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. Author manuscript; available in PMC: 2026 Mar 7.
Published before final editing as: J Stud Alcohol Drugs. 2026 Jan 28:10.15288/jsad.25-00201. doi: 10.15288/jsad.25-00201

Brief Intervention Versus More Extensive Treatment for Alcohol Use Disorder (AUD): Testing the Comparability Hypothesis

Patrick R Clifford 1, Stephen A Maisto 2, Christine M Davis 3, Robert L Stout 4, Marc L Steinberg 5
PMCID: PMC12965277  NIHMSID: NIHMS2143047  PMID: 41603416

Abstract

Objective:

There is a substantial literature indicating brief interventions (BIs) for alcohol use disorder (AUD) are as effective as more extensive treatments. The research assessment reactivity literature, however, suggests that the protocols used to study AUD treatments can have clinical efficacy, which may account for the observed findings. The purpose of this research was to experimentally investigate the moderation of AUD treatment effects by AUD assessment protocols.

Method:

Participants were recruited from the community via advertisements (e.g., Facebook, mail advertisements, posting of flyers). Eligible participants, providing informed consent, were randomized to one of four research conditions resulting from a two (Intervention: Motivational Enhancement Therapy (MET) or Cognitive Behavioral Coping Skills Therapy (CBT)) by two (Assessment: infrequent-alcohol/drug focused or frequent-comprehensive) factorial design and followed for 15 months post baseline assessment.

Results:

Across the entire sample, the proportion of abstinence days increased from 21.6% at baseline to 62.4% during follow-up months 13-15, and the proportion of heavy drinking days decreased from 64.9% at baseline to 18.1% during follow-up months 13-15. Although the hypothesized interaction ‘intervention by assessment condition’ was not supported, main effects were detected for assessment condition such that individuals assigned to the alcohol/drug focused assessment conditions reported greater abstinence and fewer heavy drinking days than their counterparts assigned to the comprehensive assessment conditions.

Conclusions:

Robust BIs, such as MET, appear to yield drinking outcomes that are comparable to that of more extensive AUD treatments such as CBT. In addition, reactivity to research assessments contributed to reduced alcohol use and these effects appear to be contingent upon intervention and participant characteristics.

Keywords: Alcohol Brief Interventions, AUD Treatment Outcomes, Assessment Reactivity

There is a substantial body of research supporting the efficacy/effectiveness of brief interventions (BIs) for problematic alcohol use (Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005; Cunningham, et al, 2017; DiClemente, Corno, Graydon, Wiprovnick, & Knoblach, 2017; Kaner, Heather, McAvoy, Lock, & Gilvarry, 1999; Kaner et al., 2018; Kahan, Wilson, & Becker, 1995; Moyer, Finney, Swearingen, & Vergun, 2002; Meredith et al., 2021; Whitlock, Polem, Green, Orleans, & Klein, 2004; Wilk, Jensen, & Havighurst, 1997). More than 30 years ago, Bien, Miller, and Tonigan (1993) pooled the findings of 18 studies comparing BIs with control conditions and 13 studies comparing BIs with more extensive alcohol use disorder (AUD) treatments. The pooled effect sizes for BIs versus control conditions and BIs versus more extensive AUD treatments were 0.38 and 0.06, respectively. More recent comprehensive reviews (Bertholet et al., 2005; Moyer et al., 2002, Whitlock et al., 2004), including a Cochrane Systematic Review (Kaner et al., 2018), are consistent with the Bien et al. (1993) findings.

Brief interventions for alcohol problems, however, reflect considerable variation (Shorter et al., 2021). In this regard, the BI literature is comprised of studies that vary in numerous ways such as healthcare setting, type of intervention, number of intervention sessions, intervention duration, control or comparison condition, sample characteristics, interventionist credentials, and outcome measures. This considerable variation likely accounts for some portion of the mixed findings reported in the BI efficacy/effectiveness literature and hampers a summarization of findings across studies. Such variation led Heather (1995) to conclude that there are two broad categories of BI studies that should be considered separately: BI versus control and BI versus more extensive AUD treatments.

Interpretations implying no difference between BIs and more extensive AUD treatments have been based on a failure to reject the null hypothesis; such interpretations are tenuous at best as statistically non-significant findings do not prove comparability (e.g., Wang, Wang, Xin, & Feng, 2017). In addition, numerous investigators have alluded to subject reactivity to the research assessment interview as a potential contributor to alcohol intervention/treatment outcomes (e.g., Bien et al., 1993; Clifford & Davis 2012; Clifford, Davis, Maisto, & Stout, 2022; Clifford, Davis, Maisto, & Stout, 2024; Cohn, Elmasry, & Ehlke, 2018; Gallen, 1974; Edwards et al., 1977; Epstein et al., 2005; Kypri, Langley, Saunders, & Cashell-Smith, 2007; Magill, Kahler, Monti, & Barrett, 2012; Meier, Lombardi, & Leffingwell, 2017; Schmidt, Bojesen, Nielsen, & Andersen, 2018; Sobell, Brochu, Sobell, Roy & Stevens, 1987; Stout, Rubin, Zwick, Zywiak, & Bellino; 1999; Wilson, 1978; Worden, Epstein, & McCrady, 2015; Zweben, Pearlman, & Li, 1988), which suggests that the protocols used to investigate BIs and more extensive alcohol treatments may have confounded study findings. In this regard, research assessment interviews may extend BIs beyond a ‘critical intensity threshold’ that results in their becoming indistinguishable in outcomes from the ostensibly more extensive AUD treatments. A comprehensive, structured assessment battery provides individuals with relevant information about their alcohol use and its consequences, related behaviors, and co-morbid conditions, which can be a potent motivator for behavior change (see Clifford & Maisto, 2000; Clifford et al., 2024).

Given this background, the purpose of this study was to investigate the extent to which research assessments enhance BI efficacy (i.e., to test the comparability of the BI and more extensive AUD treatment). Two main effect hypotheses were postulated: 1) participants assigned to the more extensive AUD treatment (i.e., cognitive behavioral therapy; CBT) will report better alcohol use outcomes (i.e., greater abstinence, less heavy drinking, and fewer drinks per drinking occasion) than their counterparts assigned to the brief intervention (i.e., motivational enhancement therapy; MET); and 2) individuals assigned to the frequent-comprehensive (FC) assessment conditions will report better alcohol use outcomes than their counterparts assigned to the infrequent-alcohol/drug focused (IA) assessment conditions. In addition, an intervention by assessment interaction was hypothesized such that assignment to the FC research assessment conditions will yield similar (i.e., statistically non-significant) alcohol use outcomes irrespective of intervention condition, and individuals assigned to the BI (i.e., MET) with IA assessments will report the poorest outcomes.

Methods

Study Participants

Three hundred sixty-two individuals inquired about the study, and 139 (38.4%) met study inclusion criteria, provided informed consent, and were randomized to a research condition. One participant was withdrawn from the study post baseline assessment but prior to treatment initiation due to a court order. A flow chart showing the distribution of participants from first contact through data analysis is presented in Figure 1. Of the remaining 138 participants, 100 (73%) were White, 82 (59%) were male, and the mean age was 51 years (SD = 12.8 years). More detailed socio-demographic and AUD information is presented in Table 1.

Figure 1.

Figure 1.

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Study Participant Flow Diagram. MET=Motivational Enhancement Therapy; CBT=Cognitive Behavioral Therapy; IA=infrequent alcohol/drug focused; FC=frequent comprehensive.

Table 1.

Participant Demographic and Baseline Characteristics by Research Condition and Overall

(n) Overall (138) MET/IA (38) CBT/IA (37) MET/FC (30) CBT/FC (33)
Mean Age (SD) 50.74 (12.78) 50.37 (13.58) 51.14 (12.92) 50.73 (11.67) 50.73 (13.21)
Gender - male (%) 82 (59.4) 27 (71.1) 21 (56.8) 13 (43.3) 21 (63.6)
    - female (%) 56 (40.6) 11 (28.9) 16 (43.2) 17 (56.7) 12 (36.4)
Race (%)
    Minority 38 (27.5) 12 (31.6) 11 (29.7) 7 (23.3) 8 (24.2)
    White 100 (72.5) 26 (68.4) 26 (70.3) 23 (76.7) 25 (75.8)
Marital Status (%)
    single 67 (48.6) 14 (36.8) 25 (67.6)** 9 (30.0)** 19 (57.6)
    married/cohabiting 71 (51.4) 24 (63.2) 12 (32.4) 21 (70.0) 14 (42.4)
Ed Level (%)
    high school or less 17 (12.3) 4 (10.5) 8 (21.6) 2 (6.7) 3 (9.1)
    some college or more 121 (87.7) 34 (89.5) 29 (78.4) 28 (93.3) 30 (90.9)
Income (%)
    < =$10K 16 (11.7) 3 (7.9) 6 (16.2) 4 (13.3) 3 (9.4)
    $10 -39,999 30 (21.9) 6 (15.8) 10 (27.0) 7 (23.3) 7 (21.9)
    $40-59,999 20 (14.6) 7 (18.4) 7 (18.9) 1 (3.3) 5 (15.6)
    $60-89,999 33 (24.1) 8 (21.1) 5 (13.5) 10 (33.3) 10 (31.3)
    >=$90K 38 (27.7) 14 (36.8) 9 (24.3) 8 (26.7) 7 (21.9)
Prior Treatment (%) 38 (27.5) 13 (34.2) 7 (18.9) 6 (20.0) 12 (36.4)
Mean AUD Severity (SD) 8.04 (2.34) 8.24 (1.90) 7.92 (2.30) 7.60 (2.54) 8.33 (2.65)
Drinks/Drinking Day - BL (SD) 7.88 (4.73) 7.89 (4.21) 7.49 (4.59) 8.54 (6.30) 7.69 (3.89)
% Days Abstinence - BL (SD) 21.77 (24.09) 28.66 (26.01) 18.24 (24.00) 14.80 (21.66) 24.12 (22.53)
% Days Drug Use-BL (SD) 5.28 (20.29) 2.16 (9.78) 5.11 (20.08) 7.59 (25.59) 6.97 (24.22)
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Note: Between group differences were tested using Chi-Square and one-way ANOVA analyses depending on whether the variables being tested were categorical or continuous. MET=Motivational Enhancement Therapy; CBT=Cognitive Behavioral Therapy; IA=infrequent alcohol/drug focused; FC=frequent comprehensive.

**

p < .01.

Experimental Design

Study aims were investigated using a 2 (Intervention: CBT or MET) by 2 (Assessment: IA or FC) factorial design. The assessment conditions implemented in the current study were based on findings from prior assessment reactivity research showing that individuals assigned to an IA assessment condition reported significantly poorer outcomes than their counterparts assigned to other assessment conditions that did not differ significantly (Clifford, Maisto, & Davis, 2007).

Participants were randomly assigned, using an urn randomization procedure, to one of four research conditions and followed for 15 months post baseline assessment. To enhance the likelihood of balanced research groups with respect to key variables, the urn randomization procedure included the following dichotomized (yes/no) variables: AUD moderate/severe, prior substance use treatment, female gender, at least 40 years of age, and ethnic/racial minority (Stout, Wirtz, Carbonari, & Del Boca, 1994). With the exception of senior project staff (PI and Co-Is), all project personnel and study participants were blinded to the true purpose of the study and the specific hypotheses under investigation. Study participants also were blinded to the different experimental conditions. Collateral informants (e.g., spouse/partner) provided participant alcohol/drug use and related negative consequences data on the same schedule as their participant counterpart.

Intervention Descriptions

The intervention conditions were based on Project MATCH. MET was a standardized BI consisting of one 60-minute and three 45-minute sessions delivered across a 12-week period (i.e., weeks 1, 2 or 3, 6, and 12). The MET approach consisted of three phases: 1) building motivation for change; 2) strengthening commitment to change; and 3) follow through strategies (i.e., reviewing progress, renewing motivation, and redoing commitment).

The CBT manual provided information for 22 sessions, of which eight were required: Introduction to Coping Skills Training, Coping with Cravings and Urges to Drink, Managing Thoughts about Alcohol and Drinking, Problem Solving, Drink Refusal Skills, Planning for Emergencies and Coping with a Lapse, Seemingly Irrelevant Decisions, and Termination. Of the remaining 14 elective sessions four were selected by the client, ideally with therapist agreement. Thus, CBT was a standardized treatment consisting of 12, 45-minute weekly sessions.

The CBT (Kadden et al., 1994) and MET (Miller, Zweben, DiClemente, & Rychtarik, 1994) manuals provide detailed information regarding the content and structure of the treatments, requisite assessment tools, crisis intervention guidelines, interventionist training, and supervision. These manuals were used to guide all aspects of the clinical interventions.

Interventionist Training and Supervision

Interventionists possessed either a master’s degree in social work or were at least a third year student in a clinical graduate program (e.g., Ph.D. clinical psychology). Interventionists were required to demonstrate a high level of familiarity with the Project MATCH therapy manuals, review videotaped examples of the intervention, engage in practice exercises with senior project staff, and conduct at least two MET and four CBT practice sessions with clients. Interventionists were certified proficient by senior project investigators. To prevent interventionist drift, ongoing supervision was conducted bi-weekly. Interventionist supervisory sessions centered on a review of randomly selected video recordings as well as recordings identified because of a clinical concern. Recordings were reviewed for therapist skillfulness, adherence to manual guidelines, and delivery of manual-specified active ingredients unique to each approach. Substantial deviation from manual guidelines resulted in increased supervision.

Assessment Condition Descriptions

Participants assigned to the FC conditions completed quarterly in-person assessment interviews (i.e., baseline and 3, 6, 9, 12, and 15 months post baseline). The content of these interviews covered the following areas: drinking/drug taking behaviors, alcohol/drug related negative consequences, AA/NA participation, treatment participation (alcohol/substance use, psychological, psychiatric), legal problems, medical and psychiatric status, as well as psychological, social, marital/relationship, and occupational functioning. Administration of the baseline and follow-up comprehensive assessment package required approximately 2.0 hours and 1.5 hours, respectively. In total, the comprehensive baseline and screening interviews, including informed consent, required about 3.0 to 3.5 hours to complete.

Participants assigned to the IA assessment conditions completed in-person baseline, 9-month, and 15-month follow-up interviews. The baseline and 9-month interviews were limited to alcohol/drug use behaviors, mediator and moderator variables, and socio-demographic data. The 15-month follow-up was comprehensive for all participants because it couldn’t affect study outcomes. After the final intervention session all participants completed three brief assessments, requiring less than 10-minutes, specific to mediator variables. The IA follow-up assessment package required about 0.5 hours and the combined IA baseline and screening interviews, including informed consent, required about 1.0 to 1.5 hours to administer.

Research Interviewer Training and Supervision

Research interviewers were trained and approved by project senior investigators. Data were collected via the use of structured and semi-structured instruments. Research Interviewers participated in bi-weekly supervision meetings to prevent interviewer drift from the prescribed protocol. To monitor the fidelity of the research procedures, each assessment interview was video recorded and reviewed during supervision. In addition, any problems/concerns raised by the interviewers were addressed during these meetings.

Participant Compensation

To maintain comparability across research conditions, participants were paid $50 for each 3-month assessment period. Participants were not paid for the end-of treatment assessment as this interview typically occurred following the last intervention session and did not involve any additional travel time or costs.

Participant Recruitment

Participants were recruited through a variety of social media (e.g., Facebook, Craigslist) and mail advertisements, as well as the posting of flyers in key locations (e.g., university healthcare clinics, bars, community centers, supermarkets). Recruitment information consisted of a brief study description, website address, and telephone number for interested persons to obtain further project information.

Screening Procedures

Individuals inquiring about the study were provided a brief overview of the study and, if interested, a quick telephone screen to determine if they were likely to be study eligible, which required less than 10-minutes. Interested individuals deemed ‘likely eligible’ were scheduled for a more in-depth, in-person screening within one week. The complete in-person screening package required about 45-60 minutes and included the collection of contact information, the Diagnostic Interview Schedule - IV (DIS-IV) mini-mental state examination (Robbins et al., 1999), Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (American Psychiatric Association, 2013) alcohol and substance use disorder criteria, and DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure for Adults, Clinical Institute Withdrawal Assessment of Alcohol – Revised (CIWA-Ar; Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989), family history section of the Addiction Severity Index (ASI; McLellan et al., 1992), and informed consent procedures. Eligible individuals were scheduled for a baseline assessment within one week.

Breath Testing for Alcohol

Participants were breath tested at the beginning of each in-person intervention and assessment session to ensure that they were alcohol free. Individuals presenting with a blood alcohol level greater than .02 had their session rescheduled.

Inclusion/Exclusion Criteria

Inclusion criteria were such that participants must have: 1) met criteria for an AUD diagnosis based on the DSM-5; 2) consumed a weekly average of at least 24 (males) or 16 (females) standard drinks during the baseline period including at least 6 episodes of heavy drinking (5 or more drinks for males, 4 or more drinks for females); 3) agreed not to seek additional alcohol/substance use treatment during the intervention/treatment phase of the study; 4) been at least 18 years of age; and 5) been sufficiently proficient in their English speaking ability to interact effectively with the interviewer. Individuals assessed as having a substance use disorder that was more severe than their AUD diagnosis (e.g., cocaine disorder more severe than alcohol), a serious psychiatric diagnosis (e.g., major depression) based on DSM-5 criteria, or organic brain impairment, as measured by the mini-mental state examination of the DIS-IV, were precluded from study participation. Individuals currently enrolled in an alcohol/substance use treatment program, mandated to alcohol/substance use treatment by a court order, or severely socially unstable (e.g., homeless) were deemed ineligible.

COVID-19 Pandemic Related Protocol Modifications

Pandemic related University policies and procedures mandated that in-person activities, such as recruitment efforts and treatment delivery, be halted until secured, remote procedures satisfying Institutional Review Board (IRB) and Health Insurance Portability and Accountability Act (HIPAA) requirements could be instituted. Consequently, research activities were shifted from in-person to remote (i.e., Skype for Business or telephone) meetings, which necessitated foregoing participant alcohol breath testing prior to conducting intervention and research assessment sessions. Overall, 29 participants received at least one research assessment remotely, and six participants were transitioned from in-person treatment delivery to remote.

Measures

Alcohol use data were collected using the TimeLine Follow-Back (TLFB) procedure and the data were blocked into three-month (i.e., 90-day) intervals. The baseline period included the 90-days preceding the baseline assessment. Three alcohol use variables, specific to each assessment period, were operationalized: proportion of days abstinent (PDA), mean number of drinks per drinking day (DDD), and proportion of heavy drinking days (PHD). The PDA variable was defined as the proportion of non-institutionalized days that the participant reported no alcohol use. The DDD variable was defined as the average number of standard drinks consumed on a drinking day. To decrease skewness, a logarithmic transformation was applied to the DDD variable. The PHD variable was defined as the proportion of non-institutionalized days that male and female participants reported ingesting five or more or four or more standard drinks, respectively.

Data Analyses

Chi Square analyses were used to determine the equivalence of participant socio-demographic characteristics (i.e., gender, minority status, prior substance use treatment, marital status, education level, and household income) across experimental conditions as well as for those retained in the study versus those lost to attrition. In addition, analysis of variance techniques were applied to baseline indices of alcohol use, AUD severity, drug use (i.e., proportion of days drug use), and age to test for differences across research conditions and two sample t-tests were conducted to determine group equivalence between those retained in the study and those lost to attrition.

Study hypotheses were tested using three repeated measures mixed effects regression models. Each analysis was specific to a measure of alcohol use. The independent variable sets for these analyses were factors representing time, assessment condition, intervention group, the two-way interaction terms (i.e., time x assessment; time x intervention; assessment x intervention) and the three way interaction term (i.e., time x assessment x intervention). In each regression model, the corresponding baseline alcohol use variable and an AUD severity measure were included as covariates. Statistically significant baseline socio-demographic variables that varied across research conditions also were included as covariates in each regression model.

Supplemental Analyses

Shifting assessment interview sessions from in-person to remote in response to the COVID-19 pandemic, may have contributed to diminished assessment reactivity effects. To account for this possibility, repeated measures Analysis of Variance (ANOVA) procedures were conducted (i.e., one for each alcohol use measure: PDA, PHD, and DDD). These analyses contrasted the drinking outcomes of individuals who received all their follow-up assessment interviews in-person with those who received any remote interviews.

Statistical Power

With a sample size of N=106, statistical power to detect a two-tailed, one degree of freedom interaction with medium effect size and alpha set at .05, was estimated to be 63%.

Results

Analyses aimed at comparing baseline socio-demographic, drug use, and drinking variables amongst those retained in the study (N = 106) and those lost to follow-up (N = 32), yielded statistically non-significant findings (p > .05) across all measures, except for the DDD variable, t (136) = 3.25, p = .002. In this regard, individuals lost to follow-up reported on average, 10.18 (SD = 6.02) DDD, while those retained in the study reported on average, 7.18 (SD = 4.05) DDD.

Comparisons of baseline socio-demographic and alcohol/drug use variables across the four research conditions (N=106) yielded statistically non-significant (p > .05) results with the exception of marital status, as 72.7% and 32.1% of those assigned to MET/FC and CBT/IA were married/cohabiting, respectively, χ2 (3, N = 106) = 9.87, p = .02. Additional information specific to these across research condition comparisons is presented in Table 2.

Table 2.

Retained Participant Demographic and Baseline Characteristics by Research Condition and Overall

(n) Overall (106) MET/IA (32) CBT/IA (28) MET/FC (22) CBT/FC (24)
Mean Age (SD) 50.21 (12.17) 50.03 (12.19) 51.21 (11.33) 49.41 (12.95) 50.00 (13.05)
Gender - male (%) 62 (58.5) 22 (68.8) 16 (57.1) 9 (40.9) 15 (62.5)
    - female (%) 44 (41.5) 10 (31.3) 12 (42.9) 13 (59.1) 9 (37.5)
Race (%)
    Minority 30 (28.3) 10 (31.3) 7 (25.0) 7 (31.8) 6 (25.0)
    White 76 (71.7) 22 (68.8) 21 (75.0) 15 (68.2) 18 (75.0)
Marital Status (%)
    single 52 (49.1) 13 (40.6) 19 (67.9)* 6 (27.3)* 14 (58.3)
    married/cohabiting 54 (50.9) 19 (59.4) 9 (32.1) 16 (72.7) 10 (41.7)
Ed Level (%)
    high school or less 12 (11.3) 2 (6.3) 5 (17.9) 2 (9.1) 3 (12.5)
    some college or more 94 (88.7) 30 (93.8) 23 (82.1) 20 (90.9) 21 (87.5)
Income (%)
    < =$10K 12 (11.3) 2 (6.3) 4 (14.3) 4 (18.2) 2 (8.3)
    $10-39,999K 20 (18.9) 4 (12.5) 8 (28.6) 4 (18.2) 4 (16.7)
    $40-59,999K 15 (14.2) 6 (18.8) 4 (14.3) 1 (4.5) 4 (16.7)
    $60-89,999K 24 (22.6) 7 (21.9) 4 (14.3) 6 (27.3) 7 (29.2)
    >=$90K 35 (33.0) 13 (40.6) 8 (28.6) 7 (31.8) 7 (29.2)
Prior Treatment (%) 25 (23.6) 11 (34.4) 4 (14.3) 2 (9.1) 8 (33.3)
Mean AUD Severity (SD) 7.98 (2.26) 8.06 (1.93) 8.18 (2.23) 6.91 (2.51) 8.63 (2.28)
Drinks per Drinking Day - BL (SD) 7.18 (4.05) 7.62 (4.12) 6.36 (2.56) 7.78 (5.68) 7.00 (3.67)
% Days Abstinence - BL (SD) 21.61 (22.29) 26.94 (23.60) 18.75 (23.11) 13.86 (18.51) 24.96 (21.45)
% Days Drug Use-BL (SD) 3.96 (16.48) 2.57 (10.63) 2.86 (13.83) 10.35 (29.56) 1.25 (3.80)
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Note: Between group differences were tested using Chi-Square and one-way ANOVA analyses depending on whether the variables being tested were categorical or continuous. MET=Motivational Enhancement Therapy; CBT=Cognitive Behavioral Therapy; IA=infrequent alcohol/drug focused; FC=frequent comprehensive.

*

p < .05.

The mixed effects regression analyses aimed at testing study hypotheses yielded statistically non-significant (p > .05) effects specific to an ‘intervention by assessment condition’ interaction across all three regression models. The effect size estimates (i.e., partial eta-squared) associated with the intervention by assessment interaction were small (i.e., .01 or less) across all three alcohol use measures. Statistically significant (p < .05) effects were observed for time and the corresponding baseline alcohol use covariate across all three regression models, and the AUD severity covariate was statistically significant for the PDA measure, F (1, 99) = 4.14, p = .04. Overall, PDA increased from 21.6% at baseline to 62.4% during follow-up months 13-15, F (4, 382) = 2.54, p = .04, and PHD decreased from 64.9% at baseline to 18.1% during follow-up months 13-15, F (4, 382) = 3.18, p = .01.

Assessment condition was significant for PDA, F (1, 99) = 4.47, p = .04, and PHD, F (1, 99) = 5.27, p = .02. Individuals assigned to the IA conditions reported a greater PDA and a lower PHD relative to their counterparts assigned to the FC conditions. Changes in reported alcohol use did not vary significantly by intervention condition (p > .05). However, there was a significant effect for the interaction term ‘intervention by time’ specific to PDA, F (4, 382) = 2.87, p = .02, such that individuals assigned to MET reported greater abstinence at the 3-month, t (382) = 2.67, p = .008, and 6-month, t (382) = 2.11, p = .04, follow-up points. PDA, however, varied across time such that individuals assigned to CBT reported greater abstinence at the 15-month follow-up, although this difference was not statistically significant. Temporal changes in reported alcohol use specific to assessment condition are presented in Figure 2 (PDA) and Figure 3 (PHD). Temporal changes in alcohol use specific to intervention condition are shown in Figure 4 (PDA).

Figure 2.

Figure 2.

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Proportion of days abstinent at baseline and across follow-up timepoints by Assessment Condition. IA: Infrequent-alcohol/drug focused assessment condition; FC: Frequent-comprehensive assessment condition.

Figure 3.

Figure 3.

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Proportion of Heavy Drinking Days at Baseline and across the follow-up timepoints by Assessment Condition. IA: Infrequent-alcohol/drug focused assessment condition; FC: Frequent-comprehensive assessment condition.

Figure 4.

Figure 4.

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Proportion of Abstinent Days at Baseline and across the follow-up timepoints by Treatment Condition. CBT: Cognitive Behavioral Therapy; MET: Motivational Enhancement Therapy.

Supplemental analyses contrasting individuals who received all in-person follow-up assessment interviews with those who received any remote follow-up interviews yielded statistically non-significant (p > .05) findings across all three alcohol use variables. Changes in alcohol use across the two timepoints (i.e., months 7-9 and months 13-15) were such that for those who received all in-person interviews: PHD decreased from .20 to .16; PDA increased from .56 to .62; and DDD decreased from 4.38 to 3.56. Alternatively, among those who received remote interviews: PHD and PDA remained fairly stable (i.e., .23 to .24 and .63 to .64, respectively); and DDD decreased from 4.37 to 3.71.

Discussion

The aim of the current study was to investigate the extent to which research assessments contribute to the efficacy/effectiveness of AUD BIs. Study hypotheses posited an intervention by assessment interaction effect such that FC assessments would enhance the efficacy of MET to be comparable to that of CBT, and individuals assigned to MET/IA would report the poorest outcomes. Data analyses did not support this pattern of findings and given the small intervention by assessment interaction effect sizes, it is unlikely that reduced statistical power accounts for the lack of hypothesis support. There are at least two possible explanations for this lack of hypothesis support. First, the main effect for assessment condition was opposite expectations as participants in the IA conditions had better outcomes than those in the FC conditions. This result may have been due to the current study sample’s baseline patterns of alcohol/drug use and associated characteristics as our prior assessment reactivity study sample was characterized by more extensive alcohol/drug use and related problems, and showed robust assessment reactivity effects (Clifford et al., 2007; Maisto et al., 2007).

Although the current study’s participants met DSM-5 AUD criteria and the average symptom score was in the severe range, DSM-5 severity scores lack sufficient sensitivity for detecting the full extent of alcohol problems as the scoring algorithm yields a summation score based on the presence of symptoms, but does not take into consideration symptom frequency or intensity. Alcohol and other drug use consumption behaviors and measures of alcohol related problems such as the ASI and the Drinker Inventory of Consequences (DrInC) provide greater sensitivity for assessing the breadth and seriousness of alcohol problems. Along these lines, in our prior assessment reactivity study, at baseline 68.5% of the sample had received prior AUD treatment, drank on average 13.84 drinks per drinking day and used drugs 37.12% of the time (Clifford et al., 2022). In contrast, in the current study 27.5% of the sample had received prior AUD treatment, drank on average 7.88 drinks per drinking day, and used drugs 5.28% of the time. Furthermore, relative to our prior assessment reactivity sample, the current sample reported significantly fewer alcohol related problems across all five DrInC subscales (p < .001) as well as significantly lower scores for the Psychiatric Status, Family/Social Relationships, and Employment/Support Status (p < .005) sections of the ASI.

Individuals with mild to moderate alcohol problems are less likely to suffer extensive co-morbid conditions or severe psychological and/or social problems relative to those with more severe alcohol problems (Finn, Hammarberg, & Andreasson, 2018). Exposure to comprehensive assessments may be distracting, or even bothersome for individuals with lower levels of alcohol/drug use as many of the assessments would be less relevant, and contribute to diminished attention during the interview. Diminished attention in turn limits self-regulatory processes that are essential for problem recognition (Carver, 2012; Carver & Schreier, 2012), which likely contributes to reduced assessment reactivity, and delayed improvement progression. In contrast, exposure to assessments specific to alcohol/drug use has high relevance for individuals presenting for alcohol treatment/intervention, and therefore would be expected to sustain focused attention throughout the interview, which in turn would lead to increased engagement and cognitive processing resulting in better problem recognition, followed by increased reactivity to the assessment package, and greater reductions in alcohol/drug use.

A second possible explanation for this study’s findings is it appears that MET operated like a more extensive AUD treatment than as an alcohol BI. In this regard, MET yielded outcomes similar to more extensive AUD treatments in two relatively large, randomized controlled trials (Project MATCH Research Group, 1997; Andersen et al., 2019), of which one was a multinational trial (Andersen et al., 2019). Neither of these two studies, however, controlled for research assessment effects. Furthermore, MET is more extensive than the typical BI used in studies contrasting AUD specialty treatments with BIs, and on which the BI versus more extensive AUD treatment comparability hypothesis was based (see Magill, Kiluk, & Ray, 2023; Morgenstern et al., 2007). Prior research contrasting BIs with more extensive AUD treatments often involved the use of a brief (i.e., ranging from a few minutes to an hour), single session BI, consisting of simple advice, feedback, provision of a manual, or some combination thereof (e.g., Chapman & Huygens, 1988; Chick, Ritson, Connaughton, Stewart, & Chick, 1988; Edwards et al., 1977; Harris & Miller, 1990; Miller, Gribskov, & Mortell, 1981; Zweben et al., 1988) or a brief, single session BI plus a follow-up session (e.g., Sannibale, 1988). Such interventions are less intense and involve less interventionist interaction than this study’s MET condition.

Future Research Directions

Although this study’s hypothesis was not supported, there is considerable empirical support for AUD treatment research assessment reactivity related behavior change, and assessment reactivity effects warrant continued investigation. This study’s results highlighted that it is important to take a more nuanced view than has been taken previously of assessment reactivity. In this regard, it appears that assessment reactivity effects are conditional on both intervention and participant characteristics, which suggests that it is important to conduct assessment condition by participant characteristic matching studies. Such investigations could validate the hypothesis that individuals suffering greater severity alcohol/drug use problems exhibit greater reactivity to the assessment process that results in reduced alcohol/drug use and related problems.

An in-depth understanding of how assessment reactivity related behavior change occurs, however, necessitates specification of underlying mechanisms of behavior change (MoBC). One theoretical framework useful for guiding MoBC research specific to assessment reactivity related behavior change is Self-Regulation Theory (SRT). Self-regulation is defined as the ability to modify one’s behavior in response to changing environmental demands and is achieved through comparison processes (Carver, 2012; Carver & Schreier, 2012). Successful self-regulatory behavior is contingent upon several component processes that include information input, self-evaluation, instigation to change, a search for alternative behaviors, planning, and implementation (Brown, 1998). In brief, this model holds that information input (i.e., focused attention) is essential for individuals to recognize the need for change. With such recognition, a self-evaluation process is initiated in which a comparative analysis is performed involving a standard of behavior (e.g., abstinence) and current behavior (e.g., problematic drinking). This self-evaluative process must result in a perceived discrepancy sufficient to cause an instigation to change, which in turn triggers a response to search for alternatives in an attempt to reduce the discrepancy. The identification of a feasible and efficacious alternative leads to the planning phase, in which the best course of action is decided upon and then implemented.

Given this framework, exposure to a highly relevant assessment battery that is administered in an empathetic manner should contribute to increased self-focused attention. Increased attention directed toward current alcohol/drug use and related problems contrasted with desired goal states, particularly at baseline, is likely to result in a discrepancy sufficient to trigger an instigation to change behavior. Therefore, large discrepancies between current alcohol/drug use and desired goal states should explain (i.e., mediate) associations between assessment exposure and subsequent alcohol/drug use. Future studies can be designed and implemented to test this proposed MoBC.

Study Limitations

The transition from in-person assessments to remote assessments may have contributed to diminished assessment reactivity effects. In addition, the manner and extent to which the COVID-19 pandemic influenced participant drinking behaviors is unknown. Therefore, caution should be exercised when interpreting and generalizing study findings.

Conclusions

The results of this study did not support its hypotheses and suggest that for a more in-depth understanding of how and for whom research assessment reactivity contributes to behavior change, future research centered on participant and AUD intervention characteristics as well as studies investigating mechanisms and self-regulatory processes underlying assessment related behavior change is warranted. To date, there is limited understanding of the conditions that enhance or dampen assessment reactivity effects or of the underlying MoBC and cognitive processes that result in the reduction of problematic alcohol/drug use symptoms and contribute to clinical improvements. Such understanding is essential to improving both the methodology of AUD treatment clinical trials research and enhancing the effectiveness of AUD treatment practice.

Public Health Significance Statement.

Prior research suggests that brief interventions (BI) for alcohol problems are effective and yield outcomes similar to more extensive alcohol use disorder (AUD) treatments. Study participant reactivity to the research protocols used in these studies, however, may have introduced a methodological confound that hampers the interpretability of these BI versus more extensive AUD treatment studies. The current study investigates this comparability hypothesis to determine if research assessments influence BIs to the extent that they become indistinguishable in outcomes from more extensive AUD treatments, which is important for improving both the methodology of AUD treatment clinical trials research and enhancing the effectiveness of AUD treatment practice.

Acknowledgments

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provided support for this research: Research Grants R01 AA022330 and R01 AA12191

Contributor Information

Patrick R. Clifford, Rutgers University, School of Public Health

Stephen A. Maisto, Syracuse University, Department of Psychology

Christine M. Davis, Rutgers University, School of Public Health

Robert L. Stout, Pacific Institute for Research and Evaluation, Quantitative Capabilities Collaboration

Marc L. Steinberg, Rutgers University, Robert Wood Johnson Medical School

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