Assessing Treatment and Treatment Processes

Glaser (1980) noted that assessing treatment and treatment processes had not been a high priority in the alcohol treatment field. Subsequent to his observation, however, a surge of interest in treat­ ment assessment has taken place among adminis­ trators, researchers, and clinicians. Indeed, a recent issue of Substance Use & Misuse (Magura 2000) contained several articles on substance abuse treatment assessment. That interest has been spurred by several developments. One is an expanding focus on systems analysis and between-program differences, prompted by efforts toward health care reform. In order to describe programs and examine interrelationships among program characteristics and quality of care indices, policymakers, administrators, and researchers recognized the need for instruments to assess program-level variables. A second reason for rising interest in treat­ ment assessment has been increasing recognition of the complex nature of predominantly psychoso­ cial interventions, such as those often used to treat alcohol use disorders even when pharmacologic agents also are provided. One example of this complexity is “therapist effects” in the delivery of treatment (Najavits and Weiss 1994; Najavits et al. 2000), that is, the way in which the “same” treatment can be delivered quite differently by different therapists. Treatment researchers have become aware of the need to not only facilitate the provision of standardized treatment through the use of therapist training, supervision, and treat­ ment manuals (e.g., K.M. Carroll 1997) but also to assess the implementation of the complex, multifaceted treatments they are studying. For example, it is important to document that distinc­ tive treatments have been applied in comparative evaluations, especially in studies of patient-treatment matching, and to conduct treatment process analy­ ses to identify “active ingredients of treatment” and “mechanisms of change.” On the clinical side, treatment providers need instruments with which to assess the quality of treatment provision, as well as the progress of their clients during treatment. Their motivation is the same as that among researchers: Such instru­ ments are seen as essential elements in the effort to improve clinical care. This chapter first presents a broad, multilevel model of the treatment processes. Then, measures of the different domains of treatment variables addressed by the model are reviewed. The predominantly recent interest in the assessment of treatment continues to be reflected in the avail­ ability of only a few established measures. A number of promising instruments are reviewed, however. When multiple measures assess a partic­ ular domain, descriptive and psychometric data for them are presented in tabular form. The final section considers additional work needed to develop high-quality measures of treatment and treatment processes.