Attitudes toward standardized assessment among individuals who use substances

Abstract Standardized assessment and progress monitoring are an important part of evidence-based practice. Despite efforts to embed standardized assessments into routine practice, they remain underutilized by practitioners. This underutilization has been attributed to a variety of factors, one of which is the concern that standardized assessments are a burden for individuals to complete. This study sought to gather the first descriptive data on substance users’ attitudes toward the use of standardized assessments as part of an initial assessment and for progress monitoring. Seventy-one Australian substance-using individuals (54.9% male) recruited via online forums, practitioner networks, and advertisements placed in relevant treatment services completed an online survey. The majority of substance-using individuals believed standardized initial assessment and progress monitoring measures to be beneficial to fill out, not burdensome, and valuable in monitoring treatment progress. Individuals would also prefer to choose the administration format of assessment (e.g. computer, mobile device, pencil-and-paper). Findings challenge the assumption that including standardized assessments in routine practice will be considered too burdensome by individuals who use substances, and offer insights that can inform patient-centred implementation.


Introduction
Globally, the majority of life lost due to mental disorders is attributable to substance use disorders (SUDs; Whiteford et al. 2013).There are a variety of evidence-based treatments for SUDs (e.g.cognitive behavior therapy) that can significantly improve outcomes for patients who receive them (Magill and Ray 2009).Evidence-based treatment forms one part of evidence-based practice (EBP).The other is evidence-based assessment (EBA), which involves using reliable, standardized instruments (e.g.validated questionnaires) to gather information about patients to inform the provision of treatment (APA Presidential Task Force on Evidence-Based Practice 2006; Institute of Medicine (US) Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders 2006; Substance Abuse and Mental Health Services Association [SAMHSA] 2008; Gullo et al. 2015;Connor et al. 2016;Achenbach et al. 2017).Assessment findings inform the provision of treatment.

Utility of standardized assessments
The use of standardized assessments is an important component of evidence-based assessment.Practitioners can administer validated, standardized assessments during the initial assessment in order to formulate a case and identify treatment targets (Weisz and Addis 2006;Jensen-Doss and Weisz 2008;Youngstrom et al. 2015;Gullo et al. 2021;Papinczak et al. 2021).Meta-analyses indicate that patients who receive standardized assessments with feedback can benefit as much as those that receive evidence-based psychosocial treatment (Poston and Hanson 2010;Smedslund et al. 2011).In the field of alcohol and other drugs (AOD), assessment with personalized feedback alone is no less effective than motivational interviewing for SUD, with the possible exception of cannabis use disorder (Smedslund et al. 2011).Such evidence provides an ethical imperative for practitioners to use standardized assessments, and there has been an increase in efforts by professional bodies to facilitate and promote the practice (Tasca et al. 2019).
Beyond initial assessment, standardized assessments can be administered routinely to monitor treatment response and provide feedback to patients as therapy progresses (termed routine outcome monitoring or progress monitoring; Tasca et al. 2019).Progress monitoring allows practitioners to track progress relative to patient history and population norms (Overington and Ionita 2012).Progress monitoring maximizes treatment outcomes by allowing practitioners to respond to patient needs on a session-to-session basis (Hutson et al. 2020).
The therapeutic benefits of progress monitoring are supported by several meta-analyses (Shimokawa et al. 2010;Gondek et al. 2016;Lambert et al. 2018;de Jong et al. 2021).It has been proposed that these therapeutic benefits are achieved by helping to guard against practitioner bias, including failure to detect deterioration (Hunsley et al. 1999;Hannan et al. 2005;Walfish et al. 2012).This is particularly helpful for patients who are not progressing as might be expected (i.e.not 'on-track'; Hutson et al. 2020), especially when the progress monitoring software offers concrete suggestions for alternative strategies (de Jong et al. 2021).Within AOD treatment, progress monitoring has shown promise for improving outcomes (Crits-Christoph et al. 2012;Schuman et al. 2015).One study found that implementing progress monitoring boosted outcomes for outpatients who showed a poorer initial response in particular, such that they achieved equivalent reductions in substance use to the 'on-track' outpatients at 12 weeks (Crits-Christoph et al. 2012).A later study in the context of a mandated group-based AOD program found that progress monitoring reduced premature dropout and increased clinically significant improvement (Schuman et al. 2015).

Practitioner attitudes toward standardized assessments
Many studies have examined practitioner attitudes toward standardized assessment, usually with the aim of examining them as a potential barrier to uptake (Garland et al. 2003;Willis et al. 2009;Curry and Hanson 2010).One large-scale survey of practitioners working with children found that 61.5% were regular users of standardized assessments (Jensen-Doss and Hawley 2010).Another large-scale survey of mostly Masters-level practitioners found that only 13.9% were frequent users of progress monitoring measures (Jensen-Doss et al. 2018).Results from these two surveys revealed that practitioners held positive attitudes toward the psychometric properties of standardized assessments and the practice of progress monitoring.However, practitioners held neutral attitudes toward the use of progress monitoring measures themselves, with reservations about their practicality and benefit over clinical judgment alone.Other studies have found that barriers to using standardized assessments include resource and time constraints, and perceptions that patients are unwilling to complete standardized measures (Hatfield and Ogles 2007;Boswell et al. 2015;Gleacher et al. 2016;Kotte et al. 2016;Ionita et al. 2020).
Fewer studies have examined AOD practitioners' attitudes specifically.The use of standardized assessments among AOD practitioners is low, despite data suggesting that they assess clinical outcomes more frequently during treatment than other mental health practitioners (Santa Ana et al. 2008).One study by Pavlick et al. (2009) found that almost all AOD practitioners (99%) assess craving, but only 5% do so using a validated instrument.In one Australian survey, most AOD practitioners endorsed the reliability and validity of standardized initial assessments and the benefits of progress monitoring for treatment planning (Revill et al. 2022).

Attitudes toward standardized assessments among patients and potential patients
Very few studies have examined attitudes toward standardized assessments in potential respondents.That is, individuals engaged in treatment (patients) or those who may benefit from treatment (potential patients).A systematic review of mental health patient experiences of progress monitoring identified that they may have suspicions about what the data is being used for, and the rationale behind its administration (Solstad et al. 2019;B€ orjesson and Bostr€ om 2020).Patients were also concerned about the rigidity of standardized assessments and that they may not capture the complexity of their mental health (Alves et al. 2016;Solstad et al. 2019).This has also recently been reported by patients completing standardized assessments as part of their treatment for alcohol use disorder (Kidd et al. 2022).For example, factors such as goals, therapeutic alliance, and social support are often overlooked in favor of a focus on symptoms.However, evidence suggests that patients do find standardized assessments and progress monitoring to be worthwhile.In particular, a recurring theme in the literature is that assessments provide an opportunity for patients to provide input on their therapeutic journey, especially when completed with a trusted therapist (Alves et al. 2016;B€ orjesson and Bostr€ om 2020;Paz et al. 2020;Solstad et al. 2021).
Few studies have examined the attitudes of individuals who use substances toward standardized assessment.Two Australian studies provide preliminary support for the acceptability and effectiveness of an electronic instant assessment and feedback system (iAx) for hospital outpatients engaged in treatment for substance use (Papinczak et al. 2021;Kidd et al. 2022).In cannabis use, patients randomly assigned to complete their initial assessment using the iAx system reported greater motivation for change, a better understanding of their results and of how their usage compared to other cannabis users than assessment-as-usual, which involved the same assessments administered as paper questionnaires (Papinczak et al. 2021).It should be noted that the majority of this sample comprised first-time patients, having been referred for assessment as part of a police diversion program.After implementing the iAx in alcohol use disorder treatment, patients were more likely to complete an outpatient cognitive-behavioral treatment program and reported increased insight into their drinking problems.However, some patients expressed concerns about the length and relevance of some of the questionnaires (Kidd et al. 2022).This echoes concerns found in other studies (Alves et al. 2016;Treiman et al. 2021).
A large-scale survey by Mark et al. (2021) examined the attitudes of SUD patients who underwent intake assessments according to a standardized computer-based protocol aligned with the American Society of Addiction Medicine (ASAM) criteria.Although the ASAM assessment protocol is standardized, it does not provide normative feedback on how a patient compares to population norms.Patients who received ASAM-based assessments reported their experience as more patient-centered than those who received non-ASAM assessments.However, ASAM-based patients were also more likely to report that the process was too long or repetitive.Similar findings were reported in interviews with a subset of the patients (Treiman et al. 2021).
Research has demonstrated that standardized assessments and personalized feedback improve treatment outcomes.There is an active line of research examining what should be assessed and monitored to further increase effectiveness based on theory and empirical evidence (Crits-Christoph et al. 2012;Brorson et al. 2019;Papinczak et al. 2021;Kidd et al. 2022).In parallel, the field needs to develop a clear understanding of views held by individuals who use substances of the ideal role that standardized assessments should play in their treatment and how they want it to be implemented.For example, preferred frequency of progress monitoring (e.g.every session, once per month) and setting (e.g. in the waiting room before the session, at home before the session).The involvement of individuals who may seek treatment is increasingly acknowledged as crucial since they have first-hand experience of the problems they are seeking help for and can inform practitioners about the relevance of assessments (Ti et al. 2012;Neale et al. 2015;Alves et al. 2016).A clearer understanding of the perspectives of individuals likely to benefit from treatment, aside from being important in its own right, could also facilitate the effective implementation of standardized assessments in practice.Practitioners will not know what patient-level barriers may arise during implementation efforts if patients or individuals likely to become patients are never asked.
The present study sought to collect detailed information on substance users' perspectives on the role of standardized assessments in treatment.This study will also apply previous findings to individuals who have sought treatment or are likely to seek treatment for substance use.

Participants and procedure
Seventy-one substance-using individuals were recruited through online forums, substance-use practitioner networks, and advertisements (e.g.posters) placed in relevant treatment services (GP clinics, substance-use treatment services) to complete an anonymous Qualtrics survey.The recruitment period lasted from June to September 2020 and sought any individuals residing in Australia aged 18 years or over, fluent in English, and who self-identified as experiencing problems with alcohol and/or other drugs.Participants entered into a prize draw to win a $200 AUD gift voucher for outlets that do not sell alcoholic beverages.The study was approved by the University of Queensland Human Research Ethics Committee (2020000254).Detailed demographic, educational, and occupational characteristics are presented in Table 1.

Measures
This study sought to assess several domains of patient attitudes toward the use of standardized assessments in substance use treatment.Specifically, (a) attitudes toward standardized assessments as part of an initial assessment; (b) as part of treatment progress monitoring; (c) attitudes toward receiving feedback on standardized assessment results; as well as, (d) broader process issues (e.g.method and frequency of administration).Participants' severity of substance use was also of interest to characterize the sample.

Substance use
Severity of substance use was measured using the five-item Severity of Dependence Scale (SDS; Gossop et al. 1995).This measure assesses the degree of psychological dependence experienced by users and has good reliability, construct and criterion validity across different substance-using populations (Ferri et al. 2000;Martin et al. 2006;Swift et al. 2000;Lawrinson et al. 2007).Items are rated on a 4-point scale from 0 (never) to 4 (always).Rather than refer to a specific drug, items were adapted to be applicable to any drug of concern and to assess the lifetime severity of dependence.

Patient attitudes toward standardized assessments (initial assessment)
The first set of attitudes measures related to the use of standardized assessments as part of an initial assessment.Participants were instructed that, 'A standardized assessment is a validated questionnaire or structured interview with a clinician.They are often given in an initial appointment, and ask specific questions about substance use (how much?how often?), and one's relationship with substance/s (symptoms, cravings ).Items were rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree).
Patient attitudes toward progress monitoring and feedback Feedback from standardized assessment was defined for participants as, 'when your responses to the standardized assessment are discussed with you.'A set of 6 items assessing attitudes and experiences of standardized assessment and progress monitoring was designed specifically for this survey.Participants reported the frequency with which they completed and received feedback from standardized assessments (1 [never] to 6 [every session]), how helpful they thought receiving feedback from a standardized assessment would be (1 [extremely helpful] to 5 [not at all helpful]), how important it was to receive the feedback immediately, and how important it was that their treatment is guided by the results from standardized assessments (1 [extremely important] to 5 [not at all important]).
Seven items developed by Smith et al. (2007) to examine practitioners' feedback practices were adapted for a patient perspective to examine their experiences of receiving feedback.
Participants were asked whether they had ever received direct feedback on treatment progress from a clinician (yes or no), how often they received feedback (4 items; 1 [never] to 5 [always or almost always]), how long a feedback session usually takes, and whether they pay an additional fee for this service.Two items were specifically designed for this survey to measure how often, and how often patients would prefer, to fill out progress questionnaires.A further 10 items developed by Smith et al. (2007) to examine practitioners' perceptions of the effects of providing feedback were adapted to examine patients' perceptions of the effects of receiving feedback (e.g.'I better understood my problems'; 1 [never] to 5 [always or almost always]).

Attitudes toward process issues in standardized assessment
Participants were asked about their preferences in testing modality, testing environment, and delivery of results.The Attitudes Around Cognitive Testing (AACT) questionnaire developed by Wong and Jacova (2018) was originally designed to examine older adults' attitudes toward cognitive testing.The AACT questionnaire examined testing preferences, the importance of having a choice, and the willingness to take cognitive tests.Seven items were adapted for administration to substance-using individuals (e.g.'If a clinician asked me to take a test to determine my pattern of substance use, I would be willing to take it'; 1 [strongly agree] to 5 [strongly disagree]).

Demographic and substance use characteristics
As shown in Table 1, there was an even gender split in the sample.The majority had completed a higher education qualification and were employed more than 20 h per week.Most were unmarried.Alcohol and cannabis were the primary drugs of concern, with a mean severity of dependence in the sample greater than the cutoff score of 3 (see Table 2).Only 13 respondents (18.31%) scored below the SDS cutoff for 'likely' substance dependence.Although most participants had never sought treatment for their substance use, they did expect psychotherapy to be beneficial.Fewer responses were received to questionnaires appearing later in the battery, but Little's (1988) Missing Completely At Random (MCAR) test indicated data were MCAR, X 2 (29) ¼ 22.74, p ¼ .79.

Attitudes toward standardized assessments (initial assessment)
The majority of participants had never completed a standardized assessment before, and had never received feedback from a standardized assessment (see Table 3).However, 77.5% expected that receiving feedback from standardized assessments would be helpful, with approximately half believing it would be at least moderately helpful.There was an even split in responses on how important it was to receive feedback immediately.Similarly, participants were split on how important they felt treatment should be guided by results obtained from standardized assessments.
On average, participants held more positive than negative attitudes toward standardized assessments (Table 4).In particular, participants indicated that they believed they could complete standardized assessments, that they believed standardized assessments were not a burden, and that they were worth the time it would take to complete them.Item means and standard deviations are reported in Table 4.

Attitudes toward standardized assessments for progress monitoring
As with standardized measures used for initial assessment, participants held more positive than negative attitudes toward standardized assessment for progress monitoring (Tables 4 and 5).In particular, participants believed that progress monitoring assessments were not a burden and were worth the time it would take to complete them.Item means and standard deviations are reported in Table 4.Despite these generally favorable attitudes, when asked how often substance-using individuals would like to complete standardized assessments, nearly half responded 'never'.

Attitudes toward substance use testing
A majority of participants were willing to take a test on their substance use if asked by a practitioner.Participants were mixed in their preferences for testing modality, with most agreeing that it was important for practitioners to let them choose the modality and that electronic modalities (e.g.computer, smartphone) were generally preferred to non-electronic modalities.There was an even split in preferences on testing location, with half preferring home and half having no preference.Most participants preferred to be alone when taking a test.Participants were mixed on their preferences for finding out their results, with most preferring phone or email (Table 6).

Discussion
This study reports the first descriptive data on substance users' attitudes toward standardized assessments.The majority believed that assessments were worthwhile to fill out, not burdensome, and that progress monitoring was valuable to  (beer, wine, spirits, etc.) 33 (54.1%)Cannabis (marijuana, pot, grass, hash, etc.) 21 (34.4%)Cocaine (coke, crack, etc.) 1 (1.6%)Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 3 (4.9%)Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 1 indicate whether treatment is working.The majority of substance users were willing to take a test on their use if asked by a practitioner.However, when presented with the prospect of having to fill out progress questionnaires regularly, participants showed reluctance.These findings are consistent with previous research indicating that mental health patients in general are open to standardized assessments and see them as beneficial (Unsworth et al. 2012;Cuperfain et al. 2021;Solstad et al. 2021).
Most substance users were willing to complete a standardized assessment on their substance use if asked by a practitioner.This finding calls into question concerns raised by practitioners that patients might find standardized assessments too bothersome to fill out (Ionita et al. 2020).Practitioners may be over-estimating the amount of resistance from individuals seeking treatment.For example, participants disagreed more strongly with the statement that standardized progress measures were too much of a burden 2.14 1.026 a Labels denote the subscale from which the modified item relates to in the original ASA/ASAM-MF.It should be noted that these items have been adapted from the original questionnaires to cater to patient respondents (see Method section).for them than results from the equivalent statement in a practitioner survey (Revill et al. 2022).This discrepancy supports interview findings from Cuperfain et al. (2021), who found that patients had more positive outlooks on standardized progress measures than their practitioners.Since practitioner attitudes can be a barrier to uptake, it is important that this discrepancy is addressed so that practitioners do not dismiss standardized assessments due to unfounded fears that patients do not see any value in them.Given the evidence on the therapeutic benefit (de Jong et al. 2021), findings support the recommendation that practitioners should err on the side of administering standardized assessments, rather than forgoing them due to a wish not to burden patients (Tasca et al. 2019).
The majority of substance users expected that receiving feedback from standardized assessments and progress monitoring would be helpful.Some of the most favorable attitudes toward progress monitoring measures included their perceived ability to determine whether treatment is working (Paz et al. 2020).In fact, participants had stronger positive attitudes on this aspect of standardized progress monitoring compared to practitioners given the equivalent statement (Revill et al. 2022).Future research using open-ended qualitative methods such as interviews could explore further the mechanisms of feedback most helpful in promoting positive attitudes.For example, what comparisons are most helpful to patients in judging their own treatment progress, and whether they prefer results to be benchmarked against the general population, non-problem substance users, or other patients engaged in treatment.Papinczak et al. (2021) found that patients gained a better understanding of their cannabis use when it was benchmarked against both non-problem and treatment-seeking users.Alternatively, such considerations may mean less to patients than what feedback format gives the greatest insights to their treating practitioner so that they can make the best use of the data.This, too, is an empirical question for future research.
Co-designing of assessment and feedback systems that can tailor them to substance user preferences may further improve their attitudes toward assessment in treatment (Solstad et al. 2021).Future research could also provide example feedback sheets to participants to show what different approaches to standardized assessment and feedback look like since the majority of participants in the present study reported never having completed any.The majority of existing research has focused on practitioner attitudes and perceived barriers.Findings from studies examining patient feedback preferences could facilitate standardized assessment implementation by involving substance users in addition to practitioners in the process, and make feedback more patient-centered.
Results also showed that substance users had varied preferences for the immediacy of feedback and mode of delivery.This reflects the importance of listening to patient preferences and suggests that a standardized assessment system that can accommodate that variance would be ideal.However, attempts to accommodate different preferences will invariably introduce complications and increase practical barriers.
For example, providing the option for paper-based assessments means that practitioners must enter obtained data manually.Therefore, it would be worthwhile for future research to investigate how important it is for patient preferences on the mode of delivery and feedback to be adhered to (Hell et al. 2021).Although it is important to involve patients in the design of assessments and feedback systems, they may be perfectly willing to engage with a low-cost, basic system with limited customization, rather than an expensive system that is perfectly tailored to their needs.Formal cost-benefit analyses could be employed to empirically investigate the ideal tradeoff.
The present study had some limitations.The sample of substance users was modest and limited to mostly alcohol and cannabis users.While some later-appearing questionnaires received significantly fewer responses, attrition was random and statistical power is not an issue for descriptive statistics.Future studies could recruit more diverse samples to enhance the generalizability of findings concerning substance users' views on standardized assessments.Furthermore, most of our participants had never completed a standardized assessment and their understanding of what this involves may have varied due to a lack of direct experience.A future qualitative study could better address this limitation.While this study provides valuable insights into how treatment-naive substance users view standardized assessments, the sample does not allow for comparisons with individuals who have completed standardized assessments as part of their treatment.Our study also did not investigate substance users' presumptions regarding the rationale or purpose behind standardized assessments.Further research is needed to determine whether users' suspicions toward the rationale behind standardized assessments translates to lower adherence (Solstad et al. 2019;B€ orjesson and Bostr€ om 2020).Notwithstanding the above limitations, the present study is the first to survey substance users' perspectives on standardized assessments and provides a foundation for future efforts to implement standardized assessment in a patientcentered way.
In conclusion, evidence-based practice provides the best outcomes for substance users.An important aspect of evidence-based practice is assessment (APA Presidential Task Force on Evidence-Based Practice 2006).Despite growing efforts in recent years, research has continued to demonstrate that evidence-based assessment is under-utilized in substance use treatment (Tasca et al. 2019).The present study found that substance users were open to completing standardized assessments and progress monitoring measures.Indeed, substance users may have fewer reservations about their use than the practitioners who seek to treat them (Cuperfain et al. 2021).At the very least, it is important that practitioners be made aware of this.Future research should investigate specifically which patient preferences, if any, affect willingness to engage with and adhere to an assessment involving standardized instruments.

Table 2 .
Drug Use Characteristics of Participants (N ¼ 61, varies by item).

Table 3 .
Attitudes and experience of standardized assessment and progress monitoring (N ¼ 40, varies by item).How important is it to you to receive immediate feedback from a standardized assessment (i.e. the same day rather than the following week)?

Table 6 .
Wong and Jacova (2018)Jacova (2018)-Attitudes toward substance use testing (N ¼ 26).It is important to me that clinicians let me choose how I take the test, either through paper and pencil, a computer or a mobile device.
a Multiple responses allowed.