Behavioral assessment and treatment planning with alcohol and drug abusers: A review with an...

Clinical Psych&~ Reulew, Vol. 8, pp. 19-54, 1988 Printed in the USA. All rights reserved.

0272.7358188 $3.00 + .OO Copyright 0 1988 Pergamon Journals Ltd.

BEHAVIORAL ASSESSMENT AND TREATMENT PLANNING

WITH ALCOHOL AND DRUG ABUSERS: A REVIEW WITH AN EMPHASIS

ON CLINICAL APPLICATION

Linda C. Sobell and Mark B. Sobell

Addiction Research Foundation and Departments of Psychology and

Behavioural Science, University of Toronto

Ted D. Nirenberg

Alcohol Dependence Treatment Program, Veterans Administration

Medical Center and Department of Psychiatry and Human Behavior, Brown University

ABSTRACT. Assessment and treatment of substance abuse is a complex and difficult task that involves more than the mere measurement of substance use. A detailed evaluation of the functions of a substance abuser’s alcohol and drug use is necessary to the development of meaningfid and effectiue treatment goals and strategies. This paper reuiews several new and established assessment methods

and instruments which can be used in clinical practice to evaluate the severity of alcohol and drug

problems and to provi& direction for treatment planning. The advantages and limitations of the various techniques are discussed with th recognition that the utility of each technique depends upon the needs and problem of each client. Tie importance and application of recent research findings to assessment and treatment planning are also noted throughout this review.

We would like to thank Louise Amantea for her patience in typing the many drafts of this paper, Ms. Gloria Leo for her repeated and careful proofreading of the manuscript, and

Dr. Adrian Wilkinson for his exceedingly helpful comments on an earlier draft of this

article. The views expressed in this publication are those of the authors and do not necessarily reflect those of the Addiction Research Foundation.

Requests for reprints should be sent to L. C. Sobell, Clinical Institute, Addiction Research Foundation, 33 Russell St., Toronto, Ontario, M5S 2S1, Canada.

I9

20 L. C. Sobell, M. B. Sobell, and T D. Nirenberg

The last two decades have witnessed the development of many behavioral assessment and treatment techniques in the alcohol field (Sobell & Sobell, 1983; Riley, Sobell, Leo, Sobell, & Klajner, 1987) and, to a lesser extent, in the drug field (Callahan, 1980; Sobell, Sobell, Ersner-Hershfield, & Nirenberg, 1982; Callahan, Dahlkoetter, & Price, 1980). This review is intended to acquaint clinicians interested in behavioral assessment and treatment planning with alcohol and drug abusers with the clinical utility of established and recently developed assessment techniques. Advantages and limitations of the various techniques are discussed. Consideration is also given to important aspects of alcohol and drug use that are not covered in standardized assessment batteries.

Although the many similarities between alcohol and drug problems allow some generalizations to be drawn, there are also many differences between these domains. Further, the published literature is weighted toward the assessment of alcohol abusers. Thus, for purposes of this paper, when it seems clinically pru- dent, aspects of assessment and treatment planning with alcohol abusers are extended to drug abusers. However, when such an extrapolation is not warranted, qualifying statements are included.

THE COMPLEXITY OF ASSESSING ALCOHOL AND DRUG PROBLEMS

Assessing and treating individuals with alcohol and drug problems is a difficult task for several reasons. First, professional education and training in the area of substance abuse has been given low priority in many professional training programs. Second, there are a multitude of misconceptions, even among profession- als, about the nature of alcohol and drug disorders. Third, some clients are reluctant to cooperate fully with the assessment process because they have been “constructively coerced” (versus self-referred) by others (e.g., spouse, probation officer, courts) to seek treatment. Also, some individuals with a clinically diagnos- able substance abuse problem do not view their use of alcohol or drugs as severe enough to warrant seeking treatment (e.g., some problem drinkers), while others reject or deny having an alcohol or drug problem because of the stigma of being labeled an “alcoholic” or “drug addict.” Fourth, although substance use can damage an individual’s health and life functioning in many ways (e.g., physically, socially, vocationally), cues (e.g., gastritis, unemployment, insomnia) suggesting the presence and severity of a particular drug or alcohol problem are diverse and may not, in isolation, appear obvious as consequences of substance use. Fifth, some correlates of substance abuse (e.g., divorce, cognitive or hepatic dysfunction) may not become manifest for many years. If clinicians limit their assessments to well known long-term complications of drinking and drug-taking (e.g., physical dependence, cirrhosis), they will fail to adequately assess many individuals who would benefit from treatment. For this reason, it is essential to determine the extent to which the use of alcohol or drugs has affected a person’s overall life functioning. Sixth, since there is evidence that symptoms of alcohol abuse are variable over time and between individuals (Pattison, Sobell, & Sobell, 1977), persons with similar drinking histories will often not have experienced the same set or ordering of adverse consequences. (The investigation of symptom manifes- tation over time has not been intensively investigated for other drug problems.) Seventh, since alcohol, drug, and tobacco use are recalcitrant clinical problems associated with a high relapse rate following treatment (Sutton, 1979; Pechacek,

Assessment and Treatment Planning with Substance Abusers 21

1979; Rounsaville & Kleber, 1985; Chaney, Roszell, & Cummings, 1982; Polich, Armor, & Braiker, 1981; Marlatt & Gordon, 1985; Miller & Hester, 1986) assessment should include a review of previous treatment strategies and the client’s response to those interventions.

SUBSTANCE ABUSE DIAGNOSTIC FORMULATIONS

Most substance abuse treatment programs require that a client’s chart contain some type of diagnostic statement. In the United States, the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Associ- ation, 1980) is the most frequently used psychiatric classification system (see Niaura & Nathan, 1987, for a review of the development of the DSM-III and other diagnostic systems for substance abuse). Besides the pro forma reasons for diagnostic statements (e.g., insurance and clinical recording requirements), diagnostic formulations can also have clinical utility. For example, some research with alcohol abusers has suggested that the severity of alcohol dependence is associated with how individuals respond to different types of treatment goals (abstinence or nonproblem drinking) and different treatment intensities (Heather & Robertson, 1983; Orford & Keddie, 1986; Annis, 1986a). Based on this research, if a client is assessed as having minor problems with alcohol abuse and as not having experienced severe withdrawals from alcohol, the treatment of choice would be a short- term or self-guided treatment. To prescribe a long-term intense treatment for such clients would require a justification based on further assessment data (e.g., other psychiatric problems or a need for a sheltered environment).

Another example of the clinical utility of diagnoses can be seen in a study of patient-treatment matching which found that both alcohol and drug dependent clients with high psychiatric severity ratings at admission had the worst outcomes, regardless of the programs in which they were treated (McLellan, Woody, Lu- borsky, O’Brien, & Druley, 1983). These clients were also more than twice as likely to be hospitalized during the 6-month followup as compared to clients with moderate or low psychiatric severity ratings. These findings led the authors to conclude that for clients with pronounced psychiatric symptoms (e.g., suicidal intention, paranoia, intense anxiety) “appropriate psychiatric interventions should be used as part of their substance abuse treatment” (p. 604).

Since the use of a variety of psychoactive substances, either concurrently or sequentially, is quite common (Grant, Adams, Carlin, Rennick, Judd, & Schooff, 1978; Carroll, 1980; Robins, 1979) all clients should be evaluated during the initial assessment for multiple drug use. In recent years several investigators (Wilkinson, Leigh, Cordingley, Martin, & Lei, 1987; Kaufman, 1982; Craddock, Bray, & Hubbard, 1985) have found that the “use of single drugs or simple patterns of drugs appears to have given way to more complex multiple drug use patterns” (Craddock et al., 1985, p. 2). Wh’l 1 e many might view alcohol as a drug that is used independently of other drugs, a review of the literature not only suggests otherwise (Carroll, Malloy, & Kenrick, 1977) but also shows a strong relationship between alcohol, tobacco, and caffeine use (Pedersen & McClearn, 1983). As well, it has long been known that some drug addicts evidence considerable involvement with alcohol (Craig, 1984; Belenko, 1979; Green, Jaffe, Carlisi, & Zaks, 1978; Kaufman, 1982; Wilkinson et al., 1987). If we accept as asserted by Wilkinson and his colleagues (1987) that “it is very probable that regular use of

22 L. C. Sobell, M. B. Sobell, and ?: D. Nirenberg

a variety of psychoactive substances is the norm among regular users of any identified psychoactive drug” (p. 260) then multiple or polydrug use has emerged as the rule rather than the exception. Consequently, for diagnostic and treatment purposes it is imperative for clinicians to know what substances are being used, as well as the types of substance-related consequences experienced.

Finally, since some substance abusers have other serious psychiatric problems, it is important to determine if the presenting problems primarily relate to substance abuse or are manifestations of some other disorder (e.g., psychosis, depression). In practice, the two most common disorders associated with substance abuse are affective and antisocial disorders (Grande, Wolf, Schubert, Patterson, & Brocco, 1984; Solomon, 1983; Rounsaville, Weissman, Crits-Christoph, Wilber, & Kleber, 1982). If 1 c inical psychopathology other than substance abuse is suspected, it can be assessed further through psychological testing and interviews with significant others as well as by securing previous clinical records. The importance of knowing about psychiatric disorders in substance abusers is illustrated in two treatment outcome studies. The first found that treated addicts with depressive disorders had a poorer prognosis than treated addicts who did not have depressive disorders (Rounsaville, Weissman, Crits-Christoph, Wilber, & Kleber, 1982; Rounsaville, Tierney, Crits-Christoph, Weissman, & Kleber, 1982). The second study found that alcohol and drug clients who had pronounced psychiatric symptoms prior to treatment had the worst outcomes and were hospitalized more than clients with no or low psychiatric symptoms (McLellan et al., 1983).

ASSESSMENT: THE CORNERSTONE OF TREATMENT

Behavioral clinicians view assessment as a continuous and interactive process which occurs before, during and following the introduction of treatment procedures (Mash & Terdal, 1976). A ssessment characterizes the problems being treated and also forms the basis for evaluating the client’s response to treatment interventions. The course of events following the implementation of treatment strategies provides a major data base for clinicians to evaluate the viability of the initial strategies and the accuracy of the initial assessment (e.g., what rates of behavioral change can be sustained by the client; what strategies are effective). Initial treatment goals and objectives can require reformulation for several reasons: (a) as a result of extratreatment events (e.g., identifying a new high risk factor for relapse); (b) during treatment clients may disclose information which they were reluctant to reveal earlier; and (c) continuation of the assessment process can reveal certain influences (e.g., peer pressure) on substance abuse that sometimes are not recognized early in treatment. If treatment is viewed as involving a continuing assessment process, then the process provides a feedback loop for increasing the efficacy of treatment. Examples of the use of such feedback can be found in an article describing several clinical case studies with alcohol abusers

(Noel, Sobell, C 11 e ucci, Nirenberg, & Sobell, 1982). Finally, although drug and alcohol abuse usually pervade many aspects of a

substance abuser’s life, substance abuse is usually not the sole problem. Moreover, some problems initially spawned by substance use can become very real problems in their own right (e.g., if substance abuse led to a divorce, the client will also have to cope with the problems typically experienced by recently divorced persons). Thus, it is important to conduct a comprehensive assessment of the client’s overall


life health. While this review primarily focuses on the assessment of substance abuse problems, clinicians who suspect an associated problem (e.g., marital disorder, depression) should consult readings containing information on assessment techniques for other disorders (e.g., ,Beck Depression Inventory, Locke-Wallace Marital Adjustment Scale).

FUNCTIONAL ANALYSIS OF ALCOHOL AND DRUG USE

The events that precede the use of various substances, as well as the short-term and long-term consequences of substance use, need to be identified, as they can be critical for understanding the functions of drug use for the individual. While direct observation would be an ideal way to accomplish this objective, it is sel-

dom practical. A variety of alternative practical techniques which can be used to identify antecedents and consequences of substance abuse will be discussed shortly.

A detailed evaluation of substance use provides information critical to the development of treatment goals and strategies. For example, if a client has had little success with being drug-free and reports using large amounts of certain drugs, then an immediate concern is the risk of experiencing major withdrawal symptoms when trying to abstain; in such cases, inpatient detoxification might be necessary. Also, since long-term abstinence as an outcome of treatment for substance abusers is rare (e.g., Vaillant, 1983; Marlatt, 1983; Stitzer, Bigelow, & Liebson, 1979), evaluating a client’s environment for risks of relapse to drinking or drug use is important.

To facilitate treatment planning it is recommended that, at a minimum, the assessment of alcohol and drug use include the following (specific techniques to aid in assessing these various behaviors are discussed in the next section of this paper) :

The specific quantities of alcohol and other drugs used and the frequency of use. It is important to obtain specific information about ethanol consumption because “average” consumption patterns may yield data which do not accu- rately reflect actual consumption patterns and levels. Instances of atypical but clinically important levels of alcohol consumption (i.e., sporadic days of heavy drinking) are not identified by estimation formulae, such as quantity-frequency methods (Caetano, Suzman, Rosen, & Voorhees-Rosen, 1982; Sobell, Cellucci, Nirenberg, & Sobell, 1982). Knowledge of such instances is important when drawing inferences about health risks associated with certain patterns of alcohol consumption.

Unlike alcohol use, where the dose is standardized (i.e., percent alcohol is usually known by drink volume), assessment of drug use is considerably more difficult for several reasons: (a) quantification is difficult because of the illicit nature of many drugs; (b) multiple and varied drug use can occur throughout a given day; and (c) the route of administration is variable. Despite these problems, it is important to develop a drug use profile for each client. At the least, clients can be asked about different categories of drug use, frequency of use, and frequency of use in a typical day of use. A recent study with drug abusers provides a good description about how to gather and evaluate such information (Wilkinson & LeBreton, 1986; Wilkinson et al., 1987).


2. Usual and unusual substance use circumstarues and patterns For example, some substance abusers may drink only with friends on weekends, never drink at home, smoke marijuana only with certain friends, take Valium before work, or take any available drug.

3. Predominant mood states and situations antecedent and consequent to substance use. For example, substance abusers may drink mainly when depressed, take Valium when anxious in social settings, or drink heavily only during occasions perceived as pleasant times.

4. History of alcohol and drug withdrawal symptoms. A reported history of major withdrawal symptoms forms the basis for a formal diagnosis of substance dependence using the DSM-III criteria (American Psychiatric Associa- tion, 1980). Also, a history of past withdrawal symptoms coupled with reports of considerable recent alcohol or drug use would be a signal that withdrawal symptoms are likely to follow cessation of use.

5. Medical problems associated with or exacerbated by substance use. For example, ul- cers, hypertension, gastritis, insomnia, diabetes, and epilepsy are just some of the problems that can be associated with or exacerbated by substance use. A recent review chapter by Wartenberg and Liepman (1987) addresses the medical consequences of alcohol and drug abuse as well as other addictive behaviors. The Manual on Alcoholism published by the American Medical Association (1977) also summarizes alcohol-related physical complications. Readers interested in the short-term effects, long-term effects, and lethality of popular drugs of abuse including alcohol should consult a text by Cox, Jacobs, LeBlanc, and Marshman (1983).

6. Identification of possible difficulties the client might encounter in initially refraining from substance use. For example, if a client has a history of never having abstained for more than a few consecutive days in the past year, or of living with friends or relatives who encourage substance abuse, initial abstinence might be especially difficult to achieve.

7. Extent and seuerity ofprevious substance abuse. For example, information can be gathered about duration of substance use and abuse, when substance abuse first started to be a problem, number of different drug and alcohol-related arrests, and number and types of hospitalizations and other treatments for drug and alcohol problems.

8. Multiple drug use. Multiple drug use is a serious problem for several reasons (e.g., synergistic actions of some drugs, cross-tolerance to other drugs). Treatment of polydrug abusers will not always parallel that prescribed for individuals who abuse a single drug (Kaufman, 1982). Information on concurrent drug and alcohol abuse can be found in papers by Kissin (1974) and Schuckit (1980). For clients who want to stop polydrug use, consideration should be given to what problems, if any, might be experienced by simultaneously giving up all forms of substance use. For example, while little has been written on this topic, a question arises as to whether moderate consumption of alcohol might make it more difficult for those with a primary drug problem to refrain from other psychoactive drugs. Since several studies have shown that rates of problem drinking increase during periods of cessation from opiate use (Green et al., 1978), another issue that can arise is the possibility that one drug may be substituted for another.

Also, with increasing concern about the dangers of tobacco use, concern

Assessment and Eeatmmt Planning with Substance Abusers 25

has been raised about alcohol abusers who smoke. Given the clear association (i.e., distinct dose gradient) between smoking cigarettes and drinking, especially heavy drinking (Mangan & Golding, 1984; Kozlowski; Jelinek, & Pope, 1986) and the fact that the proportion of heavy smokers among alcohol abusers is greater than that of the general population (Kozlowski et al., 1986), tobacco use has been identified by several investigators as an important health problem for those who abuse other substances. Unfortu- nately, research is lacking with regard to whether an alcohol problem should be treated before tackling the problem of tobacco use (Bobo & Gilchrist, 1983, Kozlowski et al., 1986; Kozlowski, Skinner, Kent, & Pope, in press). Since little is known about problems inherent in concurrent smoking and alcohol cessation, careful consideration should be given to how these two substances interrelate for clients who wish to stop tobacco

and alcohol use simultaneously. 9. Reports of frequent thoughts or urges to drink or take drugs can be assessed and

monitored and used to identify antecedents which have triggered or could trigger substance use.

10. History of previous responses to substance abuse treatment and self-initiated periods of abstinence. A review of previous successes and failures might provide helpful information about what worked or did not work in prior treatments. Recent evidence with smokers suggests that those who have had extended periods of abstinence prior to treatment have better outcomes after participating in a treatment program than those who have not had such abstinence periods (Coelho, 1985). Although no comparable evidence has been presented for alcohol and drug abusers, social learning theory would predict that previous mastery experiences would provide for increased self-efficacy which in turn would lead to better outcomes. Thus, prior success experiences with other appetitive behaviors (e.g., obesity, smoking, gambling) should be evaluated.

11. Review of the positive consequences of substance abuse. Positive consequences can include, for example, reinforcement from the sick role, social reinforcement from drinking friends, or relief from tension. Several recent studies (e.g., Brown, Goldman, Inn, & Anderson, 1980; Southwick, Steele, Marlatt, & Lindell, 1981) h ave suggested that alcohol abusers endorse positive beliefs about the effects of alcohol, and it is hypothesized that these beliefs or expectancies mediate drinking behavior. One recent study (Brown, 1985) found that alcoholics who expected the most positive reinforcement from alcohol were the most likely to relapse within the first posttreatment year. This early work suggests that expectancies may be important determinants of alcohol consumption and future alcohol abuse.

12. Other l;fe problem. Most substance abusers can identify other major life problems which need to be assessed (e.g., health problems, poor interpersonal skills, family problems), regardless of whether the person uses a substance to deal with life problems or whether the substance use has caused life problems. In some cases, substance abuse may be inextricably associated with other problems.

13. Indicants of tolerance. This section relates mainly to alcohol abusers and opioid addicts. According to DSM-III criteria, some evidence of acquired tolerance to alcohol would constitute a sufficient basis for an alcohol dependence


diagnosis. However, persons with even a minimal drinking history are likely to manifest some tolerance to alcohol (Kalant, LeBlanc, & Gibbins, 197 1). Indicants of substantial tolerance (i.e., the ability to consume large amounts of ethanol to BACs~200 mg% with minimal signs of impairment), though, are likely to indicate an extensive history of heavy drinking. Inferential evidence of tolerance can be sought from clients (e.g., the greatest amount of ethanol consumed in a 24-hour period) or arrest records (e.g., a high blood alcohol level when arrested for drunk driving). A person’s level of tolerance to alcohol can have important implications for treatment planning and goal selection (i.e., abstinence versus nonproblem drinking; Maisto, Henry, Sobell, & Sobell, 1978). For example, a person with high levels of acquired tolerance who wishes to pursue a nonproblem drinking goal must accept that he/she can expect little noticeable effect from consuming a small amount of alcohol.

For opiate addicts it is now accepted that methadone should only be prescribed for those who are not able to stop using heroin or other opiates (Peachey, 1986). While evaluation of the degree of dependence can be made by observing the withdrawal effects, there is also a safe and effective objective test for assessing tolerance and physical withdrawal from opioid drugs. The test for opiate dependence involves measuring the severity of withdrawal symptoms that develop following an injection of naloxone (Judson & Goldstein, 1983). The purpose of naloxone administration “is to exclude those individuals who report heroin abuse but do not have appreciable physical dependence and to establish the appropriate initial dose of methadone for each patient” (Peachey, 1986, p. 396).

For alcohol abusers, clinicians are also urged to consider the following. 14. Past or present indicants of hepatic dysfunction. For example, elevations of certain

liver enzymes can reflect hepatic dysfunction. The utility of these tests is discussed later in this paper.

15. Risks associated with considering a nonabstinence treatment goal. For example, drinking could exacerbate existing medical problems or it could jeopardize a marriage if the client’s spouse opposes any drinking. While some evidence suggests that at treatment entry those individuals who are more likely to be successful at nonproblem drinking are less severely dependent on alcohol, younger, and socially stable (Heather & Robertson, 1983), very recent research has found only a weak relationship between severity of dependence and the likelihood of moderate drinking outcomes (Sobell & Sobell, 1987a). These recent studies are important for several reasons. First, they present multiple demonstrations of long-term outcomes of nonproblem drinking among individuals who had previously manifested alcohol withdrawal symptoms. Second, there have been repeated failures to support predic- tions derived from the severity of dependence hypothesis. Third, the studies were conducted in different countries by different investigators using different methods with different subjects in different settings. Based on these recent studies, Sobell and Sobell (1987a) concluded that:

until more evidence is available it seems premature and ill-advised to assert that

severity of dependence is the most crucial factor for specifying the target population for moderation-oriented treatments and predicting moderation outcomes. It is obvi-


ous that persons who are more severely alcohol dependent typically have a greater amount of life problems than those who are less severely dependent, but it is not clear whether the main barrier to effective treatment or determinant of successful outcomes is the postulated dependence syndrome or the complexity of alcohol- related disabilities that typically accompanies the syndrome. (p. 18)

ASSESSMENT METHODS AND INSTRUMENTS

This section discusses the clinical utility of a variety of techniques that can be used to assess alcohol and drug problems. Decisions about which procedures and assessment instruments will be most useful in a given case should be based on the needs and problems of each client.

Retrospective Methods

Retrospective methods gather information about past events. While most retrospective information comes from clients’ self-reports, other sources include collateral informants, official records, and psychometric scales completed by clients. Retrospective methods not only provide considerable information which can be gathered quickly and inexpensively, but they sometimes constitute the only possible way of collecting pretreatment information.

Self-Reports

Until recently, skepticism abounded about the truthfulness of alcohol and drug abusers’ self-reports. Two main assertions have formed the basis for this skepticism. The first is that alcoholics and drug addicts tend to deny or minimize their substance use and related behaviors. The second is that substance abusers’ self- reports are less credible than other information sources (i.e., that their reports are dishonest). Prior to the mid-1970’s, little had been done to empirically evaluate these claims. However, the past decade has witnessed a flurry of studies evaluating the reliability and validity of substance abusers’ self-reports. These studies have been conducted by several different investigators in different countries and have examined different aspects of substance abusers’ drinking and drug use and related behaviors. Although this literature will not be reviewed here, major reviews of this literature, while recognizing that a small proportion of substance abusers’ self-reports appear to be inaccurate, generally conclude that there is no factual basis for the widespread skepticism about self-reports that has existed for many years (Sobell & Sobell, 1986; O’Farrell & Maisto, in press; Babor, Stephens, & Marlatt, in press; Polich, 1982; Maisto & Cooper, 1980; Maisto, Sobell, & Sobell, 1982/83). It is important to note that these conclusions only apply to substance abusers’ in treatment-related settings and only when they are interviewed under the following conditions: (a) drug-free, (b) in a clinical/research setting, and (c) when given assurances of confidentiality. With regard to the small proportion of clients who give unacceptable self-reports, Babor and his colleagues (in press) have suggested using various methodological techniques likely to enhance the accuracy of self-reported data,


Factors Affecting the Validity of Self-reports. Since self-reports can be gathered in different ways, it is important to know how various procedures might affect their validity. Sobell and Sobell (1981) f ound virtually no difference in the validity of alcohol abusers’ self-reports under a variety of conditions: (a) interview setting (group vs. individual), (b) method of interview administration (self vs. other), and (c) question type (alcohol vs. nonalcohol vs. demographic). Skinner and Allen (1983) 1 a so found no appreciable differences in the reliability of alcohol abusers’ (73 % of these subjects also had used illicit drugs prior to treatment) self- reports of alcohol, drug, and tobacco use whether the information was obtained face-to-face, through a computer-assisted interview, or by a self-report questionnaire. For heroin addicts, little difference has been found in the reliability and validity of their self-reports whether obtained by mailed questionnaires or face-to- face interviews (Bale, 1979).

One of the few situations where alcohol abusers’ self-reports are often invalid and underestimated is when they have a positive blood alcohol level when interviewed (reviewed in Sobell & Sobell, 1986). I n such studies, it has also been found that trained clinical raters are not able to identify individuals who have been drinking but deny that fact. Therefore, while self-reports can be used with relative confidence, there will always be some percentage of cases where self-reports are not valid. Since no single data source (including official records) is error free, it has been recommended that information be gathered from multiple sources and cross-checked (Sobell & Sobell, 1980; Van Hasselt, Milliones, & Hersen, 1981). Information sources can include: (a) the client’s self-report, (b) interviews with family members or other collaterals, (c) the therapist’s observations of the client, (d) clinical and other official records (e.g., arrests, hospitalizations), and (e) physical and mental health indices (e.g., cognitive functioning, liver functioning). When the assessment is based on a convergence of mutually corroborative data, it provides a basis for having confidence in the overall assessment conclusions.

Interview Sty/e. There are several .reasons for believing that interview style is important when talking with substance abusers. Individuals who fear the social stigma and sanctions of being labeled an “alcoholic” or “drug addict” may be reluctant to divulge much information about their drinking or drug use (see Roman & Trite, 1968 for a discussion of the problems attendant with the social labeling of someone as “alcoholic;” Thorn, 1986). Some people, especially those who have recently developed alcohol and drug problems, might be ambivalent about admitting to such problems and strong confrontation could result in their discontinuing treatment. Thus, harsh confrontation should be avoided, unless absolutely necessary. Also, with respect to illicit drug use, some individuals may fear the risk (real or imagined) of being arrested for revealing illicit activities.

Thorn (1986) h as recently reported some interesting findings regarding clients’ perceptions of barriers to their seeking treatment. Among some of the major reasons given were difficulty in asking for help, and reluctance to be labeled an alcoholic or fear of being viewed as a psychiatric patient. The reason given most frequently (60 ‘$L ; 30 of 50) by both men and women for delay in seeking alcohol services was “failure to recognize alcohol consumption as a problem or feeling that their drinking was not serious enough to warrant action” (Thorn, 1986, p. 781). Another interesting finding was that slightly over half (52%; 26 of 50) of the clients felt that at the time of contact with the alcohol clinic that alcohol was not a


problem or not their main problem. These findings are of a particular interest, as the clients had voluntarily sought services and nearly three-quarters (35 of 80) reported having been heavy drinkers for at least 5 years before seeking help. At first blush, these results might seem paradoxical, but what they probably reflect is that while many people might recognize that they drink excessively, they do not view drinking as their primary problem or as serious as those of persons typically treated at alcoholism clinics. This suggestion is supported by the fact that Thorn (1986) found that many clients reported difficulty in identifying their behavior with the traditional stereotypical image of an alcoholic. While these findings are limited to a small sample of clients, they cannot be ignored. In the absence of clinics which explicitly offer services to problem drinkers, it is suggested that when clinicians encounter clients who are ambivalent about admitting to a drinking problem, the following strategy be adopted: gather information without undu- ly threatening the client by first focusing on any alcohol or drug-related consequences (e.g., legal, marital, vocational) the client has suffered, rather than focusing on the extent of alcohol or drug use; this often obviates dealing with issues of labeling and denial and, frequently, after clients have disclosed several adverse alcohol or drug-related consequences, they form their own conclusion

that they have a problem. It is important that clients understand an interviewer’s questions and the termi-

nology used. Mandell (1983) has suggested that “the wording of the questions is very influential in determining the variation in response” (p. 419). He suggested that some terms require definition and illustration and that these definitions influence whether clients recognize and report the phenomenon. Goodwin, Crane, and Guze (1969) found that some clients misunderstood questions even when asked by interviewers. The following examples illustrate some of these problems. When asking about “blackouts,” it is important to determine that clients understand that this refers to time-bound amnesic episodes while drinking or taking drugs and not to loss of consciousness or to unclear memories about the episode (the latter is often referred to as “greyouts”). The term delirium tremens (DTs) is frequently confused with minor withdrawal symptoms (e.g., psychomo- tor agitation only). Thus, to avoid incorrect information clinicians should make certain that clients understand the symptoms associated with the phenomenon being probed.

Questions about how often a client was “drunk)) or “stoned” have little utility unless the client can define how much of the substance is needed to reach a subjective state of drunkenness, intoxication, or euphoria. For clients who have acquired considerable tolerance, the dose that they would report as creating impairment might be quite large. Similarly, reports of “being sober:’ “not drunk,” or “not stoned” are only useful if we know that the client is referring to times when absolukly no substance was used. Many alcohol abusers will report that they have been sober when, in fact, they have had a few drinks, but felt completely unim- paired. Given these examples, it is recommended that when alcohol or drug abusers are asked about their alcohol or drug use, interviewers should ask about specific amounts consumed and patterns of consumption, rather than relying on ambiguous nonquantitative descriptions.

Another commonly used, but ambiguous term in the substance abuse literature is the word “craving.” Kozlowski and Wilkinson (1987a, b) have recently asserted that the term has two different meanings. In ordinary use (i.e., dictionary defini-

30 L. C. Sobell, M. B. Sobell, and 2’7 D. Nirenberg

tion) craving is defined as a strong or great desire. Scientists, however, have extended the meaning of this term to include all dispositions of craving (i.e., any likelihood to use a drug). Kozlowski and Wilkinson (1987a) argue that the mis- match between scientific and ordinary language use creates problems and is misleading. Confusion about this term is also evident among clients. In a recent study it was found that over one-third of persons with alcohol and drug problems used the word “craving” to describe any urge or desire to use a drug, even a weak urge (Kozlowski, Mann, Wilkinson, & Poulos, in press). These recent articles illustrate the ambiguity that exists with the term “craving” for alcohol and drug clients as well as researchers. Kozlowski and Wilkinson (1987a) suggest that we limit the meaning of the term to include only “strong desires,” and that we use precise and explicit quantification when using the term in research studies.

In summary, it has been suggested (Sobell & Sobell, 1982, 1986; Maisto et al., 1982/83; Nurco, 1985) that obtaining data under the following conditions will reduce the likelihood of alcohol and drug abusers giving invalid and unreliable self-reports: (a) the client is alcohol and drug free; (b) rapport is developed by interviewer style and by stressing the confidential nature of the interview and the importance of the information provided; (c) the terminology used by the interviewer and the client is understood by both parties, that is, avoid subjective terminology; (d) the focus of the interview is on information gathering rather than on social labeling; (e) the client’s self-reports are checked against other sources; and (f) data are gathered in a clinical research setting.

Cola teral Reports

Throughout the past few years several studies have used collateral informants to verify clients’ self-reports of drinking (Sobell & Sobell, 1982, 1986; Skinner, 1984; O’Farrell & Maisto, in press). Generally, these studies have found that collaterals and clients agree about the clients’ drinking behavior. Further, several studies have shown that when alcohol abusers’ reports are discrepant with those of their collaterals, the alcohol abusers have usually described themselves more negatively than did their collaterals (e.g., more days drunk, more evidence of a drinking problem, more alcohol dependence symptoms). Although few in number, studies examining drug abusers’ self-reports have shown good agreement between client and collateral reports (Stephens, 1972; O’Brien, Raynes, & Patch, 1972). Inter- estingly, in a recent comparison of alcoholics’ self-reports and biological measures that assess alcohol consumption, it was found that correlations between alcoholics and their respective collaterals are generally higher than those between self-reports and biological measures (O’Farrell & Maisto, in press).

Alcohol and drug abusers’ self-reports of arrests and hospitalizations usually agree quite well with official records. When discrepancies occur, clients typically describe themselves more negatively (i.e., more arrests, more days incarcerated) than what is reflected in the records (reviewed in Maisto et al., 1982/83; Cooper, Sobell, Sobell, & Maisto, 1981). In this regard, the “officialness” of records has been questioned on the grounds that records are not always complete and accurate (reviewed in Nurco, 1985; Sobell, 1976).

ASSEZWZZX~ and ~ea~~~~ Planning with Substance Abusers 31

Assessment InHruments

While numerous assessment instruments have been developed for evaluating alcohol and drug use, before selecting an instrument clinicians are advised to consider two things. First, in order for the instrument to provide reliable and valid information it should have satisfactory psychometric characteristics. Such information is usually contained in the publication describing the instrument or can be found in the research literature. Second, an instrument’s clinical utility will be a function of what a clinician wants to know about his/her client. If the clinician already knows from a detailed history that his/her client has a very serious alcohol or drug problem, then administering certain tests (e.g., MAST or DAST, to be described shortly) would not seem useful. However, if a clinician wants to evaluate a client’s high risk situations for problem drinking over the past year, an instrument such as the Inventory of Drinking Situations would seem applicable for that purpose. The following section discusses selected assessment instruments. Readers interested in knowing about a broad array of research instruments for use in clinical assessments are referred to two compendiums of such instruments, one for drug abuse (Nehemkis, Macari, & Lettieri, 1976) and one for alcohol abuse (Lettieri, Nelson, & Sayers, 1985).

Dfi~ki~g Behavior, Before choosing a drinking behavior assessment instrument, it is important to decide what level of precision and what assessment interval (e.g., one year, lifetime) is required. In this section, three drinking assessment methods are reviewed: (a) Lifetime Drinking History (Skinner & Sheu, 1982), (b) Quanti- ty-Frequency estimation method (Polich et al., 1981); and (c> Time-Line technique (Sobell, Maisto, Sobell, & Cooper, 1979). Whatever method is used, it is important that the interviewer and the client agree about what constitutes a “drink,” since alcoholic beverages vary in their alcohol concentration as well as drink size. In this regard, the task of the interviewer and client can be eased if clients report their drinking in terms of Standard Drinks (e.g., 1 Standard Drink = 12-0~ of 4% beer = 1 -oz of 90-proof spirits = 4 oz of 12 % wine). Standard drink conversions have been used with ease with different populations of aicohol abusers (e.g., Maisto, Sobell, Cooper, & Sobell, 1979; O’Farrell, Cutter, Bayog, Dentch, & Fortgang, 1984).

Using the Lifetime Drinking History (LDH) method, lifetime drinking behavior (including the problem period) is recalled in discrete phases involving major changes in a person’s average drinking pattern. This is not a difficult task and can usually be accomplished in 20 to 30 minutes. This instrument is recommended if an overall picture of lifetime alcohol consumption is needed. Skinner and Sheu (1982) have reported reasonably high reliabilities for the LDH aggregate indices, with the exception that low reliability was found for the drinking phase immediately preceding treatment entry. A recent study found that the LDH questionnaire can also be used to reliably gather clients’ recollections of their drinking during seiected distant time periods in their drinking career (Sobell, et al., 1987).

Quantity-Frequency (QF) methods (e.g., Cahalan, Cisin, & Crossley, 1969; Polich et al., 1981) are estimation procedures which gather data about average drinking patterns over a specified time period (e.g., six months). Although QF measures provide some useful estimates of alcohol consumption, they mask certain types of drinking days, particularly occasional (i.e., not typical) days of heavy

32 L. C. Sobell, hf. B. Sobell, and T D. Nirenberg

and light drinking (Sobell, Cellucci, Nirenberg, & Sobell, 1982). If one is simply interested in obtaining estimates of the average number of drinking days and the approximate total amount of alcohol consumed during a period, a QF method would be adequate. However, if a clinician is interested in knowing the number of days in which heavy and light drinking occurred, or about fluctuations in drinking patterns, then a more precise measure of drinking should be used.

The Time-Line technique has been found to reliably assess daily drinking for 360 days prior to the interview for different populations of alcohol abusers (Sobell et al., 1979; Maisto et al., 1979). Generally good agreement has also been found between timeline reports of clients and their collaterals (Maisto, Sobell, & Sobell, 1982; O’Farrell et al., 1984) and between alcohol-related events (e.g., arrests, hospitalizations) recorded in official records and reported by clients (Cooper, Sobell, Maisto, & Sobell, 1980). The Time-Line technique presents clients with a calendar and asks them to recall their drinking, as well as possible, on a daily basis. For clinical populations, this takes about 20 to 40 minutes and is administered by an interviewer. Several procedures have been developed to help clients recall their drinking (Sobell et al., 1979).

Drug Use. Instruments are genuinely scarce for assessing use of drugs other than alcohol. Measurement of drug use is complicated by multiple drug use and the fact that quantification is difficult due to the illicit nature of many drugs (e.g., dosage is often undeterminable). Traditionally, the approach to reporting drug use has been in terms of the primary drug of abuse. However, since multiple drug use now seems to be quite common, it is important to examine profiles of drug use before, during, and after treatment. This is particularly important because of drug substitution (i.e., reducing or stopping one drug but increasing use of another drug; Judson, Ortiz, Crouse, Carney, & Goldstein, 1980). The complexity of drug use patterns and increases in polydrug use has led some investigators to develop typologies for classifying multiple drug users (Clayton & Voss, 1981; Craddock et al., 1985; Wilkinson et al., 1987). The importance of studies examining drug use patterns and constructing drug use typologies goes beyond the research results. The studies indicate that at the level of individual clients, “simpli- fication of the data to a single index would risk obscuring clinically important individual differences” (Wilkinson et al., 1987, p. 269). This conclusion begs for clinicians working with substance abusers to obtain detailed drug use histories and patterns of drug use.

In a recent treatment outcome study with young drug abusers, an assessment instrument which obtained information about different categories of drug use (e.g., stimulants, sedative-hypnotics), frequency of use (months of use in year, typical number of days/month), and frequency of use in a typical day of use was found to have excellent construct validity (Wilkinson & LeBreton, 1986; Wilkin- son et al., 1987).

Consequences of Substance Use. Several self-administered scales have been developed to assess psychosocial consequences and dependence symptoms of drug and alcohol use. Two scales developed to assess elements of the alcohol dependence syndrome as postulated by Edwards and Gross (1976) can easily be used in clinical practice. The first is a 25-item scale known as the Alcohol Dependence Scale (Skinner & Allen, 1982; Skinner & Horn, 1984), and the second is a 20-item

Assessment and Treatment Planning with Substame Abusers 33

scale known as the Severity of Alcohol Dependence Questionnaire (Stockwell, Murphy, & Hodgson, 1983).

The Michigan Alcoholism Screening Test (MAST Selzer, 1971) and the Drug Abuse Screening Test (DAST Skinner, 1982) are brief self-report instruments

which reliably assess various consequences related to alcohol and drug abuse, respectively. Clinically, these instruments provide a scaled measure of problem severity related to alcohol or drug abuse. The MAST is a widely used screening test for assessing alcohol abuse and takes about 5 minutes to complete. While the MAST contains 24 items, a shorter 13-item version has been found to be reliable (SMASH Selzer, Vinokur, & van Rooijen, 1975). The DAST, the drug counterpart to the MAST, is a 28-item questionnaire which assesses various consequences (e.g., social, legal, health) of drug abuse. A 20-item version of the DAST also exists which correlates quite well with the longer version.

A frequently used index to assess addiction problem severity, especially with drug abusers, is the Addiction Severity Index (ASI: McLellan, Luborsky, Woody, & O’Brien, 1980). The AS1 is a structured clinical interview which can be administered by a technician in less than 30 minutes and results in lo-point problem severity ratings in six areas frequently affected by substance abuse (e.g., medical, legal, family/social). According to the authors “within the ASI, severity is defined as ‘need for additional treatment,’ and offers a potentially different estimate of severity than other perspectives” (p. 27). Each of the six problem areas is assessed separately through objective information (e.g., test results, laboratory reports)

and the client’s subjective judgments of each problem area. The assessment covers the previous 30 days, allowing for comparison with subsequent assessments.

In a review of diagnostic and assessment instruments for alcohol abuse, Jacob- son (1976) noted that the problem with the majority of the tests was their trans- parent face validity (i.e., people can easily present an invalid profile). Thus, for identifying substance abusers some tests (e.g., DAST, MAST) may be no better than simply asking the person “Do you think you have a drug or alcohol problem?”

Personality Tests. Although several tests are available for assessing personality traits of alcohol and drug abusers, the personality test most widely used with substance abusers has been the Minnesota Multiphasic Personality Inventory (MMPI: Barnes, 1983; Wallace, 1979; Miller, 1976; Berzins, Ross, & Monroe, 1971; Sutker, Patsiokas, & Allain, 1981). While certain scale elevations (psychopathic deviance, Pd; Scale 4) have been suggested as typical for substance abusers, there appears to be no single characteristic MMPI profile for alcohol or drug abusers (Barnes, 1983; Owen & Butcher, 1979). Further, while certain MMPI code types (e.g., 2-4; 4-7; 2-4-7) are associated with the probability of being diagnosed as an alcohol or drug abuser, it is more difficult to identify individuals who have alcohol or drug problems by specific MMPI code types. Although the MMPI has been used as a differential diagnostic tool, its application, in this regard, can be criticized for its inability to differentiate among alcoholics, drug abusers, other addictive disorders, and psychopathic personalities (i.e., group profiles of individuals with different diagnostic classifications may share similar personality trait characteristics: Barnes, 1983; Owen & Butcher, 1979). The inter- relatedness of the diagnoses of alcoholism, drug abuse, and antisocial personality has also been supported in a review of studies which used criteria other than the


MMPI to formulate the diagnoses (Grande et al., 1984). Finally, with respect to personality tests, it is cautioned that while certain traits may correlate with a specific diagnosis, these traits are descriptive rather than necessarily etiological in origin.

Neuropsychological Tests. Suspected neuropsychological impairment and brain damage in alcohol and drug abusers should be assessed. Although the literature suggests that protracted ingestion of alcohol can cause serious neuropsychological impairment, the evidence for other drugs is not nearly as conclusive (reviewed in Parsons & Farr, 1981). Parsons and Farr speculate that the reason that the evidence for drugs other than alcohol is not as definitive is because of a lack of adequately controlled research. The major tests that have been used to assess neuropsychological impairment in alcohol and drug abusers are the full Halstea- d-Reitan battery, including the Trail Making Test Parts A and B, and the Wechs- ler Adult Intelligence Scale. The use of a battery of tests to diagnose probable brain damage due to substance use helps to increase confidence in the resultant diagnosis. Readers interested in the application and interpretation of tests for assessing neuropsychological functioning and impairment related to alcohol and drug use are referred to two excellent reviews (Parsons & Farr, 1981; Miller & Saucedo, 1983).

Neuropsychological impairment is a well-known consequence of protracted abusive drinking among severely dependent alcoholics. Although several studies have shown recovery of function on certain tasks after short and long periods of abstinence, other studies have failed to demonstrate similar recovery after long periods of abstinence (reviewed in Yohman, Parsons, & Leber, 1985). A recent study (Yohman et al., 1985) has found that alcoholics, including those who are abstinent, have protracted deficits compared to controls one year after testing. This lack of improvement, however, was thought to be a result, in part, of including subjects who were not abstinent following treatment. The findings in this study also suggest that cognitive functioning may be a good predictor of recidi- vism and treatment outcome. These findings have important implications for treatment planning and risk of relapse. For example, clients with deficient ab- straction abilities may be poor candidates for cognitively complex treatments.

High Risk Situations and Expectancies. Since there is a very high relapse rate among treated alcohol and drug abusers, clinicians must be prepared to deal with relapses when providing clinical services. Several years ago Marlatt and Gordon

(1985) developed a classification system to categorize situations that precede relapses. Across clients with five different types of addictive behaviors, including alcohol and drug abuse, they found that the situations associated with 72 % of all self-reported relapses fell into three of eight categories: negative emotional states

(e.g., anxiety, depression), social pressure (i.e., to use a substance), and interpersonal conflict (e.g., arguments with others). The clinical advantage of knowing what situations pose a high risk of relapse for clients is that treatment can be geared to help clients develop coping responses for those situations.

Recently, two instruments have been developed to evaluate previous and potential relapse situations with alcohol abusers (Annis, 1986b; Annis & Kelly, 1984). The first, the Inventory of Drinking Situations (IDS), requires clients to evaluate 100 different situations and to indicate on a 4-point scale the frequency with

Assessment and Eeatment Planning with Substance Abusers 35

which they drank heavily in that situation during the past year. The second instrument, the Situational Confidence Questionnaire (SCQ> contains 100 items which parallel the drinking situations in the IDS. The SCQ was developed to evaluate a client’s perceived ability to resist drinking heavily in particular situations. (Although the SCQ collects information about concurrent behaviors, i.e., present self-efficacy, it is discussed in this section because its counterpart, the IDS, is a retrospective assessment instrument.) Clients are asked to imagine themselves in each of the situations and to indicate on a scale from 0 to 100 how confident they are that at the present time they would be able to resist the urge to drink heavily in that situation. The 100 items on the IDS and SCQ are divided into two major categories of situations - Personal States (intrapersonal) and Situ- ations Involving Other People (interpersonal). Personal States include five subcategories (unpleasant emotions, physical discomfort, pleasant emotions, testing control over alcohol, urges/temptations to drink). Situations Involving Other People include three subcategories (conflict with others, pressure from others to drink, pleasant times with others). The eight subcategories parallel those postulated by Marlatt and Gordon (1985). A shorter 42-item version of both the IDS and SCQ is available; both short versions correlate quite well with their original subscales (Annis & Kelly, 1984; H.M. Annis, personal communication, June 27, 1986). Once a client completes the questionnaires, a profile of situations that might pose a high risk of relapse (i.e., vulnerability) can be developed.

Most psychotherapeutic approaches to the treatment of alcohol problems have been oriented toward helping individuals cope with negative affect or compensate for response deficiencies (e.g., social skills deficits). Viewing excessive drinking as an inappropriate coping response has historical roots (e.g., Jellinek, 1960) as well as contemporary research support (Marlatt & Gordon, 1985). Recently, however, research has also begun to explore the possibility that some excessive drinking is positively motivated. Recent research on alcohol-related expectancies (i.e., beliefs about the effects of alcohol) suggests that expectancies vary with drinking patterns and may mediate decisions to drink (Brown et al., 1980; Southwick et al., 1981; Connors, O’Farrell, Cutter, & Thompson, 1986). Alcoholics generally appear to give stronger endorsements to various domains of alcohol expectancies than do subjects in other drinker groups, including problem drinkers (Brown, Goldman, & Christiansen, 1985). It has also been found that alcoholics who had the highest scores on a questionnaire assessing positive alcohol expectancies were more likely to relapse within one year after treatment (Brown, 1985). These findings have important implications for treatment planning, as those individuals who have strong positive expectancies regarding the effects of alcohol appear to be those at the greatest risk of relapse.

Baker and Morse (1985), similarly, have noted that for persons with less severe addictions, positive affect is often associated with drug use. In an ongoing study (by Mark B. Sobell and Linda C. Sobell) of not severely dependent alcohol abusers (i.e., no history of major withdrawal symptoms), it has been noted that a large number of such individuals report their excessive drinking as mainly being associated with states of positive affect, especially in social settings (Sobell & Sobell, 198713). In fact, this pattern has been sufficiently prominent that therapists involved in the study have come to refer to such persons using the shorthand reference, “good times-social pressure drinkers.” Although it must be emphasized that this conclusion is presently based only on inspection of data from an incom-

36 L. C. Sobell, hf. B. Sobell, and 7: D. Nirenberg

plete sample, if it is eventually supported by statistical analysis and replication, it will have obvious treatment implications (i.e., the therapeutic approach would be quite different for people who drink heavily to enhance their enjoyment of positive situations, as compared to the approach taken with people who drink mainly to cope with aversive situations).

CONCURRENT METHODS

Self-Monitoring

Self-monitoring requires clients to routinely record (monitor) various aspects of their behavior. For substance abusers, this usually involves monitoring drinking and drug-taking behaviors and related events (e.g., urges, consequences). Al- though self-monitoring is a popular behavioral technique, there has been much less research in this area with substance abusers than with other clinical populations (Callahan et al., 1980; Skinner, 1984). Since self-monitoring provides feedback to the client, it has been suggested that the very act of recording may produce change in the behavior being monitored (Nelson & Hayes, 1981). If this is the case, it might be difficult to use self-monitoring to obtain a baseline rate of the problem behavior for research purposes. For clinical purposes, however, self- monitoring can still be used during the assessment process and as a therapeutic tool to monitor treatment progress, as long as the therapist is aware that the self- monitoring might itself be affecting alcohol and/or drug use.

Self-monitoring usually requires the client to maintain a diary or a log and to record different aspects of the target behavior. Alcohol abusers can be asked to record several aspects of their drinking including: (a) episodes and amount of drinking, (b) circumstances associated with drinking (e.g., setting, mood state, others present), (c) long- and short-term consequences of drinking, and (d) thoughts and urges to drink. Further, since only a small proportion of clients completely abstain from alcohol following their entry into treatment, continued assessment of any drinking can be facilitated by having clients record their drinking. Although self-monitoring might be seen as having more benefit for individuals who pursue a nonabstinent treatment goal, clients who self-monitored abstinent days (i.e., recorded zeros for each day of no drinking) have reported being reinforced by the feedback of continued abstinence (Sobell & Sobell, 1973).

For drug abusers, behaviors related to their drug use are often monitored. In one of the few studies examining self-monitoring of drug use (Callahan et al., 1980), the drug abusers telephoned the research staff several times a day to report external and internal events (i.e., antecedents) which preceded drug use. Al- though such an elaborate procedure might be difficult to implement in clinical practice, drug abusers could self-monitor drug-taking and drug-related thoughts as described in a clinical case report (Hay, Hay, & Angle, 1977).

In a recent study, multiple drug users were asked to self-monitor their drug use during treatment (Wilkinson & LeBreton, 1986). Over 70% of all clients provided daily self-monitoring data, and 87 % provided at least some drug use information. Clients’ self-monitoring data were examined in two ways. First, of three measures selected to represent initial levels of motivation with treatment, two were obtained from the self-monitoring reports. No significant differences in self- monitoring compliance were found across three treatment outcome groups (Suc-

Asse.wrwnt and Zeatment Planning mdh Substa7lce Abusers 37

cessful, Improved, Unimproved). This finding suggested that treatment failures were not associated with lower levels of initial motivation. Second, clients’ self- monitoring data during treatment were compared with their one-year treatment outcome status. Results indicated that, at least in this study, self-monitoring data obtained during treatment were associated with outcome status (i.e., those with the poorest one-year outcome status had reported the greatest drug use during treatment).

When clients are asked to self-monitor alcohol or drug use, clinicians must exercise care in responding to these reports so as to maintain their validity. For example, a punitive response to a client’s reports of drinking or drug taking may reduce the likelihood of the client reporting such behavior again. One way to minimize this problem is to instruct the client about the need for candor and to praise accurate record keeping, while not condoning substance abuse. Reports of drinking or drug use can be discussed as part of the treatment; identifying changes in drinking or drug taking patterns and correlates of substance use (i.e., setting events and consequences) can have clinical value in evaluating and monitoring the course of treatment. These reports also provide an opportunity to gather additional information about high risk situations for relapse, as well as an opportunity for the client to discuss these events.

OBjECTWE METHODS

As noted earlier, a growing body of evidence suggests that under certain conditions alcohol and drug abusers’ self-reports are usually quite reliable and valid. This, however, does not mean that all clients’ reports will be accurate. Thus, it is still valuable to use objective measures to substantiate self-report data.

Although retrospective methods have already been discussed, it should be pointed out that it is current practice to search for biological markers of alcoholism and of ethanol consumption, with an assumption that biochemical measures are unquestionably superior to self-reports. Two recent and comprehensive reviews of this literature, however, suggest caution in overreliance on biochemical measures. In the first review, O’Farrell and Maisto (in press) compared self- reports and biochemical measures. The two major conclusions drawn were: (a) “the literature does not support the widespread skepticism of alcoholics’ self- reports or the existence of a systematic underreporting except when alcoholics have a positive blood alcohol level,” and (b) “currently available biological markers do not solve the problems of measuring alcohol consumption in outcome studies. Markers correlate only modestly with self-reported consumption, are affected by factors other than alcohol consumption, show large individual differences in response to variations in alcohol intake, in certain cases have an overly long half-life, provide a specific but not very sensitive indicator of poor outcome, and may present compliance problems especially among chronic alcoholics.” O’Farrell and Maisto (in press) conclude that “researchers cannot look to available biological markers to provide a ‘gold standard’ measure of alcohol consumption. No such measure exists. Rather markers can be used as another measure in a convergent validity approach to increasing confidence in conclusions.”

The second review (Salaspuro, 1986), which addresses both conventional and potential laboratory markers, is similarly pessimistic. This review concluded that “so far biological markers cannot be used for the estimation of the absolute


consumption level of an individual patient. As to mass screenings of apparently healthy populations, the sensitivities and specificities of the currently available biological markers are still insufficient. On the basis of the present knowledge the biological markers should complement but not replace the measures of alcohol intake derived from questionnaires and from motivating personal discussions” (Salaspuro, 1986, pp. 9S-10s).

Recent Substance Use

Breath Alcohol Tests. Recent substance use can be detected through different bodily fluids (e.g., urine, sweat, saliva, blood, and breath). Some assay methods (e.g., blood, urine tests), require laboratory analysis and, thus, cannot provide immediate feedback regarding substance use. The various tests also differ in terms of cost and level of precision. One of the most immediate and clinically convenient ways of assessing a person’s present level of ethanol consumption is to use a breath alcohol test. Several inexpensive portable breath testers are available which can provide clinicians with an immediate and reasonably accurate estimate of the client’s level of alcohol intoxication (e.g., Sobell & Sobell, 1975). The major reason for using breath tests at assessment and at other times when clients are suspected of drinking is because several studies have found that one of the few times when alcohol abusers’ self-reports of recent drinking behavior are often invalid is when they have any alcohol in their system (Sobell & Sobell, 1982, 1986). These studies also show that clinicians' judgments of clients’ states of intoxication are poor, probably because of the phenomenon of tolerance and because alcohol abusers may have learned to “mask” many of the usual signs of intoxication (e.g., slurred speech, impaired gait).

Alcohol Dipstick. Recently, a novel and promising technique, known as the alcohol dipstick, has been developed to determine ethanol concentrations in different body fluids (i.e., urine, saliva, and blood; Kapur & Israel, 1983, 1984). The dipstick produces quantifiable differences in color intensity associated with different ethanol levels. The dipstick can be used in a variety of clinical settings to reliably and quickly provide an objective indicator of ethanol consumption.

Urine Tests. Urinalyses can provide qualitative (i.e., types) and quantitative (i.e., amounts) assessments of drug use. Although results are not immediate and are often costly, multiple drug use can be assessed. While urine testing provides fairly accurate results, both false negatives and false positives do occur (Cohen, 1981; Foltz, Fentiman, & Foltz, 1980). S everal studies using urinalyses generally have found that addicts’ self-reports of drug use, including the self-reported use of marijuana (Martin, Wilkinson, & Kapur, in press), are quite accurate (Bale,

VanStone, Engelsing, & Zarcone, 1981).

Substance Use Over Extended Periods

The above methods are limited to assessing recent alcohol or drug use and require that the substance or derivatives of the substance be present in bodily fluids. Considerable research has also been conducted on objective methods of assessing alcohol and drug use over extended time periods.

Assessment and Eeatment Planning with Substance Abusers 39

Sweat Patch. A sweat patch technique was developed several years ago in an effort to objectively measure ethanol consumption over a one to ten day period (M. Phillips & McAloon, 1980; Phillips, 1982). A recent field study (M. Phillips, 1984) was conducted to evaluate the sweat patch with normal volunteers. Subjects’ self-reported average daily ethanol consumption was compared with the ethanol concentration in the sweat patch. Results indicated that more than half of the subjects’ reports were inaccurate and most were underreported. Another group of investigators (E. Phillips, Little, Hillman, Labbe, & Campbell, 1984) attempted to confirm M. Phillips’ (1984) results and found that while it is possible to detect someone who has consumed large amounts in the last 24 hours, that “it is not possible to be sure of the amount of alcohol ingested” (E. Phillips et al., 1984, p. 235). E. Phillips and her colleagues’ (1984) results raise serious questions about M. Phillips’ (1984) results and suggest that the patch is not a sensitive measure of ethanol consumption and that it cannot distinguish between different levels of alcohol consumption.

Although E. Phillips et al. (1984) cautioned that their study deviated from the methods of M. Phillips and McAloon (1980), they still raised several questions which need to be addressed before the patch can be adopted for general use. Even if the sweat patch’s utility is borne out by further research, a more basic concern is whether those clients who are cooperative and motivated to wear the patch (i.e., come to the clinic to have it applied and removed) are the ones who would give inaccurate reports about their drinking in the first place. Since almost half of M. Phillips’ (1984) normal healthy volunteers failed to return to have their patches removed, the sweat patch seems to have dubious clinical value.

Acute Liver Function Tests. Numerous studies have reported convincing clinical evidence showing that elevations on some biochemical markers (mean corpuscu- lar volume; high-density lipoprotein; gamma-glutamyl transpeptidase) are corre- lated with recent heavy drinking (Morgan, 1980; Holt, Skinner, & Israel, 1981; Leigh & Skinner, in press). A few studies (e.g., Shaw, Stimmel, & Lieber, 1976) have even suggested that when particular biochemical markers are elevated, this is sufficient to justify a diagnosis of “alcoholism.” The problem with such a claim is that, to date, elevated levels have only been found to be related to recent heavy drinking (see Morgan, Wilson, & Sherlock, 1977). Further, when clients with these blood levels stop drinking for three or more weeks or significantly reduce their drinking for 3 to 6 weeks, the levels often return to normal or are significantly reduced (Chick, Kreitman, & Plant, 1981).

Other factors can also affect the various biochemical markers studied to date: (a) There is considerable intersubject variability; some clients can drink quite heavily and not evidence elevations and vice versa (Morgan, 1980). (b) Different tests have been found to be differentially affected by different drinking patterns (e.g., frequency vs. quantity; Skinner, Holt, Schuller, Roy, & Israel, 1984). (c) The biochemical test for high-density lipoprotein is only a good indicant of ethanol consumption if the client does not have liver disease (Devenyi, Robinson, Kapur, & Roncari, 1981). (d) Many of the enzymes used to assess liver functioning are also sensitive to other medical conditions and drug use (e.g., diabetes, heart failure, dilantin, barbiturates; Morgan, Colman, & Sherlock, 1981; Shaw, Korts, & Stimmel, 1982/83).

Limitations on the use of enzyme levels to assess ethanol consumption are


reflected in a recent study by Orrego, Blake, and Israel (1985). While these authors showed that gamma-glutamyl transpeptidase (GGT) levels were correlat- ed (r = .69) with alcohol consumption, they also found enough individual variations to “preclude the use of enzyme activities as indicators of the exact amount of ethanol consumed” (p. 12). They also asserted that “the half-life of GGT of almost 1 month indicates that caution should be exerted when interpreting a single determination showing elevated GGT levels, particularly in an individual who has been drinking quite heavily prior to being abstinent” (p. 12).

Some investigators have been exploring the potential of computer-based analyt- ic procedures for simultaneous processing of multiple enzymatic and other physi- ologic indices that would have discriminative power to identify long-term alcohol use by alcoholics (Ryback, Eckardt, Felsher, & Rawlings, 1982; Ryback & Rawlings, 1985). While such studies have not achieved widespread acceptance, one group of investigators (Ryback et al., 1982) f ound that a quadratic discrimi- nation procedure involving 25 commonly used laboratory tests was able to differentiate 100 % of subjects with alcoholic and nonalcoholic liver disease. The results further indicated that traditional liver tests may not allow a differentiation of the etiology of liver disease, perhaps because long-term alcohol abuse can have effects on systems other than the liver. Thus, the authors recommend a clinical battery designed to measure the anatomic and functional integrity of various organ systems. Finally, it should be noted that the studies by Ryback and his colleagues have focused primarily on alcoholics with biopsy-verified liver disease, a population that constitutes a small, and fairly easily identified, percentage of those with drinking problems.

In summary, the major clinical utility of tests assessing acute hepatic functioning would appear to be as probable, rather than definite, indicants of very recent heavy alcohol consumption. While several studies have suggested that diagnostic accuracy can be increased by using several tests in combination (e.g., Chick et al., 1981; Sanchez-Craig & Annis, 1981), two studies comparing questionnaire instruments with laboratory tests have shown that the questionnaires were superior to gamma-glutamyl transpeptidase in identifying alcohol consumption in alcoholics (Peterson, Trell, & Kristenson, 1983; Bernadt, Mumford, Taylor, Smith, &

Murray, 1982). F inally, the results from one study which found biochemical indices to correlate significantly with self-monitoring data (Sanchez-Craig & An- nis, 1982) suggest a procedure by which convergence between self-reports of ethanol consumption and biochemical measures can be enhanced.

Rib Fractures and the Trauma Scale. As a result of studies that have found more rib fractures on routine chest radiographs in clients with alcoholic liver disease than in control subjects (e.g., Lindsell, Wilson, & Maxwell, 1984; Kristensson, Lun- den, & Nilsson, 1980), it has been suggested that the presence of fractures may be a useful marker of alcoholism (Lindsell et al., 1984). The results of two recent studies (De Marchi, Basile, Grimaldi, Macor, Vitale, & Cecchin, 1984; Johnson, Davidson, Saunders, & Williams, 1984), however, suggest that the presence of fractures on chest X-rays is related to the severity of alcohol dependence. Since more severely dependent alcoholics have a higher incidence of fractures as compared with alcoholics with mild dependence symptoms, rib fractures may have little value for early identification.

To assess the diagnostic value of history of injury, Skinner et al. (1984) devel-

Assessment and Treatment Planning with Substance Abusers 4I

oped a 5-question trauma scale (e.g., fractures, dislocations). While the scale has good sensitivity (detecting actual cases) and specificity (ruling out cases that do not have the problem) for detecting excessive drinkers, its utility with other than severely dependent alcohol abusers is presently unclear.

A recent study with Brazilian alcoholic and nonalcoholic subjects casts further doubt on the utility of the trauma scale (Monteiro, Pires, & Masur, 1986). This study found that while the sensitivity and specificity figures were similar to those reported by Skinner and his colleagues (1984), that sensitivity (i.e., percentage of true cases) was affected by a person’s socioeconomic background. It was also found that only one of the live questions-the only one which directly asks about drinking-contributed substantially to the sensitivity value (i.e., the percentage of correct case classifications for four of the live questions ranged from 28% to 45 % , while the question asking about injuries after drinking resulted in 73 % correct classification). Further, for the Brazilian alcoholics, a short 4-item screening test was more sensitive than the trauma questionnaire. Thus, like so many other instruments, it appears that merely asking alcoholics if they have a drinking problem might prove as useful as obtaining a history of injuries and certainly more expedient.

Taste Test and Speed of Drinking. Two assessment techniques, speed of drinking and taste tests, can be used to directly observe drinking behavior. Speed of drinking evaluates the rate at which the first drink is consumed, and this has been related to other variables (e.g., severity of dependence, additional drinking; Hodgson, Rankin, & Stockwell, 1979). The taste test is an unobtrusive measure of drinking where subjects typically are asked to compare alcoholic beverages on various taste qualities (Marlatt, Demming, & Reid, 1973). The amount of bever- age consumed is the dependent measure. The taste test has been found to reliably differentiate between groups of alcoholic and nonalcoholic subjects (Marlatt et al., 1973). While both measures have research significance, they are not practical for most clinical settings.

Summary of Assessment Methods

In summary, this section on objective assessment methods and the earlier section on retrospective methods clearly indicate that no measure of alcohol consumption is totally accurate or error-free. In this regard, interested readers are referred to a very recent, comprehensive, and balanced review of the advantages and disadvan- tages of self-report and biological measures for assessing alcohol consumption with alcohol abusers (O’Farrell & Maisto, in press).

BEHAVIORAL TREATMENT: PLANNING, COAL SETTING,

MONITORING, AND TERMINATION

Although multiple overviews and summaries of behavioral treatment methods have been published (e.g., Nirenberg, 1983; Callahan et al., 1980; Sobell, Sobell, & Nirenberg, 1982), there is a distinct lack of published materials describing how to develop treatment plans for alcohol and drug abusers. In this section, major aspects of behavioral treatment planning and goal setting are noted. Most of this material has been developed based on work with alcohol abusers. While various aspects of treatment planning and goal setting with alcohol abusers might be

42 L. C. Sobell, M. B. Sobell, and i? D. Nirenberg

viewed as easily and logically extendable to drug abusers, caution must be exer- cised in doing so, as empirical support for such an extension is not presently available. Although much of the following will be familiar to many behavior therapists, a discussion of some basic aspects of treatment planning and implementation is important for demonstrating how assessment is an ongoing compo- nent of the entire treatment process.

Client involvement in treatment planning is essential to the development of a meaningful and useful treatment plan for several reasons. First, a client can provide his/her therapist with valuable information about the desirability, feasibil- ity and ease with which various treatment strategies can be implemented. Second, in the early part of treatment, client involvement can set the stage for continued participation (i.e., compliance). Third, involving clients in their treatment planning and goal setting better insures that the treatment goals have been mutually determined. Fourth, such involvement can help give clients a sense of mastery over their problems, especially if a shaping process is used. Although the initial assessment provides the basis and justification for the treatment plan, valuable additional information is often revealed during treatment. Thus, it is important for clinicians and clients to be sensitive to changes in the client’s environment and to use new information to change the treatment plan as needed.

It is important to define problems and goals so they are amenable to measurement and evaluation (Kazdin, 1982). Vague and ambiguous goals fail to adequately reflect the nature of the problem. For example, the goal of “becoming less anxious” can mean many things (e.g., managing an isolated event such as going for a job interview, or managing a generalized anxiety disorder). While dealing with both of these problems would involve reducing anxiety, the problems would also require very different treatment strategies. Also, positively stated goals, as compared with negatively stated goals, provide clearer direction for behavior change (e.g., “learn to express more emotional support to spouse for help with children” versus “stop nagging spouse for lack of help with children”).

Treatment plans usually contain both short-term and long-term goals. Since long-term goals reflect the ultimate aim of treatment, they usually require a significant investment of effort and time by the client (e.g., complete abstention

from drug use; reduce financial indebtedness). Consequently, progress toward long-term goals can often be illusory and difficult to recognize if the focus is predominantly on long-term goals. One way to help clients see the proverbial forest through the trees is to partition long-term goals into short-term goals. Short-term goals are usually a series of small operationalized objectives, the accomplishment of which can be measured, and which relate to a step-wise progression to the long-term goal. Short-term goals have several advantages: (a) progress can be monitored more frequently, (b) early success experiences can be built in, and ( ) c a client’s motivation for making further changes can be enhanced because there are frequent opportunities for reinforcing behavior change.

EFFECTIVE AND LEAST RESTRICTIVE TREATMENTS

Although treatment planning is a process where treatment is designed to meet the needs and resources of each client, sometimes several treatment options may appear viable for a particular client. When this occurs, the costs of the various treatment strategies should be evaluated in relation to the client’s lifestyle, values,

and resources. In this regard, a distinction should be made between “effective” and “effective and least restrictive” treatments (Sobell, Sobell, & Nirenberg, 1982). Effective treatments are those that help clients achieve their goals and have a high probability of maintaining accomplishments. Effective and least restrictive treatments not only help clients achieve their goals and have a high probability of maintaining accomplishments, but as well they require the least total lifestyle change from the client. For example, if a client reports that a high risk situation for relapse involves social settings where alcohol is present, an effective treatment strategy might involve having the client forever avoid situations where others are drinking (e.g., not going to parties, restaurants, bars). However, while this strategy might be effective, it might also place unnecessary demands on a client’s lifestyle (i.e., unnecessarily restricting social activities), when the client might easily be taught drink-refusal skills to cope with such situations (Foy, Miller, Eisler, & O’Toole, 1976).

Although not directly a test of restrictiveness, one of the most striking examples of an effective and least restrictive treatment was reported by Orford, Op- penheimer, and Edwards (1976). While the number of cases is small, they found that in brief marital counseling (one advice session) non-severely dependent alcohol abusers tended to do well and severely dependent alcohol abusers tended to do poorly; the reverse was true for intensive treatment. Thus, based on this study, it might be suggested that non-severely dependent alcohol abusers who seek marital counseling should first be offered brief counseling- the most effective and least restrictive treatment. If more intensive treatment were offered first, it might not only be valueless, it might be harmful.

PATIENT-ENVIRONMENT INTERACTIONS

Recent evidence from treatment outcome studies and studies of individuals who have resolved their drinking problems without formal treatment suggest that certain environmental factors are important determinants of successful outcomes (Ogborne, Sobell, & SobeIl, 1985). Although there is a lack of clinical trials evaluating whether treatment effects can be enhanced by incorporating beneficial extratreatment factors into treatment, the literature suggests that a socially supportive environment is associated with positive outcomes. Thus, treatment planning should consider environmental factors which might enhance the effects of treatment. Consideration should also be given to helping clients cope with immu- table aspects of their environment (e.g.) advertisements for alcohol and tobacco). Understanding person-environment interactions is similarly important and involves examining how individuals encode and react to their environment (Mis- chel, 1973). For example, treatment might focus on how to change a client’s subjective perceptions to be more in line with objective reality. In this regard, treatment strategies must consider the influence of individual-specific cognitive variables (e.g., loss of control, targets of attribution, perceived self-efficacy: Ban- dura, 1977; Phillips & Bierman, 1981).

UTILIZING CLIENT’S RESOURCES

Developing treatment goals based on a client’s existing resources and strengths is one way to build in early success experiences and to prepare clients to deal with more difficult problems. Taylor and his colleagues (1982) have asserted that such

44 L. C. Sob&, M. B. Sobell, ad T: f). ~irenber~

an approach “gives both therapist and client a ‘running start’ with already existing behavioral repertoires” (p. 173). They also suggest that, in some cases, giving priority to goals that are not linked to the client’s symptoms might indirectly reduce the presenting symptomatology. For example, while clients who drink heavily or use large doses of Valium for depression and loneliness might be resist- ant to immediately giving up all drug use, they may be receptive to increasing their circle of friends or going to a recreational facility, especially in times of acute depression and loneliness. Thus, it may be possible to build on efficacious per- sonalized coping skills to promote behavior change.

To assess clients’ assets, Taylor and his colleagues (1982) suggested that clients as well as their significant others can be asked about the client’s resources and strengths. Taylor et al. (1982; p. 174) suggested that assessment information be gathered about: (a) ways in which the person now functions well or has previously functioned well; (b) interpersonal resources (e.g., coping skills) and supportive social networks (e.g., spouse, friends, relatives); (c) agencies and other helping professions that could be used in treatment planning or aftercare; (d) how aversive the problem (i.e., substance use) is to the client; and (e) the client’s responsiveness to and investment in treatment (i.e., the priority the client accords to treatment). Two other areas that could also be probed include previous successes at refraining from alcohol and drug abuse (for helping clients identify naturally occurring successful coping responses see Sanchez-Craig, 1984) and related positive consequences from restraint, as well as past and present situations evaluated as having low risk for relapse to drinking or drug use.

MONITORING PROGRESS DURING THERAPY

Behavior therapy can be distinguished from many other psychotherapies by its reliance on evaluating behavior change. Many of the techniques used during the initial assessment (e.g., self-monitoring; functional analysis) can be used to monitor treatment progress. Conceptualizing assessment as a dynamic process which continues throughout treatment provides valuable information about new events occurring during treatment and a framework for evaluating the treatment plan. If progress is not evident or is unreasonably slow, the therapist and client should assess the present situation. The following questions, adapted from Taylor and his colleagues (1982, pp. 182-183), are intended as a guideline for assessing and probing the lack of progress in accomplishing the treatment goals, and are by no means exhaustive:

1. Is the client attempting to engage in (or refrain from) the behavior in question? If so, why are the strategies failing (e.g., assignments not complete; still abusing drugs)?

2. Was the functional analysis of the problems correct? Were the antecedents and consequences adequately delineated?

3. Were the client’s strengths and resources correctly evaluated? 4. Are there necessary supports in the client’s environment to promote or

support behavior change? 5. Are the goals appropriately specified ? Were some of the early goals too

difficult? Were early success experiences built in to help the client later accomplish more difficult goals?

6. Were the high and low risk relapse situations properly evaluated?

Assessment and Eeatmmt Planning with Substance Abusers 45

7. Are only certain of the treatment techniques effective for the particular client?

8. Does the client understand the treatment techniques? If so, are the techniques being properly applied?

9. Does the client know why he/she is experiencing continued problems? 10. Are the consequences of the client’s substance abuse serious enough to

mobilize him/her to engage in behavior change; that is, do the positive benefits of drug use outweigh the negative consequences? For example, some periodic marijuana users and problem drinkers may experience so few negative effects from their substance use that it gives them little reason to change their behavior.

INCREASING MOTIVATION TO CHANGE

Motivation is not a new concept. However, its explicit use in increasing treatment effectiveness is relatively new. Motivation is a term that has usually been used to explain a client’s lack of commitment to treatment as well as a poor outcome. In an excellent review of motivation for treatment with a focus on alcohol and other addictive behaviors, Miller (1985) p p ro osed that motivation can be viewed as the probability of engaging in behaviors that are intended to result in beneficial outcomes. Miller asserts that by viewing motivation as a dynamic interpersonal process involving the therapist, the client, and the environment, strategies for increasing motivation can be tested. Some of the components of motivational interventions that have shown promise include advice counseling with feedback and goal setting, setting specific and attainable goals, allowing clients to guide their own treatment (i.e., make voluntary choices) as much as possible, using social supports to enhance or maintain changes, and various therapist characteristics (e.g., empathy).

A recent and interesting example of a motivational intervention designed for treating young drug abusers was reported by Wilkinson and LeBreton (1986). Several variables were selected to reflect initial client motivation (e.g., self-monitoring of drug use; frequency of refusals of offers to use drugs) and change during treatment. The authors found that the three measures assessing initial levels of motivation for treatment were not associated with outcome success or failure. However, motivation during treatment as assessed by not achieving goals and by attrition from treatment was found to be associated with treatment failures. Based on their findings, Wilkinson and LeBreton (1986) suggest that in clinical practice it seems important to ensure that clients set realistic goals for themselves.

Given the high treatment dropout rate with alcohol and drug abusers (Niren- berg, Sobell, & Sobell, 1980; Maisto & Cooper, 1980) coupled with low treatment success rates, therapists should carefully and routinely monitor their client’s commitment to treatment. As well, treatment strategies which have shown promise for increasing motivation to change should be considered.

ISSUES RELATED TO RELAPSE AND THE RECOVERY PROCESS

As noted earlier, several studies have shown that alcohol and drug abusers have very high posttreatment relapse rates, with initial relapses most often occurring during the first 3 to 6 months following treatment. Since a typical outcome for most drug and alcohol abusers will include some episodes of substance use or

46 L. C. Sobell, hf. B. Sobell, and T D. Nirenberg

abuse, relapse prevention treatment emphasizes: (a) identifying situations that pose a high risk of relapse and preparing the client to deal effectively with those situations by means other than substance abuse, (b) dealing constructively with relapses that occur so as to minimize adverse consequences (i.e., by terminating the relapse as early as possible), and (c) learning to view a relapse as a learning experience rather than as a pronounced personal failure (Marlatt & Gordon, 1985). As discussed earlier, during the assessment process factors associated with a high risk of relapse can be identified and incorporated into the treatment plan.

Clinically, there are at least three advantages to discussing issues related to relapse and recovery with clients:

1. It helps clients constructively consider and prepare for relapses; 2. It gives the majority of clients a more realistic perspective of what to expect

in terms of resolving their drinking or drug problem (i.e., a gradual climb uphill accompanied by occasional small slips rather than an all-or-none recovery); and

3. It gives clients an opportunity in treatment to discuss relapse situations or potential relapse situations without being told they have failed or being dropped from treatment for failure to comply.

TREATMENT TERMINATION

If clients are making progress and are complying with the treatment plan, then the therapeutic relationship is probably positively reinforcing for the client. In this case, the following questions arise: (a) What kinds of problems, if any, will develop when the therapeutic relationship is terminated? (b) Can the client adequately function without additional treatment or support? (c) Will the treatment gains be maintained? The principle of shaping can be used to evaluate the maintenance of treatment effects as well as to facilitate the termination of treatment. One way to reduce the reward value of the therapeutic relationship without detracting from a client’s successful functioning is to gradually terminate treatment by increasing the time between sessions. Of course, this is done with the client’s explicit understanding of the procedure. For example, sessions can be changed from weekly to twice monthly, and if no problems occur, sessions can be extended over longer intervals, until treatment plays little, if any, role in the person’s life. Three case examples of how this concept has been successfully used with alcohol abusers have been reported by Noel et al. (1982). The principle of shaping in terminating treatment also allows for resumption of more frequent sessions if problems arise. Lastly, the concept of gradually terminating treatment by extending the interses- sion interval provides a performance-based criterion for ending treatment and in some ways is comparable to providing aftercare but in the absence of a formal conclusion of treatment. A formal end of treatment, in this model, results from the therapist and client mutually deciding that no further sessions are necessary.

SUMMARY

Based on the present review there should be little question that the assessment of someone with a substance abuse problem is complex and involves much more than the mere measurement of substance use. It has been repeatedly stressed that: (a) there are multiple advantages to conceptualizing assessment as a dynamic

Assessmmt and Eeatment Planning with Substame Abusers 47

process that continues throughout treatment, and (b) treatment plans should be individually tailored, and, when possible, the treatment strategies should be least restrictive. Assessment methods and questionnaires were reviewed and their advantages and limitations were noted with respect to their clinical utility and application. Guidelines for interviewing and for maximizing the likelihood of obtaining valid information were also discussed.

While there is a need for additional research on methods of assessing drug abuse, there now exists a relatively large battery of behavioral assessment methods that can be used in clinical practice with alcohol and drug abusers. In specific cases, though, the methods selected for use should be those which have the greatest potential value for guiding and evaluating treatment. Clinicians need to be familiar with the full array of assessment procedures in order to make judicious choices about which techniques to use with which clients.

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