using measures of readiness to change in individuals with schizophrenia

AM. J. DRUG ALCOHOL ABUSE, 25(1), pp. 151–161 (1999)

Using Measures of Readinessto Change in Individualswith Schizophrenia

Jean Addington, Ph.D.Nady el-Guebaly, M.D.Valerie Duchak, Ph.D.David Hodgins, Ph.D.

Department of PsychiatryUniversity of CalgaryFoothills HospitalCalgary, Alberta, Canada

ABSTRACT

The literature suggests that substance abuse treatment for schizophrenia patients should con-sider both the patients’ readiness for active treatment and matching phases of interventionwith phases of the patient’s acceptance of his or her dual problems. This study assessed thesuitability of existing measures of ‘‘readiness to change’’ for use with individuals with schizo-phrenia. Outpatients (n 5 39) with a diagnosis of schizophrenia and alcohol and/or drugdependency or abuse were given three measures to assess the stage of readiness to change.Results suggested that there was no agreement between stages defined by the interviewer andstages defined by self-report. This has implications for assessing readiness to change in termsof substance use in a population with schizophrenia.

INTRODUCTION

Abuse and dependence on alcohol and other substances in schizophrenia isbeing increasingly recognized and well documented in the literature. It has beensuggested that up to 60% of patients with schizophrenia use illicit drugs (1). Thisclearly interferes with the course and treatment of the disorder (2). Schizophrenic

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Copyright 1999 by Marcel Dekker, Inc. www.dekker.com

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152 ADDINGTON ET AL.

substance abusers are often reported to be noncompliant and resistant to ap-proaches used by psychiatric treatment systems or by substance abuse programs.Furthermore, the lack of specific programs to address dual disorders has addedto the problem. Treatment programs previously described for the dually diag-nosed have not selected subjects for treatment readiness (3–5). In one of the fewcontrolled trials, a 1-year follow-up revealed no significant advantages to patientoutcomes. Failure to engage patients in the experimental program posed a majorand enduring barrier to treatment despite intensive case management (6). Recom-mendations from this research were that future efforts must give greater consider-ation to effective engagement techniques, patients’ readiness for active treatment,and matching phases of intervention with phases of the patient’s acceptance ofhis or her dual problems. Thus, if we are to design appropriate interventions, abetter understanding of the readiness to change of individuals with schizophreniais necessary.

Based on a number of preceding models that researched motivation forchange, one concept that has been receiving attention in the literature on addic-tions is the level of readiness of individuals to change as described by Prochaska,DiClemente, and Norcross (7). Over the past 12 years, these authors have re-searched self-initiated and professionally facilitated change of addictive behav-iors using key transtheoretical constructs of stages and processes of change. Theseauthors delineate five stages: precontemplation, contemplation, preparation, ac-tion, and maintenance. Precontemplation is the stage at which there is no inten-tion to change behavior in the foreseeable future. Contemplation is the stage atwhich there is awareness that a problem exists and some serious thought hasbeen given to overcoming it, but no commitment to take action has been made.The preparation stage combines intention and behavioral criteria. The individualwill initiate action that may lead to change (e.g., seek help). Action is the stageat which individuals modify behavior experiences or environment to overcometheir problems. Maintenance is the stage at which individuals work to preventrelapse and consolidate the gains attained during action.

Prochaska and colleagues have designed two methods for assessing stagesof change: an algorithm system based on five key questions (8) and a 32-itemquestionnaire (University of Rhode Island Change Assessment Scale, URICA),to which individuals respond on a Likert scale to general questions about their‘‘problem’’ (9, 10). Data indicate good predictive validity and reliability for bothmeasures of stages of change (8). However, the authors note that, although theURICA yields more information regarding motivation and attitudes towardchange, the design of the questionnaire makes it more difficult to classify individ-uals to one stage (8).

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SCHIZOPHRENIA AND READINESS TO CHANGE 153

The Stages of Change Readiness and Treatment Eagerness Scale (SOCRA-TES) was designed to mirror the URICA questionnaire, but with items wordedto gauge the stages of change specifically among problem drinkers and drug users.A 32-item long SOCRATES and a shorter 20-item questionnaire were designedbased on the five-stage model; both questionnaires have two separate versions,one for alcohol use and one for drug use (11). Although factor analyses andsubsequent changes to the scales pointed to the reliability of both the long andshort SOCRATES, the use of a large sample size and additional factor analysesindicated that both scales were in fact measuring three dimensions rather thanfive. Findings of two studies indicated that the SOCRATES yields three reliable,continuously distributed, relatively orthogonal scales that were replicable in a 2-day test situation. The corresponding three stages of change for the latest 19-item edition of the SOCRATES were labeled ambivalence, recognition, and tak-ing steps. Miller and Tonnigan (11) recommend the use of the new version dueto its clearer factor structure and relative simplicity in terms of administration.

Heather, Gold, and Rollnick (12) have also developed a questionnaire,the Readiness to Change Questionnaire (RCQ), designed specifically to assessthe stage of change of problem drinkers. Although the RCQ is similar to theSOCRATES in item wording, there are only 12 items, making it less time con-suming for respondents to complete. Analyses of the responses of an initial sam-ple indicated that the RCQ measures three factors, corresponding to three stagesof change: precontemplation, contemplation, and action. The authors report goodreliability and predictive validity (12, 13).

Consistency across these various readiness-to-change scales has not been ade-quately tested in either normal or psychiatric samples. Furthermore, to date, thereare no reports in the literature that describe the use of these measures with indi-viduals with schizophrenia. This is important since there is some evidence thatindividuals with schizophrenia may experience difficulty with self-report mea-sures (14). This study addressed these issues by examining the consistency ofthe SOCRATES and the RCQ with Prochaska et al.’s algorithm (7).

METHODS

Subjects

For the study, 39 outpatients (32 males, 7 females) who met DSM-III-R crite-ria for schizophrenia and substance abuse or dependence were recruited frompatients with schizophrenia who were attending an outpatient clinic or who had

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been referred to a dual-diagnosis program from community agencies. Foursubjects who were invited to participate refused. Both the outpatient clinic andthe dual-disorders program are part of a general hospital department of psychi-atry.

Diagnoses of substance abuse and/or dependence and schizophrenia accordingto the DSM-III-R (Diagnostic and Statistical Manual for Mental Disorders, thirdedition, revised) criteria (15) were made using the Structured Clinical Interviewfor DSM-III-R (SCID) (16). Diagnoses were made by the principal investigator(J. A.) and a senior psychiatrist. Using a separate sample of 10 subjects, therewas 100% agreement on the diagnosis and at least 80% agreement for symptompresence between the two raters. All subjects met criteria for schizophrenia andsubstance abuse or dependence.

Subjects were excluded if they did not meet these criteria or if any of thefollowing pertained: (a) evidence of an organic central nervous system disorder(e.g., epilepsy, traumatic brain injury, infectious or toxic cerebrovascular dis-ease), (b) mental retardation, (c) under 18 or over 65 years of age. The studywas described verbally and in writing to each subject. Written informed consentwas obtained from each subject.

The average age was 35.9 years (SD 5 9.2), and the average grade achievedwas 12 (SD 5 2.6). The majority of the subjects were single, lived alone, andreceived governmental financial support. All subjects met criteria for substancedependence for at least one substance. The criteria for alcohol dependence weremet by 17 subjects, 7 met criteria for cannabis dependence, and 13 met criteriafor alcohol dependence or abuse plus cannabis dependence or abuse. Also, 2 ofthe subjects met criteria for codeine dependence. Thus, 30 subjects completedthe ratings for alcohol, and 22 completed the ratings for drugs.

All subjects were taking neuroleptics (28 on typical antipsychotics, 11 onrisperidone), and 25% were using anticholinergics. The mean dose in chlorproma-zine equivalents was 388.70 (range 40–1500) (17, 18).

Measures

Symptom ratings. The Positive and Negative Syndrome Scale (PANSS) (19)was used to obtain ratings for positive and negative symptoms in the schizophre-nia sample. The PANSS was administered by the principal investigator and aclinical research nurse. Interrater reliability was determined in a separate sampleof 5 subjects. Criteria for reliability were that the scoring of each symptom waswithin 1 point and there was at least 80% agreement on the total score for the

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PANSS and on each of three subscales: the Positive scale, the Negative scale,and the General Psychopathology scale.

Readiness to change. In this study, three measures were used to assess thestage of readiness to change. With all three measures, the stage in which a subjectwas rated was used as a categorical variable.

First, each subject was asked the five key questions by a clinical researchnurse or the principal investigator as suggested by Prochaska and colleagues (7).This information was verified by other significant workers and from charts. Inorder to compare the interviewers’ questions with the self-rating scales, only threestages (precontemplation, contemplation, and action) were determined from thealgorithm. The questions are

1. Are you currently drinking/using drugs?2. Are you seriously considering quitting in the next 6 months?3. Are you planning to quit in the next few days?4. Have you quit drinking for a period of at least 24 hours in the past year?5. How long have you been abstinent?

An answer of yes to question 1 indicate precontemplation, yes to questions 2 and3 indicates contemplation, and action is indicated by answers of yes and less than6 months more than 24 hours to questions 4 and 5, respectively.

Second, the drug and alcohol versions of the SOCRATES (version 6) wereused (11). These are both self-report questionnaires. Each has 20 items, one ver-sion with respect to alcohol and the other with respect to other drug use. Examplesof items of response include ‘‘I am a problem drinker’’ or ‘‘I really want to makechanges in my drug use.’’ Data indicate that this instrument has adequate internalconsistency and reliability. It appears to be predictive of treatment complianceand outcome events. These measures were scored using only the 19 items thatmake up the latest version of the SOCRATES (version 8). Three stages weredetermined: ambivalence, recognition, and action. These stages were seen as be-ing equivalent to precontemplation, contemplation, and action.

Third, the RCQ (12, 13) was developed for use in brief interviews amongexcessive drinkers. The authors report good reliability and validity (12, 13).This self-report questionnaire has 12 items that are rated on a 5-point Likertscale. Examples of items of response included ‘‘I don’t think I drink too much’’or ‘‘I have recently changed my drinking habits.’’ To ask equivalent questionsof those who used drugs, the word drink was changed in all 12 items to usedrugs.

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RESULTS

Results of the PANSS confirmed that subjects were stable outpatients. Themean positive syndrome score was 14.3 (SD 5 4.9), and the mean negative syn-drome score was 14.7 (SD 5 4.4).

Table 1 consists of four subtables that show how many subjects were classifiedin each of nine possible ways. Each subject can be classified according to precon-templation, contemplation, or action by the interviewer and self-classified ac-cording to precontemplation, contemplation, or action. Interviewer ratings are for

Table 1. Agreement Between Interviewer and Self-Report Ratings with Entries Being theNumber of Subjects Classified in Each Way

Subject ratings for Interviewer ratings for alcoholalcohol, SOCRATES(N 5 30) Precontemplation Contemplation Action

Precontemplation 7 3 1Contemplation 0 0 1Action 5 6 7Agreement 5 47%, kappa 5 0.20

Suject ratings for Interviewer ratings for alcoholalcohol, RCQ(N 5 30) Precontemplation Contemplation Action


Subject ratings for Interviewer ratings for drugsdrugs, SOCRATES(N 5 22) Precontemplation Contemplation Action

Precontemplation 2 3 2ContemplationAction 0 3 12Agreement 5 68%, kappa 5 0.38, approximate significance 5 0.003

Subject ratings for Interviewer ratings for drugsdrugs, SOCRATES(N 5 22) Precontemplation Contemplation Action

Precontemplation 1 3 2Contemplation 0 3 1Action 1 0 11Agreement 5 68%, kappa 5 0.45, approximate significance 5 0.002

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drugs or alcohol, and self-ratings are for the SOCRATES alcohol, RCQ alcohol,SOCRATES drug, and the RCQ drug. Percentage agreeing and kappas are alsopresented in Table 1. For alcohol, the self-ratings on the SOCRATES and on theRCQ were significantly different from those ratings made by the interviewer. Fordrugs, although the kappa was significant for the RCQ and the SOCRATES, theagreement was 68% for both scales, which is still relatively low. Fair-to-pooragreement was consistent in all categories since individual kappas tended to fallin the same range as overall kappas. The percentage of subjects rating themselvesthe same as the interviewer, the percentage rating themselves higher than theinterviewer, and the percentage rating themselves lower than the interviewer arepresented in Table 2. Furthermore, the agreement of ratings on the two self-rating scales for both alcohol and drugs was also relatively low, 47% and 57%,respectively. These results are presented in Table 3.

DISCUSSION

Results showed that subjects rated themselves differently on the self-reportmeasures compared to the interviewers’ ratings. Slightly less than 50% of thesample rated themselves the same way as the interviewer did for readiness tochange from alcohol use and 68% for readiness to change from drug use. Themajority tended to rate themselves at a higher stage. There was no agreementbetween the two self-report scales for either drugs or alcohol.

These findings can be accounted for in several ways. First, the two self-report

Table 2. How Subjects Rated Themselves Compared toInterviewer’s Ratings

In higher In lowerCorrect (%) stagea (%) stageb (%)

AlcoholSOCRATES 47 37 16RFQ 37 53 10

DrugsSOCRATES 68 27 5RFQ 68 5 27

a Percentage of subjects who rated themselves in a higher stage thanthe interviewer did.

b Percentage of subjects who rated themselves in a lower stage thanthe interviewer did.

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Table 3. Agreement Between the Two Self-Rating Scales: SOCRATES and RCQ

RCQ, alcoholSOCRATES, alcohol(N 5 30) Precontemplation Contemplation Action


RCQ, drugsSOCRATES, drugs(N 5 22) Precontemplation Contemplation Action

Precontemplation 3 3 2ContemplationAction 3 1 10Agreement 5 57%a

a Kappa statistics could not be computed since the values did not form a two-way table.

scales may not be measuring exactly the same dimensions. If the problem wasthat subjects perceived their stage of readiness to change as higher than the inter-viewer did, then reports from the two self-report scales would be consistent. Inorder to address differences among scales, there need to be comparisons amongthese different self-report scales in larger samples to improve statistical power.Samples should include subjects with and without psychiatric diagnoses sinceagreement among scales has not been adequately tested in both nonpsychiatricgroups and psychiatric groups. The lack of a nonpsychiatric substance abuse com-parison group and the small numbers, particularly of drug abusers, are limitationsof this study.

Second, difficulty in obtaining agreement may result from considering ‘‘readi-ness to change’’ as distinct categories rather than perhaps a continuous dimen-sion. Our results are similar to a recent study by Hodgins (20), who reportedpoor agreement between therapist judgments and the self-ratings (SOCRATESand RCQ) of individuals with alcohol problems. However, in Hodgins’s study,agreement was good between the scales if scores were used as continuous mea-sures and not as categorical variables. Hodgins suggests that perhaps the lack ofexact agreement reflects the difficulty in achieving high reliability with categori-cal judgments.

Third, it may be that individuals with schizophrenia are unable to completethese questionnaires. This is unlikely as the questionnaires are brief and fairlyclear, and subjects were offered help to complete the forms if they needed it.

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Furthermore, they were all stable outpatients, and it has been shown that individu-als with schizophrenia are relatively competent at completing self-report ques-tionnaires if they are stable and not in the acute stage of the illness (14). We alsodivided the sample into two groups: those who had rated themselves in the sameway as the interviewer and those who had not. There was no difference betweenthese two groups on any demographic variables, positive symptoms, or negativesymptoms. Thus, symptoms most likely do not account for the observed differ-ences. In addition, it may be that these scales are unreliable in a sample of individ-uals with schizophrenia. Test-retest reliability was not assessed with these scalesin this population.

Finally, the differences may result from the fact that individuals with schizo-phrenia who have a substance problem may actually see themselves as doingbetter than they actually are in terms of their readiness to change. The majorityrated themselves in a stage of action when they were actually in a precontempla-tion or contemplation stage. Assuming that the speculation that the clinicianshad more accurate judgment was true, this has important clinical implications.Generally, interventions for substance abuse are designed for those people whoare ready to take action to quit. Many addicted persons are not ready to quit, andoften those who present for treatment are somewhat ambivalent about changing(8). Thus, assessing readiness to change is important prior to determining treat-ment interventions, particularly for those individuals who are dually diagnosed.

In conclusion, further research is required in terms of examining and compar-ing scales that purportedly measure the same dimensions. This needs to occur inboth psychiatric and nonpsychiatric populations. It has first to be determinedwhether there is agreement on scales of readiness to change. Second, it has thento be determined whether such agreement or lack of agreement is affected by thefact that the respondents have a psychiatric problem, in this case, schizophrenia.

Furthermore, results of this study suggest that it may be important to assessreadiness to change from two perspectives. First, it must be assessed from theperspective of the treatment team so that the focus can be on engagement ifnecessary, and treatment interventions can be appropriately designed. Second,self-report measures will give the treatment team valuable information as towhich stage the individual perceives himself or herself to be. Engaging theseclients in substance abuse treatment and determining appropriate interventionswill be enhanced not only by knowing the client’s stage of readiness to change,but also his or her perceptions of that stage of readiness to change, which maynot be the same. Future research should focus on the validity of these scales. Itwould be most useful to determine the validity of their ability to predict treatmentoutcome.

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ACKNOWLEDGMENT

This study was supported by a research grant from Foothill Hospital Researchand Development.

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using measures of readiness to change in individuals with schizophrenia

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