Motivational Enhancement Therapy Therapist Manual Supplement Assessment Feedback Procedures

Preface

The instructions contained in Appendix A pertain to the assessment feedback components of Motivational Enhancement Therapy, as practiced in Project CRAFT.  It is not necessary, however, to use exactly the same assessment instruments as were employed in Project CRAFT.  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 CRAFT, information is provided at the end of this appendix for obtaining the needed instruments.  You may, however, construct your own assessment battery and design a corresponding Personal Feedback Report (PFR) based on normative data for the instruments you have chosen.

In general, your assessment battery should sample a variety of potential problem and risk domains.  Here is a brief list of pertinent domains, with examples of appropriate assessment approaches for each.

Interpreting the PFR to Clients

This information is to help you in interpreting the Personal Feedback Report to your clients.  Following general therapeutic guidelines in the MET manual, you should provide a clear explanation of the client's feedback in understandable language.  The general therapeutic style in giving MET feedback is demonstrated in the second half of Dr. Miller's "Motivational Interviewing" videotape provided to each site.

Give the original copy of the PFR to your client, and retain a copy for the file.  The PFR consists of three pages of data from interviews and questionnaires.  When you have finished presenting the feedback, the client may take home the PFR plus a copy of "Understanding Your Personal Feedback Report."  If you end a session partway through the feedback process, however, you should retain the original PFR, sending it home with the client only after you have completed your review of feedback at the next session.

You should be thoroughly familiar with each of the scales included on the PFR.
"Understanding Your Personal Feedback Report" provides basic information for the client.  Here is some additional information to help you in interpreting findings to clients:

1. DRUG USE

Here the client’s personal use of drugs in several categories is being compared with national norms, as established by the household survey of the National Institute on Drug Abuse. The survey is conducted quite carefully, with full confidentiality, and proper measures are taken to sample households representatively (e.g., not only those with telephones).

Explain what the percentile (%) scores mean that have been written on this first sheet.  A 95 in this column, for example, means that the client’s use of this drug is greater than 95 out of 100 American adults (over the age of 12).  Said another way, fewer than 5% of adults use this drug as much as the client does.

Circled on this sheet are decile ranges.  Thus a score of 75 will result in circling of decile 8.  This is just another way of showing how the client’s use compares with that of the general population.

Sources:

National Household Survey on Drug Abuse: Population Estimates (1990).  National Institute on Drug Abuse.

Eighth Special Report to the U.S. Congress on Alcohol and Health (1994).  National Institute on Alcohol Abuse and Alcoholism

Date from the 1990 National Alcohol Survey, Alcohol Research Group, Berkeley, courtesy of Dr. Robin Room

2. Lifetime Negative Consequences of Drug Use

The client’s lifetime scores from the Inventory of Drug Use Consequences (InDUC) are shown on page 2 of the PFR.  The client’s raw scores for the total scale and for five specific subscales are printed in the boxes at the bottom of the profile form (note that there are separate norms for men and women). 

These same raw scores are circled in the column corresponding to each scale, to show the client’s elevation relative to individuals currently seeking treatment for substance abuse.  Be sure to point out that the normative reference group has changed from page 1, where drug use was being compared with the general population. 

Here a “low” score is low relatively to people being treatment for substance abuse, which may still be a high score in the general population.  (This is the only normative base currently available, and actually comes from Project MATCH and a companion instrument focusing on alcohol use only.  The InDUC was modified to ask about other drugs as well, and specific norms for the InDUC are not yet available.)

Explain that this shows the extent to which the client has experienced negative consequences (problems) related to his or her drug use, in comparison with people who are being treated for such problems.

Here is some basic information to help you interpret the subscales.  This information is also on the client’s form, Understanding Your Personal Feedback Report.

Physical This score reflects unpleasant physical effects of drug use such as hangovers, sleeping problems, and sickness; harm to health, appearance, eating habits, and sexuality; and injury while drinking or using other drugs

Intrapersonal   These are personal, private negative effects such as feeling bad, unhappy or guilty because of drug use; experiencing a personality change for the worse; interfering with personal growth, spiritual/moral life, interests and activities, or having the kind of life that you want.

Social These are negative consequences more easily seen by others.  They include
Responsibility  work/school problems (missing days, poor quality of work, being fired or suspended), spending too much money, getting into trouble, and failing to meet others’ expectations.

Interpersonal These are negative effects of drug use on important relationships.  Examples are damage to or the loss of a friendship or love relationship; harm to family or parenting abilities; concern about drinking expressed by family or friends; damage to reputation; and cruel or embarrassing actions while drinking or using other drugs.

Impulse This is a group of other negative consequences of drug use that have to do with
Control self-control.  These include: overeating, increased use of other drugs, impulsive actions and risk-taking, physical fights, driving and accidents after drinking, arrests and trouble with the law, and causing injury to others or damage to property.

3. General Functioning

The third section of the report gives an indication of how the client has been doing more generally in six life areas.  These are ratings given by the RA who conducted the addiction Severity Index interview.  A low score (0, 1,2 or 3) indicates that the interviewer observed no real problem in this area.  A high score (6, 7, 8, or 9) says that the interviewer observed a serious problem in need of treatment.  Scores in between (4 or 5) reflect a less serious problem, but one that might still need to be treated.  The six areas are:
 
Medical General physical health as judged from what the client said during the interview

Employment/ The client’s general state of financial support, including work,
Support benefits,  and support from friends and family

Drug/Alcohol The interviewer’s rating of the seriousness of the client’s overall alcohol/drug problems and need for treatment

Legal Trouble with the law

Family/Social Problems in the family, or in relationships with others more generally

Psychological Problems with mood, anxiety, thinking, self-control, etc.

4.  Level of Depression

Section 4 shows a single score from the Beck Depression Inventory, a scale commonly used to screen for depression.  This is one specific area of psychological adjustment.  High scores on this scale (19 and above) indicate possibly severe depression, which would benefit from treatment.  The client’s score here is compared with American adults in general.

Source: Beck, A. T., & Steer, R. A. (1987).  Beck Depression Inventory manual.  San
Antonio: Psychological Corporation.

5.  Motivation for Change

Where was the client in readiness to make a change in drug use?  Section 5 shows the client’s scores on five scales of motivation for change, derived from the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES-D).  Here the client’s score is again compared with people being considered for treatment for alcohol/drug problems.  Here is what the scales mean:

Precontemplation A high score on this scale indicates a person who is not really ready to make a change, and who sees no real problem in need of treatment

Contemplation A high score on this scale indicates a person who is unsure whether or not he/she has problems with drugs and needs treatment.

Determination A high score on this scale indicates a person who recognizes that he or she has problems with drugs and is ready to make a change

Action A high score here indicates a person who not only recognizes a problem, but is already trying to change

Maintenance A high score on this scale indicates a person who has already made changes in his or her drug use, and is working to hold onto that change and not slip back to old patterns

Various combinations of scale elevations are possible.  These scores offer an opportunity to discuss with the client his or her perceptions (at the time of initial assessment) of a problem and need for change.

INSTRUCTIONS FOR PREPARING A PERSONAL FEEDBACK REPORT (PFR)

Section I: Drug Use

All of the data for this section are derived from the client’s Form 90-DI pretreatment interview.  From the 90-day period reconstructed by 90-DI, determine the number of days of use for each of the following drug classes.  You will find these numbers in the “Total Days” column of the Use Pattern Chart on page 8 of Form 90-DI.  Then convert the client’s use pattern into a percentile score for each of the drug classes using the following rules:

Alcohol

To determine the appropriate percentile score for alcohol use, you need to use the number of days of Level 1, Level 2, and Level 3 use as shown on the Use Pattern Chart.

Multiply Days of Level 1 use by 1

Multiply Days of Level 2 use by 2

Multiply Days of Level 3 use by 3

Then add these three numbers together to calculate the client’s QF score.

Finally, use the chart below to determine the client’s percentile score, and print it on the
Chemical Health Check-up Personal Feedback Report (PFR).

QF Score    Men     Women

0 0 0
1-40 32 53
41-90 70 89
91-135 79 94
136-159 82 95
160-180 88 96
181-200 90 98
201-270 95 99

Tobacco

For tobacco, as for many other drug classes below, we currently have only percentile scores for the presence or absence of any use.  If the client is a nonsmoker, enter a zero (0) in the
% column on the PFR.  If the client is a smoker, enter:
70 if the client is a male
75 if the client is a female
 
Marijuana

Compare the client’s total days of use in this 90-day period to determine the appropriate percentile score for marijuana.

Days Use    Men    Women

0 0 0
1-2 88 92
3-11 94 97
12-59 96 99
60 or more 99 99.5

Tranquilizers

If the client reported no abuse of tranquilizers, enter zero (0).  Any illicit use of tranquilizers results in a percentile score of 99 for both men and women.

Sedatives/Downers

If the client reported no abuse of sedative/downers, enter zero (0).  Any illicit use of sedative/downers results in a percentile score of 99 for both men and women.

[No normative data are currently available for Steroids]

Stimulants/Uppers

If the client reported no abuse of stimulant/uppers, enter zero (0).  Any illicit use of stimulant/uppers results in a percentile score of 99 for both men and women.

Cocaine

Use the total days of use in this 90-day period to determine the client’s appropriate percentile score:

Days Use    Men    Women

0 0 0
1-2 96 98
3-11 99 99
12 or more 99.6 99.8

EXCEPT that: If the client reported any use of crack, enter 99.6 for males 99.9 for females

Hallucinogens

If the client reported no use of hallucinogens, enter zero (0).  Any use of hallucinogens results in a percentile score of
99.6 for men 99.8 for women.

Opiates

If the client reported no use of opiates, enter zero (0).  Any illicit use of opiates results in a percentile score of
99.5 for men 99.8 for women

Inhalants

If the client reported no use of opiates, enter zero (0).  Any use of inhalants results in a percentile score of:
99 for men 99.6 for women

Finally, for all drug categories, circle the decile score that corresponds to each percentile score.  Thus, for a percentile score of 75 you would circle decile 8.   (There is no need to connect the circled numbers with lines.)
 
Section 2: Lifetime Negative Consequences of Drug Use

These data are derived wholly from the lifetime version of the Inventory of Drug Use Consequences (InDUC-2L). [Be careful not to use form 2R, which is for more recent consequences.]  Using the InDUC scoring form, copy the client’s responses onto the proper lines, then sum down the columns to calculate the five scale scores.  Record these raw scores in the boxes at the bottom of the profile form on page 2, noting that there are separate forms for men
(above) and women (below).  Sum the five scale scores to calculate the Total Score, and record it in the proper box.  Then for each of the six scores, circle the corresponding range or number in the column immediately above it.  This shows the elevation (in deciles) of each score.

Section 3: Interviewer Ratings of General Functioning

From the interviewer ratings section of the Addiction Severity Index (ASI), determine the rating (on a 0-9 scale) given by the ADI interviewer on each of the six scales shown, and circle that rating for each scale.

Section 4: Level of Depression

Score the Beck Depression Inventory (CDI) and print the total score in the box underneath the range into which it falls.

Section 5: Motivation for Change

To score the SOCRATES questionnaire, copy the client’s responses onto the proper lines of the SOCRATES scoring form, then sum down the columns to calculate the five scale scores. Record these raw scores in the boxes at the bottom of the profile form on page 3 of the PFR. Then for each of the six scores, circle the corresponding range or number in the column immediately above it.  This shows the elevation (in deciles) of each score.

On the following pages you will find the text of “Understanding your Personal Feedback Report,” which is to be given to a client with the completed PFR sheet.
 
CASAA Research Division 3/95

Understanding Your Personal Feedback Report

Your Personal Feedback Report gives you information from your Chemical Health Check-up.  It tells you where you stand, relative to other people, on several aspects of drug use and related problems.

1. DRUG USE

The first section compares your own use of different drugs with all adults in the United States.  For each drug group, your report shows the percentage of days on which you use the drug(s).  This information comes from the interview in which a calendar was used to help you describe your use of drugs.

The number written in the “%” column indicates how your drug use compares with that of American adults in general.  A “95" in this column would mean that you use this drug more often than 95 percent of all Americans, or that only 5 percent of Americans use this drug as often as you do.

This is also shown by circling a number on a scale of 1 to 10 comparing your use with American adults in general.  A low number (1-5) means that your use (or non-use) falls within the normal range for American adults, at least in terms of how often you use that drug.  A higher number means that you have been using this drug more often than is typical for American adults.  A ten (10), for example, means that relatively few Americans use the drug as often as you do.

These numbers tell you nothing about how much of a drug you use - only how often you use it.  It is possible, for example, that a person could drink alcohol only a few days a month (within the normal range), but drink 12 beers on those days (far beyond the normal range).

2. NEGATIVE CONSEQUENCES

This section summarizes the negative consequences of your drug use - the harmful effects it has had in your life.  Here your own personal scores are being compared with other people who are already in treatment for alcohol and other drug problems.  Thus a “medium” score on these scales means that your score is typical for people who have already had enough trouble to seek treatment.  A “medium” score here would be a very high score for Americans in general.

The first column shows you your total problem score, relative to people receiving treatment.  Then there are five more specific scales that show the level of problems you reported in five areas:

Physical This score reflects unpleasant physical effects of drug use such as hangovers, sleeping problems, and sickness; harm to your health, appearance, eating habits, and sexuality; and injury while drinking or using other drugs

Intrapersonal   These are personal, private negative effects such as feeling bad, unhappy or guilty because of drug use; experiencing a personality change for the worse; interfering with your personal growth, spiritual/moral life, interests and activities, or having the kind of life that you want.

Social These are negative consequences more easily seen by others.  They include
Responsibility  work/school problems (missing days, poor quality of work, being fired or suspended), spending too much money, getting into trouble, and failing to meet others’ expectations of you.

Interpersonal These are negative effects of drug use on your important relationships.  Examples are damage to or the loss of a friendship or love relationship; harm to family or your parenting abilities; concern about drinking expressed by your family or friends; damage to your reputation; and cruel or embarrassing actions while drinking or using other drugs.

Impulse This is a group of other negative consequences of drug use that have to do with
Control self-control.  These include: overeating, increased use of other drugs, impulsive actions and risk-taking, physical fights, driving and accidents after drinking, arrests and trouble with the law, and causing injury to others or damage to property.

These scores all reflect drug-related problems that you have ever had in your lifetime.

3. GENERAL FUNCTIONING

The third section of the report gives an indication of how you are doing more generally in six life areas. These are ratings given by the person who interviewed you.  A low score (0, 1,2 or 3) indicates that the interviewer observed no real problem in this area.  A high score (6, 7, 8, or 9) says that the interviewer observed a serious problem in need of treatment.  Scores in between (4 or 5) reflect a less serious problem, but one that might still need to be treated. 

The six areas are:

Medical Your general physical health as judged from what you said during the interview

Employment/ Your general state of financial support, including work, benefits, Support and support from friends and family

Drug/Alcohol This is the interviewer’s rating of the seriousness of your alcohol/drug problems and need for treatment

Legal Trouble with the law

Family/Social Problems in the family, or in your relationships with others more generally

Psychological Problems with mood, anxiety, thinking, self-control, etc.

4. LEVEL OF DEPRESSION

Section 4 shows a single score from the Beck Depression Inventory, a scale commonly used to screen for depression.  This is one specific area of psychological adjustment.  High scores on this scale (19 and above) indicate possibly severe depression, which would benefit from treatment.  Your score here is compared with American adults in general.

5. MOTIVATION FOR CHANGE

Where were you in readiness to make a change in your drug use?  Section 5 shows your scores on five scales of motivation for change.  Here your score is compared with people being considered for treatment for alcohol/drug problems.  Here is what the scales mean:

Precontemplation A high score on this scale indicates a person who is not really ready to make a change, and who sees no real problem in need of treatment

Contemplation A high score on this scale indicates a person who is unsure whether or not he/she has problems with drugs and needs treatment.

Determination A high score on this scale indicates a person who recognizes that he or she has problems with drugs and is ready to make a change

Action A high score here indicates a person who not only recognizes a problem, but is already trying to change

Maintenance A high score on this scale indicates a person who has already made changes in his or her drug use, and is working to hold onto that change and not slip back to old patterns

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Motivational Enhancement Therapy with Drug Abusers can be downloaded as a pdf file at
motivationalinterview.org