by William R. Miller, PhD.
Preface The
instructions contained in appendix A refer to the assessment
feedback components of Motivational Enhancement Therapy, as prac
ticed in Project MATCH. It is not necessary, however, to use exactly
the same assessment instruments as were employed in Project
MATCH. The basic idea is to assess a range of dimensions, with
particular emphasis on those likely to reflect early problems or risk.
If you wish to replicate the exact procedures used in MATCH, infor
mation is provided at the end of this appendix for obtaining the needed
instruments. You may, however, construct your own assessment bat
tery and design a corresponding Personal Feedback Report (PFR)
based on normative data for the instruments you have chosen. The
PFR used in Project MATCH is reproduced following page 89.
In general, your assessment battery should sample a variety of poten
tial problem and risk domains. Here is a brief list of pertinent domains,
with examples of appropriate assessment approaches for each.
Alcohol The volume of alcohol consumption
is a primary dimension for assess
Consumption ment, because all other risk and
problem domains are related to the
quantity and frequency of use. There are four basic approaches for
quantifying alcohol consumption.
Quantity/ The simplest approach is to ask a
few structured questions regarding
Frequency the frequency (e.g., how many
days per month does the person drink)
Questionnaire
and quantity of consumption
(e.g., on a drinking day, how many drinks
does the person have on average). Such questions can be aided by
describing a standard drink unit (see Miller et al. 1991 for alternatives)
or asking separately about different kinds of beverages (beer, wine,
spirits, etc.). An advantage of this approach is that, unlike the others,
it can be administered by paper and pencil questionnaire. This method
appears to underestimate actual consumption, however, and reliabil
ity and validity parameters have not been established.
Grid
Averaging A
second approach is to reconstruct, by structured interview, a typical
drinking week and then account for episodes of drinking that deviate
from this pattern. This approach was introduced by Miller and Marlatt
Timeline A third and still more detailed
approach is to reconstruct drinking by
Followback
filling in an actual calendar for
the past few weeks or months. Day by
day drinking data are obtained, taking advantage of the memory
prompting value of a calendar (Sobell et al. 1980). The Form 90
approach used in Project MATCH (see below) represents a hybrid of
the timeline and grid averaging methods.
Drinking
Diary Finally,
individuals can be asked to keep a daily diary of alcohol
consumption. These records can than be converted into quantitative
data. A freeware computer program for this purpose has been devel
oped by Markham, Miller, and Arciniega (see resource list at the end
of this appendix).
Alcohol-Related As heavy drinking continues, life
problems tend to accumulate. Some
Problems counting of such accumulation is
a common measure of problem
severity. Measures such as the Michigan Alcoholism Screening Test
(MAST; Selzer 1971) combine life problems with other factors such as `
alcohol dependence symptoms and help seeking. Miller and Marlatt
(1984) attempted to differentiate between common problematic conse
quences of heavy drinking and other life problems, which may or may
not be alcohol related. The DRINC questionnaire (see below), devel
oped for Project MATCH, is intended as a purer measure of negative
consequences of drinking, apart from alcohol dependence signs.
Alcohol The alcohol dependence syndrome
is currently a central diagnostic
Dependence concept. Severity of dependence
represents a third dimension to be
tapped in comprehensive assessment. A variety of alcohol dependence
scales have been published. Skinner's Alcohol Dependence Scale
(Skiller and Horn 1984) has been a popular instrument in North
America, with strong pyschometric characteristics.
Physical Health Heavy drinking also has predictable effects on physical health.
The
most common evaluation approach in this domain has been a serum
chemistry profile, screening for elevations on variables commonly
affected by excessive drinking. These include liver enzymes (SGOT, k
SGPT, GGT), mean
corpuscular volume (MCV), and high-density
lipoprotein (HDL). Blood pressure can also be screened, because heavy
drinking contributes to hypertension.
Neuro- Knowledge of all of the above
domains provides relatively little infor
psychological mation about a person's cognitive
functioning. Problem drinkers have
Functioning been found to be impaired on a
variety of neuropsychological tests
(Miller and Saucedo 1983).
Both Project
MATCH and other checkupand feedback interventions have included
neuropsychological test results (see Miller and Sovereign 1989; Miller et al.
1988), although interventions can also be effective without the inclusion of
neuropsychological testing (Bien and Miller submitted; Brown and Miller
submitted). Tests that commonly show impairment include the Block Design and
Digit/Symbol subtests of the Wechsler Adult Intelligence Scale, the Wisconsin
Card Sorting Task, and Halstead-Reitan subtests including the Tactual
Performance Test, the Trail-Making Test, and the Categories Test.
Risk Factors Markers of high risk for alcohol problems can also be measured,
apart
from the individual's current level of use and its consequences. Family
history of alcohoVdrug problems can be obtained by a variety of
methods (e.g., Cacciola et al. 1987; Miller and Marlatt 1984). Of
personality scales designed to detect correlates of risk for substance
abuse, the MacAndrew scale has fared best in research, though others
are.available (Jacobson 1989; Miller 1976). Beliefs about alcohol, as
assessed by Brown's Alcohol Expectancy Questionnaire, have also
been found to be predictive of risk (Brown 1985).
Motivation for Various approaches are available
for measuring the extent of an
Change individual's motivation for
changing drinking. Some consist of simple
Likert scales assessing commitment to abstinence or other change
goals (e.g., Hall et al. 1990). Self-efficacy scales can be constructed to
ask about confidence in one's ability to change. Respondents can be
asked to rate the extent to which alcohol is helping or harming them
on a range of life dimensions (Appel and Miller 1984). Stages of change
derived from the Prochaska and DiClemente (1984) theoretical per
spective were used as the basis for construction of the University of
Rhode Island Change Assessment (Prochaska and DiClemente 1992;
DiClemente and Hughes 1990) and the alcohol-specific Stages of
Change Readiness and Treatment Eagerness Scale (SOCRATES;
Miller).
Comprehensive
Several
questionnaires and structured interview protocols provide a
Assessment range
of quantitative scores that can be compared with normative or
Approaches diagnostic
standards. None of these taps all of the above dimensions,
but each provides a basis for judging status on several domains. The
Alcohol Use Inventory (AUI; Horn et al. 1987) is a widely used and
well-developed self-administered questionnaire that permits compar
ison of individual with normatived scores. The materials necessary to
administer, score, and interpret the AUI are available from National
Computer Systems, P.O. Box 1416, Minneapolis, MN 55440. The kit
includes the AUI manual, forms, client test book, hand-scored answer
key templates, and the AUI profile sheet, which summarizes the scores
and can be given to the client. Structured interviews include the
Addiction Severity Index (ASI; Cacciola et al. 1987), the Comprehens
sive Drinker Profile (CDP; Miller and Marlatt 1984, 1987), and the
Form 90 interview developed for Project MATCH (see below).
The crucial point is that the battery of assessment procedures to be
used as a basis for feedback can be tailored to the needs, time demands, "
and client characteristics of a program. What follows is but one
example-from Project MATCH-of how assessment feedback can bedone within
the context of Motivational Enhancement Therapy.
Prior to
the first session with an MET client, the Personal Feedback
Report
is prepared by obtaining the pertinent data from the client's
file.
The following information from the Project MATCH assessment
battery
is used:
* AUDIT
score from the Quickscreen
* Form
90-I (Initial Intake)
* ASI family history section
* MacAndrew
scale score
* DRINC
questionnaire
* Serum
chemistry profile
* Neuropsychological
test results
* Alcohol
Use Inventory
BACCuS,
an IBM-PC software program, is used for converting alcohol
consumption
data into standardized measures (Markham et al. submitted). i
Alcohol The first datum to be presented
to the client is the number of standard
Consumption drinks consumed during a week of
drinking. This calculation is avail- I,
able from Form 90-I, the Project
MATCH interview protocol for E
quantifying alcohol consumption.
Some degree of judgment is needed
here, but remember that the goal
is to provide clients with a fair
picture of their alcohol
consumption during a typical drinking week.
If the Steady Pattern Chart has
been completed (page 6), use line 38
as the number of standard drinks
per week. If no Steady Pattern Chart
has been completed, the client's
drinking was too variable to provide
a consistent weekly pattern. In this case, consult the Summary Statistics sheet.
If the client
abstained on fewer than 10 percent of days
during the 90-day window, multiply the "Average SECs per drinking 4 day"
by 7 to obtain the number of standard drinks per week. Be sure you are
examining the 90-day window and not the whole current period. If abstinent days
exceed 10 percent, examine the calendar to determine whether these abstinent
days mostly occurred within drinking weeks (e.g., no drinking on Monday through
Wednesday) or whether they occurred in blocks in between periods of drinking
(i.e., periodic drinker). In the former case, determine the typical number of
drinking days in an average week and multiply this number of days by the
Average SECs per drinking day (from the Summary Sheet) to obtain the number
of standard drinks per week. In the latter case-a purely periodic
drinker-determine from the calendar whether drinking episodes are normally at
least 7 days in length. If so, use the same procedure as for the Steady Pattern
Chart: multiply the Average SECs per drinking day by 7 to describe the number
of standard drinks consumed during a typical week of drinking. If drinking
episodes are typically shorter than 1 week (e.g., 3 days), multiply the average
number of days in an episode by the Average SECs per drinking day (from the
Summary Statistics). Again, remember that the guiding principle is to describe
the number of standard drinks that the client consumed, on average, in a
drinking week.
When you have obtained the client's average number of drinks per
drinking week, use table 3 to obtain the client's percentile among American
adults. Note the separate norms for men and women.
Estimated Blood The second set of data presented
to Project MATCH clients consists of
Alcohol computer-projected blood alcohol
concentration (BAC) peaks, based on
Concentration alcohol consumption patterns
reported on Form 90-I. These projec
Peaks tions are computed by BACCuS and
will normally have been com
pleted by
the research assistant who conducted the Form 90-I
interview. Nevertheless, you should check these calculations using
BACCuS. Any projected peak over 600 mg% should be reported as 600
mg%. The reasoning here is that projections above this level are likely
to be overestimates, because actual BAC peaks above 600 mg%, though
possible, are relatively rare.
The BAC peak for a typical drinking week is obtained from line 39
of
Form 90-I. This is the highest intoxication peak from the typical
drinking week grid. Note that it may be necessary to use the BACCuS
program (Menu #3, BAC Peak for an Episode) to estimate BAC peaks
for several different days in order to determine which yielded the
highest BAC. It is not always obvious, from visual inspection, which
period will produce the highest BAC peak. Where a day contains at
least two periods of drinking separated by several hours (e.g., 6 drinks
from noon until 2:00 pin and then 8 drinks from 7:00-11:00 pm), it is
wise to try the BAC level for each period within the day, as well as for
the whole day. (In the above example, you would run 6 drinks in 2
hours, 8 drinks in 4 hours, and 14 drinks in 11 hours. The resulting
BAC projections for a 160-pound male would be 109, 124, and 152,
respectively. In this case, the BAC of 152, from 14 drinks in 11 hours, would
be used.) If the Steady Pattern Chart was not completed on 90-I, leave this
line blank.
The BAC
peak for a heavier day of drinking is obtained from the Highest Peak BAC line of
the Summary Statistics sheet. This represents the highest BAC peak reached during the
90-day period. This will never be lower than line 39 but may be the same as
line 39. In this case, the number on both lines of section 2 would be the same.
Risk Factors The third feedback panel on the PFR reflects five risk factors.
Higher
scores
on these scales are associated with greater risk and severity of
alcohol-related
problems.
Tolerance Level Tolerance level is inferred from the BAC peaks reached during the
90-day
window. The rationale is that the higher the projected BAC
peak,
the higher the individual's tolerance. Use the higher of the two
numbers
in Section 2 to arrive at the classification:
0-60 mg% Low tolerance
61-120 mg% Medium tolerance
121-180 mg% High tolerance
181 mg% + Very high tolerance
Other Drug Risk Other drug risk is judged from the lifetime use of other drugs, as
reported on page 10 of Form 90-I. The rationale is that more frequent use of
other drugs, or any use of drugs with higher dependence potential, is
associated with greater risk for serious consequences and complications. Use
the following classification system:
HIGH
RISK Any use of
cocaine or crack
or Any
use of heroin, methadone, or other opiates
or
Frequent use (more than 3 months of at least once per week) of any
other
drug class except tobacco:
Marijuana,
Hash, THC
Amphetamines,
Stimulants, Diet Pills
Tranquilizers
Barbiturates
MEDIUM
RISK Any lifetime nonprescription use, but not frequent use (i.e., 3 months or
less of
weekly use) of any drug class except tobacco, opiates or cocaine:
Marijuana,
Hash, THC
Amphetamines,
Stimulants, Diet Pills
Tranquilizers
Barbiturates
LOW RISK
No use of other drugs (Code = 0 for all 10 drug classes except tobacco)
Family Risk Family risk is judged from the family history of alcohol and other
drug
problems
obtained in the ASI interview. The following weighting
system
is used to arrive at a total Family Risk score. Assign the designated number of
points for each blood relative indicated to be positive for alcohol/drug
problems:
If
father positive add 2 points
If
mother positive add 2 points
For each
brother positive add 2 points
For each
sister positive add 2 points
For each
grandparent positive add I point
For each
uncle or aunt positive add 1 point
Risk
levels are judged according to the following classification system:
Family
Risk Classifications
0-1 Low
risk
2-3
Medium risk
4-6 High
risk
7+ Very
high risk
MacAndrew
Scale The
MacAndrew Scale score can be obtained directly from this scale. The following
classification system is used for risk:
MacAndrew
Scale Risk Levels
0-23
Normal range; lower risk
24-29
Medium risk
30+ High
risk
Age
at Onset Age at
onset is the fifth risk factor in this panel. The rationale is that
younger onset of problems is associated with a more severe course
and
symptomatology. Age at onset is calculated by the following
procedure,
using three items obtained from the DRINC (Drinker Inventory of
Consequences) scale.
Calculating
Age at Onset
1.
Record these three numbers, if applicable, and sum them
(from page 7 of Drinker
Inventory of Consequences)
Age of
first regular intoxication (item 17): Age of first loss-of-control (item 18): +
Age of
first alcohol problems (item 19): +
TOTAL 2.
Divide by the number of ages used in step 1:
Age at
onset =
NOTE:
If an age item was not recorded for the client (e.g., the client had never
experienced loss of control), the average is based on the other two age items
(divide by 2). If only one age item was completed, this constitutes the age at
onset.
Risk level is judged
according to this classification system:
Under
25.0 Higher risk
25.0-39.9
Medium risk
40.0 +
Lower risk
Problem Severity The AUDIT score is recorded directly from this scale within the
Quickscreen. The DRINC alcohol severity score is recorded directly from
this questionnaire and is the sum of scores for the 55 lifetime consequences.
Print the client's raw score for each of these two scales under the
corresponding severity range (e.g., a 19 on the AUDIT would be printed under
the HIGH descriptor, below the 16-25 range designation.)
The
other information reviewed in the fourth panel is the profile of results from
the AUI. Use the AUI Profile form, published by National Computer Systems, for
this purpose. Circle the client's raw scores for all scales and connect the
circles with straight lines. Do not cross the solid lines that divide
categories.
Serum Chemistry Obtain the client's serum chemistry scores on SGOT, GGTP, SGPT,
uric acid, and bilirubin (total) from the lab report. Record these lab scores on
the corresponding lines of the PFR. Interpretive ranges are shown on the PFR.
Neuro psychological - A 5-point performance scale is used to interpret
neuropsychological
test results:
Test Results
1 Well above average
2 Above average
3 Average
4 Below average
5 Well below average
The scoring systems below attempt to correct for effects of age and/or
education level, based on available norms. The Shipley-Hartford
Vocabulary test is used as a "hold" test that is less likely to be
affected
by alcohol, thus providing an estimate of the level of performance that
would ordinarily be expected from an individual.
Shipley-Hart ford Use the age-adjusted score to obtain a
normalized T-score, as specified
Vocabulary Test in the revised Shipley-Hartford manual. Then use the
following table
(SV) to convert the T-score into our 1-5 scale:
>_ 63
1 Well above average
57-62 2
Above average
44-56 3
Average
38-43 4
Below average
<_37
5 Well below average
Shipley-Hartford se the age-adjusted score to
obtain a normalized T-score, as specified
Abstraction Test in the revised Shipley-Hartford
manual. Then use the following table
(SHVA) to convert the T-score into our
1-5 scale:
>_ 63
1 Well above average
57-62 2
Above average
44-56 3
Average
38-43 4
Below average
<_ 37
5 Well below average
Trail-Making The score is the number of seconds to complete Form A.
Test, Form A Age
(TMTA) 20-39 40-49 50-59 60-69
1 <_ 21 <_ 22 <- 25 <- 29
2 22-26 23-28 26-29 30-35
3 27-41 29-44 30-48 36-66
4 42-49 45-58 49-66 67-103
5 >- 50 >- 59 >_ 67 >_ 104
Based on Lezak 1976, Table 17-6, page 558.
Cutting points represent the 10th, 25th, 75th, and 90th percentiles.
Trail-Making The score is the number of seconds to complete Form B.
Test, Form B Age
(THTB) 20-39 40-49 50-59 60-69
1 <_ 45 <- 49 <_ 55 _< 64
2 46-55 50-57 56-75 65-89
3 56-93 58-99 76-134 90-171
4 94-128 1Q0-150 135-176 172-281
5 >_ 129 >_ 151 >_ 177 >_ 282
Based on Lezak, 1976,
Table 17-6, page 558. Cutting points represent the 10th, 25th, 75th, and 90th
percentiles.
Symbol Digit The score for the Symbol Digit Modalities Test is the number of
correct
Modalities Test digits associated with their respective symbols within the
90-second
(SYDM)
written testing
period.
Use this
table if client has 12 years or less of education.
Age 1 2
3 4 5
18-24
>_ 67 63-66 47-62 42-46 <- 41
25-34
>_ 65 61-64 46-60 41-45 <_ 40
35-44
_> 64 60-63 44-59 39-43 S 38
45-54
>_ 62 57-61 39-56 33-38 :5 32
55-64
>_ 55 51-54 36-53 31-35 <_ 30
65+
>_ 47 42-46 25-41 20-24 <_ 19
Table 3. Alcohol consumption norms for U.S. adults,
in percents
Drinks per week Total Men Women
0 35 29 41
1 58 46 68 l
2 66 54 77
3 68 57 78
4 71 61 82
5 77 67 86
6 78 68 87
7 80 70 89
8 81 71 89
9 82 73 90
10 83 75 91
11 84 75 91
12 85 77 92
13 86 77 93
14 87 79 94
15 87 80 94
16 88 81 94
17 89 82 95
18 90 84 96
19 91 85 96
20 91 86 96
21 92 88 96
22 92 88 97
23-24 93 88 97
25 93 89 98
26-27 94 89 98
28 94 90 98
K.
29 95 91 98
30-33 95 92 98
34-35 95 93 98 E'
F
36 96 93 98
37-39 96 94 98
40 96 94 99
41-46 97 95 99
47-48 97 96 99
49-50 98 97 99
51-62 98 97 99
63-64 99 97 >99.5
65-84 99 98 >99.6
85-101 99 99 >99.9
102-159 >99.5 99 >99.9
160+ >99.8 >99.5 >99.9
Source: 1990 National Alcohol Survey, Alcohol
Research Group, Berkeley.
Courtesy of Dr. Robin Room
