Stages of Change Readiness and Treatment Eagerness Scale

The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) measures readiness to change, with items specifically focused on problem drinkers. Developed in 1987 by William R. Miller, the initial set of items was circulated for comment among colleagues in substance abuse treatment research. A 32-item version was then produced, using five-point scales ranging from five (strongly agree) to one (strongly disagree).

The current 19-item version of SOCRATES, reproduced in Appendix B, was initially developed in 1991 and was used as a self-administered paper-and-pencil questionnaire in Project MATCH (Miller and Tonigan, 1996). The items on this short version do not measure the five stages of change constructs, but relate to three factors that have little overlap with each other: taking steps, recognition, and ambivalence.

Clinicians can use SOCRATES to provide clients with feedback about their scores as a starting point for discussion. Changes in scores when the scale is readministered could assess the impact of an intervention on problem recognition, ambivalence, and progress on making changes.

Parallel forms have been developed to assess motivation to change substance use as well as the motivation of a significant other to help change a partner's substance-using patterns. The SOCRATES variables can also be helpful, in combination with other measures, for understanding the structure of motivation and readiness for change. Spanish translations are available.

Readiness To Change Questionnaire

The Readiness To Change Questionnaire (RCQ) was developed to help professionals who are not substance abuse treatment specialists assess the change stage of clients who drink excessively (Rollnick et al., 1992b). The 12 items, which were adapted from the URICA items, correlate closely with three change stages--precontemplation, contemplation, and action--and reflect typical attitudes of persons in each of those readiness levels.

For example, a person not yet contemplating change would likely give a positive response to the statement, "Drinking less alcohol would be pointless for me," whereas a person already taking action would agree with the statement, "I have just recently changed my drinking habits." Another individual already contemplating change would be expected to agree with the item, "Sometimes I think I should cut down on my drinking." A five-point scale is used for rating responses, from strongly agree (5) to strongly disagree (1).

The RCQ, which can be self-administered, has been shown to have good psychometric properties with heavy drinkers in nontreatment settings. When the instrument was used as a screening tool with heavy drinkers in general hospitals, it accurately reflected patients' readiness to change and also predicted changes in respondents' alcohol consumption patterns at 8 weeks and 6 months following hospital discharge.

That is, those who were least ready to change showed the least improvement in drinking patterns at followup, whereas those who were most ready to act did so (Heather et al., 1993). An additional test of the instrument found that men identified as heavy drinkers in general hospital wards and as being in early stages of change responded more favorably to brief motivational interviewing than to skills-based counseling with respect to reduced alcohol consumption.

The inverse, however, was not found to be true. Men rated as ready to change did not respond any more favorably to skills-based counseling than to brief motivational interviewing. The study authors concluded that more research is necessary to ascertain what type of counseling is most suitable for persons identified as excessive drinkers in opportunistic settings who are also in a state of readiness to change (Heather et al., 1996a).

In repeated uses of the RCQ, Heather and colleagues have refined the scoring method for this instrument. The initial "quick method" simply sums the raw scores for each separate change-stage scale and uses the score that is farthest along the continuum of change stages as the most accurate reflection of the client's readiness to change.

This method is appropriate if you need a quick way of determining readiness. A more accurate and refined method and a better predictor of change for research and clinical purposes is to omit any illogical and unreliable responses and add a preparation stage to the calculations. A revised version of the Readiness To Change Questionnaire User's Manual provides more specific information about calculating scores using this method.

The RCQ (Treatment Version) (RCQ [TV]) is a recent revision of the original RCQ (Heather et al., 1996b) that is a more appropriate alternative for determining the stage of change for persons who are seeking or already undergoing treatment for alcohol problems.

This version, reproduced in Appendix B, responds to criticisms that the original RCQ was intended only for use with heavy or hazardous drinkers identified in opportunistic settings (Gavin et al., 1998), although it was being administered, inappropriately, to some alcohol-dependent persons already applying for treatment of a substance use disorder. The major problem was that drinkers identified in health care settings often chose to reduce consumption to safe limits instead of abstinence, which is the more typical decision of severely impaired persons in need of traditional treatment.

Although the developers of the revised instrument initially hoped to add questions that would identify persons in the five stages of change and to modify the questions to reflect goals of either reduced drinking or abstinence, only the latter aim was achieved with the revised instrument (Heather et al., 1996b).

The RCQ (TV) has 30 items, with six questions corresponding to each change stage, which are rated on a five-point scale ranging from strongly agree to strongly disagree. Many of the questions and statements are adaptations of those in the original RCQ that now include abstinence as a goal. For example, "I have started to carry out a plan to cut down or quit drinking."

Other new questions reflect the two additional change stages, "I've succeeded in stopping or cutting down drinking and I want to stay that way" (maintenance) or, "I have made a plan to stop or cut down drinking and I intend to put this plan into practice" (preparation).

The developers of this psychometrically sound instrument claim it is clinically useful for deciding what types of services are most appropriate for persons entering treatment. Those who are identified as ready to change can immediately be offered skills-based, action-oriented services, while those who are not yet in an action stage should be given further motivational interventions until they progress further along the readiness continuum.

More research is necessary to strengthen one of the scales and to determine the instrument's ability to predict drinking outcomes accurately (Heather et al., 1996b).

Decisional Balancing

As discussed in Chapter 5, exercises and instruments that examine decisional balancing investigate the positive and negative aspects of a particular behavior. The general benefits of the behavior--and also of changing it--are weighed against the costs, allowing clients to appraise the impact of their behavior and make more informed choices regarding changing it.

The scale reproduced in this section can be used to accentuate the costs of the client's substance use, lessen its perceived rewards, make the benefits of recovery more apparent, and identify possible obstacles to change.

The decisional balancing exercise was developed by Sobell and colleagues to help individuals identify benefits and costs of substance use as part of a cognitive appraisal process often associated with self-directed change (Sobell et al., 1996b). Such a purposeful comparison of the costs and benefits appears to facilitate the recognition and resolution of associated problems.

Ask individuals who are interested in making a behavioral change to list benefits and costs of changing and not changing in parallel columns. Then ask them to carefully consider, "Are the costs worth it?" Figure 8-3 is an example of an exercise on the decision to change.

In another decisional balancing exercise, the Alcohol (and Illegal Drugs) Decisional Balance Scale, developed by DiClemente and reproduced in Appendix B, respondents are asked to indicate on a five-point scale how important each statement is in making a decision to change drinking or drug-using behavior.

Alcohol and Drug Consequences Questionnaire

The Alcohol and Drug Consequences Questionnaire (ADCQ) is a relatively new instrument for assessing the costs and benefits of changing a substance problem (Cunningham et al., 1997). It is reproduced in Appendix B. The 29 items included on the questionnaire were derived from information reported by clients participating in a brief cognitive-behavioral intervention for guided self-change at an outpatient substance abuse treatment facility. The items are divided into two categories: costs of change and benefits of change.

Respondents are asked the importance of each item if they were to stop or cut down their use of substances (0 = not applicable, 1 = not important, 3 = moderately important, 4 = very important, 5 = extremely important). The score is determined by adding the cost items and the benefits items to obtain two separate scores that can be compared.

In initial tests of the instrument, respondents' anticipated costs and benefits of change were significantly related to the importance they attached to achieving treatment goals, and, for problem drinkers, to their drinking outcomes.

Respondents whose scores were higher on the costs of change measures were more likely to have consumed more drinks in the year following treatment, whereas those who believed the benefits of change were more important than costs were likely to reduce drinking levels posttreatment (Cunningham et al., 1997).

Motivation for Using Substances

An underlying purpose of the instruments described in this section is to encourage clients to express their expectations about substance use by completing such statements as, "If I were to stop using substances, I would expect to feel..." Research suggests that expectancies play an important role in the progression from use to abuse (Brown, 1993; Connors and Maisto, 1988; Leigh, 1989a).

Knowledge of clients' expectations regarding the effects of substances may help you understand the rationale for their substance-using behavior--clients who expect good things from substance use in most situations are likely to continue using at the same level until there is a change in perspective. Based on clients' expectations, find discrepancies between clients' behaviors and hopes and select strategies to help them address reasons for their substance use.

As with other measurement areas, less is known about motivations for using drugs than for using alcohol. The scales discussed in this section vary in length and have not all been tested on clinical samples. Leigh has reviewed and presented sample items and instructions for several questionnaires that purport to measure motivation (Leigh, 1989a).

Alcohol Expectancy Questionnaire

The Alcohol Expectancy Questionnaire is the most widely used of these instruments (Brown et al., 1987). It is reproduced in Appendix B. It contains 90 items and uses a dichotomous agree/disagree response format. The items are grouped into six categories of perceived benefits from alcohol:

Global positive changes
Social and physical pleasure
Sexual enhancement
Increased social assertion
Tension reduction/relaxation
Increased arousal and aggression

This scale measures only positive expectancies, not negative ones, and has been useful in showing that clients with continued positive expectancies at the end of treatment have poorer outcomes. It has been used with adults in both clinical and nonclinical populations (Sobell et al., 1994). A 120-item version that used the same format was developed for adolescents (Christiansen et al., 1982).

Alcohol Effects Questionnaire

The Alcohol Effects Questionnaire, reproduced in Appendix B, was constructed after researchers questioned whether the original Alcohol Expectancy Questionnaire measured the strength or intensity of alcohol-related expectancies (Collins et al., 1990). Subjects in a study were asked to rate the strength of their beliefs in addition to the agree/disagree responses in the standard Alcohol Expectancy Questionnaire.

It was hoped that this study would clarify the distinction between two types of alcohol expectancies--the nature of an attitude toward a behavior and the strength of that attitude or confidence about behavior change. Subjects were asked to report how strongly they agreed or disagreed with a particular belief on a 10-point Likert scale where 1 = mildly believe and 10 = strongly believe.

The results supported the idea that the strength of an individual's belief or disbelief in alcohol-related expectancies assessed by the Alcohol Expectancy Questionnaire is different from merely agreeing or disagreeing with these same expectancies.

Other Scales

The Effects of Drinking Alcohol scale has 20 items, each rated on a five-point scale that ranges from unlikely to very likely. The items, which reflect expected reactions to alcohol use, are grouped into five factors: nastiness, cognitive/physical impairment, disinhibition, gregariousness, and depressant effects (Leigh, 1989a).

The Alcohol Effects Scale is a 37-item, forced-choice adjective checklist that measures three factors: stimulation/perceived dominance, pleasurable disinhibition, and behavioral impairment (Southwick et al., 1981). This scale measures client expectations of how a moderate amount or excessive amount of alcohol would affect them.

The Alcohol Belief Scale was developed to assess clients' expectations regarding the usefulness of drinking different amounts of alcohol in different contexts (Connors and Maisto, 1988; Connors et al., 1987). The scale measures clients' beliefs regarding whether, for example, alcohol reduces discomfort in proportion to the amount consumed ("The more I drink, the better I feel") (Connors et al., 1987). The greatest positive expectations are reported by those with the most severe drinking problems.

The Marijuana Effect Expectancy Questionnaire (MEEQ) and the Cocaine Effect Expectancy Questionnaire (CEEQ) are two related scales that assess motivation to use substances (Schafer and Brown, 1991). The MEEQ (70 items) and CEEQ (64 items) use a yes/no format with agree/disagree instructions similar to those of the AEQ.

Subjects are asked to respond to the items according to their own beliefs and whether they have actually used the substance. Further research is needed; it appears, however, that expectancies differ across substance types in relation to the properties of the substance (e.g., expectation of arousal from alcohol and cocaine use but not from marijuana use).

Goals and Values

Your clients must value a treatment goal to progress toward it. In fact, unless clients value them, they are not goals from the clients' perspectives. From a motivational standpoint, you should understand what your clients' goals are and what they value in life. It is usually best to start where your clients are--with what is important from their own perspective.

Clinicians can assess goals and values through an open-ended interview, asking questions like, "What things are most important to you?" or, "How would you like your life to be different 5 years from now?" or "What would you like to have happen in treatment?"

As an aid to this process, some clinicians use a sheet showing a number of bubbles that contain the names of issues that a client might wish to discuss and ask, "Which of these would you like to work on while you are here?" or "What might you like to work on first?"

Some bubbles should be left empty, too, because clients may have goals other than those listed on the sheet. In developing a treatment plan, one can begin with all blank bubbles and fill in possible goals of treatment, then prioritize them. Miles Cox has developed and tested a clinical Motivational Structure Questionnaire for identifying goals and their associated degrees of commitment, outcome expectancy, and self-efficacy (Cox et al., 1993).

There are also more structured ways to assess what clients want and value. Clinicians can use the What I Want From Treatment Questionnaire, which lists a number of possible goals and aspects of treatment and asks new clients to rate the importance of incorporating each item into their own treatment (see Appendix B for a copy of this questionnaire).

Clients can also be asked at the end of treatment the extent to which they received these same treatment elements. One study using this instrument found a positive relationship between favorable outcomes and clients reporting at discharge that they had received those treatment elements they said they wanted at intake (Brown and Miller, 1993). Receiving other treatment elements they did not want was unrelated to outcomes. In other words, clients improve to the extent they receive what they want from treatment.

Extensive literature exists on measuring values in general. For example, the Study of Values Questionnaire developed in 1960 has been widely used (Allport et al., 1960). In a classic volume on the subject, Rokeach introduced a method for ranking instrumental (means) and terminal (ends) values (Rokeach, 1973).

His well-researched instrument, which is available in a published form, allows clients to prioritize their values by arranging small labels in hierarchical fashion (Rokeach, 1983). Another instrument has clients sort and prioritize cards dealing with a wide variety of values expressed in contemporary language (Miller and C'de Baca, 1994).

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From SAMHSA/CSAT  Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
Chapter 8 Measuring Components of Client Motivation