Challenge to Conventional Assessment of Alcohol Use Disorders:

Transcription

1 Challenge to Conventional Assessment of Alcohol Use Disorders: The Case for a Lifecourse Perspective Audrey Begun, Lisa Presentation Berger, Author, 2006 & Trina Salm Ward CABHR Brown Bag, May 9, 2008

2 Acknowledgements The Silberman Fund Faculty Grant Program for 2007 Center for Addiction and Behavioral Health Research, University of Wisconsin-Milwaukee Center for Urban Population Health 2

3 Treatment depends upon diagnosis, and even the matter of timing is often misunderstood. One does not complete a diagnosis and then begin treatment; the diagnostic process is also the start of treatment. Diagnostic assessment is treatment; it also enables further and more specific treatment. - Karl Menninger (1963, p. 385) 1 3

4 Outline Background Development of an assessment tool Testing the tool Conclusions 4

5 Why Challenge Conventional Assessment? Conventional assessment of individuals with alcohol use disorders generally takes into account a limited time period (e.g., the past 90 days) rather than the individual s lifetime of experiences with the problem and attempts to change Assessment is sometimes viewed as a precursor to treatment versus a part of the treatment process 5

6 Why Challenge Conventional Assessment? (cont.) Conventional assessment oftentimes is practitioner-driven and highly quantitative in nature (i.e., multiple standardized forms and measures are administered) While some standardization is an important step forward in our practices, not all information collected has clinical relevance to the individual s situation 6

7 Why Challenge Conventional Assessment? (cont.) Conventional assessment in the field is sometimes divorced from treatment: Personnel other than the treatment provider, and with different training/skills, may conduct assessment interviews Assessment may be focused more on obtaining information for agency purposes than on determining client needs and goals 7

8 Non-Integrated Assessment Assessment Treatment Integrated Assessment Assessment Treatment 8

9 Why a Lifecourse Perspective? The immediate treatment effort should be contextualized within the person s own frame of reference where they have been, where they are, and where they are going Solely addressing where they are and where they are going misses much of the context that has relevance to the individual (e.g., what they have tried before, what worked and what did not, what can be built upon rather than starting from scratch this time, etc.) 9

10 Why a Lifecourse Perspective? (cont.) Additional and more comprehensive information can be gathered about an individual and their alcohol behaviors Information can be used to better inform type and intensity of treatment needed Individuals have an opportunity to tell their alcohol experience stories Storytelling in itself may have a beneficial effect 2 10

11 Why a Lifecourse Perspective? (cont.) A Lifecourse Perspective emphasizes patterns and continuities over time, as compared to snapshot approaches that emphasize the discrete elements of a particular event or episode Promotes integration between assessment and treatment processes 11

12 Why a Lifecourse Perspective? (cont.) Individuals with current or lifetime histories of an alcohol use disorder (abuse or dependence) have engaged in multiple attempts to change their alcohol behaviors 3 12

13 Lifecourse Perspective: Theoretical Support Transtheoretical model of behavior change 4,5 Health behavior change is a process versus an event Individuals cycle (repeatedly) through five stages of voluntary behavior change Precontemplation Contemplation Preparation Action Maintenance 13

14 Spiral Model of Stages in Change Process From: 14

15 Existing Measures Life Experiences Survey 6 (47 specified items plus 3 open-ended items) Items relate to commonly experienced life changes (e.g., retirement from work) Items query only the past year Instrument is used mostly to study the impact of life events on stress-related disorders 15

16 Existing Measures (cont.) Lifetime Drinking History 7 (structured interview; approximately 25 minutes to complete) Focuses on alcohol consumption patterns from first year of regular drinking (defined as drinking at least monthly) Queries life events that may have influenced an individual s drinking habits (e.g., loss of spouse) Focus is solely on alcohol consumption 16

17 Existing Measures (cont.) Recovery Interview 8 (interviewer-administered; assesses nine behaviors) Focuses only on 12-step behaviors (e.g., AA meeting attendance; talking with sponsor) 17

18 Existing Measures (cont.) Lifetime Change Attempt Scale 9 (intervieweradministered; used in the Helix Project) Asks age of first use; frequency of use; length of use; and change in use Asks about change attempts when attempted; what method employed; how long was change; how successful was the attempt; and what was successful/unsuccessful about each attempt 18

19 Existing Measures (cont.) The Lifetime Change Attempt Scale 9 is the most similar to the LACAA The Lifetime Change Attempt Scale, however, does not: Focus solely on alcohol Does not employ memory anchors Does not ask about problem recognition 19

20 Present Study Development and Preliminary Support of the Lifecourse Alcohol Change Attempt Assessment (LACAA) Based on TimeLine FollowBack 10 techniques for recall of recent behavior (e.g., alcohol use patterns, drug use, sexual behavior) Based on an assumption that many individuals with alcohol use disorders (abuse and dependence) have had multiple alcohol behavior change attempts of multiple types across their drinking histories 20

21 Study Rationale To gain further knowledge into the lifecourse nature of alcohol behavior change attempts among individuals with a history of alcohol dependence To provide mental health professionals with a contextualized, practical tool for the purpose of improved individual treatment planning 21

22 LACAA Development (cont.) Assesses multiple and varied alcohol behavior change attempts over the lifecourse Formal attempts (e.g., outpatient counseling; residential treatment) Informal attempts (e.g., support from friends/family) Natural recovery attempts (e.g., self-control) Other attempts (e.g., incarceration) 22

23 LACAA Development (cont.) LACAA focuses solely on alcohol behavior change attempts, beginning with problem recognition and awareness of need to change Employs an individualized/personalized year-byyear lifecourse calendar and computer entry Retrospective key community dates (i.e., 9/11, sports records) and other individually specific key dates (i.e., major family/life events) serve as memory anchors 23

24 LACAA Development (cont.) Interviewer Procedures: Personalized LACAA calendar and colored pens are provided to an individual Individual is oriented to the calendar Individual is invited to enter personal events that may help to recall alcohol behavior change attempts 24

25 LACAA Development (cont.) Commonly reported personal events included: Birthdates of children Marriage/divorce dates Periods of incarceration Accidents Hospitalizations, including for detoxification Employment or loss of employment dates Moving dates/buying a house 25

26 LACAA Calendar sample 26

27 LACAA Development (cont.) The initial set of interview questions asks: When drinking was first started When alcohol dependency symptoms were first experienced When drinking was first recognized as problematic What made an individual realize it was problematic 27

28 LACAA Development (cont.) When cutting down or abstaining was first attempted What was first attempted in order to cut down or abstain (types of attempts) What was the outcome of this first attempt What facilitated or interfered with the attempt 28

29 LACAA Data Entry Screen 29

30 LACAA Development (cont.) The problem recognition and change attempt questions are then repeated for each alcohol behavior change attempt recalled over the lifecourse All individually identified change attempts across the lifecourse are recorded 30

31 Present Study Design Capitalizes on longitudinal opportunity: Data were collected in a single follow-up interview from a sample of previously enrolled participants in the National Institute on Alcohol Abuse and Alcoholism COMBINE Study at the Milwaukee site COMBINE Study: Multi-site, randomized controlled clinical trial of combinations of pharmacological and behavioral therapies were superior to monotherapy in treating individuals with alcohol dependence, and cost-effectiveness sub-study 4-month treatment period; up to 3-years of 31 follow-up

32 Present Study Sample Of the 132 former COMBINE participants, 75 gave permission to be re-contacted for future studies All 75 individuals who gave permission to be recontacted were invited to participate in the present study via recruitment letters and follow-up phone calls We were able to contact 67; Accurint database was used to locate hard to reach individuals 32

33 Present Study Procedures (cont.) Breathalyzer Informed Consent Participants must have had a reading < 0.03 in order to proceed with study informed consent and follow-up interview Study Informed Consent Including permission to relate present study data to participants data collected during the COMBINE Study 33

34 Present Study Procedures (cont.) Study Interview (in-person) Two to two-and-a-half-hours in length Self-report data is computerized; interview is computer assisted data collection by interviewer Phone option for individuals who could not travel to interview site Performed by the same study coordinator Participants were compensated $80 34

35 LACAA Interview Procedures (cont.) Interviewer must maintain empathy the interview can be a very painful experience for several reasons: Although alcohol behavior change attempt successes are identified and discussed, so too are past treatment failures In addition, significant losses may discussed (e.g., deaths, divorce, separations) 35

36 LACAA Interview Procedures (cont.) Throughout interview, the interviewer: Maintains patience often participant misremembers dates/events and needs to go back to change earlier entries Provides non-judgmental listening and reflecting Uses summarizing (as enters data into database) Encourages best guess when participant is unclear of amount or timeframe Note: It can be very difficult to recall what was occurring and when 36

37 LACAA Interview Procedures Throughout interview, the interviewer: Uses bracketing to help narrow the field were you abstinent 2 days or 6 months or somewhere in between? Probes further based on responses to get accurate and detailed information (for example, what about the amount you were drinking made it a concern for you? Offers breaks, refreshments as needed 37

38 Present Study Design (cont.) Test-Retest Ancillary Study Initiated mid-study Consisted of a second follow-up interview in which the LACAA was re-administered Six-week lag long enough to forget their earlier answers but not so long that their reality changed much Participants were compensated $70 38

39 Present Study Sample (cont.) 38 individuals have completed the initial follow-up interview for a study participation rate of ~57% 28 men; 10 women 11 individuals contacted for the test-retest ancillary study (100%) have completed the second follow-up interview 8 men; 3 women 39

40 Present Study Measures LACAA Trail Making Test Repeated from COMBINE Study: Structured Clinical Interview for DSM-IV-TR Module E (Substance Use Disorders Module) Form 90-AQ Quick Drinking Assessment Interview Drinking Questionnaire (1-item) 40

41 Present Study Measures (cont.) From COMBINE Study (cont.) Obsessive Compulsive Drinking Scale (12- items) Alcohol Abstinence Self-Efficacy Scale for Temptation (20-items) University of Rhode Island Change Assessment (24-items) 41

42 Test-Retest Reliability Study Total number of change attempts reported Concordance of age when had first drink Concordance of ages when first experienced alcohol dependency symptoms Inter-rater reliability for matching individual change attempts 42

43 Validity Study Participant report of the COMBINE Study as a formal change attempt Participant report of types of change attempts 43

44 Data Analysis Test-Retest Reliability Study Intraclass correlation (ICC) Cohen s Kappa Validity Study Descriptive statistics (percentages) 44

45 Data Analysis (cont.) ICC is an ANOVA-based type of correlation Interpret like Pearson s r 45

46 Data Analysis (cont.) The following guide was used to help interpret the ICC: to 1.0 = Excellent 0.60 to 0.74 = Good 0.40 to 0.59 = Fair Below 0.40 = Poor 46

47 Data Analysis (cont.) Cohen s Kappa (inter-rater reliability) Can be used if just two raters Proportion of agreement minus proportion of agreement by chance alone over 1-proportion of agreement by chance alone 47

48 Data Analysis (cont.) The following convention was used to interpret Kappa: = Outstanding 0.60 to 0.79 = Substantial 0.40 to 0.59 = Moderate Generally, >.70 is considered to be strong agreement 48

49 Results Of the 38 individuals who completed the initial follow-up interview: Average number of change attempts reported was approximately 3.5 (Min=1, Max=11; Median=3) Average age of first drink was approximately 15 years (Min=4, Max=40; Median=14) 49

50 Results (cont.) Average age each dependency criteria first appeared: Drinking for longer periods of time than you intended=22.6 Drinking greater amounts than you intended=25.7 Family/friends started expressing concerns=28.4 Needed to consume more alcohol to get an effect (tolerance)=30.6 Physical withdrawal symptoms=

51 Results: Reliability Study (n = 11) Total number of change attempts reported ICC = 0.92 NOTE: Overall, there were 37 quit attempts reported at time 1 and 40 reported at time 2. Concordance of age when had first drink ICC = 0.65 Mean age first drink time 1=12.9, time 2=

52 Results: Reliability (n=11) Concordance of age that dependency symptoms first reported Drinking for longer periods of time than you intended=0.42 Drinking greater amounts than you intended=0.68 Family/friends started expressing concerns=0.82 Needed to consume more alcohol to get an effect (tolerance)=0.72 Physical withdrawal symptoms=

53 Results: Reliability (n=11) Inter-rater reliability (2 raters): Kappa=0.63 Lisa matched 100% of Adam s ratings, but had additional matches that Adam did not 53

54 Validity All (100%) of participants reported COMBINE Study as a formal change attempt Type of change attempt (N=122 attempts): 23.8%=natural recovery only.8%=informal only 41%=formal only 13.1%=other type 54

55 Validity (cont.).8%=natural & informal combined 9.9%=natural & formal combined 4.1%=informal & formal combined 3.3%=formal & other combined.8%=natural, informal, & formal.8%=natural, informal, & other 1.6%=natural, forma, & other 55

56 Implications: Using the LACAA in Assessment Informs current treatment plans ~1 hour Broaden understanding of current drinking level Course of the disease symptoms worsening or improving, exacerbating factors, support systems Identify strengths & weaknesses of past attempts Plan ahead for triggers 56

57 Implications of LACAA: Client Experiences Provides a different way to look at their lives Cumulative effect of treatments Can help them verbalize what will make this attempt different, i.e., motivating factors 57

58 Core Study Team: Audrey Begun, Ph.D., Principal Investigator Lisa Berger, Ph.D., Co-Investigator Mike Brondino, Ph.D., Co-Investigator Trina Salm Ward, MSW, Project Coordinator Additional Team Members: Eric Gresnick, MA, Business Manager Jennifer Hernandez-Meier, BA, Student Research Assistant Adam Lippert, MA, Assistant Researcher Kim Smith, Student Administrative Assistant 58

59 Thank you! 59

60 References 1. Menninger, K. (1963). The vital balance: The life process in mental health & illness. New York: Viking Press. 2. Khantzian, E. J., & Mack, J. E. (1994). How AA works and why it s important for clinicians to understand. Journal of Substance Abuse Treatment, 11(2), Moos, R. H., & Moos, B. S. (1998). Long-term influence of duration and intensity of treatment on previously untreated individuals with alcohol use disorders. Addiction, 98, Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology 51(3): Glanz, K., Rimer, B. K., & Su, S. M. Theory at a Glance: A Guide for Health Promotion Practice. National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human 60

61 References Services; NIH Pub. No Washington, DC: NIH. 6. Sarason IG, Johnson JH, Seigel JM. Assessing the impact of life changes: Development of the Life Experiences Survey. J Consult Clin Psychol 1978;46(5): Skinner HA ; Sheu WJ. Reliability of alcohol use indices: The Lifetime Drinking History and the MAST. J Stud Alcohol 1982;43: Morgenstern J; Kahler CW; Frey RM; Labouvie E. Modeling therapeutic response to 12-step treatment: Optimal responders, nonresponders, and partial responders. J Subst Abuse 1996;8(1): The Helix Project. Lifetime change attempt scale. (n.d.). Retrieved April 17, 2008 from Sobell, L., Maisto, Sobell, M., & Cooper (1979). Reliability of alcohol abusers self-reports of drinking behavior. Behav Res Ther;17: Cicchetti, D. V. (1994). Guidelines criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6,

62 References 12. Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33,