Readiness to Change in a Clinical Sample of Problem Drinkers: Relation to Alcohol Use, Self-Efficacy, and Treatment Outcome

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1 Research Report Eur Addict Res 2004;10: DOI: / Readiness to Change in a Clinical Sample of Problem Drinkers: Relation to Alcohol Use, Self-Efficacy, and Treatment Outcome Ralf Demmel a Beate Beck b Dirk Richter b Thomas Reker b a Department of Clinical Psychology, University of Münster, Münster and b Westfälische Klinik für Psychiatrie und Psychotherapie Münster, Münster, Germany Key Words Alcohol dependence W Alcohol use, self-efficacy and treatment outcome W Alcoholism, outcome W Alcoholism, treatment W Construct validity W Factor analysis W Problem drinkers, readiness to change W SOCRATES, reliability W Stages of Change Readiness and Treatment Eagerness Scale - SOCRATES W Transtheoretical model, behaviour change Abstract According to the transtheoretical model of behaviour change, individuals addicted to psychotropic drugs typically cycle through a sequence of five discrete stages (precontemplation, contemplation, preparation, action, and maintenance) before achieving sustained long-term abstinence and moderation, respectively. A number of English-language questionnaires have been developed to assess client motivation in accordance with the stages of change approach. The present study aimed to expand the research on the transtheoretical model by establishing the factor structure of a German-language version of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) in a large sample of alcohol-dependent inpatients (n = 350). Furthermore, the relation of client motivation to alcohol use, self-efficacy and treatment outcome at 3-month follow-up was examined. Exploratory factor analysis revealed three separate dimensions of readiness to change (Taking Steps, Recognition, and Ambivalence). The factorial structure of the German-language SOCRATES corresponded almost exactly to that of the original version. Readiness to change accounted for 9.4% of the variance in treatment outcome. Moreover, readiness to change was positively related to pretreatment self-efficacy. Copyright 2004 S. Karger AG, Basel In accordance with a bottoming out approach, clients have been categorized either as motivated or unmotivated in traditional substance abuse treatment [1]. In contrast to this binary definition of motivation, the transtheoretical model assumes that intentional behaviour change involves passing through a sequence of discrete stages. Based on the results of numerous studies and previous versions of the model, Prochaska et al. [2] described five stages of change: (1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance. According to Prochaska et al. [2], individuals addicted to psychotropic drugs typically recycle through these stages several times before achieving sustained long-term behaviour change. Davidson [3] emphasizes that the face validity and intuitive appeal of the model may be the main reason for its popularity. The transtheoretical model has been adopted for a variety of addictive behaviours including smoking, problem drinking, and the use of illicit drugs as well as to health behaviour change in general [4]. Treatment programs based on the stages of change approach have been evaluated in a number of clinical trials [5]. ABC Fax karger@karger.ch S. Karger AG, Basel /04/ $21.00/0 Accessible online at: Dr. Ralf Demmel Department of Clinical Psychology, University of Münster Fliednerstrasse 21 DE Münster (Germany) Tel , Fax , demmel@psy.uni-muenster.de

2 Matching interventions to clients readiness to change requires both the assessment of motivation and the assignment of clients to particular stages of change. A number of self-administered questionnaires have been developed to measure client motivation, including the University of Rhode Island Change Assessment (URICA) [6], the Readiness to Change Questionnaire (RCQ) [7], and the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) [8]. Whereas the URICA was designed to assess readiness to change in a wide range of settings and behavioural domains (e.g., substance abuse, diabetes, obesity), the RCQ may be used to measure client motivation in primary health care settings. The original version of the SOCRATES was intended to categorize alcoholism treatment clients according to their motivation for change. The structure and reliability of the SOCRATES have been evaluated in a series of studies. Exploratory factor analysis revealed three separate dimensions of a shortened 19-item version of the SO- CRATES [8]. Factor 1 (Taking Steps) comprises the action and maintenance items of previous versions (e.g., I have already changed my drinking, and I am looking for ways to keep from slipping back into my old pattern ). Factor 2 (Recognition) represents the awareness of problems caused by heavy drinking (e.g., If I don t change my drinking soon, my problems are going to get worse ). The four items loading on factor 3 (Ambivalence) describe the individual s evaluation of both pros and cons of drinking (e.g., Sometimes I wonder if my drinking is hurting other people ). Cronbach s alphas reported by Miller and Tonigan [8] are 0.83 for Taking Steps, 0.85 for Recognition, and 0.60 for Ambivalence. Test-retest reliabilities over a 2-day interval range from r = 0.83 (Ambivalence) to r = 0.99 (Recognition). According to Miller and Tonigan [8], the three dimensions derived from factor analysis reflect continuously distributed motivational processes that may underlie stages of change [p. 84]. The various forms of the SOCRATES have been used to assess client motivation in a variety of settings, e.g. primary health care [9], outpatient treatment [10], and online counselling [11]. However, little is known about the predictive validity of the SOCRATES. To date, the relationship between readiness to change as indicated by the SOCRATES on the one hand and treatment outcome on the other has been investigated in two studies. Hewes and Janikowski [12] used the SOCRATES to assess pretreatment motivation in a sample of 31 alcoholism treatment clients. Participants were classified according to their readiness to change. At 30-day follow-up, groups did not differ with respect to their composite scores on the Addiction Severity Index (ASI) [13]. However, the results of this study should be interpreted with caution. First, the small sample size may have limited the ability to detect differences in the ASI composite scores. Second, participants lost to follow-up were excluded from the study. Finally, readiness to change and treatment outcome were evaluated in a mixed sample of problem drinkers participating either in inpatient or outpatient treatment programs. In another study based on the self-reports of 125 alcoholism treatment clients, readiness to change predicted abstinence at 12- month follow-up [14]. Moreover, pretreatment motivation was related to Alcoholics Anonymous affiliation at follow-up. The present study aims to expand the research on the stages of change by establishing the factor structure of a German-language version of the SOCRATES in a large sample of alcohol-dependent inpatients. Furthermore, the relation of readiness to change to alcohol use, treatment outcome at 3-month follow-up, and self-efficacy another construct relevant to client motivation [15] is examined. Method Participants Three hundred and eighty-five volunteers from four psychiatric hospitals (Westfälische Klinik für Psychiatrie, Psychotherapie und Neurologie Lengerich [WKPPN Lengerich], Westfälische Klinik für Psychiatrie und Psychotherapie Münster [WKPP Münster], Westfälische Klinik für Psychiatrie und Psychotherapie Warstein [WKPP Warstein], Westfälisches Zentrum für Psychiatrie, Psychotherapie und Psychosomatik Dortmund [WZPPP Dortmund]) participated in this study. Data from a fifth site (Hans-Prinzhorn-Klinik Hemer) were excluded from further analyses since an incomplete version of the SOCRATES was administered to the participants (n = 94). During a period of 3 months (mid-january to mid-april 2001) subjects were selected from successive admissions for participation in the study if they met the following criteria: (1) alcohol dependence according to ICD-10 (German version by Dilling et al. [16]); (2) maximum age of 60 years; (3) no cognitive or verbal impairment; (4) no primary diagnosis of drug dependence (including dependence on illicit drugs, sedatives, hypnotics or anxiolytics); (5) residence in the local community. Thirty-five subjects were excluded from the study due to incomplete data (no background variables, incomplete questionnaires). The final sample consisted of 350 inpatients (WKPPN Lengerich: n = 69; WKPP Münster: n = 90; WKPP Warstein: n = 99; WZPPP Dortmund: n = 92; mean age of years; SD = 8.33). Of the sample, 82% were male, 27% were married, and 49% were currently unemployed. The majority of the entire sample (96%) reported at least one previous detoxification (mean number of previous detoxifications = 9.46, Mdn = 4, SD = 15.1, Max = 130, n = 347). Three hundred and nine subjects (89%) were self-described smokers (information was not provided by 4 subjects). 134 Eur Addict Res 2004;10: Demmel/Beck/Richter/Reker

3 Table 1. Factor loadings and item statistics of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) Item a ij p i r it i del Miller and Tonigan [8] Factor 1: Taking Steps ( = 0.84) 10 I have already changed my drinking, and I am looking for ways to keep from slipping Taking Steps 4 I have already started making some changes in my drinking Taking Steps 14 I am actively doing things now to cut down or stop drinking Taking Steps 9 I m not just thinking about changing my drinking, I m already doing something about it Taking Steps 5 I was drinking too much at one time, but I ve managed to change my drinking Taking Steps 20 I have made some changes in my drinking, and I want some help to keep from going back to the way I used to drink Taking Steps 19 I am working hard to change my drinking Taking Steps 1 I really want to make changes in my drinking Recognition Factor 2: Recognition ( = 0.78) 11 I have serious problems with drinking Recognition 16 I know that I have a drinking problem Recognition 18 I am an alcoholic Recognition 15 I want help to keep from going back to the drinking problems that I had before Taking Steps 13 My drinking is causing a lot of harm Recognition 3 If I don t change my drinking soon, my problems are going to get worse Recognition Factor 3: Ambivalence ( = 0.68) 17 There are times when I wonder if I drink too much Ambivalence 2 Sometimes I wonder if I am an alcoholic Ambivalence 7 Sometimes I wonder if my drinking is hurting other people Ambivalence 12 Sometimes I wonder if I am in control of my drinking Ambivalence a ij = Factor loading; p i = item difficulty; r it i = corrected item-total correlation; del = if item deleted. Measures and Procedures Subjects participated in a multi-site study on the outcome of short-term inpatient treatment (for a more detailed description of measures and procedures not relevant to this report, see Reker et al. [17]). The mean length of inpatient stay was 12.3 days (Mdn = 10.5, Min = 2, Max = 72, SD = 6.97). Within 5 days following admission patients were invited to participate in the study. Written informed consent was obtained and subjects completed a number of questionnaires including a German-language version of the SOCRATES [18]. A standardized clinical interview was administered by advanced undergraduate students or staff members to all participants to assess sociodemographic background, alcohol consumption, and the number of previous detoxifications. This interview included items adapted from a German-language version of the ASI [19]. At the Münster site only, a shortened uni-dimensional version of the Drug Taking Confidence Questionnaire (DTCQ [20, 21]) was administered. A total of 63 participants completed both the DTCQ and the SO- CRATES with no missing items. At the time of baseline assessment, all subjects were completely detoxified (blood alcohol concentration was zero) and free from clinically significant symptoms of acute alcohol withdrawal. Treatment outcome was assessed 3 months after discharge. Again, a standardized clinical interview was administered by advanced undergraduate students or staff members via telephone or in person. Approximately two thirds of the follow-up interviews were administered via telephone. Follow-up assessments during a period of weeks following cessation of inpatient treatment were considered acceptable. A conservative strategy was adopted to assess treatment outcome. Two groups of subjects were defined according to their reports of alcohol use during the 3-month follow-up period. Subjects were classified either as abstainers (reporting no alcohol use at all during the follow-up period) or relapsers (having had at least one drink of alcohol during the follow-up period). Those subjects lost to follow-up were categorized as relapsers. At both baseline and follow-up, alcohol use was assessed by the following measures: (1) the number of drinking days during the month preceding the interview (frequency), (2) the average number of drinks (beer, wine or liquor) per day in the week preceding admission/follow-up (quantity). Responses to the quantity item were transformed into grams of pure alcohol. All statistical analyses were performed with the SPSS software package (Version 11.0). Results Item Analysis and Factor Structure Item difficulties ranged from 0.52 to 0.95 (table 1). No items were deleted prior to factor analysis. A preliminary common factor analysis and orthogonal varimax rotation of eigenvectors revealed four factors with eigenvalues 11 (Ï 1 = 4.42, Ï 2 = 3.33, Ï 3 = 1.87, Ï 4 = 1.04). Visual examination of the screen plot suggested three or four factors. In order to assess simple structure, an item was selected for further consideration if its loading was on a given factor and ^0.40 on the remaining factors (despite this rule, item 1 was included). Item 8 ( I am a problem drink- Readiness to Change Eur Addict Res 2004;10:

4 Table 2. Intercorrelations for scores on three SOCRATES subscales and correlations with baseline and outcome measures Taking Steps 1 2 Recognition Ambivalence *** 0.14** 4 Frequency of alcohol use (t 0 ) ** 5 Quantity of alcohol use (t 0 ) *** *** 6 Number of detoxifications (t 0 ) *** ** 0.15** 0.21*** 7 Frequency of alcohol use (t 1 ) * Quantity of alcohol use (t 1 ) ** * ** *** 9 Number of detoxifications (t 1 ) *** *** 0.35*** 0.32*** 0.32*** 1 n = 350; 2 n = 347; ^ n ^ 241; ^ n ^ 269. *p! 0.05; ** p! 0.01; *** p! Table 3. Summary of logistic regression analysis predicting abstinence (n = 314) Variable B SEOdds ratio Wald statistic Age Sex Frequency of alcohol use Quantity of alcohol use Number of previous detoxifications Taking steps *** Recognition * Ambivalence *p! 0.05; *** p! er ) was deleted because its highest factor loading was 0.30 and its exclusion increased Cronbach s alpha for factor 2 considerably (Cronbach s alpha if item included = 0.74). Factors 1 3 appeared to be relatively uniform across factor solutions. The fourth factor added only minimally to variance explained. Moreover, inspection of the item content suggested substantial overlap with factor 1. Finally, a three-factor solution that accounted for 41.70% of the variance was favoured on the basis of item statistics and theoretical considerations: (1) Taking Steps, (2) Recognition, and (3) Ambivalence (table 1). Intercorrelations of the subscores ranged from r = 0.06 to r = 0.27 (table 2). As shown in table 1, the factor structure of the German version of the SOCRATES corresponded almost exactly to that proposed by Miller and Tonigan [8]. Cronbach s alphas obtained for the three subscales ranged from = 0.68 to = 0.84 (table 1). Relation to Baseline Measures and Prediction of Treatment Outcome Correlations between pretreatment variables (drinking measures and number of previous detoxifications) and the SOCRATES scores ranged from r = 0.28 to r = 0.14 (table 2). Self-efficacy at baseline was positively related to Taking Steps (r = 0.34, p! 0.001). A total of 33 follow-up interviews (abstainers: n = 7; relapsers: n = 26) were not conducted during the period of weeks following cessation of inpatient treatment. Consequently, these follow-up assessments were excluded from further analyses. According to self-reported alcohol use, 127 subjects were classified as abstainers and 142 subjects as relapsers. Forty-eight subjects were lost to follow-up and thus classified as relapsers. Correlations between outcome measures and the SOCRATES scores ranged from r = 0.28 to r = 0.08 (table 2). A multivariate logistic regression analysis was conducted to examine the relationship between baseline 136 Eur Addict Res 2004;10: Demmel/Beck/Richter/Reker

5 measures and treatment outcome (relapse vs. no relapse). The regression model included background variables (age, gender), drinking measures, the number of previous detoxifications, and the SOCRATES scores (table 3). All predictor variables were entered simultaneously into the model. Scores on Taking Steps and Recognition added 7.5 and 1.9%, respectively, to the variance explained. The overall model accounted for 15.7% of the variance in treatment outcome. Discussion The purpose of the present study was to establish the factor structure of a German version of the SOCRATES and to examine the relation of readiness to change to both baseline and outcome variables. The dimensions of client motivation revealed by factor analysis corresponded almost exactly to those described by Miller and Tonigan [8]. Our findings are encouraging and support the internal validity of the SOCRATES. However, Davidson [3] points out that the factor structure of the URICA the most frequently used measure of readiness to change might be due to semantic overlap between the scale items. This criticism applies to the SOCRATES as well: Phrasing the same question in several ways is likely to result in a bloated factor structure [22]. Unfortunately, virtually nothing is known about the concurrent validity of assessment instruments such as the URICA or the SOCRATES, and simple measures of client motivation, e.g. single-item algorithms or rating scales [23]. Therefore, recommendations concerning the use of particular methods for assessing clients stage of change appear to be premature at this time. However, the utility of brief assessment instruments may be limited due to inadequate reliability. Clearly, reliability can be increased with the use of multi-item scales [24]. Cronbach s alphas obtained for the SOCRATES scales ranged from = 0.68 (factor 3) to = 0.84 (factor 1). According to Miller and Tonigan [8], the poor reliability of factor 3 reflects a problem inherent in the measurement of ambivalence. Obviously, it is difficult to generate items assessing the ambivalence of alcoholism treatment clients. An overall evaluation of the good things and the less good things about drinking may be a more appropriate method to assess ambivalence [25]. Correlations between the SOCRATES scores and drinking measures were low to modest. Nevertheless, readiness to change was significantly related to treatment outcome. These findings are in accordance with the results of previous research: Client motivation predicts relapse; however, once abstinence has been violated, factors other than stage of change appear to determine both frequency and quantity of alcohol use [14]. Readiness to change was related to self-efficacy. Initiation of behaviour change as reflected by high scores on Taking Steps was associated with the expectancy to cope successfully with high-risk situations. The transtheoretical model assumes a complex interaction of self-efficacy expectations, and readiness to change [26]. For example, self-efficacy and processes of change activity (e.g., counterconditioning, stimulus control, reinforcement management) have been found to be inversely correlated in the action and maintenance stages [27]. In contrast, Bandura [28] states that the transtheoretical model describes arbitrary pseudo-stages irrelevant to behaviour change. According to social learning theory of drinking and alcoholism, self-efficacy is the most powerful predictor of abstinence [29]. Future research may prove whether readiness to change adds to the prediction of treatment outcome when self-efficacy expectations and other social learning theory variables, e.g., outcome expectancies, are included in a more complex multivariate model. Some limitations should be considered when interpreting the results of the present study. First, the majority of follow-up interviews were administered via telephone. Second, evaluation of treatment outcome was based exclusively on self-reported alcohol use. Third, our baseline assessment did not include a standardized clinical interview to verify the diagnosis of alcohol dependence. Finally, additional long-term follow-up studies are needed to confirm the predictive utility of the SOCRATES. Nevertheless, the findings of the present study highlight the importance of client motivation in the treatment of alcohol dependence. Readiness to change accounted for 9.4% of the variance in treatment outcome. In contrast, background variables and previous alcohol use explained only 6% of the variance. Research on treatment outcome and clients may benefit from a more comprehensive assessment of motivation including measures of readiness to change, self-efficacy and outcome expectancies. Acknowledgements This research was supported by the Landschaftsverband Westfalen-Lippe. The authors wish to thank Alexander L. Gerlach, Jutta Hagen, and Fred Rist for their helpful comments on drafts of this article. Readiness to Change Eur Addict Res 2004;10:

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