SITE SEARCH

Assessment of alcohol and other drug (AOD) use problems serves multiple functions (e.g., Shaffer and Kauffman 1985; Jacobson 1989a, 1989b; Allen and Mattson 1993; Carroll 1995; Donovan 1995; Carey and Teitelbaum 1996; Donovan 1998). The Institute of Medicine (1990) and others (e.g., Carroll 1995) have suggested three stages of a comprehensive assessment for all individuals seeking specialized treatment for alcohol problems: a screening stage, a problem assessment stage, and a personal assessment stage. The first two stages involve screening, case finding, and identification of a substance use disorder; an evaluation of the parameters of drinking behavior, signs, symptoms, and severity of alcohol dependence, and negative consequences of use; and formal diagnosis of alcohol abuse or dependence. Each of these aspects of the assessment process is covered in detail in other chapters in this Guide.

Although these drinking–related parameters are important in defining the person’s treatment needs, a broader range of factors must be considered in the treatment planning process because alcohol use both affects and is affected by a number of other areas of life function (Donovan 1988; Institute of Medicine 1990; Donovan 1992, 1998). The personal assessment stage recommended by the Institute of Medicine focuses on this broader array of personal problems being experienced by the individual. Carroll (1995) suggested that this stage involves a comprehensive description of the individual and his or her circumstances (e.g., demographic characteristics, concurrent problems, comorbid psychiatric disorders, family history). The process should focus on clients’ strengths as well as weaknesses, problems, and needs. Some of the identified problems may be fairly directly related to alcohol use (contingent problems), while others may not be at all attributable to alcohol use (noncontingent problems). Examples may include psychological, social, and vocational problems, each of which may involve an interactive relationship with drinking. The provision of a comprehensive assessment is consistent with the recommendations derived from a biopsychosocial model of addictions and the process of assessment (Donovan 1988) and is a requirement of a number of accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations or the Commission on Accreditation of Rehabilitation Facilities.

Within the clinical context, the primary goal of assessment is to determine those characteristics of the client and his or her life situation that may influence treatment decisions and contribute to the success of treatment (Allen 1991). Additionally, assessment procedures are crucial to the treatment planning process. Treatment planning involves the integration of assessment information concerning the person’s drinking behavior, alcohol–related problems, and other areas of psychological and social functioning to assist the client and clinician to develop and prioritize short– and long–term goals for treatment, select the most appropriate interventions to address the identified problems, determine and address perceived barriers to treatment engagement and compliance, and monitor progress toward the specified goals, which will typically include abstinence and/or harm reduction and improved psychosocial functioning (P.M. Miller and Mastria 1977; L.C. Sobell et al. 1982; Washousky et al. 1984; L.C. Sobell et al. 1988; Bois and Graham 1993).

The assessment and treatment planning process should lead to the individualization of treatment, appropriate client–treatment matching, and the monitoring of goal attainment (Allen and Mattson 1993). The Institute of Medicine (1990) noted that treatment outcomes may be improved significantly by matching individuals to treatments based on variables assessed in the problem assessment and personal assessment stages of the comprehensive assessment process. Although the results of Project MATCH have raised questions about the viability of matching treatments to client attributes (Project MATCH Research Group 1997a), there was evidence on a number of variables, including anger, severity of concomitant psychiatric problems, and social support for drinking, that was sufficient to warrant continued attempts to identify potential matches between client characteristics and types of treatment (Project MATCH Research Group 1997b, 1998). Similarly, there is evidence that matching therapeutic services to the presence, nature, and severity of problems clients present at treatment entry leads to improved outcomes (McLellan et al. 1997). Assessment at intake will continue to be instrumental in attempting to match clients to the most appropriate available treatment options; however, assessment also should be viewed as a continuous process that allows monitoring of treatment progress, refocusing and reprioritizing of treatment goals and interventions across time, and determination of outcome (Donovan 1988; Institute of Medicine 1990; L.C. Sobell et al. 1994a; Donovan 1998).

This chapter reviews a number of instruments that are available to assist the clinician and clinical researcher in the personal assessment stage and in the development of appropriate treatment plans. This review attempts to provide information that has clinical utility and that can assist in the planning and conduct of treatment in clinical settings. The instruments include those assessing the areas of readiness to change, expectations about alcohol’s effects, self–efficacy expectancies, drinking–related locus of control, family history of alcoholism, and extra–treatment social support for abstinence. A number of multidimensional measures and those developed specifically for treatment placement are also reviewed.

Tables 1A and 1B provide descriptive information on these instruments, and table 2 summarizes available information concerning the reliability and validity of these instruments. The information in these tables has been derived primarily from the fact sheets in the appendix and from the published literature. A number of other instruments that may be of assistance to the treatment planning process but that did not meet the inclusion criteria are also discussed in the text. Also, several reviews provide more detailed information about the assessment process in addictive behaviors and about specific assessment instruments and procedures (e.g., Donovan and Marlatt 1988; L.C. Sobell et al. 1988; Jacobson 1989a, 1989b; Institute of Medicine 1990; Allen 1991; Donovan 1992; Addiction Research Foundation 1993; Allen and Mattson 1993; Connors et al. 1994; Longabaugh et al. 1994; L.C. Sobell et al. 1994a, 1994b; Carroll 1995; Carey and Teitelbaum 1996; Donovan 1998).

Table 1A. Assessment instruments for treatment planning: Descriptive information

Instrument	Purpose	Clinical utility	Target population	Groups used with	Norms avail.?	Normed groups
F–SMAST/ M–SMAST	To provide a structured measure of mother’s and father’s lifetime alcohol abuse	Aids in determining parental history of alcohol abuse	Adults and adolescents	Non–problem drinkers, problem drinkers, alcoholics	No	NA
ASI	To provide information on recent (past 30 days) and lifetime medical, employment and support, AOD use, legal, family/social, and psychiatric problems related to AOD use	Identifies problem areas in need of targeted intervention; aids in treatment planning and outcome evaluation	Adults	Adults seeking treatment for substance abuse problems; psychiatrically ill, homeless, pregnant, and prisoner populations	Yes	Males and females; alcohol, opiate, and cocaine treatment groups; psychiatrically ill substance users; pregnant substance users; gamblers; homeless persons; probationers; and employee assistance clients
AASE	To measure self–efficacy concerning alcohol abstinence, defined in terms of temptation to drink and confidence about not drinking in high–risk situations	Identifies high–risk situations in which the individual is highly tempted and has low levels of confidence; aids in developing relapse prevention interventions	Adults	Problem drinkers, alcoholics in treatment	Yes	Outpatient substance abusers
ADCQ	To measure perceived costs and benefits associated with changing drinking behavior	Measures relative motivation to change drinking behavior	Adults	Problem drinkers, alcoholics in treatment	?	?
ABS	To measure beliefs about the effects of three amounts of alcohol on behavior and the utility of drinking in producing desired behavioral or emotional outcomes	Identifies expectancies about alcohol’s effects on different behaviors and feelings, the usefulness of alcohol for different reasons or desired outcomes, and how these expectancies vary with the amount of alcohol	Adults	Non–problem drinkers, problem drinkers, and alcoholic clients in treatment	No	NA
AEQ–S	To provide a brief measure of both positive and negative alcohol–related expectancies	Assesses the effects desired from alcohol	Adults	College student drinkers and alcoholics	?	?
AEQ	To assess positive expectancies adults hold about alcohol’s effects	Assesses alcohol’s perceived reinforcing effects related to initiation and maintenance of, and relapse to, alcohol	Adults	College student drinkers and alcoholics	Yes	Clinical and nonclinical samples of drinkers
ADRS	To measure level of awareness or minimization of alcohol–related problems	Measures awareness of problems and perceived need or motivation to change drinking behavior	Adults	Alcoholics in treatment	?	Alcoholics in treatment
AUI	To provide a multidimensional assessment of alcohol use, styles, patterns, and perceived benefits of drinking	Aids in differential treatment assignment based on drinking patterns and styles	Adults and adolescents > 16 years	Alcoholics in treatment, DWI offenders	Yes	?
AWARE	To measure “warning signs” or high–risk situation potentially predictive of relapse	Identifies potential relapse risk and precipitants	Adults	Alcoholics in treatment	No	Alcoholics in treatment
CDAP	To provide a multidimensional assessment of AOD use history, patterns of use, beliefs and expectancies, symptoms, self–concept, and interpersonal relationships	Provides information in format useful for case conceptualization and treatment planning	Adults and adolescents >16 years	Adults and adolescents with chemical dependency problems	Yes	Alcohol abusers, polydrug abusers, social drinkers
CDP	To provide a multidimensional assessment of drinking history and behavior, motivation for treatment, demographics, and self–efficacy	Provides a systematic and consistent data set at intake for treatment planning	Adults	Adults entering alcohol treatment programs, problem drinkers	Yes	Alcohol abusers, males and females
DEQ	To assess positive and negative expectancies about alcohol’s effects	Assesses alcohol’s perceived reinforcing effects related to assertion, affective change, sexual enhancement, cognitive change, and tension reduction	Adults	Community drinkers, problem drinkers, hospitalized alcoholics	Yes	Adult clinical patients, adult community drinkers, university students
DRSEQ	To provide a multi–dimensional assessment of the strength of self–efficacy to refuse drinking in various situations	Identifies efficacy in drink refusal ability in social pressure, opportunistic, and emotional relief situations, targeting them for interventions	Adults	Adult non–problem drinkers, problem drinkers, alcoholic clients in treatment	Yes	Adult clinical patients, adult community drinkers, university students
DRIE	To provide a multi–dimensional assessment of an individual’s perception of locus of control related to drinking behavior	To provide a multi–dimensional assessment of an individual’s perception of locus of control related to drinking behavior	Adults	Problem drinkers, adults entering alcohol treatment programs	No	NA
FTQ	To assess history of alcohol problems in first– and second–degree relatives	Aids in determining risk for more serious alcohol problems and relapse vulnerability among those with positive family history	Adults	General population, problem drinkers, alcoholics	NA	NA
IPA	To assess level of social support for sobriety and for continued drinking	Determines relative support from family and friends for sobriety vs. continued drinking	Adults and adolescents	Alcoholics in treatment	Yes	Alcoholics in outpatient and aftercare treatment
IDS	To measure degree of heavy drinking in different situations over the past year	Develops a client profile of those situations having greatest risk of heavy drinking and/or relapse, to aid in planning relapse prevention	Adults	Clients seeking or in treatment for an alcohol problem	Yes	Age groups, males and females
MSAPS	To provide a multi–dimensional measure of problems related to AOD use	Assesses presence and severity of psychological, behavioral, and social problems	Adults	Substance abusers in treatment	No	NA
MSQ	To identify problem drinkers’ maladaptive patterns that underlie their motivations for drinking alcohol	Identifies clients’ concerns in major life areas, their relationship to motivations for drinking, and targets for systematic motivational counseling to change motivational patterns	Adults and adolescents	Substance abusers, cases of work inhibition/burnout, a wide range of counselees	Yes	College students, chemically dependent veterans, alcoholic inpatients, traumatically brain–injured rehabilitation patients
NAEQ	To assess the extent to which immediate, short–term, and long–term negative consequences are expected to occur if one were to drink	Identifies negative expectancies that may serve as a deterrent and represent motivation to stop or restrain drinking	Adults	Problem drinkers about to enter or currently in treatment	Yes	Non–problem abstainers; light, moderate, and heavy social drinkers; posttreatment relapsers and abstainers
PEI–A	To provide a multi–dimensional measure of AOD problem severity and psychosocial problems	Identifies substance abuse patterns and associated psychosocial problems	Adults	Substance abusers in treatment, criminal offenders	Yes	Substance abusers in treatment, criminal offenders
RTCQ	To determine stage of readiness for change among substance abusers	Assesses readiness to change drinking behaviors; may aid in treatment planning	Adults and adolescents; hazardous and harmful drinkers who are not seeking treatment	Outpatients in general medical settings, head trauma and spinal cord injury individuals, psychiatric patients	Yes	Outpatients in general medical settings, head trauma and spinal cord injury individuals, psychiatric patients
RTCQ–TV	To determine stage of readiness for change among substance abusers seeking or in treatment	Assesses readiness to change drinking behaviors; may aid in treatment planning	Adults and adolescents	Individuals in alcohol treatment	Yes	Alcohol dependents and abusers in treatment
RFDQ	To measure reasons given for returning to drinking after a period of abstinence	Identifies relapse risk and potential relapse precipitants in negative emotions, social pressure, and craving dimensions	Adults	Alcoholics in treatment	No	NA
RAATE–CE and RAATE–QI	To provide a multidimensional assessment of motivation for and resistance to current and long–term treatment, severity of biomedical and psychiatric or psychological problems, and social and environmental support	Aids in assigning individuals to appropriate level of treatment, in making continued stay or transfer decisions during treatment, and in documenting appropriateness of discharge	Adults	Problem drinkers about to enter or currently in treatment	Yes	Ethnic groups; middle–class and lower socioeconomic status groups
SCQ	To assess self–efficacy, or how confident an individual is that he or she will be able to resist the urge to drink or drink heavily in potential high–risk situations	Develops a client profile of the degree of confidence in resisting urges to drink in those situations having the greatest risk of heavy drinking and/or relapse, to aid in planning relapse prevention	Adults	Problem drinkers in treatment	Yes	Age and gender
SOCRATES	To assess stage of readiness to change drinking behavior	Identifies stage of readiness to change, helping to determine stage–appropriate interventions	Adults	Alcohol abusers and alcohol–dependent individuals	Yes	Alcoholics in treatment
URICA	To assess stage of readiness to change drinking behavior	Identifies stage of readiness to change, helping to determine stage–appropriate interventions	Adults	Alcohol abusers and alcohol–dependent individuals	Yes	Adult outpatient alcoholism treatment population
YWP	To assess alcohol–related workplace activities, particularly adverse effects of drinking on work performance, support for drinking, and support for abstinence	Determines the level of social support in the workplace that would either facilitate recovery or increase risk of relapse	Adults	Individuals in treatment for alcohol problems; employee assistance programs	Yes	Individuals in alcohol treatment

Note: Instruments are listed in alphabetical order by full name; see the text for the full names. A question mark in a table cell indicates that no information is available. AOD = alcohol and other drug; NA = not applicable.

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Table 1B. Assessment instruments for treatment planning: Administrative information

Instrument	No. of items (no. of subscales)	Format options	Time to administer	Training needed?	Time to score/interpret	Computer scoring avail.?	Fee for use?
F–SMAST/ M–SMAST	13	P&P	5 min	No	5 min	No	No
ASI	∼ 200 (7)	P&P, computer, interview	50–60 min	Yes	5–10 min	Yes	No
AASE	20 Efficacy, 20 Temptation (4)	P&P	10 min	No	5–10 min	No	No
ADCQ	29 (2)	P&P	10–15 min	No	5–10 min	No	?
ABS	48 (7)	P&P	15 min	No	15 min	No	No
AEQ–S	40 (8)	P&P	5–10 min	No	?	No	No
AEQ	120 (90 scored) (6)	P&P, computer	10–15 min	No	?	?	No
ADRS	8	Interview guided by a decision tree	10–15 min	Yes	?	No	?
AUI	228 (24)	P&P, computer	35–60 min	Yes	3–5/10 min	Yes	Yes
AWARE	28 (1)	P&P	10–15 min	No	5–10 min	?	?
CDAP	232 (10)	P&P, computer	45 min	No	5 min	Yes	Yes
CDP	88	Interview	1–2 h	Yes	30 min	Yes	Yes
DEQ	43 (6)	P&P	15 min	No	15–20 min	No	No
DRSEQ	31 (3)	P&P	10 min	No	10 min	No	No
DRIE	25 (3)	P&P	10 min	No	5–10 min	No	No
FTQ	NA	P&P, interview	5 min	No	2–3 min	No	No
IPA	19	Interview	20–30 min	Yes	30 min	No	No
IDS	42 or 100 (8)	P&P, computer	15–20 min	No	5 min	Yes	Yes
MSAPS	37 (3)	Interview	30 min	Yes	15 min	No	?
MSQ	NA	P&P	2–3 h (1 h for the briefer version)	Yes	Highly variable depending on objectives	Yes	Yes
NAEQ	22 or 60 (5)	P&P, computer, interview	15–20 min	No	5 min	Yes	Yes
PEI–A	270	P&P, computer	45 min	No	2 min	Yes	Yes
RTCQ	12 (3)	P&P	2–3 min	No	1–2 min	No	No
RTCQ–TV	15 (3)	P&P	2–3 min	No	1 min	No	No
RFDQ	16 (3)	P&P	5 min	No	3–5 min	No	?
RAATE–CE and RAATE–QI	35 (5) in CE 94 (5) in QI	Interview (CE), P&P (QI)	20–30 min for CE, 30–45 min for QI	Yes	5 min	No	Yes
SCQ	39 (8)	P&P, computer	8–10 min	No	5 min	Yes	Yes
SOCRATES	19 or 39 (3)	P&P	10–15 min for 39–item version	No	5–10 min	No	No
URICA	28 or 32 (4)	P&P	5–10 min	No	5–10 min	No	No
YWP	13 (3)	P&P	5 min	No	5 min	No	No

Note: Instruments are listed in alphabetical order by full name; see the text for the full names. A question mark in a table cell indicates that no information is available. AOD = alcohol and other drug; NA = not applicable; P&P = pencil and paper.

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Table 2. Availability of psychometric data on treatment planning measures

Measure	Reliability			Validity
	Test–Retest	Split–half	Internal consistency	Content	Criterion	Construct
F–SMAST/ M–SMAST	•	•	•	•	•	•
ASI	•	•	•	•	•	•
AASE			•		•	•
ADCQ			•		•	•
ABS					•	•
AEQ–S			•		•	•
AEQ	•		•	•	•	•
ADRS			•1	•		•
AUI	•		•	•	•	•
AWARE	•		•		•	•
CDAP	•		•	•		•
CDP	•			•	•
DEQ	•		•	•	•	•
DRSEQ	•		•	•	•	•
DRIE		•	•		•	•
FTQ	•				•
IPA			•		•	•
IDS	•		•	•	•	•
MSAPS			•		•	•
MSQ	•		•	•	•
NAEQ	•	•	•		•	•
PEI–A	•		•	•	•	•
RTCQ	•		•	•	•	•
RTCQ–TV	•		•		•	•
RFDQ			•		•	•
RAATE	•		•	•		•
SCQ	•		•	•	•	•
SOCRATES	•		•		•	•
URICA			•		•	•
YWP			•		•	•

Note: Measures are listed in the same order as in table 1; see the text for the full names.
¹ Reliability estimates based on interrater reliability.

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PROBLEM RECOGNITION, MOTIVATION, AND READINESS TO CHANGE

An important construct within the alcoholism field is the degree to which drinkers are aware of the extent of their drinking patterns, such as quantity and frequency of drinking, the negative physical and psychosocial consequences of their drinking, and their perception of these patterns and consequences as problematic. The goal of using screening instruments is, in fact, to increase the individual’s awareness and increase problem recognition. Such awareness is an important step in the process to initiate behavior change and treatment–seeking behavior (Donovan and Rosengren 1999; Tucker and King 1999).

There have been two prominent views about the alcoholic’s “inability to recognize” or “lack of awareness” of his or her problems. One view is that this is part of a defensive process of “denial,” or the tendency of heavy drinkers to minimize or deny that they have a “drinking problem.” This stance, thought to be unconscious and protective of the individual’s perception of self, has continued to exert an important influence both in definitions of alcoholism (e.g., Morse and Flavin 1992) and in the development of patient placement criteria (e.g., Mee–Lee et al. 1996).

An alternative model of behavior change presented by Prochaska and DiClemente is applicable to addictive behaviors and has come to serve as the frame of reference for assessing motivation or readiness to change (Prochaska and DiClemente 1986; Prochaska et al. 1992). They suggest that individuals go through a series of stages in this decisionmaking process, ranging from precontemplation to taking positive steps to initiate change. Each stage reflects an increased level of problem recognition and commitment to change the addictive behavior. Many individuals have gone for years without perceiving that they have a problem, seemingly oblivious to the negative consequences that others are able to observe. This behavior, characteristic of the precontemplation phase, has often been thought of as denial. Other individuals have contemplated the need for changing their drinking for some time but have not been sufficiently committed to take action. Others may have attempted action in the past but have since resumed use, raising questions in their minds about the efficacy of treatment and their ability to reach their goals. Others, acknowledging the need to change, may still be influenced by their perceptions of the positive benefits derived from drinking and are unable to make a firm commitment to take action.

Each of these two views of denial and readiness has generated assessment measures and procedures meant to determine “where the client is” with respect to problem recognition and readiness for behavior change. Clinical lore has suggested that one of the most important steps in the counseling and recovery process is to identify and “break through” the individual’s denial, often through the use of confrontational therapeutic approaches, so that he or she can take steps necessary to seek treatment. The importance of this task led Goldsmith and Green (1988) to develop the Alcoholism Denial Rating Scale (ADRS). They define alcoholic denial as “the alcoholic’s inability to connect his drinking with its resulting consequences” (Breuer and Goldsmith 1995, p. 171). The intent of the scale is to quantify denial, in order to aid counselors in enhancing treatment and its outcome. An 8–point scale is used to define a continuum from denial to awareness. The individual reporting that he or she has no problem at all and has no awareness of alcohol–related problems is at one end of the continuum. The midpoint represents an awareness of some alcohol–related problems but with none of them viewed as being out of control. The other end of the continuum is the individual who indicates that he or she has pervasive alcohol–related problems and that his or her life is out of control because of drinking. These ratings are made by clinicians following an interview with the individual that focuses on AOD use and his or her perception of the use pattern. The rating process is aided by the use of a decision tree model and descriptions of behavior and life circumstances at each of the eight levels.

Preliminary and subsequent reports suggest that the ADRS has a good to relatively high level of interrater reliability, and the level of agreement is increased by using a semi–structured interview format and the decision tree (Goldsmith and Green 1988; Breuer and Goldsmith 1995). Newsome and Ditzler (1993) also found the scale to be useful clinically by providing a heuristic tool that can be used (1) to determine issues, decisions, and prioritization regarding admission to treatment among those seeking treatment; (2) to identify and intervene preventively with individuals who are at high risk of early discharge; and (3) to assess treatment progress.

Assessment is often the first step in the formal process of treatment for an addictive disorder. Choosing to change one’s drinking pattern or give up alcohol or other drugs is not a decision arrived at easily. Individuals vary widely in their readiness to change, being more or less ready to stop drinking or other drug use. The level of motivation for change or for treatment will vary across individuals seeking treatment and will fluctuate within each individual across time. Even presenting for treatment intake does not reliably gauge the client’s level or locus (e.g., intrinsic vs. extrinsic) of motivation. One task of the assessment process is to evaluate and attempt to enhance the individual’s motivation and readiness to change and to engage in treatment (Donovan 1988; W.R. Miller 1989a; W.R. Miller and Rollnick 1991; Horvath 1993).

Clearly, knowing the stage of readiness to change drinking behavior is an important component in the treatment planning process (Connors et al. 2001). A number of assessment instruments have been developed to assist the clinician in determining the stage of readiness for change among problem drinkers or alcoholics. All are based on Prochaska and DiClemente’s stages of change model. The Readiness To Change Questionnaire (RTCQ), developed by Rollnick and colleagues (1992), is a 12–item questionnaire consisting of three subscales that correspond to the precontemplation, contemplation, and action stages as reflected in the factor structure derived from principal components analysis. Each of these scales consists of 4 items presented as 5–point rating scales ranging from strongly agree to strongly disagree. Despite the relative brevity of the scales, Rollnick and colleagues found that Cronbach alpha levels, reflecting their internal consistency, ranged from 0.73 for precontemplation to 0.85 for action in a sample of excessive drinkers (i.e., harmful and hazardous drinkers) identified in a general medical setting. A similar range was found for the test–retest reliability coefficients.

Two methods have been developed to assign drinkers to one of the three stages. The first involves assigning the individual to the stage having the highest raw score; in the event of tied scores, the person is assigned to the more advanced stage. The second method is a pattern or profile analysis of either the raw scale scores or standardized scale scores across the three scales. Both methods have been shown to have predictive validity. The stages to which excessive drinkers identified from general medical wards of a hospital were assigned, using either method, were associated with changes in drinking behavior at 8–week and 6–month followup points; those in the action stage consistently showed the greatest reduction in drinking (Heather et al. 1993). However, some have argued that the RTCQ does not measure distinct stages but rather represents a higher order measure of readiness that can be scaled along a continuum with a high level of internal consistency and predictive power (Budd and Rollnick 1997).

The RTCQ thus appears to provide a brief assessment instrument that can be used to identify readiness to change, predict subsequent drinking, direct the selection of interventions, and serve as an outcome or process measure to evaluate brief interventions among individuals identified as having drinking problems but who are not actively seeking specialized alcoholism treatment. The scale has been used with a variety of such groups, including outpatients in general medical settings (e.g., Hapke et al. 1998; Samet and O’Connor 1998), head trauma and spinal cord injury individuals (e.g., Bombardier et al. 1997; Bombardier and Rimmele 1998), and psychiatric patients (e.g., Blume and Schmaling 1997; Blume and Marlatt 2000).

The authors emphasize that the RTCQ was developed primarily for use with hazardous or harmful drinkers in general medical settings who are not seeking treatment for alcohol problems. Its use with problem drinkers in treatment has led to considerably lower estimates of reliability and different factor structures (Gavin et al. 1998); this was particularly true for the precontemplation (alpha = 0.30) and contemplation (alpha = 0.52) scales. These low internal consistency estimates raise a question about the utility of the RTCQ in treatment settings (Gavin et al. 1998). This has led to subsequent work to develop measures more appropriate to individuals in treatment. One such measure is the Readiness To Change Questionnaire Treatment Version (RTCQ–TV) (Heather et al. 1999). Through a series of factor analyses a 15–item scale was derived. It includes 5 items each for the precontemplation, contemplation, and action stages. Of these, the internal consistency reliability of the contemplation scale was the lowest (alpha = 0.60), with that of the precontemplation (alpha = 0.68) and action (alpha = 0.77) scales somewhat higher. As an index of concurrent validity the RTCQ–TV scale scores were correlated with those from the University of Rhode Island Change Assessment (URICA) (McConnaughy et al. 1983). The RTCQ–TV scales were significantly and most highly correlated with the corresponding scales on the URICA. It was also found that a significantly higher percentage of clients who at followup (an average of 7.4 months after the initial assessment) were classified as having “good” outcomes (either abstinent or drinking below recommended levels) were in the action stage at intake (57 percent), compared with the rate of clients having good outcomes who were in the contemplation stage (35 percent). Although Heather and colleagues indicated that additional research is necessary to determine the psychometric properties of the RTCQ–TV with different populations, they suggested that it is preferable for clinicians dealing with clients in treatment settings to shift from the original RTCQ to the new version specifically developed for use with clinical populations (Heather et al. 1999).

Another relatively new scale focused on use within a clinical setting is the Alcohol and Drug Consequences Questionnaire (ADCQ) (Cunningham et al. 1997). This scale derives from the general theoretical notion, and from related clinical interventions, that represent a form of decisional balance. A number of such measures have been developed previously and have explored the “pros” and “cons” of continued alcohol use (e.g., Migneault et al. 1999). However, the ADCQ focuses on the costs and benefits of stopping or changing one’s drinking. The ADCQ consists of two subscales. A 14–item subscale asks individuals to endorse those negative consequences or perceived costs involved in choosing to change their substance use pattern. A complementary 15–item subscale asks them to endorse the positive outcomes or perceived benefits derived from making such a change. Each of these subscales has an internal consistency index above 0.90. It was found that individuals who rated the perceived benefits of change higher at intake or those who rated the perceived costs of change as lower at intake were less likely to drink and drank on fewer days during a 1–year followup. Although the ADCQ appears to be a promising measure, further psychometric evaluations, such as those reported by Carey and colleagues (2001), are needed.

Two measures have been increasingly used to determine the readiness for change among problem drinkers who are seeking treatment. The first is the URICA, mentioned earlier in this chapter. This scale was originally developed as part of the evaluation of the change process in psychotherapy (McConnaughy et al. 1983). It has become a primary measure used in the context of Prochaska and DiClemente’s stages of change model and has had its greatest application in the area of smoking cessation (e.g., DiClemente et al. 1991). More recently it has been applied in the evaluation of individuals having drinking problems (DiClemente and Hughes 1990) and other drug problems (Abellanas and McLellan 1993). The scale originally consisted of 32 items presented with a 5–point response scale (from strong disagreement to strong agreement). The items are worded so that individuals respond to their perception of a general “problem” that they define themselves; the initial instruction set is used to focus the respondent’s attention to drinking as the problem to be considered.

The URICA scale operationally defines four theoretical stages of change, each assessed by eight items: precontemplation, contemplation, action, and maintenance. However, subsequent factor analyses with alcoholic subjects in an outpatient treatment program led to a reduction of the items to 28, with 7 per subscale (DiClemente and Hughes 1990). Cluster analysis yielded five patterns of respondents. Those in the precontemplation group view themselves as not having a problem. Those in the ambivalent group appear to be reluctant or ambivalent about changing their behavior. Those in the participation group appear to be highly invested and involved in change. Those in the uninvolved or discouraged group appear to have given up on the prospect of change and are not involved in attempting to do so. Those in the contemplation group appear to be interested in making changes, are thinking about it, but have not yet begun to take action. The subtypes were found to differ significantly with respect to the pattern of alcohol use, the perceived benefits of drinking, and the incidence of negative alcohol–related consequences. The validity of these typologies has been largely corroborated in subsequent cluster analyses of AOD clients seeking treatment (Carney and Kivlahan 1995; el–Bassel et al. 1998).

Willoughby and Edens (1996; Edens and Willoughby 2000) derived and replicated a two–cluster solution on the URICA in evaluating alcohol–dependent veterans in a residential setting. The two clusters appeared to resemble the precontemplation and contemplation/action stages. Their findings suggest that those individuals classified as members of the precontemplation group were less worried about their drinking and were less interested in receiving help than those in the contemplation/action group. Individuals classified as members of the precontemplation group were also found to be less likely to complete treatment (Edens and Willoughby 2000). Carbonari and DiClemente (2000) also found that profiles derived from the URICA, self–efficacy (confidence of remaining abstinent and temptation to drink), and the use of cognitive and behavioral change strategies were related to drinking outcomes in both outpatient and aftercare samples from Project MATCH. This body of results suggests that the URICA can be used to identify clinically meaningful motivational subtypes of treatment–seeking alcoholics.

The second measure receiving increased attention in the determination of readiness for change among problem drinkers seeking treatment is the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) (W.R. Miller et al. 1990; W.R. Miller and Tonigan 1996). This scale is available in either a 39–item version or an abbreviated 19–item version. Like the RTCQ, but unlike the URICA, the SOCRATES items are worded specifically in reference to changing drinking behavior. These items are responded to along a 5–point Likert scale (from strong agreement to strong disagreement). The measure has been shown to have adequate levels of internal and test–retest reliability as well as construct and criterion validity (W.R. Miller and Tonigan 1996). Conceptually, the SOCRATES assesses the stage of readiness expressed by the individual within the theoretical framework proposed by Prochaska and DiClemente, namely, precontemplation, contemplation, determination or preparation, action, and maintenance. Factor analytic studies by Miller and colleagues, however, indicate three empirically derived scales: Readiness for Change, Taking Steps for Change, and Contemplation (W.R. Miller and Tonigan 1996). Isenhart (1994) similarly found three factors on the SOCRATES, labeled Determination, Action, and Contemplation. Subsequent factor analyses with heavy–drinking college students (Vik et al. 2000) were generally consistent with the three factors. Also, the results of cluster analyses (Isenhart 1994) suggest three groups based on the pattern of their factor scores. These were similar in nature to those obtained by DiClemente and Hughes (1990) using the URICA, namely the ambivalent, uninvolved, and active groups. These groups were found to differ significantly with respect to the pattern and styles of drinking and drinking–related consequences as measured by the Alcohol Use Inventory (AUI), which is discussed later in this chapter.

Despite the general consistency in the findings concerning the factor structure of the SOCRATES, Maisto and colleagues (1999) found only two principal factors among a sample of “at risk” drinkers recruited from primary care medical clinics: a problem recognition factor and a taking action factor. The first factor was based on a scale that appeared to measure reliably the perceived degree of severity of an existing alcohol problem (nine items, Cronbach alpha = 0.91) using items from Miller and Tonigan’s Ambivalence and Recognition scales; the second factor was based on a scale composed of items that focus on taking action to change or to maintain changes that have already been made (six items, Cronbach alpha = 0.89). These two factors also were found through confirmatory factor analysis to best fit the SOCRATES data when compared with the three–factor solution derived by Miller and Tonigan (1996). At the initial assessment the problem recognition factor was most highly correlated with measures of alcohol problems and symptoms of dependence (e.g., Alcohol Dependence Scale, Alcohol Use Disorders Identification Test, Drinker Inventory of Consequences, Short Michigan Alcoholism Screening Test [SMAST; see the discussion later in this chapter]); while also significantly correlated with these measures, the magnitude of the relationships was considerably lower for the taking action factor. It was also found that the problem recognition factor at baseline significantly predicted the number of drinks, drinks per drinking day, number of heavy–drinking days, and number of negative consequences at a 6–month followup, even after age, gender, race, severity of dependence, baseline measures of each of the outcome criterion variables, and the two SOCRATES baseline factor scores were taken into account. In each case, higher scores on the problem recognition factor were associated with heavier drinking and more negative consequences. The taking action factor at baseline, however, did predict these outcome measures.

Carey and colleagues (2001) found significant correlations between the ADCQ subscales and subscales from the SOCRATES among psychiatric patients. The taking steps factor was negatively associated with the perceived costs of quitting (–0.28) and positively (0.64) with the anticipated benefits of quitting. The problem recognition factor from the SOCRATES was positively related (0.70) to the anticipated benefits of quitting. The taking steps factor was also found to be negatively related to the perceived benefits of drinking/substance use (–0.45) and positively related to the perceived negative consequences of drinking/use (0.47).

Although the stages of change model has been critiqued on methodological and conceptual grounds (e.g., Sutton 1996; Whitehead 1997; Joseph et al. 1999), the assessed stage of a client’s readiness to change has direct implications for the development of initial interventions meant to enhance the likelihood of the client engaging in and complying with treatment (Annis et al. 1996; Sutton 1996; Connors et al. 2001). Carey and colleagues (1999) provided a thorough review of a number of measures of readiness to change among substance abusers and some comparative information that may help the clinician choose which of these measures to use. The approach taken by the clinician in attempting to accomplish this task will differ depending on the client’s stage of readiness to change (Prochaska and DiClemente 1986; Prochaska et al. 1992; Connors et al. 2001). For example, a client who is in the early stages of the behavior change process, in which he or she is contemplating change and moving toward making a commitment and taking action, will likely benefit most from approaches that increase one’s information and awareness about oneself and the nature of the problem, lead to self–assessment about how one feels and thinks about oneself in light of a problem, increase one’s belief in the ability to change, and reaffirm one’s commitment to take active steps to change (Prochaska et al. 1992; Horvath 1993).

In addition to being consistent with “practice wisdom” and theoretical approaches to change, the proposed focus on such awareness–raising factors for those in the precontemplation and contemplation phases is also consistent with evidence from individuals who had resolved an alcohol problem on their own without the aid of formal treatment. L.C. Sobell and colleagues (1993) found that over half of the recoveries of such individuals could be characterized by a cognitive evaluation of the pros and cons of continued drinking.

For some individuals, the events that led them to contemplate the need for change or to take steps to seek help may be sufficient for them to stop drinking or modify their alcohol use patterns without more formal treatment (L.C. Sobell et al. 1993; Marlatt et al. 1997; Donovan and Rosengren 1999; Tucker and King 1999). For others, brief interventions based on a comprehensive assessment of their addictive behaviors and related life areas, the provision of feedback and advice to the client, and a focus on increasing motivation for change have been found to increase the likelihood of clients following through on referrals to seek and enter treatment (e.g., Heather 1989; W.R. Miller 1989a; Bien et al. 1993; Wilk et al. 1997).

In a review of measures of readiness to change, Carey and colleagues (1999) indicated that despite their common theoretical background, their high popularity among clinicians, and their heuristic value in working with clients, each measure has psychometric limitations of one sort or another. Because of this they caution that these scales should be viewed as experimental in nature and should not be used in isolation to make important clinical decisions.

ALCOHOL–RELATED EXPECTANCIES AND SELF–EFFICACY

Clinicians and clinical researchers have increasingly focused on the role of cognitive factors in decisions to drink and in drinkers’ responses to alcohol (Oei and Jones 1986; Young and Oei 1993; Oei and Baldwin 1994; Oei and Burrow 2000; B.T. Jones et al. 2001). Two broad categories of such cognitive factors having implications for the development and maintenance of drinking problems and for potential relapse following treatment are (1) the individual’s expectations about drinking and the anticipated effects of alcohol and (2) the individual’s expectations about one’s ability to cope adequately with problems (self–efficacy expectations). These categories and related instruments are discussed in the following sections.

Alcohol–Related Expectancy Measures and Reasons for Drinking

Alcohol–related expectancies typically refer to the beliefs or cognitive representations held by the individual concerning the anticipated effects or outcomes expected to occur after consuming alcohol. These expectancies are shaped by an individual’s past direct or indirect experience with alcohol and drinking behavior (Connors and Maisto 1988a). To the extent that these representations are activated and accessible to the individual in drinking–related situations, they are hypothesized to determine the anticipated outcomes in using alcohol and to mediate subsequent drinking behavior (Rather and Goldman 1994; Stacy et al. 1994; Palfai and Wood 2001).

It is often presumed that individuals drink in order to achieve or enhance the emotional or behavioral outcomes that they expect; thus, these expectancies are often viewed as being reflective of the individual’s possible “reasons for drinking” (Cronin 1997; Galen et al. 2001). Individuals differ with respect to both their experiences with alcohol and drinking and with the resultant beliefs and expectations they hold about alcohol’s anticipated effects. To the extent that individuals are found to hold expectancies that serve a functional role in maintaining problematic drinking behavior, they may be assigned to treatment strategies designed to challenge or modify their beliefs about alcohol’s effects on mood and behavior and to substitute more adaptive or realistic expectations, with the prediction that decreases in positive expectancies associated with alcohol would be associated with a decrease in drinking behavior (Oei and Jones 1986; S.A. Brown et al. 1988; Connors and Maisto 1988a; Connors et al. 1992; Darkes and Goldman 1993; Oei and Baldwin 1994; Darkes and Goldman 1998).

A number of measures of alcohol–related beliefs and expectancies have been developed and are available to help the clinician determine the nature, strength, and valence of these beliefs. The Alcohol Expectancy Questionnaire (AEQ)