Measuring readiness to change and locus of control belief among male alcohol-dependent patients in Taiwan: Comparison of the different degrees of alcohol dependence
Mei-Yu Yeh, PhD, A1010, 261, Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, Taiwan. Email: email@example.com
Aims: The purpose of the present study was to evaluate the Drinking-Related Health Locus of Control scale (DRIE) and the three aspects of readiness to change (i.e. ambivalence, recognition, and taking action), in response to the degree of dependence.
Methods: This study was carried out based on data collected from 160 male alcohol-dependent patients, and the degree of alcohol dependence was divided into three categories: light, moderate, and severe, on the basis of the total scores of the short-form Severity Degree Alcohol Dependence Data questionnaire (SADD).
Results: There were significant differences between the different degrees of dependence on drinking-related locus of control, feelings of ambivalence toward drinking, recognition of problematic drinking, and readiness to take action to change. Patients with more severe dependence usually had higher scores of drinking-related locus of control, indicating a tendency toward external locus of control, feelings of ambivalence, and recognition of their drinking problem; patients with light dependence usually had higher scores for taking action.
Conclusions: Clinicians can strengthen readiness to change problematic drinking if the importance of degree of dependence and drinking-related locus of control are taken into consideration when devising interventions.
THE TRANSTHEORETICAL MODEL (TTM) offers an integrative framework for understanding human behavior change.1 According to the transtheoretical stages of change model, alcohol-dependent patients who are in the pre-contemplation stage deny their drinking problem, use many excuses for drinking, and are unaware of a need to change. Individuals in the contemplation stage recognize they have a drinking problem and begin to consider doing something about the change; they have not yet made a commitment to take action and remain at this stage for long periods if they do not resolve their ambivalence to change. Once a person intending to take action actually tries to cut down on their alcohol consumption, they enter the taking action stage.2,3 Jung indicated that the TTM provides a powerful and practical framework in the medical therapeutic setting. It is helpful for professionals to consider the degree to which a patient is prepared to change.4
A study by Share et al. suggested that the degree of alcohol dependence is closely related to taking action to change problematic drinking. Patients with heavier drinking behavior were less likely to engage in the taking action stage.5 Recognition of a drinking problem was related to the degree of alcohol dependence.6 Zhang et al. noted that patients with dual diagnoses of severe mental illness and high dependence on alcohol were usually more ambivalent toward drinking; but recognition of the problem and taking action to change were not significant predictors of the degree of alcohol dependence.7 The relationship between the different degrees of alcohol dependence and readiness to change problem drinking, however, needs to be further clarified.
Skinner indicated that locus of control was originally the expectancy in a mathematically explicit expectancy-value model.8 Locus of control belief embedded in a social learning framework was formulated by Rotter9in 1966. It states that a person's success or failure at overcoming alcoholism depends upon his/her degree of control, and refers to the degree to which an individual perceives reinforcement as being contingent upon his/her own behavior. The key construct consists of a single bipolar internal-external dimension, with a variety of positive outcomes in the domains of health and psychological adjustment. In accordance with the concept of locus of control, a person with internal locus of control perceives that consequences result from personal action. In contrasts, a person who has external locus of control perceives consequences as caused by external events, not by individual responsibility.8
Research that compared the drinking-related locus of control between alcohol-dependent and social drinkers indicated that alcohol-dependent patients were more external in their drinking-related expectancies of control than non-alcohol-dependent social drinkers. Persons with a higher severity of drinking-related externality were associated with compulsive drinking.10 Other research also concluded that when the degree of problematic drinking was severe, the patient's locus of control apparently tended to be external, and alcohol-dependent patients in the remission stage tended toward internal locus of control.11–13 Findings indicated that, during a relapse, the alcohol-dependent patient would go back to an external locus of control.14,15 Therefore, drinking-related locus of control is commonly used by researchers as an indicator to forecast the outcome of alcoholism treatment. In the alcohol-dependent patient who is in continuous sobriety, the internal locus of control shows a tendency to increase.13,16
The research questions for the present study were as follows: (i) in the medical therapeutic setting, do alcohol-dependent patients with more severe alcohol dependence have a tendency towards external control on drinking-related locus of control; and (ii) do patients with severe alcohol dependence still recognize problematic drinking, feel ambivalence, and eventually take action to change. To answer these questions, this study evaluated the various degrees of alcohol dependence in response to drinking-related locus of control and readiness to change.
Setting and subjects
A total of 160 alcohol-dependent patients at the Taipei City Psychiatric Hospital in Taiwan volunteered as subjects in a cross-sectional research design study, lasting from January 2005 to July 2006. Participants had to be cognitively alert, able to read and answer questions and be diagnosed with alcohol dependence evaluated under DSM-IV diagnostic criteria17 by psychiatrists.
All patients were referred by their psychiatrists and agreed to this study with informed consent. All subjects had received alcohol-dependent treatment (114 inpatients and 46 outpatients), including detoxification, and were in at least their third day of sobriety after hospitalization. The exclusion criteria were delirium tremens, personality disorder, and Alzheimer's disease.
The study was approved by the Hospital Institutional Review Board of the Taiwan National Science Council and Taipei City Psychiatric Hospital in Taiwan. Before contacting participants, researchers contacted and explained the research procedures and recruiting criteria to psychiatrists, and emphasized that participants' responses were anonymous and confidential unless the participants agreed to share the results with their physicians. Researchers then met with participants and explained the purpose of the study, the risks and benefits of participation, and their right to refuse to participate without jeopardizing treatment. Finally, data were collected through a self-report questionnaire. Participants were required to complete the questionnaire within 20 min.
The instruments used were the Severity of Alcohol Dependence Data Questionnaire (SADD), the Stage of Change Readiness and Treatment Eagerness Scale (SOCRATES), and the Drinking-Related Locus of Control (DRIE). These scales were translated into Chinese through two stages. In the first stage they were translated by two researchers, one senior clinical psychologist and one senior psychiatric nursing professor. Both had master degrees and good command of English. The scales were then back-translated. Finally, they were examined by five clinical psychiatric experts for content validity before commencing the study. These experts included two senior psychiatrists, two PhD level nursing professors, and a nursing supervisor with a masters degree.
Severity of Alcohol Dependence Data Questionnaire
The short-form SADD was modified from that of Raistrick et al. and was then analyzed for discriminate validity, split-half reliability, and test–retest reliability.18 The self-completion questionnaire included 15 questions on a 4-point scale from 0 to 3. The possible score range was 0–45, with higher scores indicating heavier dependence. Raistrick et al. have suggested that scores of 0–9 points be considered light dependence; 10–19, moderate dependence; and ≥20, more severe dependence.18,19 The internal consistency Cronbach alpha was 0.86, and its test–retest reliability was 0.78 in this study. Details of the questionnaire in the present study are shown in Appendix I.
Stage of Change Readiness and Treatment Eagerness Scale
A number of self-administered questionnaires have been developed to measure patient motivation, including the Readiness to Change Questionnaire (RCQ),20 the University of Rhode Island Change Assessment (URICA),21 and the SOCRATES. The RCQ may be used in primary health-care settings and the URICA has been applied to assess readiness to change in a wide range of settings and healthy behaviors domains. The original version of the SOCRATES was developed by Miller and Tonigan and was intended to categorize alcoholism-treatment patients according to their readiness to change.6 On the SOCRATES scores reflect the impact of treatment on problem recognition, ambivalence, and taking action toward change.
There were 19 questions in total and the objectives covered three aspects. Each question was rated on a 5-point scale from 1 point (disagree very strongly) to 5 points (agree very strongly). There were eight questions in the dimension of taking action (e.g. ‘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’). The higher a patient's score the more readiness to change problematic drinking is indicated. Seven questions were in the dimension of recognition (e.g. ‘I have serious problems with drinking’). A high score was positively correlated with recognition of problematic drinking. The rest of the questions involved ambivalence (e.g. ‘There are times when I wonder if I drink too much’). A higher total score implied stronger ambivalence about drinking behavior.6 The scale was developed based on clinical practice with severely alcoholic patients; its construct validity and internal consistency in evaluating the readiness to change of alcohol-dependent patients have been verified.22 The Chinese version of SOCRATES demonstrated good psychometric properties, and its construct validity was examined.23 The 2-week test–retest reliability coefficients ranged from 0.69 to 0.84.
Drinking-Related Locus of Control
The DRIE consists of 25 items in a forced-choice paired format.24 Each pairing has an alternative indicative of internal locus of control (e.g. ‘There is no such thing as an irresistible temptation to drink’), and external locus of control (e.g. ‘Many times there are circumstances that force you to drink’). Answers indicating internal locus of control are attributed 0 points and those indicating external locus of control are attributed 1 point. The range of scores is 0–25. The DRIE has had its construct validity evaluated on confirmatory factor analysis; the study results suggest that the 16 items of the Chinese version of the DRIE provided best goodness of fit for measuring drinking-related locus of control in alcohol-dependent patients. A total score falls between 0 and 16; higher scores indicating a stronger tendency towards external locus of control. The scale has been proven valid and reliable.25 The DRIE scale in the present samples had construct validity and internal consistency, a Cronbach alpha of 0.85.25
After coding and data entry of the completed questionnaires, SPSS version 12.0 for Windows (SPSS, Chicago, IL, USA) was used for statistical analysis. The χ2 test and analysis of variance (anova) were used to conduct the subgroup comparison by level of dependence. According to Tabachnick and Fidell, in clinical work, unequal n often results from the nature of the population.26 Differences in sample sizes should reflect true differences in numbers of various types of subjects. The researchers in present study advocated use of the general linear model because it provides for flexibility in the adjustment for unequal n. Age or education level was the key factor in participants' trying or not trying to change.10,27 Hence, in the present study, analysis of covariance (ancova) and post-hoc comparison tests were used to compare the light, moderate, and severe alcohol dependence-group differences; age and education were covariates in the model. The statistical significance level was defined as 0.05, two-tailed.
The participants included 160 men; their ages ranged from 24 to 70 years with a mean age of 41.53 years (SD = 8.69). They had an average of 11.9 years of education (SD = 2.41), 42.5% (n = 68) were single, divorced or separated, and 63.1% (n = 101) had not been employed recently. The χ2 test and ANOVA results show the non-significant differences of age and education variables by the level of dependence (Table 1). Table 2 lists the results of analysis of covariance. Even after controlling for age and educational level, the locus of control and recognition score remains significant for all degrees after adjusting for the effects of severity of alcohol dependence (locus of control, η2 = 0.249; recognition, η2 = 0.124). Post-hoc comparisons indicated a tendency toward internal locus of control. Patients with more severe alcohol dependence usually had significantly higher scores for drinking-related locus of control, indicating a tendency toward external locus of control; light alcohol-dependent patients are generally more willing to take action to change, while severe patients were not considering change; and those with more severe alcohol dependence usually feel ambivalence and are more aware of their drinking problem.
Table 1. Subject details and severity of dependence on SADD
|Severity of dependence|| || ||27 (16.9)||89 (55.6)||44 (27.5)|| || |
|SADD score|| ||16.11 ± 7.65||6.00 (2.98)||14.42 (2.38)||25.75 (5.87)||/251.30 (159)||<0.001|
|Age (years)|| ||41.53 ± 8.69||42.22 (10.26)||41.95 (7.47)||40.25 (9.93)||/0.66 (159)||0.515|
|Education (years)|| ||11.90 ± 2.41||12.44 (2.45)||11.86 (2.38)||11.65 (2.43)||/0.91 (159)||0.403|
|Relationship|| || || || || ||0.51/ (2)||0.773|
| Married||92 (57.5)|| ||14 (8.75)||53 (33.12)||25 (15.62)|| || |
| Single||68 (42.5)|| ||13 (8.13)||36 (22.50)||19 (11.88)|| || |
|Employment|| || || || || ||0.84/ (2)||0.656|
| Employed ||59 (36.9)|| ||8 (5.00)||35 (21.88)||16 (10.00)|| || |
| Unemployed||101 (63.1)|| ||19 (11.88)||54 (33.75)||28 (17.50)|| || |
Table 2. Analysis of covariance (n = 160)
|Locus of control||11.123|| *** ||0.067||10.988|| *** ||0.066||25.669|| *** ||0.249||2.184||6.155||8.529||Severe > Moderate***|
Moderate > Light***
|Ambivalence||0.657||0.419||0.004||0.018||0.895||0.000||2.989||0.053||0.037||16.204||15.704||16.814||Severe > Moderate*|
|Recognition||0.686||0.409||0.004||0.149||0.700||0.001||10.982|| *** ||0.124||26.067||28.106||30.812||Severe > Moderate***|
Severe > light**
|Taking action||0.497||0.482||0.003||0.368||0.545||0.002||3.719|| * ||0.046||35.493||33.172||34.168||Light > Moderate*|
Locus of control and severity of dependence
Successful quitters of substance abuse reported a stronger locus of control.27 Overall, the present findings suggest that severely alcohol-dependent individuals have an external control orientation, while lightly alcohol-dependent individuals tend toward internal locus of control. This is similar to others' findings that severely alcohol-dependent patients apparently lean toward external locus of control.7,10,11,14,15 Donovan and O'Leary indicated that alcoholic people who had an external locus of control appeared to perceive that significant events in daily life were beyond their control, determined more by chance than personal initiative or significant others' influences.24 Skinner indicated that when people believe that they have no control, they will remain passive, not exert themselves, and give up easily.8 When perceived control is high, an alcohol-dependent person tends to orient toward taking action. In comparison to patients with severe alcohol dependence, a patient in the remission stage tends to have internal locus of control but might go back to external locus of control once they resume drinking alcohol.12,14,15
Sharp et al. claimed that using the autogenic relaxation to facilitate acquisition of self-control by biofeedback training, increase personal responsibility and foster an internal locus of control in alcohol-dependent treatment;28 the present findings suggest that therapists should make an effort to produce control experiences and promote the internal locus of control for alcohol-dependent patients in the processes of clinical treatment. The present results show that patients with severe alcohol dependence mainly attribute problematic drinking to external factors and they rarely take action to change even if they recognize their problem. Therefore, in the clinical setting, professionals have to help patients prepare realistic plans by reviewing their history of behavioral change to support and facilitate active change by flexibly intervening.29 In addition to motivating and encouraging patients to participate and maintain treatment, strengthening their belief in internal locus of control may also significantly improve patients' drinking behavioral changes.
Readiness to change and severity of dependence
The present alcohol-dependent subjects were categorized predominantly into the areas of moderate (n = 89, 55.6%) to heavy (n = 44, 27.5%) dependence, while there were only 27 patients (n = 16.9%) with light dependency. In the present sample analysis of covariance indicated that the recognition stage of drinking has significant differences across different dependence severity levels, but neither the ambivalence stage nor the action stage significantly differed across severity levels. Share et al. indicated that higher-severity patients had not escalated their readiness to change their problematic drinking,5 which is consistent with the present finding. Jung indicated that when treatment fails, it is often attributed to the patient's lack of readiness to change.4 According to the TTM, in the contemplation stage patients perceive the severity of their problematic drinking and begin to consider changing but are not determined to take action to change. In general, drinking severity is correlated with cost of change; there are more perceived benefits of change compared with costs of change for the action stage than for the contemplation stage.2,3,5
One Taiwanese research study that followed the effects of alcoholism treatment noted that, of 163 alcohol-dependent patients admitted to a psychiatric hospital detoxification and rehabilitation program, only 15.3% (n = 24) remained in sustained remission for >2 years; 34.3% (n = 56) suffered periodic relapses and remissions, 28.2% (n = 46) remained alcohol dependent, and 22.1% (n = 36) died.30 The study indicated that only a minor proportion of the Taiwanese patients achieved remission from alcohol addiction after receiving treatment, and most could not maintain sobriety. The literature suggests that providing treatment appropriate to stage of change is an important strategy for a successful treatment outcome.1 In the clinical setting, most patients we encounter are in the contemplation stage and have yet to enter the taking action stage. But creating or enhancing ambivalence is still an important step in fostering contemplation of change. In addition, strengthening the ability to hold conflicting feelings in one's awareness and making efforts to reduce ambivalence can help patients to actually understand and be more able to identify readiness to change.29
The present results show that patients with severe alcohol dependence mainly attribute problematic drinking to external locus of control and they rarely take action for change, even if they recognize their problem drinking and are ambivalent.5,8 The present results, however, suggest that clinicians should help patients strengthen readiness to change problematic drinking, taking into consideration the importance of different degrees of dependence and locus of control beliefs while devising interventions. Hence, when patients' dependence is at a life-threatening level, helping them perceive the problematic nature of their drinking and decreasing the ambivalence toward their problem drinking increases the possibility of changing their addictive behavior.6 When patients have less-severe dependence they have internal direction with regard to problem drinking; they should try to increase their feelings of self-control, believe they can overcome their challenges, enhance their internal control, and gain confidence, all to help them maintain their change.15
Finally, there are certain limitations of this research to consider. All participants were Taiwanese and male. Furthermore, the data are cross-sectional, rather than longitudinal, and the findings cannot be used to explain causal relationships.
This research was supported by Taiwan National Science Council grant NSC93-2314-B255-001 to Mei-Yu Yeh.
Severity of Alcohol Dependence Data Questionnaire (SADD)
- 1Do you have difficulty getting the thought of drinking out of your mind?
- 2Is getting drunk more important than your next meal?
- 3Do you plan your day around when and where you can drink?
- 4Do you drink in the morning, afternoon, and evening?
- 5Do you drink for the effect of alcohol without caring what the drink is?
- 6Do you drink as much as you want irrespective of what you are doing the next day?
- 7Given that many problems that might be caused by alcohol, do you still drink too much?
- 8Do you know that you won't be able to stop drinking once you start?
- 9Do you try to control your drinking by giving it up completely for days or weeks at a time?
- 10The morning after a heavy drinking session do you need a drink to get yourself going?
- 11The morning after a heavy drinking session do you wake up with definite shakiness of your hands?
- 12After a heavy drinking session do you wake up and retch or vomit?
- 13The morning after a heavy drinking session do you go out of your way to avoid people?
- 14After a heavy drinking session do you see frightening things that you later realize were imaginary?
- 15Do you go drinking and the next day find you have forgotten what happened the night before?