coping
Behaviours Inventory (CBI), and the Effectiveness
of Coping Behaviours Inventory (ECBI) (Litman
et al. 1977, 1979, 1983
a, 1983b, 1984; Litman
1986). Although not used extensively since their
introduction in the literature, these scales have
been used in clinical research and have potential
utility in the assessment of relapse risk.
The RPI consists of 25 items, reflecting a
variety of drinking situations. The individual is
asked to rate the extent to which each situation is
“dangerous to staying off drink” using a 4-point
scale from “very dangerous” to “not at all.” Initial
factor analyses suggested a four-factor solution; a
subsequent set of analyses on a new sample
suggested three factors: unpleasant mood states,
external events/euphoria, and decreased cognitive
vigilance. In a retrospective analysis comparing
individuals who were either relapsers or survivors,
relapse was associated with more situations overall
being rated as dangerous as well as with higher
scores on the unpleasant mood states and external
events/euphoria factors. The same pattern of find-
ings was obtained in a prospective study, with the
total number of relapse precipitants and these two
factors differentiating between relapsers and
survivors at followups from 6 to 15 months post-
treatment.
The CBI and the ECBI assess the behavioral
and emotional coping strategies the individual
uses to avoid relapse and the perceived effective-
ness of these strategies. The CBI consists of 36
items reflecting ways in which individuals may
try to avoid drinking when they are tempted to
start drinking again. The individual rates each
item on a 4-point scale reflecting the frequency of
attempting each strategy, from “usually” to
“never.” The ECBI uses the same 36 items but
asks the individual to rate how well each of the
coping strategies has worked for them. The CBI
has been found to have four factors: positive
thinking, negative thinking, distraction/substitu-
tion, and seeking social supports. The same factor
structure was found for the ECBI.
While no differences were found between
relapsers and survivors in a prospective study on
the frequency of using different coping strategies,
differences were found on the ECBI in the pattern
of perceived effectiveness of these strategies. At the
beginning of treatment, individuals who were more
likely to maintain posttreatment abstinence tended
to perceive themselves as having more effective
coping strategies overall and as rating positive
thinking and avoidance as more effective than those
who would relapse during followup. Similarly, Ito
et al. (1988) found that alcoholics evidenced an
increased frequency of use of both cognitive and
behavioral coping strategies across 8 weeks of
aftercare treatment. Cognitive coping assessed by
the CBI at intake contributed significantly to the
discrimination between those who relapsed and
those who abstained over a 6-month followup
154

Assessment To Aid in the Treatment Planning Process
per
iod even after demographic measures and
indices of chronicity of alcohol problems were
entered first into the discriminant function analysis
(Ito and Donovan 1990). Patients abstinent for the
entire 6-month period had fewer years of problem
drinking, had fewer prior alcohol treatments, and
used more cognitive coping strategies than did
those who relapsed. The CBI has also been used as
part of the assessment battery in the exploration of
the validity of Marlatt’s relapse taxonomy (Maisto
et al. 1996) and in the comparison of individuals
having a cocaine-only addiction versus those with a
cocaine-alcohol comorbidity (Schmitz et al. 1997).
Two relatively new scales may prove useful in
future attempts to assess relapse risk. The first is
the Reasons for Drinking Questionnaire (RFDQ)
(Zywiak et al. 1996). This 16-item scale is an
adaptation for use with alcohol of a scale origi-
nally developed by Heather, Stallard, and Tebbutt
(1991) for use with heroin addicts. Individuals are
asked to rate how important each of the 16 reasons
were to their resuming drinking along a 10-point
scale (0 = not at all important, 10 = very impor-
tant). Three factors were derived. The first and
most prominent was negative emotions, the second
involved social pressure and positive emotion, and
the third was an amalgam of physical withdrawal,
wanting to get high, testing personal control, and
urges to drink. High scores on the negative
emotions scale were associated with high levels of
anger, depression, and alcohol dependence and
were predictive of blood alcohol concentration on
the first day of a relapse, the duration of the
relapse, and the likelihood of a second relapse.
The second relatively new scale is a measure
based on Gorski’s post-acute withdrawal model of
relapse (Gorski 1990). W.R. Miller and Harris
(2000) compiled an initial list of 37 relapse-related
warning signs, the Assessment of Warning-Signs of
Relapse (AWARE). Each individual rates the extent
to which each statement applies to him or her along
a 7-point Likert scale (1 = never, 7 = always).
Responses of alcoholics in treatment were subjected
to factor analysis. It was found that 28 of the initial
37 items defined a single factor, which had a
Cronbach alpha coefficient greater than 0.90. The
scale had a test-retest reliability of 0.80 over a 2-
month followup interval. Further, individuals with
high scores on the AWARE had significantly higher
relapse rates than those with lower AWARE scores.
L.C. Sobell and colleagues have offered a
number of important caveats concerning the
assessment of relapse risk and self-efficacy;
although their comments were directed specifi-
cally at the IDS and the SCQ, they apply equally
well to the evaluation of the other questionnaire
measures of self-efficacy reviewed above. L.C.
Sobell et al. (1994
a) noted tha
t the situations iden-
tified by measures such as the IDS as potentially
risky have only been
associa
ted with
hea
vy drink-
ing; therefore, one cannot presume a causal link
between the types of situations endorsed, drinking
behavior, and relapse probability. A number of
other factors, such as coping skills deficits, may
represent a common third factor that may moder-
ate this relationship. Second, while using such
scales to assess temptation, confidence, and
coping can be useful clinically in the treatment
planning process, these scales only identify
generic situations or general problem areas. Also,
an important fact arising from the investigation of
Marlatt’s relapse taxonomy is that the high-risk
situation associated with one’s most recent relapse
has a very low probability of being the situation
predictive of the next relapse in the future (Maisto
et al. 1996). Sobell et al. (1994
a) indica
ted that it
is important to explore in more depth the unique
and personally relevant high-risk situations or
areas where the client lacks self-confidence for
resisting drinking. One might choose to expand
more fully on those situations associated with
frequent heavy drinking, high temptation ratings,
and/or low levels of perceived confidence on the
structured questionnaires. Sobell et al. (1994
a)
also recommended that clinicians ask clients to
describe in detail their three highest risk situations
for drinking over the past year.
The last recommendation is consistent with
the development and use of semi-structured, indi-
vidualized approaches to the assessment of self-
efficacy. K.J. Miller and colleagues (1994), for
example, examined the usefulness of an individu-
155

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
aliz
ed approach to the assessment of self-efficacy
in an outpatient alcohol treatment program. An
Individualized Self-Efficacy Survey (ISS) was
developed for each client. This survey was derived
by (1) administering a questionnaire about drink-
ing patterns to identify important problem areas
for the individual (e.g., work, children, marital
problems) and specific drinking antecedents and
(2) constructing a 15-item scale using each
drinker’s most important drinking cues. The
method of having clients choose their own high-
risk drinking cues appeared to be clinically useful.
Ratings on the ISS were reflective of changes in
perceived efficacy over the course of treatment,
and ISS scores at the end of treatment were
predictive of subsequent relapse.
A second example of an ideographic approach
to assessment is the Substance Abuse Relapse
Assessment (SARA) developed by Schonfeld and
colleagues (Schonfeld et al. 1989; Peters and
Schonfeld 1993; Schonfeld et al. 1993). The
SARA is a semi-structured interview protocol that
was developed to assist clinical staff in developing
relapse prevention goals by identifying high-risk
situations and deficits in coping skills. It assesses
AOD use patterns, antecedents or precipitants of
drinking and drug use, and positive and negative
consequences of drinking. Although the focus of
the assessment is on a “typical drinking day” over
a 30-day period, the interview could also quite
easily be adapted to focus on single or multiple
relapse episodes. In addition to being asked about
the parameters of their use patterns, such as the
number of days of use and number of days of
intoxication, clients are also asked to classify their
use patterns as steady, periodic or binge, weekend
use, or infrequent. The interview focuses on situa-
tions, thoughts, feelings, cues, and urges as related
to drinking and/or other drug use; each of these is
assessed as an independent category that is probed
for occasions of drinking or other drug use. To
provide additional structure to the assessment of
emotions as a possible antecedent of drinking,
clients are provided with a list of 28 positive and
negative emotions and are asked to choose that
feeling most prominent immediately before drink-
ing, to explain what that emotion means to them,
and to continue doing this until they have rank-
ordered the five most notable emotions experi-
enced prior to use. In addition, clients are asked
how they dealt with these thoughts and feelings on
days when they experienced them but did not
drink. They are also asked about their responses to
prior “slips.” Information derived from the 45- to
60-minute interview is used by the clinician to
complete relapse prevention planning forms that
provide an overview of the individual’s substance
abuse behavior chain, the current level of neces-
sary coping skills to avoid relapse, the level of
confidence the client has in his or her ability to
avoid relapse, and a set of goals for relapse
prevention interventions targeted on those situa-
tions, thoughts, feelings, cues, and urges identified
as having a high risk for relapse.
While measures of self-efficacy, whether self-
report questionnaires or interviews, appear to have
a number of potential clinical and research appli-
cations, questions remain concerning their use.
The first question is which measure(s) to use.
Selection of a measure depends on the treatment
goal (abstinence or harm reduction), the amount
of time available, and the availability of staff for
interviews versus self-report approaches. Second,
how can one best use these measures in some
meaningful combination? For example, the
AASE Scale has both confidence and temptation
ratings; the IDS and SCQ are often presented
together; and the RPI and CBI or ECBI are used
in conjunction. However, each often appears to be
analyzed separately. DiClemente and colleagues
(1994) noted that temptation scores reflect the cue
strength of each situation in terms of its ability to
precipitate alcohol consumption. This level of
temptation may be relatively independent of rated
confidence in each situation. Thus, temptation to
drink in one situation can be low while efficacy to
abstain is quite high. Or, as is more often likely to
be the case during the early stages of the treatment
and recovery process, the individual may experi-
ence high temptation but have only moderate to
high levels of efficacy to abstain based on skills
and commitment. Similarly, the individual may
156

Assessment To Aid in the Treatment Planning Process
r
eport high frequencies of heavy drinking in a
situation on the IDS, suggesting high cue strength,
yet may have a high level of confidence on the
SCQ. Conversely, a situation may occur relatively
infrequently but is one in which the person
expresses very little efficacy. A similar set of
patterns could be described for the relationship
between the rated danger of potential relapse situ-
ations and coping on the RPI and CBI.
Complicating the picture even more is the poten-
tial situation in which an individual may report
frequently using a given coping strategy when
confronted with a high-risk situation yet perceiv-
ing this strategy as relatively ineffective.
The point of this discussion is to note that in a
clinical context it is important to integrate the
information derived from these various sources in
order to determine an accurate estimate of relapse
risk and to develop an appropriate intervention.
Litman (1986) began to explore the relationship
between relapse risk and coping styles.
DiClemente et al. (1994) suggested that the rela-
tionship between efficacy and temptation presents
an important area for future research. It appears
that the difference between the temptation and
efficacy scores of the AASE Scale, as well as their
correlations, provides important and potentially
useful information related to stages of behavior
change for alcohol-dependent clients (DiClemente
and Hughes 1990).
Rela
tionship Between Alcohol-Related
Outcome Expectancies and Self-Efficacy
Expectancies
Resear
ch is needed on the relationship between
alcohol-related outcome expectancies and self-
efficacy expectancies. Young and colleagues have
noted that self-efficacy is an important construct
in understanding relapse or treatment success;
however, the precise role that outcome expectan-
cies play in relapse and how such expectancies
relate to self-efficacy have received relatively little
direct evaluation (Young et al. 1991
b; Y
oung and
Oei 1993; Oei et al. 1998; Oei and Burrow 2000;
Young and Oei 2000). Oei and Baldwin (1994)
suggested that these two expectancy constructs
play different but complementary roles. Alcohol-
related outcome expectancies appear to operate in
a “weighing up” process in which the individual
assesses the relative anticipated positive and nega-
tive consequences associated with taking a drink.
To the extent that the individual believes that a
consequence will occur and that desirable conse-
quences are more likely to occur than undesirable
ones, then the likelihood of drinking is high. Self-
efficacy expectancies, on the other hand, do not
contribute to this weighing-up process. Rather,
they are hypothesized to intervene between the
weighing up and the behavioral response.
N. Lee and Oei (1993
b) in
vestigated the rela-
tionship of these two constructs, as operationalized
by the DEQ and the DRSEQ, to drinking behavior
among a general population sample. It was found
that they had differing predictive utilities depending
on the parameter of drinking being considered. Low
levels of self-efficacy in general, and more specifi-
cally in those situations where there was an oppor-
tunity to drink, were related to a higher frequency of
usual alcohol consumption and larger maximum
quantities consumed on any one drinking occasion.
The alcohol-related outcome expectancies were
related to frequency of drinking but not to quantity
of alcohol consumed. Those individuals who
expected greater negative affective states while
drinking drank their usual and maximum amounts
less often, while those who had higher expectations
of poor control over drinking drank their usual and
maximum amounts more often. The complexity of
these relationships, as well as similar ones found in
a college sample (Baldwin et al. 1993), likely
reflects the nature of the interactions between self-
efficacy and alcohol expectancies and their influ-
ence on drinking behavior. It is clear that this area
warrants further investigation.
P
ERCEIVED LOCUS OF CONTROL OF
DRINKING BEHAVIOR
A f
inal set of cognitions that have played a role in
some cognitive-behavioral models of problem
157

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
dr
inking and alcoholism is the individual’s
perception of control (e.g., Donovan and O’Leary
1983; Carlisle 1991). The concept of locus of
control, originally developed by Rotter (1966,
1975), refers to the extent to which an individual
believes that the outcomes of important life events
are under personal control (internal locus of
control) or under the influence of chance, fate, or
powerful others (external locus of control). Rotter
suggested that the predictive utility of the locus of
control construct is increased by using measures
directly related to the behavior under considera-
tion rather than ones assessing a more generalized
perception of control.
To this end, Keyson and Janda (1972) devel-
oped a locus of control scale that measures control
expectancies related to drinking behavior. This
scale, which was subsequently reproduced as the
Drinking-Related Locus of Control Scale (Lettieri
et al. 1985) and is also known as the Drinking-
Related Internal-External Locus of Control Scale
(DRIE), assesses the specific beliefs the individ-
ual holds concerning his or her perceptions of
control with respect to alcohol, drinking behavior,
and recovery. It is a 25-item self-report question-
naire adapted from Rotter’s conceptual model and
assessment method. In a forced-choice format,
individuals are asked to choose which of two
response options best matches their beliefs. These
response options include an internal (“I have
control over my drinking”) and an external (“I feel
completely helpless when it comes to resisting a
drink”) alternative. The scale is scored in the
direction of increasing externality.
Donovan and O’Leary (1978) found that the
DRIE has a high degree of reliability; is multidi-
mensional, having empirically defined factors
assessing perceived control over interpersonal
factors, intrapersonal factors, and general factors
associated with drinking; and differentiates
between alcohol-dependent individuals (more
external scores) and nondependent drinkers. They
also found that an external locus of control was
associated with more physical, social, and psycho-
logical impairment from drinking. Hartmann
(1999) found a similar factor structure among
alcoholics; however, female alcoholics had a more
elaborated sociability dimension than did male
alcoholics. In contrast, Hirsch and colleagues
(1997) failed to replicate the three-factor structure
found previously by others. Instead they found a
single factor that seemed to tap into a dimension
of perceived helplessness and inability to abstain
from alcohol.
Clements et al. (1995) found that being an
adult child of an alcoholic was associated with a
more external perception of control on the DRIE.
Further, those who were both alcoholic and had an
alcoholic parent had considerably higher scores
on the DRIE than those with either one of these
two conditions. Collins et al. (2000) found that the
Cognitive and Emotional Preoccupation subscale
from the Temptation and Restraint Inventory
(TRI) was strongly and positively associated with
the DRIE, while the Cognitive and Behavioral
Control subscale was positively and moderately
correlated with the DRIE. The DRIE has been
found to differentiate between drinking groups
with varying histories of drinking problems and
sobriety or with varying degrees of commitment
to change, with more internal scores being associ-
ated with longer periods of sobriety or more
advanced action in the recovery process (Mariano
et al. 1989; Strom and Barone 1993). Consistent
with this pattern, the perception of control appears
to become more internal over the course of
alcohol treatment; individuals with more external
perceptions are also more likely to drop out of
treatment prematurely (J.W. Jones 1985;
Prasadarao and Mishra 1992). There appears to be
a complex interactive relationship between the
primary reasons alcoholics give for their pretreat-
ment drinking and their drinking-related locus of
control in predicting posttreatment relapse
(Kivlahan et al. 1983), suggesting possible
avenues of treatment matching within a relapse
prevention framework. Following treatment, alco-
holics having an internal drinking-related locus of
control were less likely to relapse, drank less and
were less likely to have a more prolonged drink-
ing episode if they did relapse, and had a better
158

Assessment To Aid in the Treatment Planning Process
o
verall drinking-related outcome than alcoholics
with an external DRIE score (Koski-Jannes 1994).
The DRIE represents an additional measure to
consider in the assessment of those cognitions that
may be related to the maintenance of, cessation
of, and relapse to drinking behavior. Its relation-
ship with the other cognitive constructs discussed
in this chapter, namely alcohol-related outcome
expectancies and self-efficacy expectancies, needs
to be pursued further.
M
EASURES OF FAMILY HISTORY OF
ALCOHOL PROBLEMS
Shif
fman (1989) indicated that in addition to assess-
ing factors that are relatively proximal in time to a
relapse episode (e.g., temptation and confidence
levels), a comprehensive assessment should also
measure factors in the individual’s life that are more
distal, both in time and influence, on drinking.
These more distant, often relatively enduring and
unchanging personal characteristics may provide
the background context that predisposes individuals
toward involvement with alcohol, differing patterns
of drinking, and potentially increased risk of
relapse. From a clinical perspective, focusing on
such distal background factors may help to predict
who will relapse, but not when they will relapse
(Shiffman 1989). A potentially important back-
ground characteristic in this regard is a positive
family history of alcoholism, which may represent
such a predisposing variable (e.g., Schuckit 1991;
Tarter 1991). This variable may influence the nature
and strength of alcohol-related expectancies and
have an interactive effect on drinking behavior
among young adults (e.g., S.A. Brown et al. 1987
b;
L.M. Mann et al. 1987; Sher et al. 1991), as noted
above in the discussion of the role of parental
alcohol problems on drinking-related locus of
control (Clements et al. 1995). Positive family
history may also be a contributing factor to an alco-
holic subtype having a significantly different devel-
opmental course, different patterns of drinking and
related problems, and poorer treatment prognosis
(Babor et al. 1992
a, 1992b; Litt et al. 1992).
Determination of the presence or absence of a
family history of alcoholism has been based
primarily on individuals’ self-reports concerning
the drinking behavior and consequences of their
parents or first-degree relatives. In some cases,
this has involved the use of structured diagnostic
interview protocols, such as the Family History–
Research Diagnostic Criteria (FH-RDC) (Endicott
et al. 1975; Merikangas et al. 1998), in which the
individual is interviewed with a focus on parental
drinking behavior and other psychiatric disorders
to determine whether the diagnostic criteria of
alcohol abuse or dependence are met.
A number of relatively brief and reliable self-
report forms have been developed to assist in the
assessment of familial alcohol problems. One
such measure is the Family Tree Questionnaire for
Assessing Family History of Alcohol Problems
(FTQ) (R.E. Mann et al. 1985). The FTQ is a
brief, easily administered questionnaire that
provides subjects with a consistent set of cues for
identifying blood relatives with alcohol problems.
Subjects are given a family tree diagram that
includes first-degree (parents and siblings) and
second-degree (grandparents, aunts, and uncles)
relatives. To assure comparability in the frame of
reference used in classifying relatives with respect
to their drinking, individuals are provided with a
set of descriptions for each of four possible
drinker categories. They are asked to classify their
blood relatives on their mother’s side and father’s
side of the family into one of the following cate-
gories: (1) never drank (a person who never
consumed alcoholic beverages); (2) social drinker
(a person who drinks moderately and is not known
to have or have had an alcohol problem); (3)
possible problem drinker (a person who the indi-
vidual believes or was told might have [had] an
alcohol problem but where there is a lack of
certainty); and (4) definite problem drinker (only
those persons either known to have received treat-
ment for an alcohol problem or who have experi-
enced several alcohol-related consequences).
The FTQ has been shown to have satisfactory
reliability with alcohol abusers and normal
drinkers. The reliability of subjects’ classification
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Assessing Alcohol Problems: A Guide for Clinicians and Researchers
of pa
ternal and maternal first-degree and second-
degree relatives of alcoholic and non-alcoholic
subjects was examined. Results indicated that both
alcoholics and non-alcoholic subjects reliably clas-
sified their relatives as alcoholics or problem
drinkers over a 2-week test-retest interval (R.E.
Mann et al. 1985). Similar high levels of test-retest
reliability were found in classification of family
members even over an approximately 4-month
interval (Vogel-Sprott et al. 1985). Using liberal
criteria (e.g., relative known to be a problem
drinker) provided a more sensitive basis for the
diagnosis of relatives’ alcohol problems than more
stringent criteria (e.g., relative definitely an alco-
holic with reported consequences or prior treat-
ment) (R.E. Mann et al. 1985). Evidence for this
questionnaire’s validity derives from the fact that
alcohol abusers had a higher number of family
history–positive relatives than non–alcohol-
abusing subjects. Alcoholics in treatment with a
positive family history of alcoholism, as assessed
by the FTQ, had an earlier onset of drinking,
higher indices of quantity and frequency of drink-
ing, a greater preoccupation with drinking, a more
sustained drinking pattern, more serious negative
psychosocial consequences from drinking, and a
greater reliance on alcohol to manage their moods
than those alcoholics without a history of familial
alcoholism (Worobec et al. 1990).
A second set of measures of familial alcohol
problems is based on an adaptation of the Short
Michigan Alcoholism Screening Test (Selzer et al.
1975). These scales, the Adapted Short Michigan
Alcoholism Screening Test for Fathers (F-
SMAST) and Mothers (M-SMAST), were devel-
oped by Sher and Descutner (1986). The
individual is asked to respond to each of the 13
items of the SMAST with respect to either father’s
or mother’s drinking behavior or alcohol-related
negative consequences, with a dichotomous
response format (yes/no). Separate forms are
provided for the assessment of each parent with
appropriate modifications in the wording.
Individuals are also asked to make a global judg-
ment concerning whether they think their father or
mother is (was) an alcoholic.
Overall, there was a relatively high level of
reliability as defined as the extent of agreement
between the responses on each item between
sibling pairs who rated each parent. Agreement
was higher for those items asking about specific
behavioral acts or consequences (e.g., seeking
help, being arrested); lower levels of agreement
were found on items that required the individual
to make an inference (e.g., the presence or
absence of guilt about drinking, what others
thought about the parent’s drinking). Reliability
also appeared to be higher for ratings of fathers’
drinking than for mothers’ drinking. Crews and
Sher (1992) replicated this finding with a larger
sample. They also replicated the previous finding
that a cutoff score of 5 to define parental alco-
holism was best in terms of maintaining a high
level of intersibling agreement.
In an extension of their previous work, Crews
and Sher (1992) found that these scales had a high
degree of test-retest stability and internal consis-
tency, that there is a high level of agreement in the
diagnosis of parental alcoholism derived from the
F-SMAST or M-SMAST and from the individ-
ual’s responses to the FH-RDC about each
parent’s drinking, and that there is a high correla-
tion between the individual’s scores on the F-
SMAST and M-SMAST for each parent and the
parents’ actual scores when taking the SMAST
about their own drinking behavior. Parental
history of alcoholism, as measured by these
adapted SMAST scales, appears to serve as an
increased risk factor in the subsequent diagnosis
of alcohol disorders (Kushner and Sher 1993) and
to interact with personality factors to define differ-
ent subtypes of drinking disorders among young
adults (Martin and Sher 1994).
E
XTRA-TREATMENT SOCIAL SUPPORT
An impor
tant area to consider as part of the
assessment process is the extent and nature of the
individual’s social support system. Perceived
social support may serve as a moderator of the
relationship between a positive family history of
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Assessment To Aid in the Treatment Planning Process
alcoholism and the de
velopment of alcohol prob-
lems (Ohannessian and Hesselbrock 1993).
Litman (1986) noted that the ability to access
social support was one of the main methods of
coping in an attempt to avoid relapse as assessed
by the CBI. Also, social skills training programs,
often incorporated into the treatment for alco-
holism, are thought to operate in part by enhanc-
ing the client’s social support for sobriety and
providing more appropriate alternatives for coping
with interpersonal stress than drinking (Monti et
al. 1994). The nature of social support and the
level of the individual’s investment in it also
appear to interact with different types of treatment
to affect differential outcomes, suggesting the
possibility of using the domain of social support
for the purposes of treatment matching
(Longabaugh et al. 1995
a).
Much research has examined the role of
general social support in the recovery process.
However, a number of authors have questioned
whether this is the most appropriate focus (e.g.,
Havassy et al. 1991; Beattie et al. 1993). Rather,
there is an increasing awareness that a more criti-
cal variable to assess is the degree of support the
social network provides specifically for absti-
nence versus continued drinking. Beattie et al.
(1993) suggested that general social support is
most likely to affect the individual’s sense of
subjective well-being, whereas alcohol-relevant
social support is more directly related to alcohol
involvement. Havassy et al. (1991) noted that both
social integration and abstinence-specific func-
tional support are important in predicting relapse.
Longabaugh and colleagues have developed a
family of measures that are designed to assess
different areas of alcohol-specific social support.
They have separated the influence of individuals
in the client’s work environment (if he or she is
working) from the support provided by family and
friends. The measure derived to assess the former
is Your Workplace (YWP) (Beattie et al. 1992).
The YWP is a 13-item self-report measure that
can be administered either as an interview or a
self-administered scale. It was developed from the
responses of alcoholics in treatment. The scale has
been found to have three factor-analytically
derived subscales: Adverse Effects of Drinking on
Work Performance, Cues and Support for
Consumption, and Support for Abstinence.
The reliability indices of these three subscales
ranged from 0.61 to 0.78. The YWP subscales
were unrelated to measures of general workplace
support as measured by the Work Environment
Scale (Billings and Moos 1982), while the YWP
subscales assessing adverse effects of drinking on
work performance and support for consumption
were related to concurrent measures of drinking
behavior. Supporting the relative importance of
alcohol-specific measures of support, the YWP
subscale assessing support for consumption was
related to higher numbers of drinks per drinking
day and the number of heavy drinking days during
months 7–12 following treatment, while the
Support for Abstinence subscale was related to
lower levels drinking on drinking days. However,
none of the indices of general workplace support
predicted drinking behavior following treatment.
Rice, Longabaugh, and Stout (1997) reported on
an extensive psychometric evaluation of YWP using
the large sample of participants in Project MATCH.
Confirmatory factor analysis supported the original
three-factor solution obtained by Beattie et al.
(1992). These subscales appear to be relatively inde-
pendent, sharing less than 20 percent of variance,
suggesting that each assesses a different component
of support. Further, the internal consistency esti-
mates for these three subscales were in the same
range as those previously obtained. Correlation
analyses indicate, as would be expected, that the
Adverse Effects subscale was positively related and
the Support for Abstinence subscale was negatively
related to measures of drinking. It should be noted
that support for abstinence from the YWP was not
correlated with a measure of general social support
from friends and family (Rice and Longabaugh
1996). However, these indices of general and
alcohol-specific social support have a complex rela-
tionship in which each appears to add uniquely to
subsequent drinking by alcoholics in treatment
(Beattie and Longabaugh 1999). The alcohol-related
measure was consistently more highly related to
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Assessing Alcohol Problems: A Guide for Clinicians and Researchers
outcome than the measur
e of general support; both
were related to percentage of days abstinent at 3
months posttreatment; but only the alcohol-specific
measure was significantly related to percentage of
days abstinent at the 15-month followup.
The Important People and Activities (IPA)
instrument was developed to assess alcohol-
specific social support from family and friends
(Clifford et al. 1992; Beattie et al. 1993; Clifford
and Longabaugh 1993; Longabaugh et al. 1993,
1995
a, 1995b). T
he IPA is an interviewer-admin-
istered instrument that provides information about
those individuals with whom clients have frequent
contact, how important each of these individuals
is to the clients, how much they like each of these
individuals, and how these individuals respond to
clients’ drinking and abstinence. Clients also rate
the drinking behavior of those important individu-
als in their social network as well as the frequency
with which these individuals drink during activi-
ties that are important to or valued by the client.
The IPA is meant to tap into three primary
domains: attitudinal and behavioral support from
members of the social network for drinking, the
lack of sanctions against drinking, and attitudinal
and behavioral support for abstinence. The
Cronbach alpha coefficient of internal consistency
for items assessing these three areas ranged from
0.61 to 0.78 (Clifford et al. 1992; Beattie et al.
1993). An index of affiliative support for alcohol
involvement versus abstinence has been developed
(Longabaugh et al. 1993). Those individuals char-
acterized as having interpersonal networks
supportive of alcohol involvement have important
people who are perceived as more accepting of the
clients’ drinking and who are more likely to be
drinkers themselves. Conversely, those character-
ized as having a network supportive of abstinence
have important people who are perceived as less
accepting of the clients’ drinking and are more
likely to be abstainers themselves. Beattie et al.
(1993) found that this index of affiliative support
for alcohol involvement correlated significantly
with a similar index of workplace support for
alcohol involvement as measured by the YWP;
however, the IPA index of support for drinking
was not correlated significantly with actual
pretreatment drinking behavior.
Longabaugh and colleagues (1993, 1995
a)
found that three different forms of alcoholism
treatment had differential outcomes as a function
of the nature of the client’s alcohol-specific social
support and the investment in this support
network. At the 18-month followup (Longabaugh
et al. 1995
a), those subjects w
ho had either a
network that was unsupportive of abstinence or a
low level of investment in their network had better
outcomes following an extended relationship
enhancement therapy. A broad-spectrum treatment
approach was most effective with clients who had
both a social network unsupportive of abstinence
and a low investment in their network or with
clients who were highly invested in a social
network that was supportive of abstinence. More
recently, Longabaugh and colleagues (1998)
found that 12-step facilitation therapy was particu-
larly effective with alcoholics having a social
network supportive of their continued drinking.
Clearly, the results suggest that a therapeutic
focus should be directed toward the enhancement
of interpersonal relationships, the development of
a social network supportive of abstinence, and a
means of facilitating the client’s investment in this
group. While this seems like a straightforward
goal, it is an area typically underemphasized in
the treatment process (Beattie et al. 1993).
The Significant-Other Behavior Question-
naire (SBQ) (Love et al. 1993) was developed to
assess the responses of a single significant other
to the presence or absence of drinking in
alcohol-involved clients. The SBQ is a 24-item
questionnaire that uses a 5-point response scale
for the client to rate the likelihood that a signifi-
cant other would respond in a variety of ways to
the client’s drinking. Two forms are available,
allowing the client to rate the significant other’s
behavior from either the client’s or the signifi-
cant other’s point of view. Four factors were
derived for both the client form and the signifi-
cant other form of the SBQ. On the client form
these included the perception that the significant
other punishes drinking, supports sobriety,
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Assessment To Aid in the Treatment Planning Process
suppor
ts drinking, and withdraws from the
patient when drinking. Internal consistency
indices for these four subscales ranged from 0.75
to 0.87. The same patterns of factors and item
loadings on factors were found on the significant
other form and on the client form. With the
exception of the subscale measuring perceived
withdrawal from the patient when drinking, the
SBQ subscales showed fair concordance between
the client and corresponding significant other
scores. General social support from family and
friends was not related to the rated support of the
significant other for drinking or sobriety.
However, the SBQ subscales also demonstrated a
relative independence from measures of drinking
behavior and sobriety.
M
ULTIDIMENSIONAL ASSESSMENT
MEASURES
Dr
inking behavior and alcohol problems are
multidimensional. As such, it is often important to
have a broad overview of the parameters of drink-
ing, the expectancies that accompany and poten-
tially maintain alcohol use, and the
biopsychosocial aspects of the individual’s life
that are affected by drinking (Donovan 1988).
Assessments thus need to be relatively broad to
capture the extent and complexity of the multiple
facets of alcohol problems. This can be done by
the use of instruments derived from a variety of
assessment domains or that assess a broad range
of factors within a single interview or question-
naire. A number of such instruments are reviewed
in this section.
The Addiction Severity Index (ASI)
(McLellan et al. 1980, 1992
b) is one of the most
frequently used measures in substance abuse treat-
ment and outcome evaluation; it is widely used as
an intake evaluation form to aid in identifying
areas in need of treatment and as a multidimen-
sional measure of treatment outcome. The ASI
can be used to effectively explore problems within
any adult group of individuals who report
substance abuse as their major problem.
The ASI is a semi-structured interview
designed to provide an overview of a variety of
problem areas related to substance use rather than
focusing on any single area. The items on the ASI
address seven rationally developed potential
problem areas in substance-abusing patients:
medical status, employment and support, drug
use, alcohol use, legal status, family/social status,
and psychiatric status. Factor analysis has
suggested that the ASI may have four independent
empirically derived factors: chemical dependence,
criminality, psychological distress, and health-
related problems (Rogalski 1987). A trained tech-
nician or counselor can gather information on
recent (past 30 days) and lifetime problems in
each of these problem areas.
Following the completion of each section of
the interview, the client is asked to rate on a 5-
point scale (from “not at all” to “extremely”) the
extent to which he or she feels troubled or both-
ered by the problem and the extent to which the
client feels a need for counseling or treatment for
this problem. The interviewer also makes a sever-
ity rating on a 10-point scale for each problem
area based on a review of the client’s responses to
the interview items. The interviewer also rates his
or her level of confidence that the client has
understood and answered the questions truthfully.
In addition to these subjective ratings, composite
scores, representing weighted mathematical
combinations of specific items, are computed to
provide more objective measures of problem
severity during the prior 30 days. A number of
clinical indices, based on responses to both the
lifetime and recent (30-day) problem questions,
have been developed and evaluated in conjunction
with the composite scores as well as the subjective
ratings (T.G. Brown et al. 1999; Alterman et al.
2000
a, 2001).
The ASI has been used across a wide range of
clinical groups of substance abusers and treatment
settings, including gender and ethnic groups (e.g.,
J.A. Lee et al. 1991; L.S. Brown et al. 1993),
groups of clients differing in their primary drug of
choice and seen in multiple treatment centers
(e.g., McLellan et al. 1985, 1994), psychiatrically
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Assessing Alcohol Problems: A Guide for Clinicians and Researchers
impair
ed groups (Hodgins and El-Guebaly 1992;
Appleby et al. 1997; Zanis et al. 1997), homeless
substance abusers (Argeriou et al. 1994; Zanis et
al. 1994; Joyner et al. 1996), and those with
differing HIV serostatus (Davis et al. 1995).
Overall, the ASI and its subscales have
demonstrated a high degree of concurrent validity
against established and previously validated
measures of psychosocial problems (Kosten et al.
1983; Hendricks et al. 1989), test-retest reliability
and stability across relatively short and longer
term time intervals (McCusker et al. 1994;
Stoffelmayr et al. 1994; Zanis et al. 1994;
Cacciola et al. 1999), and interrater reliability
(Alterman et al. 1994; Stoffelmayr et al. 1994).
These high levels of internal consistency and
validity have been found even in a very large field
study lacking the rigorous controls over adminis-
tration that has typically accompanied most of the
previous psychometric evaluations (Leonhard et
al. 2000). However, the level of interrater agree-
ment appears to be considerably lower for the
clinician severity ratings than for the composite
scores (Alterman et al. 1994). Additional and
continued training and monitoring may be neces-
sary to maintain high levels of agreement across
raters over time (Fureman et al. 1994). This train-
ing can be supplemented by using standardized
case vignettes (Cacciola et al. 1997). The psychi-
atric severity scale from the ASI has been found
to be a potentially important measure with respect
to matching clients to different intensities and
types of treatment (McLellan et al. 1983;
McLellan 1986) or aftercare services (Kadden et
al. 1989).
Although there are a number of potential limi-
tations of the scale that its authors acknowledge
(McLellan et al. 1992
b, 1992c), the ASI has been
widely accepted as an extremely useful instrument
in the field (Grissom and Bragg 1991). In fact, both
computerized (Carise et al. 1999; Butler et al.
2001) and self-report versions (Rosen et al. 2000)
of the ASI have been developed. Although the
authors of the scale have not recommended or
supported the development of computerized admin-
istration of the ASI, they have recognized that
adding items to extend the coverage of areas of
particular clinical interest or relevance can increase
the scale’s clinical utility (McLellan et al. 1992
b,
1992
c). Some of the def
iciencies in content cover-
age have been addressed in the most recent edition
of the ASI (McLellan et al. 1992
b), w
hich includes
additions to the AOD use, legal, and family/social
areas. Accompanying software is available that can
be used to score the ASI by computer, generate
composite scores, and convert scores into
computer-generated reviews of history and initial
treatment plans. Jacobson (1989
a) sug
gested that
the available clinical and research evidence and the
range and flexibility of the instrument’s applica-
tions strongly support the ASI being included as a
part of a pretreatment evaluation process.
The development and use of the Treatment
Services Review (TSR) as a companion instru-
ment to the ASI allows clinicians and administra-
tors to determine the extent to which those
problems identified at intake by the ASI have
been addressed during the course of treatment
(McLellan et al. 1992
a; Alter
man et al. 1993,
2000
b). Suc
h an evaluation of the linkage between
severity of problems and service utilization is an
area of relevance clinically but also could be
incorporated into the broader context of quality
assurance and quality improvement reviews at a
programmatic level. It is possible to estimate costs
of clinical services and cost offsets of providing
these services from either the ASI or the TSR
(French et al. 2000
a, 2000b).
A second multidimensional measure with a
long history of use in alcoholism treatment and
research is the Alcohol Use Inventory (Wanberg et
al. 1977; Wanberg and Horn 1983; Horn et al.
1987). The AUI was developed within a differen-
tial conceptual and measurement model of alco-
holism. It was developed and validated on several
large samples of alcoholics admitted to inpatient
treatment, with subsequent developmental work
on outpatient samples and groups of driving while
intoxicated (DWI) offenders (Horn et al. 1987).
The inventory consists of 228 items that can be
administered either as a self-report questionnaire
or via computer. The multiple alternative items
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Assessment To Aid in the Treatment Planning Process
contr
ibute to a set of 24 scales (17 first-order
factors, 6 second-order factors, and 1 third-order
factor). The AUI scales were empirically
constructed from a series of factor analytic studies
of large sets of items measuring aspects of the use
and abuse of alcohol. They provide operational
indicators for important constructs of a multiple-
condition or differential theory of the use and
abuse of alcohol (Wanberg and Horn 1983).
The AUI is based on a theory about how
people differ in their perceptions of benefits
derived from drinking, in their styles of drinking,
in their ideas about the consequences of drinking,
and in their thoughts about how to deal with
drinking problems. Correspondingly, four broad
domains are assessed by the scales: perceived
benefits of drinking (e.g., mood management,
social enhancement), styles or patterns of drinking
(e.g., solitary vs. gregarious, continuous), physical
and psychosocial consequences of drinking (e.g.,
symptoms of alcohol dependence, behavioral
impairment), and concerns and acknowledgment
of problems which reflect the individual’s aware-
ness of drinking problems and readiness to accept
help for these problems.
Studies reported by the instrument authors
(Horn et al. 1987) indicate that the AUI scales
demonstrate good to excellent levels of internal
consistency, test-retest reliability, and both concur-
rent and construct validity. The pattern of these
findings concerning the AUI’s reliability and valid-
ity has been replicated and extended by other inves-
tigators (e.g., Rohsenow 1982; Skinner and Allen
1983; Tarter et al. 1987; Isenhart 1990). However,
Chang, Lapham, and Wanberg (2001) found the
reliability estimates to be lower in a sample of DUI
offenders than in the normative sample.
The AUI has been used in a wide range of
applications, some of which are described here.
DiClemente and Hughes (1990) found that groups
of alcoholics differing in their readiness to change
as measured by the URICA differed across AUI
subscales. Similarly, alcoholic subtypes based on
personality types defined by either their Millon
Clinical Multiaxial Inventory (MCMI) or their
Minnesota Multiphasic Personality Inventory
profiles have been found to differ with respect the
symptoms and consequences of alcohol use as
assessed by the AUI (Robyak et al. 1984;
Corbisiero and Reznikoff 1991). Conversely,
subtypes of alcoholics derived by cluster analyz-
ing AUI scale scores were found to differ with
respect to the personality and symptom scales of
the MCMI-II (Donat 1994).
A number of more recent studies have investi-
gated the derivation of clinical subtypes based on
the AUI (Rychtarik et al. 1998, 1999; Chang et al.
2001). Rychtarik and colleagues derived and inde-
pendently replicated eight subtypes, with variations
within three light, moderate, and heavy drinking
groups. These groups included low severity, gregar-
ious drinkers; low severity, steady drinkers; overall
moderate-low severity drinkers; moderate severity,
solitary, mental enhancement drinkers; moderate
severity, gregarious drinkers; steady, solitary,
moderate impairment drinkers; higher severity,
mental enhancement drinkers; and high severity,
compulsive, mood management drinkers. These
groups differed across a number of dimensions,
including client background, cognitive functioning,
psychosocial functioning, history of alcohol use,
and pretreatment drinking behavior; they also
differed in percentage of days abstinent and drinks
per drinking day at a 12-month posttreatment
followup. The AUI has also served as the primary
dependent measure in studies examining patterns,
perceived benefits, and consequences of drinking
among heavy social drinkers (Rohsenow 1982),
male and female alcoholics and non-alcoholics
(Olenick and Chalmers 1991), and Black and
White alcoholics (Robyak et al. 1989).
Although it has an extensive background as a
research instrument, the AUI was developed
primarily as a clinical assessment tool. Based on
their psychometric analysis, Skinner and Allen
(1983) suggested that the AUI has considerable
promise as a differential assessment instrument. It
can provide a profile across the 24 scales, reflect-
ing the individual’s unique pattern and style of
use, perceived benefits derived from drinking, and
the resultant physical and psychosocial conse-
quences (Donat 1994; Rychtarik et al. 1998, 1999;
165

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
Chang et al. 2001). T
he individual’s scale scores
and profile can also be compared with normative
information (Horn et. al. 1987). The authors
suggest that this information can help the clinician
select the most appropriate treatment setting (e.g.,
inpatient vs. outpatient), intensity, or modality
(e.g., group vs. individual therapy, behavioral vs.
insight-oriented therapies). The test manual (Horn
et al. 1987) provides a number of relatively
specific recommendations concerning the treat-
ment implications for scores on given scales or
typologies of alcoholics based on the pattern of
relationships among scales. While this seems to
be one of the many potential benefits of the AUI,
further research is needed to validate its utility in
this treatment-matching process.
W.R. Miller and Marlatt (1984, 1987) intro-
duced a family of structured multidimensional
clinical interviews known as the Comprehensive
Drinker Profile (CDP). This family includes the
standard CDP and an abbreviated form (the Brief
Drinker Profile), both of which are administered
at intake, the Follow-up Drinker Profile to assess
treatment outcome, and the Collateral Interview
Form, which provides a systematic method of
eliciting information about the client from a
significant other. The 88 items of the CDP, which
requires 1–2 hours to administer, are designed to
obtain both objective and subjective data on a
client’s status at intake and followup in multiple
domains: demographic information, drinking
history (e.g., quantity, frequency, pattern, drinking
settings, dependence symptoms), motivation (e.g.,
reasons for drinking, alcohol-related expectan-
cies), and self-efficacy (e.g., selection of client’s
own treatment goals, perceived likelihood of
achieving these goals). The CDP has been used to
compare the characteristics of alcohol-dependent
men and women at treatment entry (W.R. Miller
and Cervantes 1997) and to compare the relative
effectiveness and cost-effectiveness of a 5-week
inpatient program and a 2-week in- and day-
patient regime (Long et al. 1998).
Jacobson (1989
a) noted tha
t the style of
conducting the interview, as outlined in the
manual, is quite individualized and is intended
both to facilitate information gathering and to
engage and motivate the client in the assessment
and treatment process. The nonconfrontational,
empathic, nonjudgmental, and supportive style
advocated for use in the CDP interview process
appears to have served as the background from
which more formalized motivational interviewing
techniques have emerged (W.R. Miller 1983; W.R.
Miller and Rollnick 1991; W.R. Miller et al.
1993). The manual also provides a number of
clinical implications associated with certain
response patterns, suggesting treatment-matching
recommendations, some of which are based on
previous treatment outcome research and others
based on clinical observations (Jacobson 1989
a).
The Chemical Dependency Assessment
Profile (CDAP) (Davis et al. 1989; Harrell et al.
1991) is a multidimensional, self-report clinical
research questionnaire composed of 232 multiple-
choice, true/false, and open-ended items. Its
primary purpose is to evaluate parallel dimensions
of cognitive and behavioral dysfunction related to
alcohol use, use of other drugs, and mixed or
polydrug abuse over a 2-month time period prior
to entering treatment. The CDAP assesses chemi-
cal use history, patterns of use, use beliefs and
expectancies, use symptoms, self-concept, and
interpersonal relations. Content dimensions, ratio-
nally developed based on clinician card sorts of
items, provide measures of quantity and frequency
of use, physiological symptoms, situational stres-
sors, antisocial behavior, interpersonal skills,
affective dysfunction, attitude toward treatment,
and degree of life impact. Also, three scales of
expectancies concerning the anticipated effects of
alcohol (tension reduction, social facilitation, and
mood enhancement) were included from a
measure previously developed and validated by
Farber et al. (1980).
Harrell et al. (1991) found the Cronbach coef-
ficients of internal consistency to range from 0.78
to 0.88 across the CDAP subscales. Similarly high
test-retest reliabilities were found (with all but one
scale exceeding 0.83) following a 1-week interval.
Results of factor analyses at the scale level
suggested three primary factors: (1) behavioral/
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Assessment To Aid in the Treatment Planning Process
ph
ysiological (composed of the physiological
symptoms, affective dysfunction, antisocial
behavior, and quantity/frequency of use dimen-
sions and the tension reduction expectancy), (2)
social (composed of the interpersonal skills
dimension and the social facilitation and mood
enhancement expectancies), and (3) cognitive
(composed of the situational stressors and the atti-
tude toward treatment dimensions). Significant
differences were found across the problem dimen-
sions and expectancy scales among samples of
alcohol abusers, polydrug abusers, and social
drinkers, with the clinical groups evidencing a
greater degree of dysfunction and stronger
expectancies than the group of social drinkers.
Harrell et al. (1991) suggested that the CDAP reli-
ably assesses a number of dimensions thought to
be important in attempting to match substance-
abusing clients to treatments. Although this
measure appears to be of potential use in clinical
practice, there is no recent evidence in the litera-
ture concerning its further development.
A relatively new instrument is the Minnesota
Substance Abuse Problems Scale (MSAPS)
(Westermeyer et al. 1998). This is a semi-structured
interview protocol that attempts to assess a broad
range of psychological, behavioral, and social
problems associated with AOD use. It was
designed to be completed within a 30-minute
interview. Three factors were derived from a
factor analysis of the 37 items of the scale: the
Psychiatric-Behavioral Problems scale (14 items),
the Social Problems scale (11 items), and the
Addictive Use Symptoms scale (12 items). The
Cronbach alpha measures of internal consistency
were 0.83, 0.82, and 0.79, respectively. The
pattern of correlations with measures of psycho-
logical distress, depression, anxiety, social prob-
lems, and substance use and problems suggests
that the MSAPS scales have a high degree of
concurrent validity.
Another relatively new instrument is the
Personal Experience Inventory for Adults (PEI-A)
(Winters 1999). The measure has two parts. The
first part, Problem Severity, consists of 120 ques-
tions organized around 10 problem severity scales,
3 validity scales, and AOD use consumption char-
acteristics (e.g., quantity, frequency, duration, age
of onset); an additional research scale assesses
receptivity to treatment. The second part,
Psychosocial Problems, consists of 150 items
distributed across 8 personal risk adjustment scales,
3 environmental scales, 10 problem screens, and 2
validity scales. Adequate to good internal consis-
tency indices were obtained. The median alpha
levels for the 10 Problem Severity scales were 0.89,
0.81 for the 11 Psychosocial Problems scales, and
0.63 for the 5 validity scales. One-week test-retest
reliability was also acceptable. The scales demon-
strated a high level of concurrent validity when
correlated with measures of psychopathology and
psychological functioning, alcohol dependence,
reports of clients’ behavior as provided by a signifi-
cant other, DSM-III-R diagnoses (American
Psychiatric Association 1987), and referral recom-
mendations (no treatment, outpatient treatment, or
residential treatment).
M
EASURES TO ASSIST IN DIFFERENTIAL
TREATMENT PLACEMENT
Client-tr
eatment matching attempts to place the
client in those treatments most appropriate to his
or her needs. There are a number of dimensions
on which treatments may vary and which need to
be considered in attempting to make an appropri-
ate referral or match (Marlatt 1988; W.R. Miller
1989
b; Institute of Medicine 1990; Dono
van et al.
1994; Gastfriend and McLellan 1997). Among
these dimensions are treatment setting (e.g., inpa-
tient, residential, outpatient), treatment intensity,
specific treatment modalities, and the degree of
therapeutic structure. A number of possible vari-
ables may interact with these dimensions to lead
to differential outcomes, making the clinician’s
task more difficult.
The American Society of Addiction Medicine
(ASAM) has established a set of rationally devel-
oped criteria for admission, placement, discharge,
and transfer of individuals with alcohol problems to
different levels of care (Hoffman et al. 1987, 1991;
167

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
Mee-Lee et al. 2001). T
hese criteria, which are
based on a consensus of treatment specialists, are
meant to facilitate the matching of patients to the
most appropriate level of care (Gastfriend et al.
2000). They are also assumed to facilitate clinical
decisions that will lead to increased quality of care
while maintaining fiscal accountability (e.g.,
managed care considerations). Separate criteria have
been developed for adults and adolescents. The
criteria are based on an assessment of six general
problem areas: acute intoxication and/or withdrawal
potential; biomedical conditions and complications;
emotional, behavioral, or cognitive conditions or
complications; readiness to change (previously
treatment acceptance or resistance); relapse, contin-
ued use, or continued problem potential; and recov-
ery/living environment. From this assessment, one
of four levels of care is selected as the most appro-
priate: outpatient treatment of less than 9 hours per
week, intensive outpatient or partial hospitalization
with a minimum of 9 hours per week, medically
monitored intensive inpatient treatment, or
medically managed inpatient treatment.
Despite potential limitations in the ASAM
placement criteria (McKay et al. 1997), these
criteria have been used increasingly in a variety of
States and clinical settings (e.g., Gondolf et al.
1996; Gregoire 2000; Heatherton 2000). Further,
there is increasing evidence concerning their
validity and clinical, administrative, and fiscal
utility (Turner et al. 1999).
A pair of complementary instruments, one
interviewer-administered and the other a self-
report questionnaire, have been developed to
provide a standardized assessment of the dimen-
sions included in the ASAM criteria: the
Recovery Attitude and Treatment Evaluator
(RAATE) Clinical Evaluation (CE) and
Questionnaire I (QI) (Mee-Lee 1988; Mee-Lee et
al. 1992; Smith et al. 1992, 1995). The RAATE-
CE and RAATE-QI instruments were designed to
assist in placing patients into the appropriate level
of care at admission, making continued stay or
transfer decisions during treatment (utilization
review), and documenting appropriateness of
discharge.
The RAATE-CE is a 35-item structured clini-
cal interview, which may be administered by a
trained technician or counselor in 20–30 minutes.
It uses five scales to measure the constructs of
resistance to treatment (current treatment/recovery
motivation and denial), resistance to continuing
care (future and long-term treatment/recovery
motivation and denial), severity of biomedical
problems, severity of psychiatric/psychological
problems, and social/environmental support (the
extent to which family, friends, and others in the
individual’s home setting are supportive of or
detrimental to recovery). Severity profiles, based
on a 5-point rating scale, can be derived for each
of these areas and can be used to determine initial
treatment matching, admission and placement,
continued stay, and treatment planning decisions.
The interrater reliability on the severity ratings
was higher with raters having more clinical exper-
tise than with less skilled clinicians (Mee-Lee
1988). The lowest levels of agreement were for
the dimensions assessing the acuity of biomedical
and psychiatric problems. These initial severity
ratings have subsequently been revised to be less
reliant on clinical judgment; the severity scale has
been changed to a 4-point rating, and profiles are
based on standard scores that are based on a ratio-
nal expert judgment approach (Smith et al. 1992).
Smith et al. (1992) found that the RAATE-CE’s
average interrater reliability (across three experi-
enced nonmedical chemical dependency clini-
cians) ranged from 0.59 to 0.77, and the internal
consistency reliabilities ranged from 0.65 to 0.87.
The lowest level of interrater reliability was again
associated with the severity of psychiatric prob-
lems; however, the biomedical acuity scale had
the highest level of agreement among the raters.
The RAATE-QI is a 94-item true/false self-
report questionnaire, taking approximately 30–45
minutes to complete. It was designed to be
compatible with and assess the same five underly-
ing dimensions as the RAATE-CE from the
patient’s point of view (Smith et al. 1995). In
addition, an experimental validity scale,
composed of infrequently endorsed items,
attempts to detect patients who either are in
168

Assessment To Aid in the Treatment Planning Process
e
xtreme denial or who are responding in a pattern
suggestive of falsification. Scores from the five
primary scales are converted to standard scores
and profiled with respect to problem severity.
Also, there is a conversion table available to trans-
late client severity scores to ASAM criteria. The
RAATE-QI internal consistency reliabilities
ranged from 0.63 to 0.78, and the test-retest relia-
bilities (over a 24-hour period) ranged from 0.73
to 0.87.
Najavits and colleagues (1997) evaluated the
interrater reliability of the RAATE-CE. Both
professional-level raters (e.g., master’s degree or
above) and nonprofessional interviewers adminis-
tered the measure. A high level of agreement was
found across all the raters, although the reliability
was somewhat higher for the professional raters.
Internal consistency coefficients ranged from 0.45
for the resistance to treatment scale to 0.71 for the
social and environmental support scale.
Exploratory factor analysis led to a four-factor
solution. These factors to a large extent mirrored
the a priori rational subscales of the RAATE. The
factors were labeled psychological problems,
acceptance of alcohol/drug problems, family and
environmental problems, and biomedical prob-
lems. Gastfriend and colleagues (1995) also found
evidence for the validity of the RAATE-CE, with
scores on the RAATE subscales being predictive
of the level of care to which alcoholics in a detox-
ification unit were subsequently referred. Britt et
al. (1995) investigated the usefulness of the
RAATE in relation to attrition from treatment for
pregnant and postpartum women. They found no
differences across three groups (completers,
dropouts, and administrative discharges) on the
RAATE-CE. However, on the self-report RAATE,
it was found that those women who completed the
treatment had lower ratings on resistance to treat-
ment and continuing care; those who completed
less than 1 month of treatment had the highest
resistance scores.
The COMPASS (Craig and Craig 1988) is an
interesting and potentially useful multidimen-
sional instrument for both the general purpose of
assessing adult or adolescent alcohol-involved
individuals and the specific purpose of assisting
the clinician in making treatment referral and
placement decisions. The scale is a 98-item, direct
question, self-report questionnaire designed to
measure the frequency of substance abuse and
personal adjustment problems experienced over
the last 6-month time period. The focus is on
assessing the frequency of occurrence of behav-
iors associated with substance use rather than on
issues such as quantity and frequency of drinking
or other substance use. The scale assesses two
broad dimensions, each with a number of ratio-
nally developed subscales. The first area consists
of four substance abuse scales assessing dimen-
sions consistent with DSM-III criteria of
substance use disorders: psychological depen-
dence (frequency of drinking alcohol for its actual
or expected effects in assisting the person cope
with various life situations); abusive, secretive,
and irresponsible use (how frequently negative
consequences of excessive drinking are experi-
enced); interference due to use (frequency of
alcohol use negatively affecting function in a
variety of life areas); and signs of withdrawal. The
second area includes three personal adjustment
scales: frustration problems, interpersonal prob-
lems, and self-image problems. Additionally, a
number of validity scales are included to identify
response patterns suggestive of defensiveness,
inconsistency, or minimization. Based on data
provided in the COMPASS manual (Craig and
Craig 1988), test-retest reliability over a 7-day
interval was high, ranging from 0.89 to 0.91 for
the substance abuse scales and from 0.78 to 0.86
for the personal adjustment scales. Significant
differences between a sample of substance abusers
in an inpatient treatment program and a general
population sample who had reported using at least
one psychoactive drug over the previous 6 months
suggest discriminant validity of the scale.
The COMPASS is presented as a measure
useful to treatment selection. It takes into account
both the severity of substance abuse problems and
the severity of personal adjustment problems. The
total scores from the substance abuse and personal
adjustment problems dimensions are entered onto
169

Assessing Alcohol Problems: A Guide for Clinicians and Researchers
a r
eferral guide. Based on the severity of the indi-
vidual’s scores on these two dimensions, specific
recommendations are made to refer the individual
to substance abuse information/education classes,
outpatient counseling, intensive outpatient treat-
ment, inpatient hospitalization, or inpatient hospi-
talization with substantial structured aftercare.
The COMPASS appears to have potential clinical
and research utility, but it needs considerably
more developmental work and psychometric
research to extend the test developers’ initial work
on reliability, concurrent validity with other rele-
vant measures, and predictive validity with respect
to the differential effectiveness of treatments to
which individuals are assigned via the referral
guide versus other clinical methods of treatment
matching.
S
UMMARY
T
his chapter’s review of instruments potentially
helpful in the treatment planning process should
not be seen as exhaustive. Other measures of
similar assessment domains likely exist and may
be useful to the clinician. There are also a number
of other important assessment domains that were
not included in this review. Examples include
affective states, such as anxiety and depression;
cognitive/neuropsychological functioning; the
concurrent use of other drugs with alcohol; the
presence of comorbid major (Axis I) psychiatric
disorders and personality disorders (Axis II); and
perceived barriers to treatment (L.C. Sobell et al.
1994
a). T
hese domains clearly should be consid-
ered for inclusion in clinical assessment protocols,
since these areas have been shown to affect the
course of treatment and recovery.
For a comprehensive and thorough treatment
plan to be developed, information derived from
the assessment domains reviewed above must be
integrated with that derived from the diagnostic
process and the assessment of the parameters of
drinking behavior. While the assessment involved
in diagnosis will allow the determination of the
client’s meeting certain criteria, it does not
provide much information about the overall para-
meters of the target behaviors, namely alcohol
consumption or other drug use, or other psychoso-
cial factors. The role of assessment goes beyond
that of classifying the individual’s problem diag-
nostically to providing a more extensive picture of
other areas of life functioning. A major function
in initial assessment and at followup is to deter-
mine the individual’s general quality of life
(Longabaugh et al. 1994).
Shiffman (1989) suggested that three levels of
information are necessary in order to gain a sense
of the individual’s “relapse proneness,” and thus
are relevant to treatment planning. These fall
along a continuum of their proximity, in both time
and influence, to the probability of relapse. The
first of these represents general personal charac-
teristics, such as demographic variables, personal-
ity factors, degree of dependence on the addictive
behavior, and family history of addictions.
Somewhat closer in time and influence are “back-
ground variables” likely to be experienced during
the time of treatment and maintenance, such as the
degree of personal, professional, and/or interper-
sonal stress and the availability of individuals
supportive of the positive changes being imple-
mented and of continued abstinence. The third
and most proximal level includes those factors
most directly associated with high-risk relapse
situations. Examples of this category include the
perceived self-efficacy or level of confidence that
one will not relapse when encountering situations
involving risk factors (e.g., social pressure to use,
interpersonal conflict, depression, urges and temp-
tation [e.g., Annis and Davis 1988
a, 1988b]), the
expectations that one holds about the positive
outcomes associated with the addictive behavior
(e.g., Goldman et al. 1987), and the coping skills
available to deal specifically with the temptations
to engage in the addictive behavior (Litman 1986;
Shiffman 1989). Shiffman (1989) indicated that
the more distal characteristics provide the back-
ground against which the relative risk of more
proximal factors is moderated by their influence
on the person’s appraisal of the situational factors
in the relapse situation.
170

Assessment To Aid in the Treatment Planning Process
An impor
tant component of personal resources
that needs to be considered in the assessment
process is the individual’s more generalized coping
and problem-solving abilities. DeNelsky and Boat
(1986) provided a model of psychological assess-
ment, diagnosis, and treatment that is based on the
individual’s coping skills and deficits in dealing
with interpersonal relationships, thoughts, and
feelings; approaches to oneself and life; and the
ability to sustain goal-directed effort. The avail-
ability of such skills is seen as important in dealing
with problems that can be anticipated to occur
during the course of the treatment and mainte-
nance phases and, as such, should have an effect
on the probability of relapse.
The assessment process should be comprehen-
sive; however, from a practical perspective, one
also needs to be relatively parsimonious, given the
array of areas that could be assessed (Donovan
1988; Institute of Medicine 1990; L.C. Sobell et
al. 1994
a, 1994b). A n
umber of different strate-
gies can be used to provide a framework and
direction for the assessment process in each of the
systems and domains noted above. The first is to
use a sequential approach, in which a less inten-
sive screening of a broad range of areas is
conducted; those areas noted as being potentially
problematic can be pursued further with more
intensive and specialized assessment (Skinner
1988; Institute of Medicine 1990). The second is a
form of clinical hypothesis testing, in which the
clinician formulates hypotheses about the individ-
ual’s behavior based on his or her theoretical
perspective and collects information through the
assessment process to test the apparent validity of
these hypotheses (Shaffer and Kauffman 1985;
Shaffer and Neuhaus 1985; Shaffer 1986). Each of
these approaches is meant to provide information
about the most critical factors needed to determine
the assignment of the client to treatment.
Assessment is the initial step in the longer
term process of therapy and behavior change. Its
functions extend well beyond that of information
gathering. The hope is that the clinician, through
the assessment process, will motivate the individ-
ual, helping him or her move from the point of
contemplating the need to change, through the
action phase of change, and into a productive
maintenance of the desired new behavior pattern.
It is also hoped that the clinician can use the
results from the assessment process to facilitate
the selection of the most appropriate treatment
intensity, modality, and setting and in so doing
maximize the chances of success for the client
(Institute of Medicine 1990; Connors et al. 1994).
A
CKNOWLEDGMENTS
T
he preparation of this chapter was supported, in
part, by the National Institute on Alcohol Abuse
and Alcoholism Cooperative Agreement on
Combining Pharmacological and Behavioral
Treatments for Alcoholism, U10–AA11799.
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