Chapter 8 Measuring Components of Client Motivation

Motivation is multidimensional, not a single domain that can be easily measured with one instrument or scale. This chapter describes a variety of tools for measuring the building blocks of motivation discussed throughout this TIP. This chapter should be regarded as a progress report because concepts of motivation for change are evolving, and new approaches for assessment are being tested.

Measures often have to be adapted, and their psychometric characteristics change when they are applied to new problems and populations. There are also specificity challenges in assessing motivation. For example, clients are often at very different points of readiness with regard to different substances.

A person may be in the action stage for cocaine, the contemplation stage for alcohol, and the precontemplation stage for marijuana and tobacco. No doubt, motivation measures will become more precise in the years ahead.

In this chapter is a set of measures endorsed by the Consensus Panel. For most measures, there is good psychometric documentation, but some are at earlier stages of validation. Most have not been normed for different racial or ethnic groups. Many clinicians have found these formal tools to be valuable and appreciate the structure and focus these instruments can provide--the sense that their work with the client is task-centered and grounded in reality.

The results also provide one more type of feedback to use with clients throughout the change process to enhance motivation. For some clients, test scores add a dimension of objectivity to the counseling situation, which may otherwise seem highly subjective. One risk to be aware of in using these tools, however, is that some clients might focus too heavily on scores indicating their vulnerabilities rather than on those indicating their strengths.

This chapter offers ways of measuring the following dimensions of motivation:

Self-efficacy
Readiness to change
Decisional balancing
Motivations for using substances
Goals and values

The purpose of this chapter is to aid you in assessing where clients are in terms of motivation levels and also to help you apply the motivational principles and appropriate strategies for different stages of change that are discussed in Chapters 4 through 7. A variety of valuable and psychometrically sound instruments and scales that are easy to administer are now available (Allen and Columbus, 1995).

You may wish to try several different instruments to find those that work best with your clients, that measure the dimensions of most interest to you, and that match your clinical style. Many of the instruments discussed in this chapter appear in Appendix B.

Self-Efficacy

Individuals in recovery have very different levels of confidence regarding their ability (self-efficacy) to change and abstain from substances. Some are overly confident, while others feel hopeless about achieving sobriety or even reducing use.

Self-efficacy, particularly with respect to capabilities for overcoming alcohol dependence or abuse, is an important predictor of treatment outcome (DiClemente et al., 1994). Because certain situations are more likely to lead to setbacks for those in recovery (Marlatt and George, 1984), identifying these high-risk situations is an important step in treatment.

Self-efficacy questionnaires ask clients to rate how risky certain situations are and to estimate their confidence in how well they would do in avoiding the temptation to use substances in these situations. The numerical scores provide an objective measure of a client's self-efficacy for a specific behavior over a range of provocative situations. Some computerized versions of these instruments generate small bar graphs that add a visual dimension to the numbers.

By using these tools, clients gain an understanding of where their individual risks lie--high-risk situations in which they have low self-efficacy. This information can be extremely useful in setting realistic goals and developing an individualized change plan and can provide a sound basis for self-monitoring. Clients who rank many situations as high risk (i.e., low self-efficacy) may need to learn new coping strategies.

Situational Confidence Questionnaire

The Situational Confidence Questionnaire (SCQ) has been used specifically with those who drink heavily. The instrument consists of 100 items that ask clients to identify their level of confidence in resisting drinking as a response to the following eight types of situations (Marlatt and Gordon, 1985):

Unpleasant emotions
Physical discomfort
Testing personal control over substance use
Urges and temptations to drink
Pleasant times with others
Conflicts with others
Pleasant emotions
Social pressure to drink

Clients are asked to imagine themselves in each situation and rate their confidence on a 6-point scale, ranging from not at all confident (a rating of 0) to totally confident (a rating of 6) that they can resist the urge to drink heavily in that situation.

The SCQ generally takes about 20 minutes to complete, using either pencil and paper or computer software that automatically scores answers and generates a profile of the client's alcohol use.

The SCQ is accompanied by an Inventory of Drinking Situations that assesses the frequency of heavy drinking in different situations. The results of this questionnaire can be used to provide personalized feedback to the client as well as for treatment planning (Annis and Davis, 1991).

High confidence scores have been shown to predict positive treatment outcomes (Annis and Davis, 1988), whereas low confidence scores have identified clients who are likely to have poor treatment outcomes (Sobell et al., 1997). An amended version of the SCQ, the SCQ-39, is the version recommended by the questionnaire's developer (see Appendix B).

Brief Situational Confidence Questionnaire

The Brief Situational Confidence Questionnaire (BSCQ) was developed as an alternative to the SCQ because some treatment programs found the length and scoring and graphing systems of the original instrument to be too time-consuming in clinical practice (Sobell, 1996). The eight items of the BSCQ, reproduced in Appendix B, correspond to the eight subscales in the original SCQ.

Respondents in a community study (Sobell et al., 1996b) were asked to rank their confidence at the time of taking the questionnaire in resisting using alcohol or a primary drug in each situation on a scale from 0 (not at all confident) to 100 (totally confident). A comparison of the brief and long versions of the SCQ (Breslin et al., 1997) found that the shorter version is also effective and corresponds well with the longer version on most subscales.

The BSCQ, although not as comprehensive and not yet as extensively tested, has several clinical advantages over the longer version. It can be administered in a few minutes, is easily interpreted by clinicians, provides immediate feedback for the client, and can be used easily in primary care and other nonaddiction-specific settings (Breslin et al., 1997). The BSCQ is also available in Spanish.

Alcohol Abstinence Self-Efficacy Scale

The Alcohol Abstinence Self-Efficacy Scale (AASE) measures an individual's self-efficacy in abstaining from alcohol (DiClemente et al., 1994). Although similar to the SCQ, the AASE focuses on clients' confidence in their ability to abstain from drinking across a range of 20 different situations derived from the eight high-risk categories listed above.

The AASE consists of 20 items and can be used to assess both the temptation to drink and the confidence to abstain (see Figure 8-1). Clients rate their temptation to drink and their confidence that they would not drink in each situation on separate 5-point Likert scales that range from 1 (not at all likely) to 5 (extremely likely). Scores are calculated separately for temptation and self-efficacy (DiClemente et al., 1994).

The items in this version are divided into several subcategories that measure four types of recurrence precipitants: negative affect, social situations, physical or other concerns, and craving and urges. A study conducted on 266 adults in treatment at an outpatient treatment program for alcohol use disorders over a 24-month period found strong indices of reliability and validity for this scale (DiClemente et al., 1994).

This brief version also appears to be equally effective with men and women. It is easy to use, comprehensive, and a psychometrically sound measure of self-efficacy to abstain from drinking.

Readiness To Change

An instrument for assessing the importance of change has been developed (Sobell et al., 1996b), based on a four-question scale originally used with smokers (Richmond et al., 1993). The questions were modified to inquire about drinking, with responses in a specific range for each question. A composite motivation score is calculated with a possible range from 0 to 10, based on the sum of the responses.

The four questions are

Would you like to reduce or quit drinking if you could do so easily? (No = 0, Yes = 1)

How seriously would you like to reduce or quit drinking altogether? (Not at all seriously = 0, Not very seriously = 1, Fairly seriously = 2, Very seriously = 3)

Do you intend to reduce or quit drinking in the next 2 weeks? (Definitely no = 0, Probably no = 1, Probably yes = 2, Definitely yes = 3)

What is the possibility that 12 months from now you will not have a problem with alcohol? (Definitely not = 0, Probably not = 1, Probably will = 2, Definitely will = 3)

As discussed throughout this TIP, readiness to change can be considered a prerequisite for responding to treatment. However, motivational states are not binary--with clients either motivated or not motivated. Rather, readiness exists along a continuum of steps or stages and can vary rapidly, sometimes from day to day.

The stages-of-change model has inspired instruments for assessing readiness to change or a client's motivational change state. Depending on the level of readiness--or change stage--different motivational intervention strategies will be more or less effective (see Chapters 2 through 7).

Readiness Ruler

The Readiness Ruler, developed by Rollnick and used extensively in general medical settings, is a simple method for determining clients' readiness to change by asking where they are on a scale of 1 to 10 (see Figure 8-2). The lower numbers indicate less readiness, and the higher numbers indicate greater readiness for change.

Depending on how ready to change clients think they are, the conversation can take different directions. For those who rate themselves as "not ready" (0 to 3), some clinicians suggest expressing concern, offering information, and providing support and followup. For those who are unsure (4 to 7), explore the positive and negative aspects of treatment. For clients who are ready for change (8 to 10), help plan action, identify resources, and convey hope (Bernstein et al., 1997a).

As clients continue in treatment, you can use the ruler periodically to monitor how motivation changes as treatment progresses. Remember that clients can move both forward and backward. Also, helping clients move forward, even if they never reach a decisionmaking or action stage, is an acceptable outcome.

Most clients cycle through the change stages several times, sometimes spiraling up and sometimes down, before they settle into treatment or stable recovery. One significant feature of the readiness to change scale is that clients assess their own readiness by marking the ruler or voicing a number.

Another feature is that the clinician can pose the question, "What would it take to move from a 3 to a 5?" or can recognize movement along the continuum by asking, "Where have you come from last year to now?" Chapter 4 provides more information about fostering readiness.

In other similar studies (Sobell et al., 1993b; Sobell and Sobell, 1993, 1995b), clients responded on a scale of 0 to 100 to the following two questions:

At this moment, how important is it that you change your current drinking? (Not important at all = 0, About as important as most of the other things I would like to achieve now = 50, Most important thing in my life now = 100)

At this moment, how confident are you that you will change your current drinking? (I do not think I will achieve my goal = 0, I have a 50 percent chance of meeting my goal = 50, I think I will definitely achieve my goal = 100)

Both goal importance and confidence ratings have been associated with better treatment outcomes (Sobell et al., 1996b).

University of Rhode Island Change Assessment Scale

The University of Rhode Island Change Assessment Scale (URICA) was originally developed to measure a client's change stage in psychotherapy (McConnaughy et al., 1983) in terms of four stages of change: precontemplation, contemplation, action, and maintenance.

The scale has 32 items, with eight items for each of the four stage-specific subscales (see Appendix B). Respondents rate items on a five-point Likert scale from 1 (strong disagreement) to 5 (strong agreement). Scores for each of the four stages are obtained. The instrument is designed for a broad range of concerns and asks clients general questions about their "problem."

A 28-item version of the URICA, with seven items corresponding to each stage, has also been used with clients in alcoholism treatment (DiClemente et al., 1994). Subscale scores from this instrument can then be used to create profiles related to the stages of change or to create a single readiness score by adding together the contemplation, action, and maintenance mean scores and subtracting the precontemplation score.

In various research studies, these scores have been related to treatment outcome. In Project MATCH, a multisite clinical trial of psychosocial treatments for alcohol problems that involved 1,726 clients, the readiness score predicted abstinence from drinking outcomes at a 3-year followup (Project MATCH Research Group, 1997a).