Disease and debt: Findings from the 2019 Panel Study of Income Dynamics in the United States.

Medical debt has grown dramatically over the past few decades. While cancer and diabetes are known to be associated with medical debt, little is known about the impact of other medical conditions and health behaviors on medical debt. We analyzed cross-sectional data on 9174 households - spanning lower-income, middle-income, and higher-income based on the Census poverty threshold - participating in the 2019 wave of the nationally representative United States Panel Study of Income Dynamics (PSID). The outcomes were presence of any medical debt and presence of medical debt≥ $2000. Respondents reported on medical conditions (diabetes, cancer, heart disease, chronic lung disease, asthma, arthritis, anxiety disorders, mood disorders) and on health behaviors (smoking, heavy drinking). Medical debt was observed in lower-income households with heart disease (OR = 2.64, p-value = 0.006) and anxiety disorders (OR = 2.16, p-value = 0.02); middle-income households with chronic lung disease (OR = 1.73, p-value = 0.03) and mood disorders (OR = 1.53, p-value = 0.04); and higher-income households with a current smoker (OR = 2.99, p-value<0.001). Additionally, medical debt ≥$2000 was observed in lower-income households with asthma (OR = 2.16, p-value = 0.009) and a current smoker (OR = 1.62, p-value = 0.04); middle income households with hypertension (OR = 1.65, p-value = 0.05). These novel findings suggest that the harms of medical debt extend beyond cancer, diabetes and beyond lower-income households. There is an urgent need for policy and health services interventions to address medical debt in a wider range of disease contexts than heretofore envisioned. Intervention development would benefit from novel conceptual frameworks on the causal relationships between health behaviors, health conditions, and medical debt that center social-ecological influences on all three of these domains.

FRAMES Elements Associated With Alcohol Treatment Research Assessments and Related Behavior Change.

OBJECTIVE: Assessment reactivity research has contributed substantially to our understanding of alcohol treatment research protocols influencing clinical outcomes. The state of the science is such that relatively little is known about how alcohol treatment research participation influences behavior. The purpose of this study was twofold: (a) to determine the distribution of FRAMES elements (i.e., Feedback, personal Responsibility, Advice, a Menu of options, Empathic style of interaction, and support for Self-efficacy) contained in alcohol treatment research assessment interviews; and (b) to examine their association with subsequent alcohol use among a sample of clients presenting for alcohol use disorder treatment. METHOD: Audiotaped recordings of participant (n = 189) research assessment interviews were converted to digital recordings and reviewed for FRAMES elements using the FRAMES Checklist Instrument. RESULTS: Feedback, personal responsibility, empathic style of interaction, and support for self-efficacy were the more frequently occurring elements across follow-up periods. Alternatively, menu of options and advice occurred infrequently. Feedback and support for self-efficacy predicted subsequent alcohol use, although the association between feedback and alcohol use was unexpectedly positive. CONCLUSIONS: As part of the assessment interview process, alcohol treatment research participants receive multiple instances of feedback and support for self-efficacy specific to their alcohol use that are predictive of changes in alcohol use.

Alcohol Treatment Research Contributing to Changes in Substance Use Behavior and Related Negative Consequences.

OBJECTIVE: The purpose of this study was to investigate the extent to which two of the more salient characteristics of a treatment research assessment protocol (i.e., the comprehensiveness of the assessment battery and the frequency of its administration) for alcohol use disorder contribute to reductions in substance use and related negative consequences. METHOD: Study participants were recruited from two hospital-administered substance use disorder outpatient clinics. Two hundred thirty-five individuals presenting for outpatient alcohol treatment screened study eligible and provided informed consent. Study participants were randomized to one of four research assessment conditions (i.e., frequent-comprehensive, frequent-brief, infrequent-comprehensive, and infrequent-brief) based on the crossing of a 2 (i.e., assessment comprehensiveness: comprehensive vs. brief) by 2 (i.e., assessment frequency: frequent vs. infrequent) factorial design. RESULTS: Individuals assigned to the frequent assessment conditions reported greater reductions in substance use and substance use-related negative consequences relative to their counterparts assigned to the infrequent assessment conditions. In addition, a greater proportion of individuals assigned to the frequent assessment conditions reported abstinence from both alcohol and other substances. CONCLUSIONS: The improvements in substance use and related negative consequences associated with more frequent research assessments were statistically significant and clinically meaningful.

Development of the alcohol use discrepancy instrument (AUDI): An instrument for measuring a purported mechanism of behavior change underlying self-regulation theory.

Self-regulation theory (SRT) posits that individuals make decisions regarding behavior change based on a comparison of their actual (e.g., excessive alcohol use) and desired (e.g., abstinence) behaviors. This comparison must result in a discrepancy of sufficient magnitude to motivate an individual toward behavior change. It appears that this purported mechanism of behavior change (MOBC) has not been tested with regards to alcohol use disorder (AUD) treatment. Furthermore, there seems to be no psychometrically sound instrument for assessing such discrepancies in a clinical sample. The purpose of this study was to establish the psychometric properties of an instrument developed to assess actual versus desired alcohol use discrepancies that could be used to test this purported MOBC underlying SRT. The Alcohol Use Discrepancy Instrument (AUDI) was administered to 235 individuals participating in the Clifford et al. (2007) alcohol treatment outcome study that centered on research assessment exposure reactivity effects. Principal axis factor analysis yielded a unidimensional construct (Cronbach's α = 0.80). Baseline and six-month AUDI scores were correlated with concurrent alcohol use (proportion days abstinent, drinks per drinking day, and proportion heavy days, p < .01) in expected directions. Parallel process models provided further evidence of the AUDI's construct validity, as well as its potential as a measure of discrepancy as a MOBC. The AUDI has good psychometric properties and is likely to prove useful for assessing discrepancies between actual and desired alcohol use behavior, which, according to the principles of SRT, is essential for behavior change and maintenance.

Alcohol use post AUD treatment initiation as a predictor of later functioning.

OBJECTIVE: To replicate and extend the earlier work of Maisto and colleagues showing an association between early post-treatment alcohol use and later functioning (1, 2, 3). METHODS: The present study classified adults presenting for alcohol use disorders (AUD) treatment (n = 114) into one of three drinker groups (i.e., abstainer, moderate drinker, or heavy drinker) based upon alcohol use during the first 6-months following outpatient AUD treatment initiation, and examined the associations between drinker group classification and later alcohol use and psychosocial functioning. RESULTS: Study results showed that individuals classified within the heavy drinker group tended to have the poorest outcomes (i.e., greater alcohol use and poorer psychosocial functioning) relative to individuals classified within the abstainer or moderate drinker groups. CONCLUSIONS: Study findings are consistent with the prior work of Maisto and colleagues. In addition, it appears that alcohol use, particularly heavy alcohol consumption, during the early post-treatment initiation period may serve as a marker for later alcohol related problems and poorer overall psychosocial functioning.

The utility of collateral informants in substance use research involving college students.

Collateral informants have been routinely included in substance abuse treatment research to corroborate subject self-reported alcohol and other drug use. However, only a few studies to date have examined subject-collateral correspondence with respect to non-clinical populations (e.g., college students). The purpose of the present study was to examine the associations between college students self-reported substance use and corresponding collateral (i.e., friends') reports. A total of 100 subject-collateral pairs were recruited from psychology courses at a large public university located in the Southeastern, United States. Subjects and collaterals provided information specific to their own, as well as their friend's, recent (i.e., last 90-days) substance use. Study data yielded moderate to good, statistically significant, correlations between subject-friend pairs for each type of substance use. Discrepancy analyses revealed that the majority of subjects reported greater substance use relative to their collateral reports. This pattern of response (i.e., subject reporting greater use) is consistent with the extant literature. In addition, the friend's personal substance use appeared to influence his/her report of the subject's alcohol and other drug use. It appears that college student self-reports regarding alcohol and other drug use are reasonably accurate.

Do patient intervention ratings predict alcohol-related consequences?

Little is known about treatment process for behavior change for brief interventions. Patient ratings of treatment process during a patient-centered brief intervention for alcohol were used to predict post-treatment alcohol use and consequences. We use data from a randomized clinical trial that compared the effects of BI (1 session) to BI and booster (BIB, 2 sessions) to reduce harmful drinking and alcohol consequences. Subjects were n=167 (BI) and n=82 (BIB). Five of the 12 ratings were rated significantly higher by those in the BIB condition compared to BI. The only predictor of reduced alcohol consequences at 12-months was higher ratings of, "I have obtained some new understanding," for BIB participants (t=-2.50, p<.05). Patient perspectives on treatment may have a role in patient outcomes and should be explored as a dimension of treatment process.

Social norms theory-based interventions: testing the feasibility of a purported mechanism of action.

UNLABELLED: Social norms-based interventions targeting college student drinking behaviors have become increasingly popular. Such interventions purportedly modify student misperceptions of fellow student drinking behaviors, which leads to changes in individual drinking behavior. Despite claims of successful interventions, research demonstrating that social norms-based interventions modify student perceptions is lacking. OBJECTIVE: The authors conducted a laboratory experiment examining the feasibility of this mechanism of action and aimed to determine the validity of the campus-specific drinking norms hypothesis. PARTICIPANTS AND METHODS: The authors randomly assigned 60 students to 1 of 3 research conditions: Alcohol 101 (national drinking norms), a didactic presentation of campus specific drinking norms, or a control condition. RESULTS: Both intervention groups modified student misperceptions regarding peer alcohol use, and these changes were sustained 1 week later. CONCLUSIONS: Social norms-based interventions can contribute to more accurate drinking perceptions among college students.

Drinking in the year after treatment as a predictor of three-year drinking outcomes.

OBJECTIVE: Previous research suggests that abstinence from alcohol during the first year posttreatment for alcohol-use disorders (AUDs) is an important, independent predictor of longer-term alcohol consumption and related functioning. The purpose of this study was to test the hypothesis that abstinence during the first year posttreatment initiation predicts alcohol use at Months 37-39. A second aim of this study was to explore the relationship between "moderate" drinking in the first year and drinking at Months 37-39. METHOD: Secondary data analyses were conducted on the outpatient Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) sample (N = 952 at baseline and 802 at Months 37-39). For these analyses, participants were classified first as abstainers, moderate drinkers, or heavy drinkers based on their alcohol use in the first year posttreatment initiation. RESULTS: Analyses of covariance showed that the first-year drinker classification predicted both percentage of days abstinent and drinks per drinking day at Months 37-39. Subsequent analyses showed that the abstainers functioned significantly better than (1) both of the other drinker groups combined and (2) either of the other two groups, which did not differ from each other on either measure of alcohol use. A third set of exploratory analyses evaluated first-year abstinence and heavy drinking as continuous variables and showed an essentially linear relationship between them and drinking at 3 years. CONCLUSIONS: This study confirmed the strong relationship between first-year abstinence and later drinking but did not show that participants who engaged in moderate drinking during the first year had positive alcohol-use outcomes at 3 years. The clinical implications of the findings, their generalizability to different populations of individuals presenting for specialty alcohol treatment, and future research directions are discussed.

Ascertaining the relationships between the trajectories of specific categories of alcohol-related negative consequences and subsequent drinking behavior.

The first year following alcohol use disorder (AUD) treatment has been identified as a period of high risk for relapse and an important timeframe for enquiry regarding alcohol-related behavior change and its maintenance. In addition, at least among individuals with AUD, alcohol use and negative consequences have been shown to be reciprocally related. A commonly used measure of alcohol-related negative consequences is the Drinker Inventory of Consequences (DrInC). Investigations of specific categories of alcohol-related negative consequences and their trajectories, however, have been lacking. Given this background, the purpose of this study was to: follow the course of the 5 DrInC categories of alcohol-related negative consequences over the first year post-AUD treatment initiation; investigate whether these trajectories varied by gender, age, and/or treatment condition; examine the relationships between these trajectories and subsequent drinking behavior; and investigate whether these relationships varied by gender, age, and/or treatment condition, via secondary data analyses. Data from the outpatient arm of Project MATCH (n = 952) were utilized. Study results revealed that the trajectory of each DrInC category was indicative of improved alcohol-related problems across the first year posttreatment initiation. Specific DrInC categories varied as a function of gender, age, and treatment condition, and the trajectories were predictive of subsequent drinking behavior. Specifically, higher intercepts during the treatment period were associated with poorer drinking behavior 1 year later. Alternatively, steeper negative slopes were associated with improved drinking behavior. Some of these relationships were modified by gender, age, and treatment condition. It was concluded that assessing alcohol-related negative consequences during the first year posttreatment initiation period has clinical utility. (PsycINFO Database Record

Can the short index of problems (SIP) be improved? Validity and reliability of the three-month SIP in an emergency department sample.

OBJECTIVE: Although the Short Index of Problems (SIP) is often used, little is known about the psychometric properties of the SIP in special populations. The present study seeks to determine the following: (1) whether it is possible to substitute items to enhance the psychometric properties of the SIP and (2) whether the SIP, or improved scale, is as sensitive as the Drinker Inventory of Consequences (DrInC) to assess intervention effectiveness. METHOD: The sample consisted of 404 injured patients who were treated in the Emergency Department (ED) of a major teaching hospital that serves southern New England. Three approaches were used to guide development of the 3-month SIP-R, the potential alternative to the SIP. Cronbach's alpha assessed intrascale reliability; hierarchical multiple regression assessed construct validity; performance of the scales assessing intervention change were compared to the total 3-month DrInC as a function of intervention using analysis of covariance (ANCOVA). RESULTS: There was no evidence that changing the current SIP items will significantly improve performance. The 3-month SIP performed as well as the 3-month DrInC-2R in predicting 12-month DrInC scores and in determining intervention change at 12 months. Of the 45 DrInC items, 31 also predicted a difference across intervention groups. CONCLUSIONS: These results suggest there is no advantage to changing the current SIP items. The 3-month SIP is a psychometrically sound measure for assessing consequences of alcohol consumption in an ED sample and is almost as sensitive to intervention change as the full DrInC.

Marijuana use and prior injury among injured problem drinkers.

OBJECTIVES: The purpose of this paper is to better understand marijuana use among injured problem drinkers in the emergency department (ED). The specific objectives are: 1) to assess the prevalence of marijuana use; 2) to identify factors associated with marijuana use; 3) to determine whether prior injury is associated with marijuana use; and 4) to determine whether marijuana-using problem drinkers want to change behaviors. METHODS: The authors conducted a post-hoc analysis on data obtained prospectively. Subjects had injury and problem drinking: either measurable alcohol level (blood alcohol concentration, BAC), report of drinking, or an Alcohol Use Disorders Identification Test (AUDIT) score of > or =8. The study was conducted on weekend nights; 3,776 injured ED patients were screened, 383 refused, 578 were enrolled, and 433 had complete data. RESULTS: Of the 433 subjects, 48.3% reported using marijuana in the three months prior. Marijuana-using problem drinkers had more hazardous drinking, higher AUDIT scores (14.0 vs. 11.4, p < 0.001), and higher risk-taking scores (12.4 vs. 10.1, p < 0.001). More used other drugs (69.7% vs. 30.3%, p < 0.001). In regression analyses, marijuana use remained an independent predictor of prior injury (OR = 2.16, 95% CI = 1.25 to 3.75), particularly prior alcohol-related (OR = 2.26, 95% CI = 1.45 to 3.53) and motor-vehicle-related (OR = 1.69, 95% CI = 1.03 to 2.79) injury. Readiness-to-change scores were similar (4.14 vs. 4.22, p = 0.21) between users and nonusers. CONCLUSIONS: Marijuana use among injured problem drinkers is prevalent. Their risk of prior injury is increased. Counseling for alcohol and injury should address marijuana use.

Research fundamentals: follow-up of subjects in clinical trials: addressing subject attrition.

Many published clinical trials have less than adequate follow-up. When conducting a clinical trial, researchers attempt to minimize data loss; however, some data may not be collected, particularly when subjects are lost to follow-up. Careful planning of research protocols, including comprehensive initial data collection, identification of locators, flexible scheduling, systematic subject tracking, monitoring subject loss, and systematically approaching problem cases can ensure high follow-up rates. This article presents a compendium of techniques and procedures that researchers can use to enhance follow-up and address attrition in their studies. Finally, this article outlines statistical techniques that can be used to address the effects of missing data, particularly when patients are lost to follow-up.

The relationship between abstinence for one year following pretreatment assessment and alcohol use and other functioning at two years in individuals presenting for alcohol treatment.

OBJECTIVE: The purpose of this study was to replicate and extend research that shows abstinence from alcohol during the first year following treatment predicts better longer term functioning in alcohol use and other areas. METHOD: The subjects were 187 men and women who had participated in a clinical trial of the differential effectiveness of two behavioral treatments for alcohol problems as a function of subject characteristics. All subjects who participated in this phase of the study were classified as either abstinent from alcohol or not based on their drinking behavior during the first 12 months following treatment initiation. Subjects' alcohol use and other behaviors were evaluated for Months 13-24. The primary dependent variables of interest were alcohol use, self-efficacy, and psychological functioning. RESULTS: A comparison of the two abstinence groups showed that abstainers, compared to drinkers, had less alcohol use, higher self-efficacy, and better psychological functioning. CONCLUSIONS The results suggest the association is robust between abstinence during the first year following treatment initiation or cessation and later functioning, and extend this finding to include psychological functioning. Future research should focus on possible mediators of the abstinence correlations with later behavior that are of theoretical and practical importance, and on specifying gradients of duration of abstinence or other drinking patterns reflecting improvement and their relationship to longer term functioning.

Alcohol treatment research assessment exposure: a critical review of the literature.

Alcohol treatment researchers have speculated about the benefits of research participation (e.g., research follow-up interviews functioning as aftercare) for more than 4 decades (Gallen, 1974). Alternatively, research participation can decrease study design sensitivity and hamper the interpretability of research findings. To the extent that the typical alcohol treatment trial is characterized by frequent and comprehensive data collection, accounting for potential research assessment-related effects is essential for proper interpretation of study findings. Given this background, the purpose of this article is to review the alcohol treatment research literature on assessment exposure resulting in subject reactivity. In addition, interventions that use data collection activities to inform clinical practice are receiving increased attention, and such interventions share common characteristics with research assessment-related clinical improvements. Therefore, a second purpose of this article is to compare and contrast these 2 influences of behavior change. Study findings indicate that during and posttreatment data collection activities (i.e., both research and clinical data) positively influence clinical outcomes, although there appears to be important differences in regard to the mechanisms by which these 2 data collection activities exert their influence. Understanding of mechanisms of behavior change, effect boundaries, and the conditions under which clinical improvement is most likely to occur is only at a rudimentary level.

Collateral informant assessment in alcohol use research involving college students.

OBJECTIVE: This study examined the associations between college students' self-reported alcohol use and corresponding collateral reports and identified factors that influence agreement between both sets of reports. PARTICIPANTS/METHODS: Subject-collateral pairs (N = 300) were recruited from undergraduate psychology courses. RESULTS: Data yielded moderate correlations between subject-collateral pairs for all alcohol use measures, whereas discrepancy analyses revealed a tendency for subjects to report greater alcohol use relative to collateral reports. Greater subject-collateral agreement regarding frequency of subject alcohol use was predicted by a greater frequency of shared drinking occasions between the dyads, lower subject self-reported drug use, and lower levels of collateral guessing, whereas greater correspondence for quantity of alcohol consumed was predicted by fewer subject self-reported alcohol-related negative consequences, lower levels of subject self-reported drug use, and lower levels of alcohol ingestion among collaterals. CONCLUSIONS: College students appear to provide reasonably accurate self-reports of their alcohol use.

Factors mediating the association between drinking in the first year after alcohol treatment and drinking at three years.

OBJECTIVE: Previous research has shown a significant relationship between alcohol consumption in the first year following alcohol treatment admission and longer term functioning. This finding is clinically important and pertains to the clinical course of alcohol-use disorders(AUDs). This study investigated mediators of these relationships, focusing on the first year after treatment admission and alcohol consumption 3 years later. METHOD: Analyses were conducted on the outpatient Project MATCH (Matching Alcohol Treatment to Client Heterogeneity) sample at baseline (N=952) and at Months 37-39 after treatment admission (n=802; hereafter referred to as 3 years). Participants were classified as first-year "abstainer," "moderate drinker," or "heavy drinker." A model featuring three latent variables (psychosocial functioning, self-efficacy, and treatment experiences) whose indicators were collected at 15 months after treatment admission was initially tested for its fit to the data. The 3-year outcomes were percentage of days abstinent and drinks per drinking day. Each model was run on randomly split subsamples and then cross-validated on the remaining participants. RESULTS: Model tests by use of structural equation modeling methods showed poor model fit, owing primarily to problems involving the psychosocial-functioning variable. Consequently, a reduced model was tested that dropped the psychosocial factor. Initial tests of this model showed an excellent fit to the data that replicated across subsamples and 3-year drinking variables at the overall model and individual path levels. There was strong support for the hypothesis that the total effects of first-year alcohol use on 3-year drinking is mediated in part (31% and 23% for the two drinking outcomes) through self-efficacy to abstain from alcohol at 15 months. CONCLUSIONS: First-year posttreatment admission alcohol use predicts longer term (3-year) alcohol use, and a substantial portion of this relationship seems to be mediated through self-efficacy at 15 months to abstain from alcohol use. The apparent benefit of sustained abstinence in the first year may be in part the result of facilitation in the rate or strength of the acquisition of self-efficacy. Discussed are the clinical implications of these findings as well as directions for future research involving longitudinal studies of alcohol use, treatment experiences, psychosocial factors, and their interaction both within the first year and afterward in the determination of the clinical course of alcohol-use disorders.

Alcohol treatment research assessment exposure subject reactivity effects: part I. Alcohol use and related consequences.

OBJECTIVE: There has been increasing recognition among alcohol treatment researchers that research assessment exposure subject reactivity effects can contribute to clinical outcomes, decrease study design sensitivity, and confound research findings. The present study is an experimental investigation of two of the more salient components of the research assessment interview (i.e., frequency and comprehensiveness) and their effects on clinical outcomes (Part I: Alcohol Use and Related Consequences) and treatment participation (Part II: Treatment Engagement and Involvement). METHOD: The study design was a 2 (Frequency of Assessment) x 2 (Comprehensiveness of Assessment) completely randomized factorial, and study participants were randomly assigned, using an urn randomization procedure, to one of the resulting four experimental research assessment exposure conditions: (1) frequent-comprehensive, (2) frequent-brief, (3) infrequent-comprehensive, and (4) infrequent-brief. Study participants were recruited from one of two hospital-based outpatient alcohol- and other substance-abuse clinics. Two hundred thirty-five subjects were randomly assigned to one of the four research assessment exposure conditions. RESULTS: Research assessment exposure subject reactivity effects were related significantly to alcohol use and related negative consequences, such that subjects assigned to the infrequent-brief research assessment exposure condition reported the poorest outcomes. CONCLUSIONS: The research protocols used to study alcohol treatments have clinical efficacy and can alter the outcomes (e.g., alcohol use) under investigation. It is important for researchers to control/account for subject reactivity effects when conducting alcohol treatment outcome trials. Accurate interpretation of data derived from clinical trials of alcohol treatments necessitates taking research assessment exposure subject reactivity effects into consideration.

Alcohol treatment research assessment exposure subject reactivity effects: part II. Treatment engagement and involvement.

OBJECTIVE: This is the second of two articles in this issue on participant reactivity to alcohol treatment research assessment protocols. In the first article, Clifford et al. presented experimental evidence that the combination of less frequent and less comprehensive assessment results in the least assessment reactivity, as measured by alcohol use and related consequences at 1 year after admission for adult outpatient treatment for alcohol problems. In addition, Part I revealed that the presence of either frequent or comprehensive research assessment tends to result in a greater degree of reactivity. This article extends the analyses by Clifford et al. to treatment for substance use-disorders engagement and involvement across a 1-year follow-up. METHOD: The design, participants, and procedures were identical to those described in Clifford et al. Treatment data were obtained from hospital records and participants' self-reports as part of the Timeline Followback interview. RESULTS: Analyses revealed several effects of frequency of assessment and comprehensiveness of assessment on treatment engagement or involvement. The reactivity effect observed varied with the dependent variable, which included if a participant presented for outpatient treatment (more likely in the comprehensive groups), the number of days of outpatient substance use-disorders treatment during follow-up (no reactivity effects), if a participant engaged in intensive treatment for substance-use disorders during follow-up (more likely for the frequent groups in Months 1-6, but the reverse in Months 7-12, and overall more likely in the brief conditions), and the number of days of intensive treatment for substance-use disorders during follow-up (more days in the frequent groups in Months 1-6, no frequency differences in Months 7-12, and overall more days in the brief groups), respectively. Additional analyses showed that treatment participation did not mediate the reactivity effects on alcohol use and related consequences reported by Clifford et al. CONCLUSIONS: Data provide experimental evidence for a causal relationship between frequency of assessment and comprehensiveness of assessment on substance abuse-treatment engagement and involvement. Future research should be directed at understanding the factors in the assessment process that determine reactivity effects.