Vol.4. pp. 409 to 413 ,~ PcrgamonPrcssLid 1979.Printedin Great Britain
0306-4603/79/I 101-0409502.00/0
Addictice Behaviors.
A COMPARISON OF QUESTIONNAIRE AND S E L F - M O N I T O R E D REPORTS O F A L C O H O L INTAKE IN A N O N A L C O H O L I C P O P U L A T I O N DEBORAH C. UCHALIK* Department of Psychiatry, University of California at Los Angeles Abstract--Alcohol use assessment research focused in the past on alcoholic populations, making generalization of similar procedures to non-alcoholic samples questionable at best. In the present study, questionnaire and self-monitoring approaches were employed to measure alcohol consumption in a college student sample. Comparison of the two methods, with each other and with subjects' retrospective estimates of drinking, revealed considerable discrepancies. Implications of these findings are discussed with emphasis on research to determine and improve the validity of measurement of drinking behavior in non-alcoholics.
The measurement of alcohol intake in normal and alcoholic populations represents an important assessment issue because amount of alcohol consumption serves as one criterion for the recognition and diagnosis of alcohol abuse and of recovery from alcoholism. Questionnaires (Selzer, 1971) and structured (Marlatt, 1976) and general interviews (Sobell & Sobell, 1976) have been utilized as alcohol assessment techniques. Although a number of studies have examined the validity of these procedures for assessing alcohol use (Miller, 1976; Murphy, 1956; Sobell & Sobell, 1975), validation research has focused primarily on alcoholic populations. This approach calls into question the validity of these same assessment approaches for detecting potential problem drinkers in nonalcoholic groups. Indeed, most alcoholism assessment instruments were not designed for this purpose at all. Nevertheless, assessment of excessive alcohol use in non-alcoholic individuals is an important clinical undertaking because knowledge of aberrant drinking patterns could facilitate the implementation of early intervention procedures. In this manner, some of the detrimental physical and psychological consequences which accompany chronic alcohol abuse might be alleviated. In the special case of pregnant women, for whom alcohol abuse has been associated with poor health and developmental retardation in the unborn child (Streissguth, 1976), knowledge of alcohol use could facilitate prevention of such deficits. Assessment of alcohol abuse in non-chronically addicted persons would differ of necessity from approaches whose purpose is to diagnose alcoholism. One dimension which might be expected to differ between chronic alcoholics and early alcohol abusers is awareness of drinking behavior. Alcoholics, because of long-term experience with drinking and with reactions to their alcohol abuse from individuals in their environment, may consequently be more aware of their alcohol use. Furthermore, chronic alcoholics may be involved in several treatment programs. Awareness of alcohol consumption is thus further reinforced through repeated exposure to questionnaires and interviews which examine drinking practices. However, in the case of the person for whom alcohol abuse is not a well developed behavior pattern, drinking may be more surreptitious and, as a result, environmental consequences may be less notable. Thus, the less experienced drinker has neither the benefit of treatment experiences nor of reactions from the environment to facilitate awareness of maladaptive drinking behaviors. One potentially valuable means of assessing alcohol use and of increasing awareness of alcohol intake is through self-monitoring (SM). Self-monitoring has been used extensively in the assessment of ingestive behaviors (i.e. smoking, eating) (Bellack & Schwartz, 1976). However, the use of SM to measure alcohol intake has been restricted to a *Send reprint requests to Deborah C. Uchalik, Department of Psychiatry, University of California at Los Angeles, Neuropsychiatric Institute, Los Angeles, CA 90024, U.S.A. 409
410
DEBORAH C. UCHALIK
few programs involved in behaviorally oriented outpatient treatment of alcoholics with a controlled drinking goal (Miller, 1972; Sobell & Sobell, 1973). There are several advantages to the SM assessment approach. As an assessment procedure, SM allows behaviors of interest to be specified and immediately recorded. Thus, estimates of alcohol intake may be less distorted by events subsequent to drinking and by alcohol's state dependent effects on memory (Overton, 1968). Furthermore, it has been noted that SM not only increases awareness of drinking and of stimuli associated with alcohol use, but that such awareness facilitates early detection of problem drinking episodes in alcoholic outpatient populations (Sobell & Sobell, 1973). Finally, the SM record may be modified to include specific stimuli that may occur antecedent to or following drinking, thus providing additional information about patterns of alcohol use. In the present study, the utility of SM as a technique for assessing alcohol use was examined with a non-alcoholic sample. Of particular interest were the ease and feasibility of using this procedure and the frequency of drinking behaviors which subjects would be willing and able to record. In addition, because questionnaires or interview data regarding alcohol use are utilized in clinical settings, frequency of alcohol use was obtained through a questionnaire both prior and subsequent to self-monitoring. Both sets of questionnaire data were compared with the SM records to examine the degree of agreement between the two assessment procedures. Finally, questionnaire data were compared across time to assess the potential of SM for producing changes in selfreported drinking frequencies. METHOD Subjects were 32 female and 26 male undergraduate and graduate level psychology students ranging in age from 19 to 33 yr (X = 21.5 yr). Subjects were recruited through posters requesting volunteers to record daily alcohol and caffeine use for a study of common drug use patterns. Subjects' drinking practices, according to Cahalan & Cisin (1968) were as follows: a b s t a i n e r s ~ , light users--6, moderate users--32, heavy users--20. Each subject participated in an initial group session. At this time subjects were administered a questionnaire requesting information about weekly alcohol and caffeine use over the previous 3-month period. The questions read as follows: "In the past 3 months, what is the number of (a) drinks (beer, wine, mixed drinks), (b) cups of coffee, that you usually had in one week's time?" The reference amounts indicated below for the self-monitoring procedure were specified. General biographical data were also gathered. The self-monitoring procedure was described in detail to subjects, and verbal and written reference information concerning quantities to be recorded was provided. Subjects were requested to record each incidence of alcohol or caffeine intake as described in the reference key after consumption on a prepared form, Subjects placed one tally mark for each 8 oz serving of coffee or tea or 8-12 oz serving of cola drinks. For alcoholic beverages, 8 oz of beer, 4 oz of wine, or 1 oz of distilled liquor were recorded. Cards (3 x 5) printed with the hour of the day and beverage name were provided for this purpose. Each person received a set of 7 cards to be used for 1 week of self-monitoring. Subjects reported back at 1 week intervals to return data, discuss problems, and obtain new record cards. A follow-up session was conducted one month after completion of the last week of monitoring. At this time, subjects again filled out the initial drug use questionnaire. In addition, subjects were asked to specifically report their alcohol intake, by beverage, for each week of the SM period. Comments about difficulties with the SM procedure and changes in drinking during the study period were made at this time. RESULTS Twenty-four subjects, 12 females and 12 males, completed 3 weeks of SM. An additional 29 subjects recorded their beverage intake for a 2-week period. Follow-up data
Questionnaire and self-monitored reports of alcohol intake
411
were obtained for 23 subjects. Subjects composing this latter group tended to be younger (X = 20.5 yr) and to consume more alcohol per week on the average (X = 20.1 drinks/ week) than the remainder of the sample (X = 22.5 yr; 13.8 drinks/week). Recorded alcohol use ranged from 0 to 112.5 drinks per week. Average alcohol intake for the 3-week period ranged from 2 to 91 incidences of alcohol consumption per week. Caffeine data will be presented in another paper. Questionnaire estimates of weekly alcohol use obtained prior to self-monitoring were compared with average weekly self-monitored alcohol consumption using two-tailed t-tests for dependent measures for all subjects. A significant difference was observed between questionnaire and recorded frequencies (t = -3.09; P < 0.01). Likewise, questionnaire reports of alcohol intake obtained after SM differed from average self-monitored weekly alcohol use (t = 2.6; P < 0.02). A comparison of pre-monitoring data with retrospective estimates of self-monitored drinking revealed that average weekly alcohol intake estimates did change over time (t = 2.22; P < 0.05), with follow-up responses being lower than initial reports. These findings indicate that subjects' recorded drinking behavior differed from retrospective questionnaire estimates of average alcohol use for a specific time period. Thus, the initial discrepancy observed between pre-monitoring questionnaire data and SM reports of alcohol intake continued to occur even after subjects had kept track of their drinking. ALCOHOL CONSUMPTION ~
2O 18.8
~'=: 16 -~"o 14
o~ ~ ~ " ~ 4
o/t~'Esfimated 10.6
I 1
I 2
I 5
Weeks Fig. 1. Mean self-monitored and retrospective estimates of weekly alcohol consumption.
Examination of the direction of estimation discrepancy between questionnaire and SM data, for the most part, indicated that both pre-SM estimates and retrospective estimates of SM drinking were lower than recorded drinking. Eighty-five per cent (85Y/o) of pre-SM and 72Y/oof post-SM questionnaires followed this pattern. In addition, amount of alcohol intake recorded was found to be significantly related to the discrepancy between actual and self-reported intake (r = 0.908). Thus, the more alcohol subjects purported to consume in their SM reports, the .greater was the difference between their recorded and reported drinking. Comparison of subjects' retrospective estimates of alcohol use for each week of the recording period with SM frequencies revealed that the two assessment procedures differed for the 1st week of recording (t = -2.96; P < 0.01). However, these differences were only marginally significant for the 2nd (t = 1.48; P < 0.1) and 3rd (t = 1.59; P < 0.1) weeks of self-monitoring (see Fig. 1). Thus, when subjects were asked about alcohol use for a specific time period in which they had recorded their drinking behavior, retrospective estimates appeared to increase in agreement with recorded data over time. DISCUSSION
The present study supports the potential utility of self-monitoring as a method of assessing alcohol intake in a non-clinical drinking population. Subjects indicated that the recording process was easily executed and nonaversive. The range of drinking frequencies recorded, 0-112 per week, indicates that subjects will record multiple occurrences of drinking behavior. Differences were observed between self-monitored alcohol
412
DEBORAH C. UCHALIK
use and prospective and retrospective estimates of self-monitored drinking. However, these findings should be interpreted with caution because of the limited number of subjects (39%) composing the follow-up group and the specific pattern of alcohol use which characterized this sample. The comparison of questionnaire and SM data suggest several factors which may influence the validity of these procedures for alcohol use assessment. First, differences in questionnaire items with respect to the specific, temporal framework over which drinking behavior was to be recalled (i.e. average weekly intake vs exact frequency), could have contributed to greater agreement between SM and retrospective reports. The fact that the initial questionnaire required subjects to estimate alcohol use over a 3-month period compared with a 1 month reference in the post self-monitoring questionnaire may have enhanced accuracy in the latter case. Likewise, pre- and post-monitoring questionnaires examined recall of average drinking frequency while self-monitoring required specific daily alcohol use recording. Some of the discrepancy between selfmonitored and self-report data may have been due to variations in instructions. Although the degree of agreement between SM and subsequent weekly retrospective estimates of alcohol use appeared to increase as SM progressed, the extent to which the SM process itself by increasing awareness of drinking behavior, or the questionnaire makeup contributed to this effect is uncertain. Validation of SM reports with corroborative sources would aid in resolving this issue. A second consideration in establishing the validity of SM as an alcohol use assessment technique relates to the relationship between amount of alcohol intake and subjects' ability and/or willingness to report drinking. The discrepancy between SM alcohol use and follow-up reports of the same varied directly with the number of drinks recorded. Thus, the heaviest drinkers exhibited the largest differences between the self-report and SM drinking. This effect might be accounted for in part by the greater error range possible in retrospective reports of higher frequency drinkers. However, it should also be noted that because alcohol is a drug with state-dependent learning effects (Overton, 1968), intoxicated individuals might have greater difficulty in recalling drug influenced behavior in the sober state. In addition, factors such as social, cultural, and sex role proscriptions may influence attitudes toward alcohol use (Gomberg, 1976), and consequently willingness to report drinking behavior may vary. Thus, social desirability may influence accounts of drinking or motivation to record such behaviors. The relationship of frequency of alcohol use, number of drinks per occasion, variability of drinking patterns and social desirability to accuracy of SM reports of drinking should be addressed in future studies of this nature. Among the populations for which SM may be employed in alcohol use assessment are clients in outpatient counseling settings. Past research has indicated that excessive drinking often accompanies anxiety (Menaker, 1967), depression (Rosenberg, 1969), mania (Reich et al., 1974), and suicide (Pitts & Winokur, 1966). For the emotionally disturbed client, perhaps minimally aware of alcohol's depressant drug interactions, the combination of alcohol with psychotropic medication may provide one avenue for accidental or intended suicide. In addition, extended alcohol use as a coping strategy may promote the development of tolerance and physical dependence on alcohol. Thus, awareness of alcohol use by the therapist is certainly indicated. Self-monitoring of alcohol use in conjunction with other behaviors may provide one means of assessing drinking in clinical settings. Self-monitoring of alcohol use also deserves consideration as an assessment technique in alcoholism prevention programs. Although data are lacking on the characteristics of drinking which are likely to develop into alcoholism, SM may provide a means of measuring frequency related variables in a number of target samples, such as homemakers, industrial workers and high school and college students. To summarize, research examining the assessment of alcohol use in nonalcoholic samples has been lacking. The present study utilized questionnaire and self-monitoring methods to measure drinking in a group of normal drinkers. While the SM procedure
Questionnaire and self-monitored reports of alcohol intake
413
holds promise as a means of assessing alcohol use, discrepancies in reported frequencies across assessment techniques, and the drinking practices characteristic of the sample studied, suggest that the validity of SM for recording alcohol use and related factors such as social desirability and amount of alcohol consumed which could affect reports of drinking, should receive attention in future studies. Acknowledgement The author expresses her appreciation to Stephen Haynes for his valuable comments made on an earlier draft of this paper. REFERENCES Bellack, A. S. & Schwartz, J. S. Assessment for self-control programs. In M. Hersen & A. Bellack (Eds) Behavior Assessment, A Practical Handbook. New York: Pergamon, 1976. Cahalan, D. & Cisin, I. H. American drinking practices: summary of findings from a national probability sample I. Extent of drinking by population subgroups. Quarterly Journal of Studies on Alcohol, 1968, 29, 130-151. Gomberg, E. S. The female alcoholic. In R. E. Tarter & A. A. Sugerman (Eds) Alcoholism: Interdisciplinary Approaches to an Enduring Problem. Reading, MA: Addison-Wesley, 1976. Marlatt, G. A. The drinking profile: a questionnaire for the behavioral assessment of alcoholism. In E. J. Marsh & L. G. Terdal (Eds) Behavior Therapy Assessment: Diagnosis, Design, and Evaluation. New York: Springer, 1976. Menaker, T. Anxiety about drinking in alcoholics. Journal of Abnormal Psychology, 1967, 72, ~43-59. Miller, P. M. The use of behavioral contracting in the treatment of alcoholism: a case report. Behavior Therapy, 1972, 3, 593-596. Miller, W. R. Alcoholism scales and objective assessment methods: a review. Psychological Bulletin, 1976, 83, 649-674. a'~Iurphy, D. G. The revalidation of diagnostic tests for alcohol addiction. Journal of Consulting and Clinical Psychology, 1956, 20, 301 304. Overton, D. A. Dissociated learning in drug states. In D. H. Efron (Ed.) Psychopharmacology: A Review of Progress 1957-1967. PHS Publication No. 1836. Washington, DC: U.S. Government Printing Office, 1968. Pitts, F. & Winokur, G. Affective disorder--VII: Alcoholism and affective disorder. Journal of Psychiatric Research, 1966, 4, 37-50. Reich, L. H., Davies, R. K. & Himmelhoch, J. M. Excessive alcohol use in manic-depressive illness. American Journal of Psychiatry, 1974, 131, 83-86. Rosenberg, C. N. Young alcoholics. British Journal of Psychiatry, 1969, 115, 181-188. Seizer, M. L. The Michigan Alcoholism Screening Test: the quest for a new diagnostic instrument. Archives of General Psychiatry, 1971, 127, 1653-1658. Sobell, M. B. & Sobell, L. C. Alcoholics treated by individualized behavior therapy: one-year treatment outcome. Behavior Research and Therapy, 1973, 11, 599-618. Sobell, L. C. & Sobell, M. B. Outpatient alcoholics give valid self-reports. Journal of Nervous and Mental Disease, 1975, 161, 32-42. Sobell, M. B. & Sobell, L. C. Second-year treatment outcome of alcoholics treated by individualized behavior therapy: results. Behavior Research & Therapy, 1976, 14, 195-215. Streissguth, A. P. Psychologic handicaps in children with the fetal alcohol syndrome. Annals of New York Academy of Sciences, 1976, 273, 140-145.
0306-4603/79/I 101-0409502.00/0
Addictice Behaviors.
A COMPARISON OF QUESTIONNAIRE AND S E L F - M O N I T O R E D REPORTS O F A L C O H O L INTAKE IN A N O N A L C O H O L I C P O P U L A T I O N DEBORAH C. UCHALIK* Department of Psychiatry, University of California at Los Angeles Abstract--Alcohol use assessment research focused in the past on alcoholic populations, making generalization of similar procedures to non-alcoholic samples questionable at best. In the present study, questionnaire and self-monitoring approaches were employed to measure alcohol consumption in a college student sample. Comparison of the two methods, with each other and with subjects' retrospective estimates of drinking, revealed considerable discrepancies. Implications of these findings are discussed with emphasis on research to determine and improve the validity of measurement of drinking behavior in non-alcoholics.
The measurement of alcohol intake in normal and alcoholic populations represents an important assessment issue because amount of alcohol consumption serves as one criterion for the recognition and diagnosis of alcohol abuse and of recovery from alcoholism. Questionnaires (Selzer, 1971) and structured (Marlatt, 1976) and general interviews (Sobell & Sobell, 1976) have been utilized as alcohol assessment techniques. Although a number of studies have examined the validity of these procedures for assessing alcohol use (Miller, 1976; Murphy, 1956; Sobell & Sobell, 1975), validation research has focused primarily on alcoholic populations. This approach calls into question the validity of these same assessment approaches for detecting potential problem drinkers in nonalcoholic groups. Indeed, most alcoholism assessment instruments were not designed for this purpose at all. Nevertheless, assessment of excessive alcohol use in non-alcoholic individuals is an important clinical undertaking because knowledge of aberrant drinking patterns could facilitate the implementation of early intervention procedures. In this manner, some of the detrimental physical and psychological consequences which accompany chronic alcohol abuse might be alleviated. In the special case of pregnant women, for whom alcohol abuse has been associated with poor health and developmental retardation in the unborn child (Streissguth, 1976), knowledge of alcohol use could facilitate prevention of such deficits. Assessment of alcohol abuse in non-chronically addicted persons would differ of necessity from approaches whose purpose is to diagnose alcoholism. One dimension which might be expected to differ between chronic alcoholics and early alcohol abusers is awareness of drinking behavior. Alcoholics, because of long-term experience with drinking and with reactions to their alcohol abuse from individuals in their environment, may consequently be more aware of their alcohol use. Furthermore, chronic alcoholics may be involved in several treatment programs. Awareness of alcohol consumption is thus further reinforced through repeated exposure to questionnaires and interviews which examine drinking practices. However, in the case of the person for whom alcohol abuse is not a well developed behavior pattern, drinking may be more surreptitious and, as a result, environmental consequences may be less notable. Thus, the less experienced drinker has neither the benefit of treatment experiences nor of reactions from the environment to facilitate awareness of maladaptive drinking behaviors. One potentially valuable means of assessing alcohol use and of increasing awareness of alcohol intake is through self-monitoring (SM). Self-monitoring has been used extensively in the assessment of ingestive behaviors (i.e. smoking, eating) (Bellack & Schwartz, 1976). However, the use of SM to measure alcohol intake has been restricted to a *Send reprint requests to Deborah C. Uchalik, Department of Psychiatry, University of California at Los Angeles, Neuropsychiatric Institute, Los Angeles, CA 90024, U.S.A. 409
410
DEBORAH C. UCHALIK
few programs involved in behaviorally oriented outpatient treatment of alcoholics with a controlled drinking goal (Miller, 1972; Sobell & Sobell, 1973). There are several advantages to the SM assessment approach. As an assessment procedure, SM allows behaviors of interest to be specified and immediately recorded. Thus, estimates of alcohol intake may be less distorted by events subsequent to drinking and by alcohol's state dependent effects on memory (Overton, 1968). Furthermore, it has been noted that SM not only increases awareness of drinking and of stimuli associated with alcohol use, but that such awareness facilitates early detection of problem drinking episodes in alcoholic outpatient populations (Sobell & Sobell, 1973). Finally, the SM record may be modified to include specific stimuli that may occur antecedent to or following drinking, thus providing additional information about patterns of alcohol use. In the present study, the utility of SM as a technique for assessing alcohol use was examined with a non-alcoholic sample. Of particular interest were the ease and feasibility of using this procedure and the frequency of drinking behaviors which subjects would be willing and able to record. In addition, because questionnaires or interview data regarding alcohol use are utilized in clinical settings, frequency of alcohol use was obtained through a questionnaire both prior and subsequent to self-monitoring. Both sets of questionnaire data were compared with the SM records to examine the degree of agreement between the two assessment procedures. Finally, questionnaire data were compared across time to assess the potential of SM for producing changes in selfreported drinking frequencies. METHOD Subjects were 32 female and 26 male undergraduate and graduate level psychology students ranging in age from 19 to 33 yr (X = 21.5 yr). Subjects were recruited through posters requesting volunteers to record daily alcohol and caffeine use for a study of common drug use patterns. Subjects' drinking practices, according to Cahalan & Cisin (1968) were as follows: a b s t a i n e r s ~ , light users--6, moderate users--32, heavy users--20. Each subject participated in an initial group session. At this time subjects were administered a questionnaire requesting information about weekly alcohol and caffeine use over the previous 3-month period. The questions read as follows: "In the past 3 months, what is the number of (a) drinks (beer, wine, mixed drinks), (b) cups of coffee, that you usually had in one week's time?" The reference amounts indicated below for the self-monitoring procedure were specified. General biographical data were also gathered. The self-monitoring procedure was described in detail to subjects, and verbal and written reference information concerning quantities to be recorded was provided. Subjects were requested to record each incidence of alcohol or caffeine intake as described in the reference key after consumption on a prepared form, Subjects placed one tally mark for each 8 oz serving of coffee or tea or 8-12 oz serving of cola drinks. For alcoholic beverages, 8 oz of beer, 4 oz of wine, or 1 oz of distilled liquor were recorded. Cards (3 x 5) printed with the hour of the day and beverage name were provided for this purpose. Each person received a set of 7 cards to be used for 1 week of self-monitoring. Subjects reported back at 1 week intervals to return data, discuss problems, and obtain new record cards. A follow-up session was conducted one month after completion of the last week of monitoring. At this time, subjects again filled out the initial drug use questionnaire. In addition, subjects were asked to specifically report their alcohol intake, by beverage, for each week of the SM period. Comments about difficulties with the SM procedure and changes in drinking during the study period were made at this time. RESULTS Twenty-four subjects, 12 females and 12 males, completed 3 weeks of SM. An additional 29 subjects recorded their beverage intake for a 2-week period. Follow-up data
Questionnaire and self-monitored reports of alcohol intake
411
were obtained for 23 subjects. Subjects composing this latter group tended to be younger (X = 20.5 yr) and to consume more alcohol per week on the average (X = 20.1 drinks/ week) than the remainder of the sample (X = 22.5 yr; 13.8 drinks/week). Recorded alcohol use ranged from 0 to 112.5 drinks per week. Average alcohol intake for the 3-week period ranged from 2 to 91 incidences of alcohol consumption per week. Caffeine data will be presented in another paper. Questionnaire estimates of weekly alcohol use obtained prior to self-monitoring were compared with average weekly self-monitored alcohol consumption using two-tailed t-tests for dependent measures for all subjects. A significant difference was observed between questionnaire and recorded frequencies (t = -3.09; P < 0.01). Likewise, questionnaire reports of alcohol intake obtained after SM differed from average self-monitored weekly alcohol use (t = 2.6; P < 0.02). A comparison of pre-monitoring data with retrospective estimates of self-monitored drinking revealed that average weekly alcohol intake estimates did change over time (t = 2.22; P < 0.05), with follow-up responses being lower than initial reports. These findings indicate that subjects' recorded drinking behavior differed from retrospective questionnaire estimates of average alcohol use for a specific time period. Thus, the initial discrepancy observed between pre-monitoring questionnaire data and SM reports of alcohol intake continued to occur even after subjects had kept track of their drinking. ALCOHOL CONSUMPTION ~
2O 18.8
~'=: 16 -~"o 14
o~ ~ ~ " ~ 4
o/t~'Esfimated 10.6
I 1
I 2
I 5
Weeks Fig. 1. Mean self-monitored and retrospective estimates of weekly alcohol consumption.
Examination of the direction of estimation discrepancy between questionnaire and SM data, for the most part, indicated that both pre-SM estimates and retrospective estimates of SM drinking were lower than recorded drinking. Eighty-five per cent (85Y/o) of pre-SM and 72Y/oof post-SM questionnaires followed this pattern. In addition, amount of alcohol intake recorded was found to be significantly related to the discrepancy between actual and self-reported intake (r = 0.908). Thus, the more alcohol subjects purported to consume in their SM reports, the .greater was the difference between their recorded and reported drinking. Comparison of subjects' retrospective estimates of alcohol use for each week of the recording period with SM frequencies revealed that the two assessment procedures differed for the 1st week of recording (t = -2.96; P < 0.01). However, these differences were only marginally significant for the 2nd (t = 1.48; P < 0.1) and 3rd (t = 1.59; P < 0.1) weeks of self-monitoring (see Fig. 1). Thus, when subjects were asked about alcohol use for a specific time period in which they had recorded their drinking behavior, retrospective estimates appeared to increase in agreement with recorded data over time. DISCUSSION
The present study supports the potential utility of self-monitoring as a method of assessing alcohol intake in a non-clinical drinking population. Subjects indicated that the recording process was easily executed and nonaversive. The range of drinking frequencies recorded, 0-112 per week, indicates that subjects will record multiple occurrences of drinking behavior. Differences were observed between self-monitored alcohol
412
DEBORAH C. UCHALIK
use and prospective and retrospective estimates of self-monitored drinking. However, these findings should be interpreted with caution because of the limited number of subjects (39%) composing the follow-up group and the specific pattern of alcohol use which characterized this sample. The comparison of questionnaire and SM data suggest several factors which may influence the validity of these procedures for alcohol use assessment. First, differences in questionnaire items with respect to the specific, temporal framework over which drinking behavior was to be recalled (i.e. average weekly intake vs exact frequency), could have contributed to greater agreement between SM and retrospective reports. The fact that the initial questionnaire required subjects to estimate alcohol use over a 3-month period compared with a 1 month reference in the post self-monitoring questionnaire may have enhanced accuracy in the latter case. Likewise, pre- and post-monitoring questionnaires examined recall of average drinking frequency while self-monitoring required specific daily alcohol use recording. Some of the discrepancy between selfmonitored and self-report data may have been due to variations in instructions. Although the degree of agreement between SM and subsequent weekly retrospective estimates of alcohol use appeared to increase as SM progressed, the extent to which the SM process itself by increasing awareness of drinking behavior, or the questionnaire makeup contributed to this effect is uncertain. Validation of SM reports with corroborative sources would aid in resolving this issue. A second consideration in establishing the validity of SM as an alcohol use assessment technique relates to the relationship between amount of alcohol intake and subjects' ability and/or willingness to report drinking. The discrepancy between SM alcohol use and follow-up reports of the same varied directly with the number of drinks recorded. Thus, the heaviest drinkers exhibited the largest differences between the self-report and SM drinking. This effect might be accounted for in part by the greater error range possible in retrospective reports of higher frequency drinkers. However, it should also be noted that because alcohol is a drug with state-dependent learning effects (Overton, 1968), intoxicated individuals might have greater difficulty in recalling drug influenced behavior in the sober state. In addition, factors such as social, cultural, and sex role proscriptions may influence attitudes toward alcohol use (Gomberg, 1976), and consequently willingness to report drinking behavior may vary. Thus, social desirability may influence accounts of drinking or motivation to record such behaviors. The relationship of frequency of alcohol use, number of drinks per occasion, variability of drinking patterns and social desirability to accuracy of SM reports of drinking should be addressed in future studies of this nature. Among the populations for which SM may be employed in alcohol use assessment are clients in outpatient counseling settings. Past research has indicated that excessive drinking often accompanies anxiety (Menaker, 1967), depression (Rosenberg, 1969), mania (Reich et al., 1974), and suicide (Pitts & Winokur, 1966). For the emotionally disturbed client, perhaps minimally aware of alcohol's depressant drug interactions, the combination of alcohol with psychotropic medication may provide one avenue for accidental or intended suicide. In addition, extended alcohol use as a coping strategy may promote the development of tolerance and physical dependence on alcohol. Thus, awareness of alcohol use by the therapist is certainly indicated. Self-monitoring of alcohol use in conjunction with other behaviors may provide one means of assessing drinking in clinical settings. Self-monitoring of alcohol use also deserves consideration as an assessment technique in alcoholism prevention programs. Although data are lacking on the characteristics of drinking which are likely to develop into alcoholism, SM may provide a means of measuring frequency related variables in a number of target samples, such as homemakers, industrial workers and high school and college students. To summarize, research examining the assessment of alcohol use in nonalcoholic samples has been lacking. The present study utilized questionnaire and self-monitoring methods to measure drinking in a group of normal drinkers. While the SM procedure
Questionnaire and self-monitored reports of alcohol intake
413
holds promise as a means of assessing alcohol use, discrepancies in reported frequencies across assessment techniques, and the drinking practices characteristic of the sample studied, suggest that the validity of SM for recording alcohol use and related factors such as social desirability and amount of alcohol consumed which could affect reports of drinking, should receive attention in future studies. Acknowledgement The author expresses her appreciation to Stephen Haynes for his valuable comments made on an earlier draft of this paper. REFERENCES Bellack, A. S. & Schwartz, J. S. Assessment for self-control programs. In M. Hersen & A. Bellack (Eds) Behavior Assessment, A Practical Handbook. New York: Pergamon, 1976. Cahalan, D. & Cisin, I. H. American drinking practices: summary of findings from a national probability sample I. Extent of drinking by population subgroups. Quarterly Journal of Studies on Alcohol, 1968, 29, 130-151. Gomberg, E. S. The female alcoholic. In R. E. Tarter & A. A. Sugerman (Eds) Alcoholism: Interdisciplinary Approaches to an Enduring Problem. Reading, MA: Addison-Wesley, 1976. Marlatt, G. A. The drinking profile: a questionnaire for the behavioral assessment of alcoholism. In E. J. Marsh & L. G. Terdal (Eds) Behavior Therapy Assessment: Diagnosis, Design, and Evaluation. New York: Springer, 1976. Menaker, T. Anxiety about drinking in alcoholics. Journal of Abnormal Psychology, 1967, 72, ~43-59. Miller, P. M. The use of behavioral contracting in the treatment of alcoholism: a case report. Behavior Therapy, 1972, 3, 593-596. Miller, W. R. Alcoholism scales and objective assessment methods: a review. Psychological Bulletin, 1976, 83, 649-674. a'~Iurphy, D. G. The revalidation of diagnostic tests for alcohol addiction. Journal of Consulting and Clinical Psychology, 1956, 20, 301 304. Overton, D. A. Dissociated learning in drug states. In D. H. Efron (Ed.) Psychopharmacology: A Review of Progress 1957-1967. PHS Publication No. 1836. Washington, DC: U.S. Government Printing Office, 1968. Pitts, F. & Winokur, G. Affective disorder--VII: Alcoholism and affective disorder. Journal of Psychiatric Research, 1966, 4, 37-50. Reich, L. H., Davies, R. K. & Himmelhoch, J. M. Excessive alcohol use in manic-depressive illness. American Journal of Psychiatry, 1974, 131, 83-86. Rosenberg, C. N. Young alcoholics. British Journal of Psychiatry, 1969, 115, 181-188. Seizer, M. L. The Michigan Alcoholism Screening Test: the quest for a new diagnostic instrument. Archives of General Psychiatry, 1971, 127, 1653-1658. Sobell, M. B. & Sobell, L. C. Alcoholics treated by individualized behavior therapy: one-year treatment outcome. Behavior Research and Therapy, 1973, 11, 599-618. Sobell, L. C. & Sobell, M. B. Outpatient alcoholics give valid self-reports. Journal of Nervous and Mental Disease, 1975, 161, 32-42. Sobell, M. B. & Sobell, L. C. Second-year treatment outcome of alcoholics treated by individualized behavior therapy: results. Behavior Research & Therapy, 1976, 14, 195-215. Streissguth, A. P. Psychologic handicaps in children with the fetal alcohol syndrome. Annals of New York Academy of Sciences, 1976, 273, 140-145.
