Assessment of alcohol and substance use problems serves multiple functions (e.g., Allen and Mattson 1993; Jacobson 1989a, b; Shaffer and Kauffman 1985). The Institute of Medicine (1990) has suggested that all individuals seeking specialized treatment for alcohol problems undergo a comprehensive assessment comprising three stages: screening, problem assessment, and personal

assessment.

The first two stages involve screening, case finding, and problem identification; 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 elsewhere in this volume.

A broader range of factors must be considered in the treatment planning process, since alcohol use both affects and is affected by a number of other areas of life (Donovan 1988, 1992; Institute of Medicine 1990). The personal-assessment stage focuses on this broader array. Some problems may be fairly directly related to alcohol use (contingent problems) while others may not be at all attributable to alcohol use (noncontingent problems). For example, psychological, social, and vocational problems may or may not 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 process of assessment (Donovan 1988).

Within the clinical context, the primary goal of assessment is to determine those characteristics of clients and their life situation that may influence treatment decisions and contribute to treatment success (Allen 1991). The Institute of Medicine (1990) noted that treatment outcomes may be improved significantly by matching individuals to treatments based on such variables. Thus, 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. These assist the client and clinician develop and prioritize shortand 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, improved psychosocial functioning, and harm reduction (Bois and Graham 1993; Jacquot 1992; Miller and Mastria 1977; Sobell et al. 1982, 1988; Washousky et al. 1984).

In short, the assessment and treatment planning process leads to the individualiza

tion of treatment, appropriate client-treatment matching, and the monitoring of goal attainment (Allen and Mattson 1993). Assessment should also 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).

This chapter reviews a number of available instruments to assist the clinician and clinical researcher in the personal-problem assessment stage and in the development of appropriate treatment plans. The instruments included assess 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 discussed. Finally, several instruments specific to the assessment of adolescents are also included.

The instruments that have met the criteria for inclusion in this Guide are listed in table 1 and are designated in the text by an asterisk beside their primary mention. Table 2 presents a summary of available information about their reliability and validity. The information in each of these tables was derived primarily from instrument authors' fact sheets that appear in the appendix.

Several other instruments that may be of assistance to the treatment planning process that did not meet the inclusion criteria are also discussed. It should be noted that a number of other reviews provide more detailed information about the assessment process in addictive behaviors and specific assessment instruments and procedures (e.g., Addiction Research Foundation 1993; Allen 1991; Allen and Mattson 1993; Connors et al. 1994; Donovan 1992; Donovan and Marlatt 1988; Institute of Medicine 1990; Jacobson 1989a, b; Longabaugh et al. 1994; Sobell et al. 1988, 1994, in press).

Motivation and Readiness To Change

The decision to change one's drinking pattern or give up alcohol or drugs is not arrived at easily. The level of motivation for change or for treatment will vary across individuals seeking treatment as well as fluctuating within each individual across time. Even presenting for treatment intake does not reliably gauge the client's level or locus (e.g., intrinsic versus extrinsic) of motivation. One task of the assessment process is to both evaluate and attempt to enhance the individual's motivation and readiness to change and engage in treatment (Donovan 1988; Horvath 1993; Miller 1989a; Miller and Rollnick 1991).

Prochaska and DiClemente (1986; Prochaska et al. 1992) presented a model of behavior change applicable to addictive behaviors that has served as the frame of reference for assessing motivation or readiness to change. 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 go for years without perceiving that they have a problem, seemingly oblivious to the negative consequences that others are able to observe. This behavior, often characteristic of the precontemplation phase, has been described as being “in 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 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.

Instruments

A number of assessment instruments developed in the recent past to assist the clinician in determining the stage of readiness for change among problem drinkers or alcoholics are based on Prochaska and DiClemente's stages-of-change model. The Readiness To Change Questionnaire* (RTCQ) was developed by Rollnick and associates (1992). It is a brief 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 factor analysis. Each subscale consists of four items presented as 5-point ratings ranging from strongly agree to strongly disagree.

Despite the relative brevity of the scales, Chronbach 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 that 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). Thus, the RTCQ provides a brief assessment instrument that can be used to identify readiness to change, pre

dict subsequent drinking, direct the selection of interventions, and serve as an outcome or process measure to evaluate brief interventions.

It is important to note that the authors stress that the scale 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. 1994).

Two measures have been used increasingly to determine the readiness for change among problem drinkers who are seeking treatment. The University of Rhode Island Change Assessment (URICA) 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 used with individuals having drinking problems (DiClemente and Hughes 1990) and other drug problems (Abellanas and McLellan 1993).

The scale consists 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 being considered.

The URICA operationally defines four theoretical stages of change-precontemplation, contemplation, action, and maintenance each assessed by eight items. However, subsequent factor analysis 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).