- Email: [email protected]
Readiness to change alcohol drinking habits after traumatic brain injury
592
Readiness to Change Alcohol Drinking Traumatic Brain Injury Charles H. Bombardier,
PhD, Dawn Ehde, PhD, Jason Kilmer, MS
ABSTRACT. Bombardier CH, Ehde D, Kilmer J. Readiness to change alcohol drinking habits after traumatic brain injury. Arch Phys Med Rehabil 1997;78:592-6.
Objective: To describe how motivated are persons with recent traumatic brain injury (TBI) to change their alcohol drinking habits and what factors affect their motivation. Design: Survey. Setting: Acute inpatient rehabilitation program. Patients: Subjects were 50 patients with recent TBI during inpatient rehabilitation. Main Outcome Measures: Readiness to Change (RTC) questionnaire, Michigan Alcoholism Screening Test (MAST), and alcohol use questions. Results: Subjects were 36 years old; 86% were men. Eightfour percent fell in the contemplation or action phases. Comparisons with a separate medical patient sample suggested that TBI may be associated with greater contemplation of change and greater readiness to take action to change alcohol use. Multivariate analyses indicated that within the TBI sample a positive history of alcoholism, alcohol involved in the accident, and higher daily consumption were associated with greater readiness to change (especially contemplation scores). Conclusions: Soon after TBI, drinkers frequently contemplate changing their alcohol use. This situation may represent an underutilized window of opportunity to reduce postinjury alcohol use and abuse. Motivational interviewing techniques seem well suited to facilitate change during this period. 0 1997 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
I
T IS WELL RECOGNIZED that preexisting alcohol problems are relatively common among persons who sustain traumatic brain injury (TBI). A recent review of the literature indicated that 44% to 66% of persons with TBI have a history of alcohol abuse.’ Unfortunately, harm from alcohol often continues after TBI. The National Head Injury Foundation* reported that approximately 40% of patients in postacute rehabilitation facilities had moderate to severe problems with substance abuse, and alcohol was the substance abused in more than 95% of the cases. Others estimate that approximately two-thirds of the heavy drinkers return to excessive alcohol use after TBI.3 To From the Department of Rehabilitation Medicine, University of Washington School of Medicine (Drs. Bombardier, Ehde), and Department of Psychology, University of Washington (Mr. Kilmer), Seattle. Submitted for publication May 2, 1996. Accepted in revised form October 28, 1996. Supported in part by grants from the Centers for Disease Control and Prevention: Promoting the health of people with disabilities (U48KCUOO9654; Donald Patrick, P.I.) and the Harborview Injury Prevention and Research Center (R49/ CCR002570; Frederick Rivara, PI.). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Charles H. Bombardier, PhD, Box 359740, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104. 0 1997 by the Amencan Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/97/7806-4004$3.00/O
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date, the most representative sample of persons with TBI shows that drinking declines significantly through 1 month postinjury; after this, alcohol use increases but not to the preinjury levels by 1 year after injury.4 Finally, alcohol use and abuse may be potentially more harmful for people with TBI than in the general population. Evidence suggests that poor neurological outcomes are associated with alcohol use or abuse, including cerebral atrophy,5 poorer neuropsychological test performance,6-9 deterioration of emotional and behavioral functioning during the postacute recovery phase,” and development of postconcussive symptoms after mild TBI.” It is possible that even “normal” use of alcohol may be deleterious to neurological recovery.” Therefore, abstinence from alcohol after TBI is generally recommended. With increased awareness of alcohol problems in this population, investigators have begun to question how and when to address alcohol use disorders. To date, most investigators have adopted a tertiary prevention approach, treating alcohol problems in postacute settings.‘.r3 Another potential approach, however, is to conduct secondary prevention during the acute rehabilitation phase, a strategy that could reach a greater number of people with TBI. Traumatic injury (especially when it is alcohol-related) may create an opportunity in which survivors are more motivated to change their drinking behavior.‘4.‘s If there is substantial motivation, the stage may be set for the implementation of effective brief interventions during the acute rehabilitation phase. Moreover, if specific intervention strategies can be matched to the type or degree of motivation to change, even greater therapeutic change may result. I6 To date there are no data describing motivation to change alcohol-related problems among persons with TBI and, consequently, there is no guidance regarding the appropriateness of attempting interventions soon after injury. The purpose of this study was to describe readiness to change alcohol use among persons undergoing acute rehabilitation for recent TBI. The study is based on the transtheoretical stages of change modelI This model characterizes motivation to change on a spiral continuum from precontemplation (not considering change), through contemplation (ambivalent about change), determination (getting ready for change), action (making behavioral changes), and maintenance (maintaining change). We predicted that soon after TBI, patients would be characterized by high levels of readiness to change, significantly more than in a general medical sample. We also predicted that independent indicators of greater problems with alcohol would be positively correlated with greater readiness to change. Our specific hypotheses were as follows: (1) Patients with recent TBI and significant comorbid alcohol problems will be characterized by contemplation and action rather than precontemplation (denial). Additionally, readiness to change will be higher in this group than among a sample of general medical patients.” (2) Patients with a history of significant alcohol problems will report significantly greater motivation to change alcohol use compared with patients who do not have a history of alcohol problems. (3) Motivation to change will be greater among persons with positive blood alcohol levels at the time of TBI. (4) Motivation to change will be positively correlated with greater quantity/frequency of recent alcohol consumption.
READINESS
TO CHANGE,
METHOD Subjects Subjects were 50 patients with TBI admitted to an acute inpatient rehabilitation program housed within a Level I trauma center. Patients were administered the questionnaires as a part of standard rehabilitation care. Nondrinkers and non-English speakers were excluded.
Procedures All patients were administered the self-report measures by a trained psychometrist as part of a neuropsychological screening examination. Measures were administered an average of 28 days after TBI (median = 25 days) and 19 days after admission to the rehabilitation unit (median = 16 days). Patients were not assessed until they scored greater than 20 on the Mini-Mental Status Examination and it had been determined that the patient had intact language function as assessed by the team speech pathologist. Response options for some measures were presented to subjects both orally and in written form using a largeprint cue card. To prevent potential reactivity effects of the alcoholism measure on the measure of readiness to change, the readiness to change instrument was always administered first. Relevant medical diagnostic and clinical information was obtained from the patient’s chart. All procedures were approved by our human subjects institutional review board.
Measures Readiness to change.
Stage of change was assessed using the 12-item Readiness to Change Questionnaire (RTC).” This scale measures thoughts and behaviors associated with the most common stages of change found among persons in health care settings (ie, precontemplation, contemplation, and action) and was specially developed by British and Australian researchers for brief opportunistic assessments in medical settings.” Each stage of change is represented by four items. Precontemplation items refer to the denial of alcohol-related problems. Contemplation items refer to beliefs that alcohol may be a problem. Action items reflect behavior changes the person is already making to cut down or stop drinking. Subjects rate the degree to which they agree or disagree with each item on a five-point Likert scale. Scores range from -2 (strongly disagree) through 0 (unsure) to 2 (strongly agree). Agreement with contemplation and action items reflects greater readiness to change, while disagreement with precontemplation items denotes greater readiness to change. The internal consistency of the three four-item scales range from .73 to .80 and test-retest reliabilities over 2 days ranged from .78 to .86.19 The RTC has been shown to correlate with changes in drinking 2 to 6 months after assessment in a medical sample.20 For correlational analyses, an overall readiness to change score was computed consisting of the sum of contemplation and action scale scores minus the precontemplation scale score.” Quantity/frequency of alcohol consumption. Subjects were asked how many drinks they typically consumed each day during the month before their injury, as well as the number of days on which they consumed two or more and five or more drinks. Lifetime alcohol-related problems. The Michigan Alcoholism Screening Test (MAST)” is a 25item list of common signs and symptoms of alcoholism. The subject indicates whether he or she has ever experienced each symptom of problem drinking during his or her lifetime. Item scores are weighted from one to five points. The MAST is used because it is brief, has demonstrated reliability and validity in a number of populations, and
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may be useful in differentiating subgroups of alcoholics.‘” Because the traditional cutoff of 5 has yielded unacceptably high false positive rates, a total score of 12 or more was used to indicate a clinically significant history of alcohol problems.”
RESULTS Demographic Variables The 50 subjects were on average 35.8 (? 12.7) years old, and 43 (86%) were men. Glasgow Coma Scale scores from the time of admission to the hospital were available on 30 subjects (60%), with 8 (27%), 3 (lo%), and 19 (63%) falling in the mild, moderate, and severe ranges of severity, respectively. Forty-four (88%) of all subjects were Caucasian, 3 (6%) were AfricanAmerican, and 3 (6%) were Native American. Thirteen (26%) reported less than a high school education, 21 (42%) reported a high school education, 9 (18%) had some college, and data were missing on 7 (14%). Twenty-three (46%) of the sample were single, and 15 (30%) were married. The remaining 12 (24%) were divorced, separated, or widowed.
Alcohol-Related Variables Initial blood alcohol levels (BAL) were available for 43 (86%) members of the sample. Of these, 16 (37%) had a negative BAL, 3 (7%) were below lOOmg/dL, and 24 (56%) were intoxicated (at or above the legal limit of lOOmg/dL). Alcohol involvement at the time of the accident was determined for all cases based on a combination of BAL, clinical information (eg, alcohol on breath in the emergency room), or self-report data. Alcohol was involved in the onset of TBI in 32 (64%) of all cases. On the MAST the average score was 20.1 (+-12.6), and 37 (74%) scored greater than 11, in the “alcoholic” range. Subjects reported drinking a mean of 2.6 drinks on a typical day during the month before their injury (median = 1.5). Fifteen (30%) reported drinking nothing on a typical day, and 6 (12%) reported drinking eight drinks or more. Alcohol-related variables such as the MAST, BAL, and recent typical consumption were moderately intercorrelated (Y values = .36 to .49).
Readiness to Change As predicted in the first hypothesis, the sample was characterized by greater contemplation and action than precontemplation. Means and standard deviations for subscale scores for the total sample were as follows: Precontemplation, -0.7 (3.4); Contemplation, 2.6 (3.3): and Action, 2.4 (3.5). For the subset of 37 subjects who endorsed significant lifetime alcohol-related problems on the MAST (2 12), a similar pattern of responses was obtained. Subscale scores were: Precontemplation, - 1.4 (3.2); Contemplation, 3.4 (3.3); and Action, 2.4 (3.7). These data suggest greater agreement with contemplation and action subscale items than with precontemplation items among this TBI sample. To further describe the sample in terms of stage of change, subjects were assigned to mutually exclusive stages of change based on their highest subscale score.” Ties (there were 10) were assigned to the higher stage as recommended by Heather and Rollnick.” Using this method, 8 subjects (16%) fell in the precontemplation group, 19 (38%) in the contemplation group, and 23 (46%) in the action group. It was also predicted that readiness to change would be greater during rehabilitation for recent TBI than during general hospitalization. Since no control group was available, readiness to change scores from the 37 persons who were positive on the MAST were compared with readiness to change scores obtained from a sample of general medical patients found to be excessive alcohol users.” These were the patients used in the original
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READINESS
Table
1: Stages
of Change Among Alcoholics: Patients Versus Patients With
Subject Samples
Precontemplation
General TBI
TO CHANGE,
Medical
Contemplation
Action
.Ol (4.1)”
General medical patients* (n = 141)
Patients
with
-1.19
(3.5)”
1.81 (3.8)”
-1.4
(3.2)”
3.4
TBI
(n = 37)
(3.3jb
2.4
(3.7jb
Values are mean (SD). Means with different superscripted letters within each column are significantly different (p i .05). * Data are from a sample of medical patients who were excessive alcohol users but not seeking treatment for alcohol problems.”
RTC scale development study.” Two-sample t tests were computed on each of the three RTC subscales by using a pooled estimate of the variance. Results showed that patients in the TBI sample reported significantly greater contemplation (t( 176) = 2.32, p < ,025) and action (t(176) = 3.22, p < .Ol) subscale scores, but equivalent scores on precontemplation (table 1). To test the second hypothesis, patients with and without a significant history of alcohol problems (MAST 2 12 vs. MAST < 12) were compared on the three readiness to change subscales using a multivariate analysis of variance (MANOVA). The overall MANOVA was significant (Hotelling’s t = .266, F = 4.08, p = ,012) and univariate F tests were significant for precontemplation @ = .028) and contemplation (p = .004), but not action. Mean scores were in the direction of significantly less precontemplation and significantly greater contemplation among those with a history of alcohol problems. Similarly, among the total sample the correlation of the MAST scores with the summary readiness to change score was significant and positive (r = .39; p = ,005) indicating greater readiness was associated with a more severe history of alcohol problems. Similar results were obtained when the correlational analysis was limited to the 37 individuals within the alcoholic subgroup (Y = .37, p = .023). To test the third hypothesis, a MANOVA was computed on readiness to change subscales with alcohol involvement at the time of injury as the grouping factor. Alcohol involvement was judged to be positive if blood alcohol, self-report, or other chart data indicated the presence of alcohol at the time of injury. The overall MANOVA was significant (Hotelling’s t = .39, p = .002) and the univariate tests showed significantly greater contemplation among the group with alcohol involvement (F = 16.6, p < .OOl). The correlation between overall readiness to change and blood alcohol level was also significant (Y = 51, p < .OOl). To test the final hypothesis, a median split was performed on the typical daily consumption variable (1.5 drinks per day) and a MANOVA was used to compare readiness to change between the higher and lower consumption groups. The overall MANOVA was significant (Hotelling’s t = .29, p = .Ol) and among the univariate tests, only contemplation differed between groups (F = 12.9, p = .OOl) with significantly greater contemplation scores obtained among the group who drank greater than the median. The correlation between typical daily consumption and overall readiness to change was significant (Y = .36, p = .Ol). DISCUSSION The results of this study suggest that soon after TBI, drinkers are frequently contemplating change or reporting readiness to take action regarding their alcohol use. Survivors of TBI tended to disagree with precontemplation statements such as, “It is a waste of time thinking about my drinking,” and tended to agree with contemplation and action statements such as, “I am at the
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stage where I should think about drinking less alcohol,” and “I am actually changing my drinking habits right now.” No control group was available; however, there appears to be greater endorsement of contemplation and action subscales among persons who recently sustained TBI than among the general medical patients used in the development of the RTC questionnaire. These data are consistent with the idea that TBI may motivate problem drinkers to consider reducing their alcohol use. These data are also consistent with the spontaneous change toward abstinence and reduced consumption that seems to occur following TBI.‘,9 It should be noted that these conclusions are preliminary and future studies should seek noninjured control subjects from the same institution matched on potentially important variables such as age, sex, and alcoholism severity. Caution should be exercised in making comparisons to the original RTC validation sample because the measure was developed on general medical patients primarily from urban Australia. These patients were similar to the TBI sample in terms of age (35.4 vs. 35.8 years) and sex (94% vs. 86% male), but unknown demographic or cultural dissimilarities between groups may also contribute to differences on readiness to change. Contrary to traditional beliefs that people with alcohol problems are characterized by denial and resistance, study results show that greater lifetime alcohol problems and typical daily consumption are positively correlated with greater readiness to change. Since all three of these measures are based on selfreport information, it could be argued that the correlations reflect no more than an underlying willingness to admit problems. However, an independent medical test result, blood alcohol level in the emergency room, was also associated with greater readiness to change. This finding gives support to the idea that alcohol-related consequences, not just a willingness to admit problems, may account for higher readiness to change scores. The high level of reported contemplation and action noted in this study may represent the window of opportunity researchers have described as occurring in the wake of trauma.24 To paraphrase Waller,14 the best window of opportunity for initiating rehabilitation for alcohol problems may be when a patient is still hurting from the acute effects of an alcohol-related TBI, but has become cognitively aware enough to understand and remember what his or her rehabilitation team is advising. On the other hand, this window does not give the rehabilitation professional a green light to confront patients about their “problem drinking’ ’ or to simply refer patients for treatment. In our sample, less than half of the subjects fell into the action stage, and the high level of contemplation reported implies that significant ambivalence and resistance to change remains. When rehabilitation professionals perceive ambivalence and resistance from patients with an alcohol problem, this phenomenon can be viewed most usefully from an interpersonal perspective. Recent research has shown that resistance is not so much a personality characteristic of a person with an alcohol problem but the result of counterproductive therapeutic interactions, especially confrontational behavior by the therapist.‘” For example, upon recognizing that a rehabilitation patient has an alcohol problem, staff may recommend that the patient attend AA. This approach often increases resistance, partly because the patient may not label himself or herself as an alcoholic. Also the recommendation “go to AA” is an action stage activity and may not match the patient’s stage of change (frequently contemplation). One way to avoid this problem is to include a readiness to change measure along with alcohol screening tests and to tailor further assessment and interventions to the person’s stage of change. For example, precontemplators may benefit most from
READINESS
TO CHANGE,
nonconfrontational consciousness-raising strategies such as informing them of how their self-reported alcohol consumption compares to national norms. Contemplators primarily need help exploring the pros, and cons of change in order to resolve their ambivalence before taking action. These strategies are examples of a motivational enhancement therapy approach to alcohol problems. Motiva ional enhancement therapy has been developed specifically or people who do not necessarily see themselves as having n alcohol problem or are ambivalent about change and, as su 1 h, seems to be an excellent match for persons with recent TBI.lh Several other potential limitations of this study should be acknowledged. Subjects were not a consecutive series of patients admitted to’the rehabilitation unit and, thus, may not be representative of the larger population from which they were selected. For example, our study criteria prevented us from including those with very severe TBI, those with significant communication impairments, and non-English speakers. Comparisons with a large-scale study of consecutive persons with TBI at our institutior? suggest that our sample may be biased toward a greater proportion of persons who were intoxicated at the time of their injury (37% vs. 56%) males (77% vs. 86%) and Caucasians (43% vs. 88%). Another issue has to do with the reliability of the self-report data. Concerns may arise about the reliability of self-reports of alcohol-related behavior more generally as well as about the reliability of self-report soon after TBI. In response to the first issue, reviews of the literature conclude that persons with alcohol problems generally provide reliable and valid reports if interviewed in cliuical settings when they are alcohol-free and given reassurances of confidentiality.2h.27 Each of these conditions was met in the present study. Regarding potential unreliability related to TBI, precautions were taken to exclude persons with communication impairments as assessed by the staff speech pathologists. We also attempted to compensate for inattention or poor memory by using an interview format ‘and by presenting the materials in both oral and large-print written formats. Future studies should include test-retest data and provide corroborating information from family or friends. A final reliability issue has to do with the fact that 46% of our subjects fell in the action phase on the readiness to change measure. Our clinical experience, however, suggests that many of these persons remain ambivalent about changing their drinking and behave more like contemplators. This possible bias toward assigning people to the action phase may be attributable to the recommended scoring procedures that place those with tied scores into the higher stage of change.” Overassignment of patients to the acrion phase also may be caused by the enforced abstinence from alcohol associated with inpatient rehabilitation. Patients may indicate agreement with action stage items because they misattributei abstinence to themselves rather than to the controlled rehabiq’itation environment. Finally, patients may endorse action-oriented items in a defensive or acquiescent manner when being evaluated in a clinical setting. On the other hand, these same attributional and motivational factors were likely operating in the original inpatient medical sample on which the RTC measure was developed. Consequently, comparisons made between these two separate samples are not necessarily invalid. Clearly, the reliability and validity of the stage assignment method merits further study, especially as it applies to persons considered to be in the action phase. Ultimately, the single composite readiness to change score used in our correlational analyses may prove to be more reliable and valid than stage assignbent procedures. No data are available to demonstrate the predictive validity
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of the RTC measure in a population with TBI. That is, we do not yet know if, in this population, persons reporting greater readiness to change are more likely to accept treatment, abstain from alcohol after discharge, or reduce their consumption. Research on excessive drinkers from a general medical population, however, has shown that stage of change was a significant predictor of drinking behavior at g-week and 6-month follow-up assessments.‘” Data are being collected to address this question among persons with brain injury. These data support the notion of attempting secondary prevention programs soon after TBI. The data suggest that during acute rehabilitation there may be an opportunity to motivate persons with TBI to abstain or significantly restrict their use of alcohol during the months and years ahead. Rather than heralding denial or resistance, a history of chronic alcohol problems, alcohol involvement at the time of injury, and greater recent alcohol consumption are associated with greater contemplation of the possibility that one needs to change his or her alcohol use. Recent clinical research based on the transtheoretical stages of change model suggests that confronting such people with their alcohol problems may be counterproductive. Several clinical strategies that make up motivational enhancement therapy seem potentially useful to promote action among persons who might otherwise only contemplate, not change, the role of alcohol in their life after TBI. Acknowledgments: We are grateful to Drs. Frederick Rivara and Donald Patrick for their support of this project, to Drs. Carl Rimmele and Dennis Donovan for their guidance, and to Heather D&her and Art Blume for their help with data collection.
I.
References Corrigan J, Lamb-Hart G, Rust E. A programme of intervention for substance abuse following traumatic brain injury. Brain Inj 1995; 9:221-36.
National Head Injury Foundation. Substance abuse task force white paper. Southborough (MA): National Head Injury Foundation, 1988. 3. Kreutzer JS, Doherty K, Harris J, Zasler N. Alcohol use among persons with traumatic brain injury. J Head Trauma Rehabil 1990; 2.
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Dikmen S, Machmer 3, Donovan D, Winn R, Temkin N. Alcohol use before and after traumatic head injury. Ann Emerg Med 1995;
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Ronty H, Ahonen A, Tolonen U, Heilkkila J, Niemela 0. Cerebral trauma and alcohol abuse. Eur J Clin Invest 1993:23:182-7. Brooks N, Symington C, Beattie A, Campsie L, Bryden J, McKinlay W. Alcohol and other predictors of cognitive recovery. Brain Inj 1989;3:235-46. Sparadeo F, Strauss D, Barth J. The incidence, impact and treatment of substance abuse in head trauma rehabilitation. J Head Trauma Rehabil 1990; 5: 1-8. Solomon D, Malloy P. Alcohol, head injury and neuropsychological function. Neuropsychol Rev 1992;3:249-80. Dikmen S, Donovan D, Lobeg T, Machmer J, Temkin N. Alcohol use and its effects on neuropsychological outcome in head injury. Neuropsychol 1993;7:296-305. Dunlop T, Udvarhelyi G, Stedem A, O’Connor J, lsaacs M, Puig J, et al. Comparison of patients with and without emotional/behavioral deterioration during the first year after traumatic brain injury. J Neuropsychiatry Clin Neurosci 1991; 3: 150-6. Evans R. The postconcussion syndrome and the sequelae of mild head injury. Neurol Clin 1992; 10:815-47. Corrigan J. Substance abuse as a mediating factor in outcome from
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NeuroRehabil 1992;2:27-34. Waller J. Management issues for trauma patients with alcohol. J Trauma
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persons with recent spinal cord injuries. Alch Health Res World 1989; 13:110-7. Miller WR, Rollnick S. Motivational interviewing. New York: Guilford, 1991. Prochaska J, DiClemente C, Norcross J. In search of how people change. Am Psycho1 1992;47:1102-14. Heather N, Rollnick S. Readiness to Change Questionnaire: users manual (revised edition). Technical Report No. 19. National Drug and Alcohol Research Centre. Kensington: The University of New South Wales, 1993. Rollmck S, Heather N, Gold R, Hall W. Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic interventions among excessive drinkers. Br J Addict 1992;87:743-54. Heather N, Rollnick S, Bell A. Predictive validity of the readiness to change questionnaire. Addiction 1993; 88: 1667-77. Donovan D, Dunn C, Gentile110 L, Daranciang E. Readiness to change drinking behavior among trauma victims. Presented at the Research Society on Alcoholism, Steamboat Springs, CO, June, 1995.
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22. Selzer ML. The Michigan alcoholism screening test: the quest for a new diagnostic instrument. Am J Psychiatry 1971; 127:89-94. 23. Jacobson GR. A comprehensive approach to pretreatment evaluation: I. Detection, assessment and diagnosis of alcoholism. In: Hester RK, Miller WR, editors. Handbook of alcoholism treatment ;;Fhes: effective alternatives. New York: Pergamon, 1989: 1724. Gentile110 L, Duggan P, Drummond D, Tonnensen A, Degner E, Fischer R, et al. Major injury as a unique opportunity to initiate treatment in the alcoholic. J Surgery 1988; 156558-61. G. 25. Gurney J, Rivara F, Mueller B, Newell D, Copass M, Jurkovich The effects of alcohol intoxication on the initial treatment and hospital course of patients with acute brain injury. J Trauma 1992;33: 709-13. 26. Babor TF, Stephens RS, Marlatt GA. Verbal report methods in clinical research on alcoholism: response bias and its minimization. J Stud Alcohol 1987;48:410-24. 27. Sobell LC, Sobell MB. Self report issues in alcohol abuse: state of the art and future directions. Behav Assess 1990; 12:77-90.
Readiness to Change Alcohol Drinking Traumatic Brain Injury Charles H. Bombardier,
PhD, Dawn Ehde, PhD, Jason Kilmer, MS
ABSTRACT. Bombardier CH, Ehde D, Kilmer J. Readiness to change alcohol drinking habits after traumatic brain injury. Arch Phys Med Rehabil 1997;78:592-6.
Objective: To describe how motivated are persons with recent traumatic brain injury (TBI) to change their alcohol drinking habits and what factors affect their motivation. Design: Survey. Setting: Acute inpatient rehabilitation program. Patients: Subjects were 50 patients with recent TBI during inpatient rehabilitation. Main Outcome Measures: Readiness to Change (RTC) questionnaire, Michigan Alcoholism Screening Test (MAST), and alcohol use questions. Results: Subjects were 36 years old; 86% were men. Eightfour percent fell in the contemplation or action phases. Comparisons with a separate medical patient sample suggested that TBI may be associated with greater contemplation of change and greater readiness to take action to change alcohol use. Multivariate analyses indicated that within the TBI sample a positive history of alcoholism, alcohol involved in the accident, and higher daily consumption were associated with greater readiness to change (especially contemplation scores). Conclusions: Soon after TBI, drinkers frequently contemplate changing their alcohol use. This situation may represent an underutilized window of opportunity to reduce postinjury alcohol use and abuse. Motivational interviewing techniques seem well suited to facilitate change during this period. 0 1997 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
I
T IS WELL RECOGNIZED that preexisting alcohol problems are relatively common among persons who sustain traumatic brain injury (TBI). A recent review of the literature indicated that 44% to 66% of persons with TBI have a history of alcohol abuse.’ Unfortunately, harm from alcohol often continues after TBI. The National Head Injury Foundation* reported that approximately 40% of patients in postacute rehabilitation facilities had moderate to severe problems with substance abuse, and alcohol was the substance abused in more than 95% of the cases. Others estimate that approximately two-thirds of the heavy drinkers return to excessive alcohol use after TBI.3 To From the Department of Rehabilitation Medicine, University of Washington School of Medicine (Drs. Bombardier, Ehde), and Department of Psychology, University of Washington (Mr. Kilmer), Seattle. Submitted for publication May 2, 1996. Accepted in revised form October 28, 1996. Supported in part by grants from the Centers for Disease Control and Prevention: Promoting the health of people with disabilities (U48KCUOO9654; Donald Patrick, P.I.) and the Harborview Injury Prevention and Research Center (R49/ CCR002570; Frederick Rivara, PI.). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Charles H. Bombardier, PhD, Box 359740, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104. 0 1997 by the Amencan Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/97/7806-4004$3.00/O
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Phys Med
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date, the most representative sample of persons with TBI shows that drinking declines significantly through 1 month postinjury; after this, alcohol use increases but not to the preinjury levels by 1 year after injury.4 Finally, alcohol use and abuse may be potentially more harmful for people with TBI than in the general population. Evidence suggests that poor neurological outcomes are associated with alcohol use or abuse, including cerebral atrophy,5 poorer neuropsychological test performance,6-9 deterioration of emotional and behavioral functioning during the postacute recovery phase,” and development of postconcussive symptoms after mild TBI.” It is possible that even “normal” use of alcohol may be deleterious to neurological recovery.” Therefore, abstinence from alcohol after TBI is generally recommended. With increased awareness of alcohol problems in this population, investigators have begun to question how and when to address alcohol use disorders. To date, most investigators have adopted a tertiary prevention approach, treating alcohol problems in postacute settings.‘.r3 Another potential approach, however, is to conduct secondary prevention during the acute rehabilitation phase, a strategy that could reach a greater number of people with TBI. Traumatic injury (especially when it is alcohol-related) may create an opportunity in which survivors are more motivated to change their drinking behavior.‘4.‘s If there is substantial motivation, the stage may be set for the implementation of effective brief interventions during the acute rehabilitation phase. Moreover, if specific intervention strategies can be matched to the type or degree of motivation to change, even greater therapeutic change may result. I6 To date there are no data describing motivation to change alcohol-related problems among persons with TBI and, consequently, there is no guidance regarding the appropriateness of attempting interventions soon after injury. The purpose of this study was to describe readiness to change alcohol use among persons undergoing acute rehabilitation for recent TBI. The study is based on the transtheoretical stages of change modelI This model characterizes motivation to change on a spiral continuum from precontemplation (not considering change), through contemplation (ambivalent about change), determination (getting ready for change), action (making behavioral changes), and maintenance (maintaining change). We predicted that soon after TBI, patients would be characterized by high levels of readiness to change, significantly more than in a general medical sample. We also predicted that independent indicators of greater problems with alcohol would be positively correlated with greater readiness to change. Our specific hypotheses were as follows: (1) Patients with recent TBI and significant comorbid alcohol problems will be characterized by contemplation and action rather than precontemplation (denial). Additionally, readiness to change will be higher in this group than among a sample of general medical patients.” (2) Patients with a history of significant alcohol problems will report significantly greater motivation to change alcohol use compared with patients who do not have a history of alcohol problems. (3) Motivation to change will be greater among persons with positive blood alcohol levels at the time of TBI. (4) Motivation to change will be positively correlated with greater quantity/frequency of recent alcohol consumption.
READINESS
TO CHANGE,
METHOD Subjects Subjects were 50 patients with TBI admitted to an acute inpatient rehabilitation program housed within a Level I trauma center. Patients were administered the questionnaires as a part of standard rehabilitation care. Nondrinkers and non-English speakers were excluded.
Procedures All patients were administered the self-report measures by a trained psychometrist as part of a neuropsychological screening examination. Measures were administered an average of 28 days after TBI (median = 25 days) and 19 days after admission to the rehabilitation unit (median = 16 days). Patients were not assessed until they scored greater than 20 on the Mini-Mental Status Examination and it had been determined that the patient had intact language function as assessed by the team speech pathologist. Response options for some measures were presented to subjects both orally and in written form using a largeprint cue card. To prevent potential reactivity effects of the alcoholism measure on the measure of readiness to change, the readiness to change instrument was always administered first. Relevant medical diagnostic and clinical information was obtained from the patient’s chart. All procedures were approved by our human subjects institutional review board.
Measures Readiness to change.
Stage of change was assessed using the 12-item Readiness to Change Questionnaire (RTC).” This scale measures thoughts and behaviors associated with the most common stages of change found among persons in health care settings (ie, precontemplation, contemplation, and action) and was specially developed by British and Australian researchers for brief opportunistic assessments in medical settings.” Each stage of change is represented by four items. Precontemplation items refer to the denial of alcohol-related problems. Contemplation items refer to beliefs that alcohol may be a problem. Action items reflect behavior changes the person is already making to cut down or stop drinking. Subjects rate the degree to which they agree or disagree with each item on a five-point Likert scale. Scores range from -2 (strongly disagree) through 0 (unsure) to 2 (strongly agree). Agreement with contemplation and action items reflects greater readiness to change, while disagreement with precontemplation items denotes greater readiness to change. The internal consistency of the three four-item scales range from .73 to .80 and test-retest reliabilities over 2 days ranged from .78 to .86.19 The RTC has been shown to correlate with changes in drinking 2 to 6 months after assessment in a medical sample.20 For correlational analyses, an overall readiness to change score was computed consisting of the sum of contemplation and action scale scores minus the precontemplation scale score.” Quantity/frequency of alcohol consumption. Subjects were asked how many drinks they typically consumed each day during the month before their injury, as well as the number of days on which they consumed two or more and five or more drinks. Lifetime alcohol-related problems. The Michigan Alcoholism Screening Test (MAST)” is a 25item list of common signs and symptoms of alcoholism. The subject indicates whether he or she has ever experienced each symptom of problem drinking during his or her lifetime. Item scores are weighted from one to five points. The MAST is used because it is brief, has demonstrated reliability and validity in a number of populations, and
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may be useful in differentiating subgroups of alcoholics.‘” Because the traditional cutoff of 5 has yielded unacceptably high false positive rates, a total score of 12 or more was used to indicate a clinically significant history of alcohol problems.”
RESULTS Demographic Variables The 50 subjects were on average 35.8 (? 12.7) years old, and 43 (86%) were men. Glasgow Coma Scale scores from the time of admission to the hospital were available on 30 subjects (60%), with 8 (27%), 3 (lo%), and 19 (63%) falling in the mild, moderate, and severe ranges of severity, respectively. Forty-four (88%) of all subjects were Caucasian, 3 (6%) were AfricanAmerican, and 3 (6%) were Native American. Thirteen (26%) reported less than a high school education, 21 (42%) reported a high school education, 9 (18%) had some college, and data were missing on 7 (14%). Twenty-three (46%) of the sample were single, and 15 (30%) were married. The remaining 12 (24%) were divorced, separated, or widowed.
Alcohol-Related Variables Initial blood alcohol levels (BAL) were available for 43 (86%) members of the sample. Of these, 16 (37%) had a negative BAL, 3 (7%) were below lOOmg/dL, and 24 (56%) were intoxicated (at or above the legal limit of lOOmg/dL). Alcohol involvement at the time of the accident was determined for all cases based on a combination of BAL, clinical information (eg, alcohol on breath in the emergency room), or self-report data. Alcohol was involved in the onset of TBI in 32 (64%) of all cases. On the MAST the average score was 20.1 (+-12.6), and 37 (74%) scored greater than 11, in the “alcoholic” range. Subjects reported drinking a mean of 2.6 drinks on a typical day during the month before their injury (median = 1.5). Fifteen (30%) reported drinking nothing on a typical day, and 6 (12%) reported drinking eight drinks or more. Alcohol-related variables such as the MAST, BAL, and recent typical consumption were moderately intercorrelated (Y values = .36 to .49).
Readiness to Change As predicted in the first hypothesis, the sample was characterized by greater contemplation and action than precontemplation. Means and standard deviations for subscale scores for the total sample were as follows: Precontemplation, -0.7 (3.4); Contemplation, 2.6 (3.3): and Action, 2.4 (3.5). For the subset of 37 subjects who endorsed significant lifetime alcohol-related problems on the MAST (2 12), a similar pattern of responses was obtained. Subscale scores were: Precontemplation, - 1.4 (3.2); Contemplation, 3.4 (3.3); and Action, 2.4 (3.7). These data suggest greater agreement with contemplation and action subscale items than with precontemplation items among this TBI sample. To further describe the sample in terms of stage of change, subjects were assigned to mutually exclusive stages of change based on their highest subscale score.” Ties (there were 10) were assigned to the higher stage as recommended by Heather and Rollnick.” Using this method, 8 subjects (16%) fell in the precontemplation group, 19 (38%) in the contemplation group, and 23 (46%) in the action group. It was also predicted that readiness to change would be greater during rehabilitation for recent TBI than during general hospitalization. Since no control group was available, readiness to change scores from the 37 persons who were positive on the MAST were compared with readiness to change scores obtained from a sample of general medical patients found to be excessive alcohol users.” These were the patients used in the original
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READINESS
Table
1: Stages
of Change Among Alcoholics: Patients Versus Patients With
Subject Samples
Precontemplation
General TBI
TO CHANGE,
Medical
Contemplation
Action
.Ol (4.1)”
General medical patients* (n = 141)
Patients
with
-1.19
(3.5)”
1.81 (3.8)”
-1.4
(3.2)”
3.4
TBI
(n = 37)
(3.3jb
2.4
(3.7jb
Values are mean (SD). Means with different superscripted letters within each column are significantly different (p i .05). * Data are from a sample of medical patients who were excessive alcohol users but not seeking treatment for alcohol problems.”
RTC scale development study.” Two-sample t tests were computed on each of the three RTC subscales by using a pooled estimate of the variance. Results showed that patients in the TBI sample reported significantly greater contemplation (t( 176) = 2.32, p < ,025) and action (t(176) = 3.22, p < .Ol) subscale scores, but equivalent scores on precontemplation (table 1). To test the second hypothesis, patients with and without a significant history of alcohol problems (MAST 2 12 vs. MAST < 12) were compared on the three readiness to change subscales using a multivariate analysis of variance (MANOVA). The overall MANOVA was significant (Hotelling’s t = .266, F = 4.08, p = ,012) and univariate F tests were significant for precontemplation @ = .028) and contemplation (p = .004), but not action. Mean scores were in the direction of significantly less precontemplation and significantly greater contemplation among those with a history of alcohol problems. Similarly, among the total sample the correlation of the MAST scores with the summary readiness to change score was significant and positive (r = .39; p = ,005) indicating greater readiness was associated with a more severe history of alcohol problems. Similar results were obtained when the correlational analysis was limited to the 37 individuals within the alcoholic subgroup (Y = .37, p = .023). To test the third hypothesis, a MANOVA was computed on readiness to change subscales with alcohol involvement at the time of injury as the grouping factor. Alcohol involvement was judged to be positive if blood alcohol, self-report, or other chart data indicated the presence of alcohol at the time of injury. The overall MANOVA was significant (Hotelling’s t = .39, p = .002) and the univariate tests showed significantly greater contemplation among the group with alcohol involvement (F = 16.6, p < .OOl). The correlation between overall readiness to change and blood alcohol level was also significant (Y = 51, p < .OOl). To test the final hypothesis, a median split was performed on the typical daily consumption variable (1.5 drinks per day) and a MANOVA was used to compare readiness to change between the higher and lower consumption groups. The overall MANOVA was significant (Hotelling’s t = .29, p = .Ol) and among the univariate tests, only contemplation differed between groups (F = 12.9, p = .OOl) with significantly greater contemplation scores obtained among the group who drank greater than the median. The correlation between typical daily consumption and overall readiness to change was significant (Y = .36, p = .Ol). DISCUSSION The results of this study suggest that soon after TBI, drinkers are frequently contemplating change or reporting readiness to take action regarding their alcohol use. Survivors of TBI tended to disagree with precontemplation statements such as, “It is a waste of time thinking about my drinking,” and tended to agree with contemplation and action statements such as, “I am at the
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stage where I should think about drinking less alcohol,” and “I am actually changing my drinking habits right now.” No control group was available; however, there appears to be greater endorsement of contemplation and action subscales among persons who recently sustained TBI than among the general medical patients used in the development of the RTC questionnaire. These data are consistent with the idea that TBI may motivate problem drinkers to consider reducing their alcohol use. These data are also consistent with the spontaneous change toward abstinence and reduced consumption that seems to occur following TBI.‘,9 It should be noted that these conclusions are preliminary and future studies should seek noninjured control subjects from the same institution matched on potentially important variables such as age, sex, and alcoholism severity. Caution should be exercised in making comparisons to the original RTC validation sample because the measure was developed on general medical patients primarily from urban Australia. These patients were similar to the TBI sample in terms of age (35.4 vs. 35.8 years) and sex (94% vs. 86% male), but unknown demographic or cultural dissimilarities between groups may also contribute to differences on readiness to change. Contrary to traditional beliefs that people with alcohol problems are characterized by denial and resistance, study results show that greater lifetime alcohol problems and typical daily consumption are positively correlated with greater readiness to change. Since all three of these measures are based on selfreport information, it could be argued that the correlations reflect no more than an underlying willingness to admit problems. However, an independent medical test result, blood alcohol level in the emergency room, was also associated with greater readiness to change. This finding gives support to the idea that alcohol-related consequences, not just a willingness to admit problems, may account for higher readiness to change scores. The high level of reported contemplation and action noted in this study may represent the window of opportunity researchers have described as occurring in the wake of trauma.24 To paraphrase Waller,14 the best window of opportunity for initiating rehabilitation for alcohol problems may be when a patient is still hurting from the acute effects of an alcohol-related TBI, but has become cognitively aware enough to understand and remember what his or her rehabilitation team is advising. On the other hand, this window does not give the rehabilitation professional a green light to confront patients about their “problem drinking’ ’ or to simply refer patients for treatment. In our sample, less than half of the subjects fell into the action stage, and the high level of contemplation reported implies that significant ambivalence and resistance to change remains. When rehabilitation professionals perceive ambivalence and resistance from patients with an alcohol problem, this phenomenon can be viewed most usefully from an interpersonal perspective. Recent research has shown that resistance is not so much a personality characteristic of a person with an alcohol problem but the result of counterproductive therapeutic interactions, especially confrontational behavior by the therapist.‘” For example, upon recognizing that a rehabilitation patient has an alcohol problem, staff may recommend that the patient attend AA. This approach often increases resistance, partly because the patient may not label himself or herself as an alcoholic. Also the recommendation “go to AA” is an action stage activity and may not match the patient’s stage of change (frequently contemplation). One way to avoid this problem is to include a readiness to change measure along with alcohol screening tests and to tailor further assessment and interventions to the person’s stage of change. For example, precontemplators may benefit most from
READINESS
TO CHANGE,
nonconfrontational consciousness-raising strategies such as informing them of how their self-reported alcohol consumption compares to national norms. Contemplators primarily need help exploring the pros, and cons of change in order to resolve their ambivalence before taking action. These strategies are examples of a motivational enhancement therapy approach to alcohol problems. Motiva ional enhancement therapy has been developed specifically or people who do not necessarily see themselves as having n alcohol problem or are ambivalent about change and, as su 1 h, seems to be an excellent match for persons with recent TBI.lh Several other potential limitations of this study should be acknowledged. Subjects were not a consecutive series of patients admitted to’the rehabilitation unit and, thus, may not be representative of the larger population from which they were selected. For example, our study criteria prevented us from including those with very severe TBI, those with significant communication impairments, and non-English speakers. Comparisons with a large-scale study of consecutive persons with TBI at our institutior? suggest that our sample may be biased toward a greater proportion of persons who were intoxicated at the time of their injury (37% vs. 56%) males (77% vs. 86%) and Caucasians (43% vs. 88%). Another issue has to do with the reliability of the self-report data. Concerns may arise about the reliability of self-reports of alcohol-related behavior more generally as well as about the reliability of self-report soon after TBI. In response to the first issue, reviews of the literature conclude that persons with alcohol problems generally provide reliable and valid reports if interviewed in cliuical settings when they are alcohol-free and given reassurances of confidentiality.2h.27 Each of these conditions was met in the present study. Regarding potential unreliability related to TBI, precautions were taken to exclude persons with communication impairments as assessed by the staff speech pathologists. We also attempted to compensate for inattention or poor memory by using an interview format ‘and by presenting the materials in both oral and large-print written formats. Future studies should include test-retest data and provide corroborating information from family or friends. A final reliability issue has to do with the fact that 46% of our subjects fell in the action phase on the readiness to change measure. Our clinical experience, however, suggests that many of these persons remain ambivalent about changing their drinking and behave more like contemplators. This possible bias toward assigning people to the action phase may be attributable to the recommended scoring procedures that place those with tied scores into the higher stage of change.” Overassignment of patients to the acrion phase also may be caused by the enforced abstinence from alcohol associated with inpatient rehabilitation. Patients may indicate agreement with action stage items because they misattributei abstinence to themselves rather than to the controlled rehabiq’itation environment. Finally, patients may endorse action-oriented items in a defensive or acquiescent manner when being evaluated in a clinical setting. On the other hand, these same attributional and motivational factors were likely operating in the original inpatient medical sample on which the RTC measure was developed. Consequently, comparisons made between these two separate samples are not necessarily invalid. Clearly, the reliability and validity of the stage assignment method merits further study, especially as it applies to persons considered to be in the action phase. Ultimately, the single composite readiness to change score used in our correlational analyses may prove to be more reliable and valid than stage assignbent procedures. No data are available to demonstrate the predictive validity
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of the RTC measure in a population with TBI. That is, we do not yet know if, in this population, persons reporting greater readiness to change are more likely to accept treatment, abstain from alcohol after discharge, or reduce their consumption. Research on excessive drinkers from a general medical population, however, has shown that stage of change was a significant predictor of drinking behavior at g-week and 6-month follow-up assessments.‘” Data are being collected to address this question among persons with brain injury. These data support the notion of attempting secondary prevention programs soon after TBI. The data suggest that during acute rehabilitation there may be an opportunity to motivate persons with TBI to abstain or significantly restrict their use of alcohol during the months and years ahead. Rather than heralding denial or resistance, a history of chronic alcohol problems, alcohol involvement at the time of injury, and greater recent alcohol consumption are associated with greater contemplation of the possibility that one needs to change his or her alcohol use. Recent clinical research based on the transtheoretical stages of change model suggests that confronting such people with their alcohol problems may be counterproductive. Several clinical strategies that make up motivational enhancement therapy seem potentially useful to promote action among persons who might otherwise only contemplate, not change, the role of alcohol in their life after TBI. Acknowledgments: We are grateful to Drs. Frederick Rivara and Donald Patrick for their support of this project, to Drs. Carl Rimmele and Dennis Donovan for their guidance, and to Heather D&her and Art Blume for their help with data collection.
I.
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