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Art ic 1 es Concurrent Validity of the Schwartz Outcome Scale With a Chemically Dependent Population John M. Laux Bob Ahern Clients (N = 151) completed the Schwartz Outcome Scale (SOS-10; M. A. Blais et al., 1999) and the Substance Abuse Subtle Screening Inventory-3 (F. G. Miller & L. E. Lazowski, 1999). The results show a negative relationship between sub- stance use symptoms and SOS-10 scores and a positive relationship between defensiveness and SOS-10 scores. It is vital that counselors conduct outcome research both to demonstrate the effec- tiveness of treatments and programs (Sexton, 1996) and to further the effort to gain support from third-party payers (Joint Commission on Accreditation of Healthcare Organizations, 1997). However, constraints that are posed by lengthy or invasive instruments or the targeting of particular change variables have restricted wide- spread use of particular outcome measures (e.g., the Symptom Checklist-90-Revised [Derogatis, 19831;the Brief Psychiatric Rating Scale [Overall & Gorham, 19621). In an effort to meet counselors’ needs for a brief, cost-effective,unobtrusive, and easy- to-administer assessment device that can be used as an outcome measure, Blais et al. (1999) introduced the Schwartz Outcome Scale (SOS- 10). The SOS-10 was developed using a multifaceted process. A literature review and an expert panel that included psychologists, psychiatrists, a neurosurgeon, and two focus groups made up of patients produced an initial pool of 8 1 Likert-style items that were believed to identify changes in people’s lives that might be seen as a result of successful mental health treatment. Item elimination was conducted through a process of reviewing the responses of individuals who had been patients in an outpatient psychiatry clinic, a psychopharmacy clinic, an emergency room acute psychiatry clinic, a 21-bed inpatient medical psychiatry unit, or a community men- tal health clinic and responses from hospital employees. Retained items consis- John M . Lux, Department of Counseling and Mental Health Services, The University of Toledo; Bob Ahern, Consolidated Care, Inc., Maysville, Ohio. Theauthors thankJohn Schott for his assistance in the data-gathering process. This article is based on a paper presented at the 2001 midwinter meeting of the Society of Personality Assessment, Philadelphia. Correspondence concerning this article should be addressed to John M. Lam, Department of Counseling and Mental Health Services, The University of Toledo, 2801 West Bancroft Street, MS 119, Toledo, OH 43606-3390 (e-mail: john.lauxQutoledo.edu). 2 Journal of Addictions .si Oflender Counseling October 2003 Volume 24

Concurrent Validity of the Schwartz Outcome Scale With a Chemically Dependent Population

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Art ic 1 es

Concurrent Validity of the Schwartz Outcome Scale With a Chemically Dependent Population

John M . Laux Bob Ahern

Clients (N = 151) completed the Schwartz Outcome Scale (SOS-10; M. A. Blais et al., 1999) and the Substance Abuse Subtle Screening Inventory-3 (F. G. Miller & L. E. Lazowski, 1999). The results show a negative relationship between sub- stance use symptoms and SOS-10 scores and a positive relationship between defensiveness and SOS-10 scores.

It is vital that counselors conduct outcome research both to demonstrate the effec- tiveness of treatments and programs (Sexton, 1996) and to further the effort to gain support from third-party payers (Joint Commission on Accreditation of Healthcare Organizations, 1997). However, constraints that are posed by lengthy or invasive instruments or the targeting of particular change variables have restricted wide- spread use of particular outcome measures (e.g., the Symptom Checklist-90-Revised [Derogatis, 19831; the Brief Psychiatric Rating Scale [Overall & Gorham, 19621). In an effort to meet counselors’ needs for a brief, cost-effective, unobtrusive, and easy- to-administer assessment device that can be used as an outcome measure, Blais et al. (1999) introduced the Schwartz Outcome Scale (SOS- 10).

The SOS-10 was developed using a multifaceted process. A literature review and an expert panel that included psychologists, psychiatrists, a neurosurgeon, and two focus groups made up of patients produced an initial pool of 8 1 Likert-style items that were believed to identify changes in people’s lives that might be seen as a result of successful mental health treatment. Item elimination was conducted through a process of reviewing the responses of individuals who had been patients in an outpatient psychiatry clinic, a psychopharmacy clinic, an emergency room acute psychiatry clinic, a 21-bed inpatient medical psychiatry unit, or a community men- tal health clinic and responses from hospital employees. Retained items consis-

John M . L u x , Department of Counseling and Mental Health Services, The University of Toledo; Bob Ahern, Consolidated Care, Inc., Maysville, Ohio. Theauthors thankJohn Schott for his assistance in the data-gathering process. This article is based on a paper presented at the 2001 midwinter meeting of the Society of Personality Assessment, Philadelphia. Correspondence concerning this article should be addressed to John M . Lam, Department of Counseling and Mental Health Services, The University of Toledo, 2801 West Bancroft Street, MS 119, Toledo, OH 43606-3390 (e-mail: john.lauxQutoledo.edu).

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tently discriminated between the patients in the various facilities and the hospital employees (i.e., consistently loaded on one factor after Varimax rotation) and were not vulnerable to ceiling effects. The final 10-item scale has strong internal consis- tency (Cronbach’s alpha = .96) and item-to-scale correlations of .74 to .90. A 1- week test-retest reliability coefficient of .87 was found in a nonpatient population. Principal components factor analysis revealed one factor that accounted for 76% of the total variance. Strong convergent validity and divergent validity for the SOS-10 were established with measures of hopelessness, self-esteem, positive and negative affect, mental health, fatigue, life satisfaction, psychiatric symptoms, and desire to live (Blais et al., 1999).

Since its introduction in 1999, several SOS-10 validation studies have been conducted, the results of which have extended the instrument’s usefulness to populations beyond the original normative sample. Laux, Young, Waehler, and Phillips (2000) used the Outcome Questionnaire-45 (Lambert, Lumen, Umphress, Hansen, & Burlingame, 1994; Wells, Burlingame, Lambert, Hoag, & Hope, 1996), an established measure of progress and outcomes in outpatient psychotherapy, to examine the validity of the SOS-10 in a population of college counseling center clients. Laux et al. found that the SOS- 10 was a robust measure of overall general well-being and distress in a population of college students who sought services at a university counseling center.

Young, Laux, Waehler, McDaniel, and Hilsenroth (2001) conducted an investiga- tion of the SOS- 10’s psychometric properties in several additional populations. The SOS- 10 and the Rotter Incomplete Sentences Blank-College Version (RISB; Rotter & Rafferty, 1950) were administered to a group of undergraduates at a large midwestern university. The comparison of the SOS-10, a self-report measure, with the RISB, a projective measure, resulted in a significant correlation, indicating that the two in- struments were similarly measuring general well-being. Young et al. concluded that the SOS- 10 demonstrated sensitivity in measuring the general adjustment construct related to the RISB, although approaching the measurement of the general adjust- ment construct with a different psychological assessment method. Also, these authors reported an acceptable estimate of 1-week temporal stability of the SOS-10 in a nonclinical undergraduate population at a large southern university. Finally, these authors assessed the SOS- 10’s sensitivity to change in an outpatient community-based adult population; these clients completed the SOS-10 at intake and again at either the end of treatment or following the 10th session, whichever came first. The increase in these clients’ SOS- 10 scores was similar to the increase reported by Blais et al. (1999) and supports the utility of the SOS-10 as a measure of change in psychotherapy. Taken together, these studies provided evidence that the SOS-10 was a reliable and valid instrument for use with college students and adults who received counseling services at an outpatient community mental health center.

However, Blais et al. (1999), Laux et al. (2000), and Young et al. (2001) all indicated that one potential shortcoming of the SOS- 10 is that it is a face-valid instrument (i.e., the intent of the items is obvious). As such, questions remain regarding its utility with individuals who might have a vested interest in minimiz- ing their presenting concerns (Graham, 1993; Groth-Marnat, 1997; Otto & Hall,

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1988) or with people who are in denial about their distress (Shedler, Mayman, & Manis, 1993). Until we undertook our current study, the psychometric accuracy of the SOS-10 had not been tested with these questions in mind.

The purpose of our study was to explore the validity of the SOS-10 for use with people who might be motivated to “fake good,” and therefore unwilling to admit problems, and with people who, by virtue of their denial, might be unaware of their psychological distress. Specifically, we investigated the discriminant validity of the SOS- 10 by comparing it with another measure that was designed primarily to assess for the presence and denial of chemical dependence criteria-the Substance Abuse Subtle Screening Inventory-3 (SASSI-3; Miller & Lazowski, 1999).

Method

Participants

We used the admissions data of 15 1 clients for this study. Of this population, 75% ( n = 114) were men. The mean age of all the participants was 32 years (SD = 8.9, range = 18-59). Fifty participants (33.1%) were single or nonpartnered, 48 (3 1.8%) were married or partnered, 48 (31.8%) were either separated or divorced, and 5 (3.3%) did not identify a partnership status. Of this group of clients, 138 (91.4%) self-identified as European American, 2 (1.3%) identified as African American, and 2 (1.3%) identified as Native American. Nine (6%) participants did not iden- tify their ethnic affiliation. The mean education level was 12 years (SD = 2.7, range = 8-15).

Procedure

All clients who received alcohol and other drug assessment services at the county community mental health and recovery services center of a small midwestem city between October 2000 and August 2001 were asked to participate in this study. This population was selected because persons who are referred by the legal system or by an employer for chemical dependence assessment may, as a result of denial, be unable or unwilling to identify alcohol or other drug-related problems. Denial is seen to be a chief identifying feature of chemical dependence (Schaefer, 1987) and is characterized as a refusal to acknowledge or admit a problem (Milam & Ketcham, 1983). Due to the nature of denial (Carver & Scheier, 1996; Corsini & Wedding, 1995; Royce, 1989; Wiseman, Souder, & O’Sullivan, 1996), persons with chemical dependence diagnoses may be either unable or unwilling to admit to a clinician that they have problems or may be unable to identify that their troubles are related to their alcohol or drug use (Svanum & McGrew, 1995). For example, persons who are re- ferred by a court for a substance dependence assessment may be motivated to present themselves in a way to minimize their use of alcohol or other drugs and the degree to which these substances have affected their lives. Consequently, persons who are in denial about the impact of their chemical use may lack the objectivity required to answer the SOS-10 (Blais et al., 1999), a face-valid assessment, in a way that accu- rately reflects their distress related to chemical dependence. The effectiveness of the

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SOS- 10 as an outcome assessment measure may be limited to the degree to which it is subject to impression management. As stated, because persons who have been referred for alcohol and other drug assessment may have reasons to minimize their usage, they are ideal to serve as participants in a group to examine the degree of vulnerability of the SOS- 10 to impression management or “faking good.”

Each participant in this study completed an assessment packet, which included an informed consent form, the SOS-10, and the SASSI-3, at intake. All the participants completed the assessment packet as a process of admission and agreed to allow their data to be included in this study. To protect client confi- dentiality, the assessment packets were numbered, and the master identification list was stored separately under lock and key.

Instruments

The SOS-10 (Blais et al., 1999) is a 10-item, Likert-style scale that measures psychologi- cal well-being and distress. The range of scores per item is 0-6, with a possible total score ranging from 0 to 60; higher scores represent psychological health and well-being.

The SASSI-3 (Miller & Lazowski, 1999) was designed to provide a wide range of information regarding a respondent’s patterns of drug and alcohol use. The SASSI-3 was particularly useful in this investigation because it purports to identify respondents with a high probability of having a substance disorder, even if those respondents do not acknowledge substance misuse or the symptoms associated with it. According to Lazowski, Miller, Boye, and Miller (1998), it was first published in 1988; the cur- rent form is the second revision. The SASSI-3 was empirically created and re- quires only 15 minutes to complete and 2 minutes to score and interpret.

The SASSI-3 consists of the 12-item Face Valid Alcohol scale and the 14-item Face Valid Other Drug scale. Respondents are asked to indicate whether they have “never,” “once or twice,” “several times,” or “repeatedly” experienced the situation described. In addition, there are 67 questions that are seemingly not related to alcohol or other drugs. These true/false items load on eight empirically established scales. In addition to the two face-valid scales, we used the Symp- toms, Subtle Attributes, and Defensiveness scales in this study.

The Symptoms scale has 11 items that are related to the causes, consequences, and correlates of substance misuse. The 8 items that make up the Subtle Attributes scale provide information regarding a respondent’s efforts to conceal evidence of personal problems and limitations. The Subtle Attributes scale discriminates be- tween substance-dependent and non-substance-dependent persons regardless of potential response bias. This scale is particularly important to our study because face-valid alcohol specific measures (e.g., the Michigan Alcoholism Screening Test; Selzer, 1971) have shown limited ability to identify persons who are at risk or who have experienced only limited numbers of alcohol or other drug symp- tomatology (Svanum & McGrew, 1995). High scores on this scale reflect a lack of awareness about how substance abuse pervades the individual’s life.

The Defensiveness scale allows for interpretation of both high and low scores. High scores on the 11 items in this scale suggest to the clinician that the respon- dent lacks insight and self-awareness and may have been motivated to conceal

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evidence of personal problems, whether related to substances or to other prob- lems. Low Defensiveness scores are indicative of low self-esteem, a sense of worthlessness, and a tendency to focus on personal limitations and faults. The SASSI-3 has 6 items that load on the Random Answering Pattern scale to identify persons who have approached the assessment with a random answering pattern.

One of the strengths of the SASSI-3 is the confidence that its results provide for positive predictive power. Clinicians can be 98% certain that persons who test posi- tive on the SASSI-3 will meet the criteria for chemical dependence as given in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994). Similarly, the SASSI-3 boasts con- siderable sensitivity and specificity. For persons with a diagnosable substance dependence disorder, 94% will test positive on the SASSI-3. Also, for persons who do not meet DSM-IVcriteria for substance dependence, 94% will test nega- tive on the SASSI-3. Finally, for persons who test negative on the SASSI-3, the probability is 80% that they do not meet DSM-IV criteria for substance depen- dence. For the purposes of this study, we have confidence that persons who test positive on the SASSI-3 are very likely to be diagnosable with substance depen- dence disorder. The face-valid nature of the SOS-10 suggests that there will also be a negative relationship between SOS-10 scores and the face-valid scales, the Subtle Attributes scale, and the Symptoms scale and a positive relationship be- tween the SOS-10 and the Defensiveness scale.

Results

The means, standard deviations, and range of SOS-10 and SASSI-3 scale scores for this sample are presented in Table 1. The distribution of SOS-10 scores is rep- resented in Figure 1. In this population, 15 (10%) participants produced scores at the SOS-10 ceiling (i.e., 60). This suggests that for the majority of the individuals in this population, the SOS-10 is sensitive to a wide range of client responses.

TABLE 1

SOS-10 and SASSI-3 Community Counseling Center Clients’ Descriptive Data ( N = 151)

Scale M SD Range

sos-10 44.0 14.3 4-60 FVA 8.0 8.6 0-33 FVOD 7.4 10.1 0-36 SYM 4.4 3.1 0-1 1 DEF 5.3 2.6 0-1 0 SAT 3.4 1.3 0-7

Note. SOS-10 = Schwartz Outcome Scale (Blais et al., 1999); SASSI-3 =Substance Abuse Subtle Screening Inventory-3 (Miller & Lazowski, 1999); FVA = SASSI-3 Face Valid Alcohol scale; FVOD = SASSI-3 Face Valid Other Drug scale; SYM = SASSI-3 Symptoms scale; DEF = SASSI-3 Defensiveness scale: SAT = SASSI-3 Subtle Attributes scale.

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7.00 15.00 26.00 32.00 36.00 41.00 47.00 51.00 55.00 59.00

10.00 23.00 30.00 34.00 39.00 45.00 49.00 53.00 57.00

FIGURE 1

Distribution of Schwartz Outcome Scale Total Scores Across Study Participants ( N = 151)

A correlation matrix of Pearson product-moment correlation coefficients between the SOS-10 and the SASSI-3 subscales is presented in Table 2. Statistically significant Pearson product-moment correlation coefficients were found between the SOS- 10 and the Face Valid Alcohol scale, the Face Valid Other Drug scale, the Symptoms scale, and the Defensiveness scale. The Pearson product-moment correlation coefficient between the SOS- 10 and the Subtle Attributes scale was not statistically significant.

TOTAL

TABLE 2

SOS-10 and SASSI-3 Pearson Product-Moment Correlation Matrix

Clients IN = 151) ~ ~~

Scale 1 2 3 4 5 6

1. sos-10 - -.50* -.51 -.55' .71* -.01 2. FVA - .55' .80' -.53' .29' 3. FVOD - .63* -.61* .21' 4. SYM - -.66* .27* 5. DEF - -.09 6. SAT -

Note. SOS-10 = Schwartz Outcome Scale (Blais et al., 1999); SASSI-3 =Substance Abuse Subtle Screening Inventory-3 (Miller & Lazowski, 1999); FVA = SASSI-3 Face Valid Alcohol scale; FVOD = SASSI-3 Face Valid Other Drug scale; SYM = SASSI-3 Symptoms scale; DEF = SASSI-3 Defensiveness scale; SAT = SASSI-3 Subtle Attributes scale. ' p c ,001. All correlations were one-tailed.

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Discussion

The statistically significant negative correlations between the SOS- 10 and the Face Valid Alcohol, Face Valid Other Drug, and Symptoms scales suggest high concur- rent validity between the SOS-10 and the SASSI-3 in this population of partici- pants. Specifically, participants who scored higher on the SOS-10 were less likely to have alcohol or other drug problems and consequences than those who scored lower on the SOS-10. Participants who were willing to admit to having a drug or alcohol dependence disorder reported lower estimates of overall psychological health on the SOS- 10. Participants who felt worthless and presented with low self-esteem scored lower on the SOS-10. Conversely, participants whose SASSI-3 scores sug- gested a lack of insight and self-awareness or who may have been motivated to conceal evidence of personal problems or limitations tended to present themselves as well-adjusted on the SOS-10. The relationship between the SOS-10 and the Subtle Attributes scale was not significant. The Subtle Attributes scale was empirically validated to identify persons who might be motivated to conceal their level of de- pendence on drugs or alcohol. As such, we conclude that our results provide sup- port for the hypothesis that the SOS- 10 is a valid and useful measure of well-being in groups of people who are dependent on alcohol or other drugs. However, the statistically significant correlation between the SOS- 10 and the Defensiveness scale suggests that researchers and clinicians use caution in interpreting extremely high SOS-10 scores in this population.

Post hoc analyses were performed to test the claim of Blais et al. (1999) that the SOS-10 has only one factor. Cronbach’s alpha for the SOS-10 in the population of participants in this study was .95. Principal components factor analysis pro- duced a one-factor solution that accounted for 70% of the total variance. All 10 of the SOS- 10’s items loaded predominantly on this one factor with a factor load- ing range of .75-.90. These data support Blais et al.’s assertion that the SOS-10 has only one factor.

The SOS-10 is a succinct and easily scored instrument. Clinicians do not re- quire lengthy training, education, or supervision to administer, score, and inter- pret SOS-10 data. Because of its face-valid status, the SOS-10 may be used to develop rapport and to facilitate communication between clients who are depen- dent on alcohol or other drugs and the therapist with minimal concern for impres- sion management issues. An additional advantage of using the SOS-10 is that it is economical. The SOS-10 is inexpensive and virtually cost free to administer and score. As such, the SOS-10 may be more useful than longer, more costly, and more cumbersome assessment instruments.

Finally, it is important to identify aspects of this study that may serve to limit the generalizability of these results. First, the participants were primarily European American men from a rural midwestern community. Although 25% of the partici- pants were women, it is uncertain how or if a population that had greater gender and ethnic diversity would influence the results of these analyses. Second, only persons ages 18 years and above were included in this study. Psychometric studies of the SOS-10 among adolescents and children have yet to be conducted. Third,

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the SOS-10 instructions require individuals to respond based on the last 7 days; however, the participants in our study responded to the SASSI-3 based on their behaviors over the course of their lifetime. It is possible for an individual to be classified on the SASSI-3 as having a high probability of a substance disorder and yet meet DSM-ZV (American Psychiatric Association, 1994) criteria for sub- stance dependence in sustained full remission. This dynamic may have served to diminish the strength of the relationship between the SOS-10 and the two face- valid scales of the SASSI-3. Finally, the limited sample size may have restricted the range of variability. A larger sample may have allowed relationships that were otherwise masked to be uncovered.

We offer the following suggestions for future research. Although our study failed to uncover a significant relationship between the SOS- 10 and the Subtle Attributes scale, a larger sample may provide sufficient power to detect a significant rela- tionship, if one exists. The inclusion of more women and greater ethnic diversity would allow the potential for comparisons on the basis of gender and ethnicity. Finally, comparing the SOS-10 and the Adolescent Substance Abuse Subtle Screening Inventory would provide evidence regarding the validity of the SOS-10 in an ado- lescent population.

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Rotter, J . B., & Rafferty, J. E. (1950). Manual: The Rotter Incotnplete Sentences Blank. New York: Psychological Corporation.

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