Interpreting Project MATCH therapists follow a
systematic approach in discussing
the PFR to the Personal Feedback Report with
clients. The general therapeutic
Clients style in giving MET feedback is
illustrated in Dr. Miller's "Motiva
tional Interviewing" videotape.
The original copy of the PFR is given to the client and a copy is retained
for the therapist's file. The PFR consists of two pages of data from
interviews and questionnaires plus the client's Alcohol Use Inventory
Profile sheet. When the therapist has finished presenting the feed
back, the client may take home the PFR plus a copy of "Understanding
Your Personal Feedback Report." If a session ends partway through
the feedback process, however, the therapist retains the original PFR,
sending it home with the client only after the review of feedback is
completed. Clients are given a copy of Alcohol and You at the end of
the first session (a copy is included at the end of appendix A).
Therapists need to be thoroughly familiar with each of the scales
included on the PFR. "Understanding Your Personal Feedback
Report" provides basic information for the client. Here are some
additional points helpful in reviewing the PFR with clients.
Alcohol The idea of a standard drink is
an important concept. Explain that all
Consumption alcohol beverages-beer, wine,
spirits-contain the same kind of alco
hol, ethyl alcohol. They just contain different amounts of this drug.
Use the "Standard Drink" graphic depicted in the client handout
"Understanding Your Personal Feedback Report" to explain this. We
are using, as a standard drink, any beverage that contains half an
ounce of ethyl alcohol. Thus, the following beverages are each equal
to one standard drink:
Beverage Usual % x Ounces = Alcohol content
Beer .05 x 10 oz = 0.5 oz
Table wine .12 x 4 oz = 0.5 oz
Fortified wine .20 x 2.5 oz = 0.5 oz
Spirits
80 proof .40 x 1.25 oz = 0.5 oz
100 proof .50 x 1 oz = 0.5 oz
Explain that the number of standard drinks per week is calculated from the
client's own report of regular and periodic drinking patterns, converted into
standard units as shown in the graphic. The normative table provides an
estimate of the client's standing among American adults of the same sex with
regard to alcohol con sumption. The conversion table provides percentile levels
for various numbers of standard drinks per week, based on data from the 1990 National
Alcohol Survey, provided by Dr. Robin Room of the Alcohol Research Group at
Berkeley. A good explanation of this percentile figure is that, "This
means you drink more than_percent of American [men/women] do, or that ( 100-X )
percent of American (men/women) drink as much or more than you do."
Estimated BAC The number of drinks consumed is
only part of the picture. A certain
Peaks number of drinks will have
different effects on people, depending on
factors like their weight and sex. The pattern of drinking also
makes
a difference: having 21 drinks
within 4 hours on a Saturday is different
from having 21 drinks over the
course of a week (3 a day).
Another
way to look at a person's drinking, then, is to estimate how intoxicated he or
she becomes during periods of drinking. Be clear here that we are discussing
"intoxicated" in terms of the level of alcohol (a toxin)
in the body and not the person's subjective sense of being drunk. It is
common for alcoholics to be quite intoxicated (high BAC) but not to look or
feel impaired.
The unit
used here is milligrams of alcohol per 100 ml of blood,
abbreviated
"mg%." This is the unit commonly used by pharmacolo
gists
and has the additional convenience of being a whole number
rather
than a decimal (less confusing for some clients). If you or your
client
wish to compare this with the usual decimal expressions of BAC,
simply
move the decimal point three places to the left. Thus:
80 mg0/o
= .08
100mg0lo
=.10
256 mg%
= .256 and so on
Note
that the "normal social drinking" range is defined as from 20-60 mg%
in peak intoxication. In fact, the vast majority of American drinkers do not
exceed 60 mg% when drinking.
Risk Factors Introduce this section by explaining "risk." Elevated scores on risk factors
are not predestination. A person with a family history of heart disease is not
doomed to die of heart disease-but such a person needs to be extra careful
about diet and exercise, for example, and to keep a careful eye for warning
signs. The five scores in this section are markers of higher risk for serious
problems with alcohol. They indicate a greater susceptibility to alcohol
problems.
Tolerance The behavioral effects as shown in "Understanding Your
Personal
Feedback Form" can be understood as the ordinary effects of various
BAC levels. Because of tolerance, people may reach these BAC levels
without feeling or showing the specific effects listed.
The presence of a high BAC level, especially if accompanied by a
reported absence of apparent or subjective intoxication signs, is an
indication of alcohol tolerance. This should be discussed with the client
as a risk factor. That is, people with a high tolerance for alcohol have
a greater risk of developing serious problems because of drinking! A
few points to cover are
Tolerance is partly inherited, partly learned.
For the most part, tolerance does not mean being able to get rid
of alcohol at a faster rate (although this occurs to a small extent).
Rather it means reaching high levels of alcohol in the body
without feeling or showing the usual effects.
Normal drinkers are sensitive to low doses of alcohol. They feel
the effects of 1-2 drinks, and this tells them they have had
enough. Other people seem to lack this warning system.
A result of tolerance is that the person tends to take in large
quantities of alcohol-enough to damage the brain and other
organs of the body over time-without realizing it. Thus you
damage yourself without feeling it. An analogy would be a
person who loses all sensations of pain. While at first this might
seem a blessing, in fact, it is a curse, because such a person can
be severely injured without feeling it. The first sign that your
hand is on a hot stove is the smell of the smoke. Similarly, for
tolerant drinkers, the first signs of intoxication are felt at rather
high BAC levels.
Other
Drug Risk A
second risk factor to consider is other drug use. In essence, the more drugs
the client is using, the greater the risk for problems, cross-tolerance,
dependence, drug substitution (decreasing one but increasing another), and so
forth. Discuss these risks with your client.
Family Risk Evidence is now strong that alcohol problems run in families
and are
genetically influenced. Of course, many people develop alcohol prob
lems without having a family history, but your risk is higher if you
have blood relatives with alcohol problems. Any family history should
be discussed with the client.
MacAndrew
Score Higher
scores on the MacAndrew scale, a subscale of the MMPI, have been found for
alcoholics than for norrnals or people with other psychological problems.
Elevations on this scale have also been found to be predictive, in young
people, of later development of alcohol problems. This personality scale
taps a variety of personal characteristics that are associated with higher risk
of serious alcohol problems.
Age at Onset Alcohol problems tend to be more severe when they begin at a
younger
age. Three items from the Drinker Inventory of Consequences are
averaged to obtain an "age of onset" for alcohol
difficulties. The
younger this age, the greater the risk for developing severe
problems
if drinking continues. Young emergence of "loss of
control" (difficulty
stopping once started or in keeping one's drinking within planned
limits), for example, may be an indicator of high risk for severe
alcohol
problems.
Problem Severity Two measures from Project MATCH screening are used here to reflect
overall alcohol problem severity. One is the AUDIT scale, developed by the
World Health Organization and used in the Quickscreen. The other is the Drinker
Inventory of Consequences. Explain that these scores are very broad, general
measures of negative effects of drinking in an individual's life. Notice that
the AUDIT focuses on recent patterns, whereas the DRINC measures lifetime
effects.
Your
larger task here is to review with the client his or her scores from the
Alcohol Use Inventory. To do this, you should be thoroughly familiar with the
manual (Horn et al. 1987), particularly chapter 6. It is helpful, in
understanding and interpreting scales, to be familiar with the items that
constitute each scale (see page 71 of the manual). Refer to (and provide the
client with a copy of) the AUI Profile Sheet, available from National Computer
Systems, Minneapolis, MN. Remember when interpreting elevations on the AUI that
the reference population is people already seeking treatment for alcohol
problems. Thus, a "low" score in the white (decile 1-3) range is
low relative to people entering treatment for alcohol problems. Scores in the
middle deciles (4-7; light grey) are by no means average for the general
population. General population norms on most scales would be expected to fall
in deciles 1-2. A possible exception is GREGARIOUS, where high scores reflect
drinking in social settings-a common style for young American men.
Serum Chemistry These five serum assays can be elevated by excessive drinking and
thereby reflect the physical impact of alcohol on the body. It is noteworthy
that many heavy and problematic drinkers have normal scores on serum assays.
The physical damage reflected by elevations on these scales may emerge much
later than other types of problems. Also, i normal scores on these tests cannot
be interpreted as the absence of physical damage from drinking. The
destruction of liver cells near the portal vein where blood enters, for
example, can occur before liver enzymes reflect a warning. When these scales are
elevated, then, it is information to be taken seriously.
Therapists
should clarify that, as a nonmedical professional, you are not qualified to
interpret these findings in detail. Clients who are concerned and want more
information should be advised to discuss their results with a physician.
If possible, referral should be made to a physician who is knowledgeable about
alcohol abuse. A physician in general practice who is not familiar with alcohol
abuse may advise a patient that their elevations are "nothing to worry
about," undermining the feedback process.
The
following information will help explain to clients the basic processes
underlying these assays and what they may mean.
SGOT/SGPT Serum glutamic oxalcetic transaminase (SGOT; newer name: AST aspartate
animotransferase) and serum glutamic pyruvate transaminase (SGPT; newer name:
ALT-alanine transferase) are enzymes that reflect the health of the liver. The
liver is important in metabolism of food and energy and also filters and
neutralizes poisons and impurities in the blood. When the liver is damaged, as
happens from heavy drinking, it becomes less efficient in these tasks and
begins to leak enzymes into the bloodstream. These two are general indicators, reflecting
overall health of the liver.
GGTP Serum
gamma glutamyl transpeptidase is an enzyme found in liver, blood, and brain,
which is more specifically sensitive to alcohol's effects. Elevations of this
enzyme have been shown to be predictive of later serious medical problems
related to drinking, including injuries, illnesses, hospitalizations, and
deaths. This enzyme is often elevated first, with SGOT and SGPT rising into the
abnormal range as heavy drinking continues.
Bilirubin (Total) The liver is also importantly involved in the recycling of
hemoglobin, the molecule which makes the blood red. Bilirubin is one breakdown product
of hemoglobin. When the liver is not working properly, it cannot recycle
hemoglobin efficiently, and the byproducts back up into the bloodstream and
eventually into the brain. High bilirubin levels
over
time result in jaundice-yellowing of the skin. Elevations of bilirubin are not
common, even among heavy drinkers, and are indicative of severe physical impact
from alcohol.
Uric Acid Uric acid is a waste product that results from the breakdown of
RNA.
Alcohol's damage to the liver reduces the kidney's ability to excrete
uric acid, which then builds up in the bloodstream. High levels of uric
acid result in gout, the painful inflammation of joints, particularly
fingers and toes. Uric acid is also an important component of a certain
type of kidney stones.
If your site is including other relevant assays in your serum
chemistry
package (e.g., HDL, MCV), these could be included on your feedback
form.
Enzyme elevations can occur for reasons other than heavy drinking.
GGTP, for example, can be elevated by cancer or hormonal changes. In this
population, however, the most likely cause of an elevation is heavy drinking.
In this case, these assays tend to return toward normal if the person ceases
heavy drinking. Reductions in GGTP (by changed drinking) have been shown to be
associated with dramatically reduced risk of serious medical problems.
Neuro- The last panel of assessment
results in the Project MATCH MET
psychological feedback is from the brief
neuropsychological testing. Scores on these
Test Results tests range from 1 (well above
average) to 5 (well below average).
Scores
of 4 are often interpreted as "suggestive" of cognitive impair
ment, and scores of 5 as "indicative" of cognitive impairment.
The first (SV) result is from the Shipley-Hartford Vocabulary test. It
is included as a "hold" test to indicate the approximate level of
cognitive functioning that would be expected for a particular individ
ual. Performance on this test is not commonly affected by alcohol use.
This score, then, gives you an approximate reference point with which
to compare other performances.
The
other four tests appear to be sensitive to the effects of alcohol on
the brain. They tend to be. impaired in heavy drinkers and often show
substantial improvement over the first weeks and months of sobriety.
No judgment can be made about a client's general neuropsychological
functioning or "brain damage" from this brief set of tests. Rather,
they
are indicators of the types of cognitive impairment commonly
related
to heavy drinking.
The
Trail-Making Test has two forms. Trails A is a follow-the-dot
format that mainly tests psychomotor speed. Alcoholics tend to be
impaired (slow) on this test, though normal scores are more common
than on Trails B. Trails B requires not only test psychomotor speed
but also a mental switching back and forth between two cognitive
sets-numbers and letters. As a group, alcoholics are rather consis
tently impaired (slow) on this test.
The
Symbol Digit Modalities test is a reversal of the more familiar
Digit/Symbol subtest of the WAIS. It is a timed test requiring the
copying of numbers that correspond to symbols. It is influenced not
only by psychomotor speed but also by memory. Alcoholics tend to
perform more poorly (complete fewer correct digits) than others on this
scale.
Finally,
the Abstraction scale of the Shipley-Hartford taps a cognitive
capacity-verbal abstraction ability-that is commonly impaired in
heavy drinkers. Lower scores are associated with more concrete think
ing styles. The common observation in alcoholics is a poorer perform
ance on Abstraction than on the Vocabulary scale of the Shipley.
Be aware
of other factors that may have influenced performance. Speed on Trails
and Symbol/Digit, for example, will be slowed by an injury to the writing hand
or arm. Visual impairments will also slow performance on these tests.
The
PFR form and the handout
explaining the data on the PFR form as used in Project MATCH are provided as
examples. These can be modified to suit the needs of other research studies.
Assessment Both published and newly
developed assessment instruments were
Instruments employed in Project MATCH as a
basis for providing client feedback
Used in Project in Motivational Enhancement
Therapy. The sources from which these
instruments can be obtained are provided below.
The
DRINC should be regarded as an experimental instrument, currently in
development. An initial psychometric study with 299 drinkers found good
internal consistency (Cronbach alpha = .92 for "ever" and .90 for
past 3 months). Initial analyses further indicate the negative consequences as
a construct is related to but not identical with alcohol dependence and alcohol
consumption. Correlations with Skinner's Alcohol Dependence Scale were .58 for
Ever and. 56 for Past 3 Months. DRINC scores were correlated with recent
quantity/ frequency of drinking at .37 for Ever and .47 for Past 3 Months.
Based on initial studies using this instrument (including NIAAA's Project
MATCH), it will be modified to improve its reliability, validity, and utility.
A proper
current citation, pending formal publication of the instrument, is:
Miller,
W.R. "The Drinker Inventory of Consequences." Unpublished manuscript,
University of New Mexico.
The
DRINC is available for use and can be obtained from William R. Miller, Ph.D.,
Department of Psychology, University of New Mexico, Albuquerque, NM 87131.
MacAndrew The MacAndrew Scale is a subscale
of the original Minnesota Multi
Scale phasic Personality Inventory. It
is described in the following article:
MacAndrew,
C. The differentiation of male alcoholic outpatients from nonalcoholic
psychiatric outpatients by means of the MMPI. Quarterly Journal of Studies on Alcohol 26:238-246, 1965.
Addiction The Addiction Severity Index is
a research instrument under ongoing
Severity Index development. For information
regarding the current version, contact
Dr. A. Thomas McLellan, VA Medical Center (116 ),
Philadelphia, PA 19104.
AUDIT The
Alcohol Use Disorders Identification Test was developed for a
large collaborative study of brief intervention conducted by the World
Health Organization (Babor and Grant 1989; Saunders et al. in press).
Personal This form is used in Project
MATCH to summarize information
Feedback obtained from the pretreatment
assessment battery and is discussed
Report Form with and given to the client in
the early sessions of MET. It is an
example of the type of form that may be adapted for use in other
reseach studies involving MET.
Understanding Project MATCH clients receive a copy of this material to take home
Your Personal with them to read in conjunction
with their PFR. It summarizes
Feedback important information that helps
the client understand the implica
Report tions
of their scores on the assessment instruments. Again, it is an
example of the Project MATCH
material that may be adapted for use
in other research studies involving MET.
"Alcohol
and This pamplet was developed by Dr. William R. Miller and is suitable
You" for duplication and distribution
to clients.
