Loss and readiness to change substance abuse

Addictive Behaviors, Vol. 21. No. 4. DD.527-530.1996 Copyright 0 1996 El&ier Science Ltd Printed in the USA. All rights reserved 0306.4603/96 $15.00 + .OO

Pergamon SSDI 0306~4603(95)00079-8

BRIEF REPORT LOSS AND READINESS

TO CHANGE SUBSTANCE ABUSE

ARTHUR Department

W. BLUME

of Psychiatry and Behavioral Sciences, Harborview University of Washington, Seattle, WA, USA

Medical

Center,

KAREN B. SCHMALING Department

of Psychiatry

and Behavioral

Sciences,

University

of Washington,

Seattle,

WA, USA

Abstract -

Little empirical study has been done on specific content targets for cognitive-behavioral interventions at each stage of change among substance abusers. Clinical observation has noted losses to be associated with decisions to change, but this relationship has not been studied empirically. 110 dually diagnosed psychiatric inpatients completed self-report questionnaires on losses and Readiness to Change. Total number of losses correlated with precontemplation, contemplation, and overall readiness to change scores. In addition, several individual losses accounted for statistically significant variability in each stage of change. These data suggest that focus upon specific losses may motivate change in dually diagnosed substance abusers.

Prochaska and DiClemente’s transtheoretical model (Prochaska, DiClemente, & Norcross, 1992) describes one theory of behavior change characterized by a progression through sequential stages: precontemplation, contemplation, preparation, action, and maintenance (Prochaska et al., 1992). This model of change is thought to be valid for a variety of addictive behaviors (DiClemente, 1993; Fava, Velicer, & Prochaska, 1995). However, specific therapeutic topics associated with the advancement from one stage of change to another have not been fully investigated. Loss is hypothesized to be one such pivotal topic. This study examines the predictive value of losses in the decision to change substance abuse behavior. In addition, these data will be discussed in terms of their clinical implications. METHOD

Subjects The sample consisted of 110 consecutive psychiatric inpatient admissions at an urban, public hospital, who had at least one DSM-IV (American Psychiatric Association, 1994) Axis I diagnosis upon admission and were suspected of substance abuse. During the course of a standard clinical interview, the patients were administered the CAGE test (Ewing, 1984) to confirm substance abuse. All subjects met substance abuse or dependence criteria and endorsed substance use the previous two months. They averaged 34.42 years of age (SD = 9.84, Range = 186.5). 79 (72%) were male and 77 (70%) were white.

Requests for reprints should be sent to Arthur W. Blume, Box 359820, Harborview 9th Avenue, Seattle, WA 95104-2499. [email protected].

527

Medical

Center,

325

528

A. W. BLUME

Table 1. Prediction

of readiness

Contemplation

Action Total RTC

K. B. SCHMALING

to change

for the total sample

(N = 110)

Predictor

R2

T

Less happy Many regrets Less cognitive acuity Lost pride Many regrets Lost family Lost possessions Abstinence Less self-care Many regrets Abstinence Less cognitive acuity Less self-esteem

.13 .18 .22 .26 .I2 .I6 .19 .17 .21 .12 .19 .22 .29

2.85 2.53 -2.98 2.17 -3.77 2.21 -2.10 -4.88 2.20 -3.22 -3.51 3.31 -3.17

Criterion Precontemplation

and

Note. All T, Fare p < .05 with all significant criterion.

predictors

in the equation;

R2 are cumulative

F

9.05

8.41 13.99

10.65 by

Measures

Subjects completed the Readiness to Change Questionnaire (RTC: Rollnick, Heather, Gold, & Hall, 1992) and the Losses of Significance Self-report Questionnaire (LOSS-Q)*. The RTC was scored for precontemplation, contemplation, action, and total readiness to change (contemplation + action - precontemplation). The LOSS-Q, developed by the first author to assess the presence or absence of 22 losses, had a Cronbach’s alpha of .842 for this study. Procedure

Each subject was administered the CAGE by the interviewer, then completed the LOSS-Q and RTC. The LOSS-Q and RTC were read to 29 subjects who requested assistance. RESULTS

Subjects reported numerous losses on the LOSS-Q (N = 110, M = 12.99, SD = 5.05)2. Total losses were significantly and positively correlated with total RTC (r(108) = .257. p < .Ol) and contemplation (~(108) = .290, p < .Ol), negatively with precontemplation (r(108) = -.331, p < .Ol), but not with action scores (r(108) = .014, p > .05). Forward stepwise regression analyses were performed to identify specific LOSS-Q items predictive of RTC scores. As Table 1 illustrates, specific losses accounted for significant portions of variability in each stage, as well as in total RTC scores. Differences were noted between genders (see Table 2). DISCUSSION

This study found that total losses predicted precontemplation, contemplation, and total RTC scores. An association between losses and taking action was not supported. Similarly, life changes were not related to modifying substance abuse in a previous study (Sobell, Sobell, Ioneatto, & Leo, 1993). ‘The LOSS-Q

is available

upon request

from the first author.

ITen medical center employees who denied substance abuse voluntarily completed the LOSS-Q comparison to the sample of interest to this paper. Their average score was 1.3 (SD = 1.83).

for

Loss and readiness to change

529

Table 2. Prediction of readiness to change by gender Predictor (Men, N = 79)

R*

T

Lost pride Less cognitive acuity Less happy Less self-esteem Loss of money Abstinence Homelessness Less self-care Less self-esteem Abstinence Less cognitive acuity Many regrets

.14 .19 .26 .12 .17 .19 .25 .29 .13 .23 .31 .35

2.95 -2.83 2.64 -2.40 -2.16 -4.30 2.40 2.05 -3.86 -3.55 3.22 -2.13

Criterion

Predictor (Women, N = 39)

R2

T

F

Precontemplation Contemplation Action

Lost partner Many regrets Less cognitive acuity Many regrets Many regrets Lost child

.31 .13 .14 .25 .14 .27

3.57 -2.13 2.52 -2.08 -2.48 2.21

12.77 4.52

Criterion Precontemplation

Contemplation Action

Total RTC

Total RTC

Note. All T, Fare p < .05 with all significant predictors

F

8.78 7.75

10.22

9.93

4.78 5.15

in the equation;R* are cumulative by criterion.

Several losses were associated with each stage of change, as well as total readiness to change. Regrets were associated with less precontemplation, but greater contemplation and total RTC scores. Contemplation may be characterized by greater awareness of past consequences (or regrets); action may be characterized by greater focus on the present or future. Inactivity has been associated with regret over time (Gilovich & Medvec, 1994). More activity was related to better self-care and abstinence in this study. The association of self-care with higher action scores is similar to previous results that health concerns were associated with behavior change (Prochaska, 1994). Loss of cognitive acuity was associated with higher precontemplation and lower total RTC scores. Neurocognitive impairment is a well-documented consequence of chronic substance abuse (Lezak, 1995). Alternatively, subjects might have endorsed this item as a function of the singular focus on substance use (Beck, Wright, Newman, & Liese, 1993) that characterizes the precontemplation stage. Grief may interfere with contemplation of change since loss of family was associated with lower contemplation scores. This is consistent with other studies in which grief/ bereavement (e.g., Vance et al., 1994) were associated with increased substance use. Differences

in gender

Regrets were significantly associated with higher total RTC scores in both genders and were predictive of higher contemplation and action scores in women. Women tend to engage in ruminative coping; rumination has been associated with longer, more severe depressive episodes (Nolen-Hoeksema, Parker, & Larson, 1994). Conversely, rumination in the form of regrets was predictive of contemplation and action among dually diagnosed women in the present study. Loss of partners and children were predictive of less precontemplation and lower total RTC scores, respectively, among women. Loss of intimate others may impede changing substance use among women.

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and

K. B. SCHMALING

Loss of money significantly predicted higher contemplation scores in men. Men tend to report negative financial consequences related to substance use (Orford & Keddie, 1985). Homelessness significantly predicted lower action scores among men in this study. Implications for therapy and limitations of the study.

This study is relevant to a dually diagnosed population, but future research is important to explore the generalizability of these findings to those without other psychiatric disorders. Another limitation was the small number of women in the sample. These data suggest that discussion of specific losses may increase cognitive dissonance (Festinger, 1957) about substance use, prompting behavior change. These ideas are consistent with specific intervention strategies for each stage of change (Prochaska et al., 1992). Losses that are significant predictors of specific stages of change could be explored within the context of these intervention strategies. The results of this study suggest that use of information about significant losses may enhance the change process. Therapeutic use of significant losses may have the most impact in the precontemplation and contemplation stages. Discussion of losses may be used to augment intervention strategies consistent with the transtheoretical stages of change model. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC. Beck, A. T., Wright, F. D.. Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford. DiClemente, C. C. (1993). Changing addictive behaviors: A process perspective. Current Directions in Psychological Science, 2. 101-106. Ewing, J. A. (1984). Detecting alcoholism:The CAGE questionnaire. Journal of the American Medical Association, 252.1905-1907. Fava, J. L., Velicer, W. F., & Prochaska, J. 0. (1995). Applying the transtheoretical model to a representative sample of smokers. Addictive Behaviors, 20, 189-203. Festinger, L. (1957). A theory of cognifive dissonance. Stanford, CA: University Press. Gilovich,T., & Medvec, V. H. (1994).The temporal pattern to the experience of regret. Journal of Personaliry and Social Psychology, 67.357-365. Lezak, M. (1995). Neuropsychologicul assessment. Oxford: Oxford University Press. Nolen-Hoeksema, S., Parker, L. E., & Larson, J. (1994). Ruminative coping with depressed mood following loss Journal of Personality and Social Psychology, 67.92-l 04. Orford, J., & Keddie, A. (1985). Gender differences in the functions and effects of moderate and excessive drinking. Brifish Journal of Clinical Psychology, 24,265279. Prochaska, J. 0. (1994). Strong and weak principles for progressing from precontemplation to action on the basis of twelve problem behaviors. Health Psychology, 13.47-51. Prochaska, J. 0.. DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-l 114. Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic interventions among excessive drinkers British Journal of Addiction, 87.743-754. Sobell, L. C., Sobell, M. B., loneatto, T., & Leo, G. 1. (1993). What triggers the resolution of alcohol problems without treatment? Alcoholism: Clinical and Experimental Research, 17,217-224. Vance, J. C., Najman, J. M., Boyle. F. M., Embelton, G., Foster, W. J. & Thearle, M. J. (1994). Alcohol and drug usage in parents soon after stillbirth, neonatal death, or SIDS. Journal of Paediatrics & Child Health, 30,269-272.