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Intrinsic and extrinsic sources of motivation for change in drinlgng behaviour: Development and validation of the Reasons for Change in
Drinking ( .CD) Scale.
Susan J. Souter
A dissertation submitted to the Faculty of Graduate Studies in partial fulfillment of the revirements
for the degree of
DOCTOR OF PHILOSOPHY
Graduate Programme in Psychology York University Toronto, Ontario
December, 1997
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Intrinsic and extrinsic sources of mtivation for change in drinking behoviour: Developnent and val idation of the kasons for Change in Iirinking (Ki)) ScaLe
a dissertation subrnitted to the Faculty of Graduate Studies of York University in partial fulfillment of the requirernents for the degree of
DOCTOR OF PHILOSOPHY
0 1997 Permission has been granted to the LIBRARY OF YORK UNIVERSITY to lend or seIl copies of this dissertation. to the NATIONAL LIBRARY OF CANADA to microfilm this dissertation and to lend or seIl copies of the film, and to UNIVERSITY MICROFILMS to publish an abstract of this dissertation. The author reserves other publication rights, and neither the dissertation nor extensive extracts from it rnay be printed or otherwise reproduced without the author's written permission.
Abstract
Clinical experience suggests that motivation is an
essential component of change in addictive behaviour. At
present, however, a comprehensive understanding of the
association between motivation and habit change is lacking.
A basic problem facing research in this area is the need for
the development of reliable measures of client motivation.
Three recently developed measures of the "stage of change"
motivational construct, namely, URICA (McComaughy, Prochaska
& Velicer, 1983, SOCRATES (Miller et al., 1990)and the
Readiness to Change Questionnaire (Rollnick et al., 1992) a l 1
assess client motivation indirectly through self-reported
beliefs and behaviours purported to be indicative of
motivation for change. Likewise, other authors have assessed
client motivation for change indirectly by measuring A.A.
attendance, willingness to accept therapy, prior abstinence,
etc.
Relatively little research attention has been f ocused on
the development of direct measures of clientsr motivation for
change. The only current method is to simply ask clients to
generate persona1 incentives or motives for habit change.
However, there are inherent problems in an idiographic
approach to the measurenient of motivation for change in terms
of self-report issues, consistency and comparability.
i iv)
The present study draws upon Motivational Control Theory
and empirical findings from both the natural recovery and
treatment outcome literatures to develop a direct measure of
clients1 motivation for change in drinking behaviour.
Specif ically. the objectives of the study are: 1) to develop
and validate the Reasons for Change in Drinking (RCD) Scale;
2) to explore gender di£ f erences in reasons for change ; and 3 1
to determine the utility of the RCD Scale for predicting
treatment attrition.
Confirmatory factor analysis provided evidence for an
eight factor model to classify the motivational sources
related to initiation of change in drinking behaviour.
Analysis further suggested that the eight factors could be
dichotomized into intrinsic and extrinsic dimensions. Gender
differences on the eight subscales were determined. The
construct of motivation was validated in relation to the stage
of change motivational concept. Convergent validity was
established with three types of outcome expectancies while
discriminant validity was affirmed in relation to perceived
stress and efficacy expectancies. Predictive validity in
terms of predicting treatment attrition could not be
established.
Weaknesses in the present study are discussed along with
(v>
future research directions. The potential utility of the RCD
Scale in clinical practice is presented in relation to its
influence on motivational counselling strategies for clients.
Key Words : intrinsic and extrinsic motivation, alcohol , habit change initiation
During the course of any research there are many minds
that inspire the course of investigation and mould the final
product. The present paper was influenced and shaped by
several people who 1 would like to acknowledge and thank.
First and foremost, 1 would like to express my deep
respect and gratitude to Dr. Helen Annis. She initially
presented the a rea of motivation as a possible domain of
investigation. Her knowledge and guidance over the many years
of this project have provided an invaluable source of focus
and direction.
I would like to thank my supenrisor at York University,
Dr. Paul Kohn, for agreeing to assume that position during the
final year of the project . It has been a great delight for me
to work with a supervisor of his calibre and I sincerely
appreciate his valuable guidance on the project.
1 would also like to thank my third comrnittee member, Dr.
Kathryn Koenig. She agreed to be on the committee during her
final year a t York, when it would have been easier not to be
taking on new commitments.
(vii)
It is also important to acknowledge several of the group
therapists, case therapists and researchers at the Addiction
Research Foundation for their valuable comments and assistance
on design, item creation and data collection (alphabetically) :
Carolynne Cooper, Miguel de Sousa, the late Martin Graham,
Storey Holt, Eva Ingber, Robyn Levy, Nina Littman-Sharp,
Carole Neron, Barbara MacDonald, Diana Randerson, Sandra Rump,
Delvyn Thornhill, Veronica Small and Parmina Singh. 1 would
also like to express gratitude to Sherry Sklar and Nigel
Turner for their invaluable assistance on statistical analysis
procedures.
1 would also like to acknowfedge Peggy Willett and her
staff in Computer Services at the Addiction Research
Foundation for computer programming assistance and their
endless hours of entering and cleaning the data.
1 would especially like to acknowledge and thank the many
clients who shared with me their personal reasons for changing
their drinking behaviour. It was their responses that focused
and shaped the initial development of the RCD scale.
Finally, 1 would like to express my gratitude to my
husband, william, for his tireless support of the project and
his endless patience waiting for me to complete. It is
(viii)
through his deep understanding of the alcoholic dilemma that
interest was initially spawned in this area and his
perspective has added greatly to the understanding of the
issues involved in initiating change in drinking behaviour.
Muchas gracias!
TABLE OF CONTENTS
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figures xv
CHAPTER 1: INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Motivation ........................................ 7 Motivational Theories of Habit Change . . . . . . . . . . . . . . . . 9 Motivational Control Theory .......................... 13
Perceptual Input .................................... 15 Persona1 Standard .............................. 16 Discrepancy/Threshold of Action ................... 17 Expectancies .................................... 17
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corrective Behaviour 19 . . . . . . . . Hierarchical Organization of Control Loops 22
.............................. Motivational Subsystems 23
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intrinsic Motivation 24
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extrinsic Motivation 25 . . . . . . . Relationship to Concept of Locus of Control 25
Sources of Motivation ................................. 27 Intrinsic Sources of Motivation . . . . . . . . . . . . . . . . . . . 28
................................. Self Concerns 28 Health Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Extrinsic Sources of Motivation . . . . . . . . . . . . . . . . . . . 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Influence 30
. . . . . . . . . . . . . . . . . . . . . . . . . . Situational Influence 31 . . . . . . A Four Factor Approach to Motivation for Change 32
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Change Maintenance 36 Change Initiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
. . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER 2: PURPOSES OF THE STUDY 39 STUDY 1 Development of the Reasons for Change in Drinking
.......................................... (RCD) Scale 40 Intrinsic Sources of Motivation . . . . . . . . . . . . . . . . . . . 41 Extrinsic Sources of Motivation ................... 43
. . . . . . . . . . Gender Differences in Sources of Motivation 43 . . . . . . . . . . . . . . . . . . . . . . . . Construct Validity of the RCD 47 . . . . . . . . . . . . . . . . . . . . . . . Predictive Validity of the RCD 49
STUDY II Development of the Reasons for Change in Drinking
.......................................... (RCD) Scale 51 Socially Desirable Response Style . . . . . . . . . . . . . . . - 5 1
Convergent Validity of the RCD ....................... 53 Outcome Expectancy ................................ 53
. . . . . . . . . . . . . . . . . . . . Change Outcome Expectancies 53 ........................... Alcohol Expectancies 54
Drinking-related Locus of Control . . . . . . . . . . . . . . 55 . . . . . . . . . . . . . . . . . . . . . Discriminant Validity of the RCD 56 ............................... Efficacy Expectancy 56
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Perceived Stress ...58
CHAPTER 3: METHOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
STUDY 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subjects 60
. . . . . . . . . . . . . . . . . . . . . . . . . Sample Size Justification 6 1 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 - - Study Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3 Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . 63
. . . . . . Reasons for Change in Drinking (RCD) Scale 64 Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) . . . . . . . . . . . . . . . . . . . . 65
Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Sample Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
. . . . . . . . . Confimatory Factor Analyses of the RCD 66 . . . . . . . . . . . . . . Psychometric Evaluation of the RCD 70
Evaluation of Gender Differences . . . . . . . . . . . . . . . . 71 . . . . . . . . . . . . . . . . . . . Construct Validity of the RCD 71 . . . . . . . . . . . . . . . . . . Predictive Validity of the RCD 72
STUDY II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subjects 73
Sample Size Justification . . . . . . . . . . . . . . . . . . . . . . . . . 73 - . Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
-
Study Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 . . . . . . . . . . . . . . . . . . . . Development of the RCD Scale 74
. . . . . Marlowe-Crowne Social Desirability Scale 74 . . . . . . . . . . . . Convergent Validity of the RCD Scale 75
. . . . . . . . . . . . . . . . . . . . . Outcome Expectancy Scaie 75 ............. Alcohol Expectancy Questionnaire 76
Drinking-Related Locus of Control Scale . . . . . . 77 . . . . . . . . . . Discriminant Validity of the RCD Scale 77 . . . . . . . . . Situational Confidence Questionnaire 77
Perceived Stress Scale ....................... 79 A
............................. Data Analysis /U Development of the RCD Scale . . . . . . . . . . . . . . . . . . . . 80
. . . . . . . . . . . . Convergent Validity of the RCD Scale 80 . . . . . . . . . . Discriminant Validity of the RCD Scale 80
CHAPTER 4: RESULTS STUDY I
. . . . . . . . . . . . . . . . . . . . . . . . . . . . Sample Characteristics 82 ~evëlo~rnent of the Reasons for Change in Drinking (RCD) Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
. . . . . . . . . . . . . . . Socially Desirable Response Style 85 . . . . . . . . . . . . . . . . . . . . Confirmatory Factor Analyses 86
. . . . . . . . . . . . . . . . . . . . . . . . . . . First-Order Models 86 . . . . . . . . . . . . . . . . . . . . . . . . . . Second-Order Models 91
Interna1 Consistency and Reliability of the RCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
. . . . . . . . . . . . . . . . . Gender Differences i n Motivation 100 . . . . . . . . . . . . . . . . . . Construct Validity of the RCD 3 2 . . . . . . . . . . . . . . . . . . Predictive Validity of the RCD . 1 0 3
STUDY II Sample Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
. . . . . . . . . . . . . . . . . . . Convergent Validity of the RCD 106 . . . . . . . . . . . . . . . . . . . . Change Outcome Expectancies 106
Alcohol Expectancies . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 . . . . . . . . . . . . . . Drinking-related Locus of Control 107
. . . . . . . . . . . . . . . . . Discriminant Validity of the RCD 108 . . . . . . . . . . . . . . . . . . . . . . . . . . Efficacy Expectancies 108
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Perceived Stress 109
CHAPTER 5: DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Research 130
CHAPTER 6: POSSIBLE CLINICAL APPLICATION OF THE REASONS . . . . . . . . . . . FOR CHANGE IN DRINKING (RCD) SCALE 133
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The RCD Scale 1 3 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scoring of the RCD 133
. . . . . . . . . . . . . . . . . . . . . . . Possible Clinical Application 134
Appendix A: 48-item Reasons f o r Change i n Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (RCD) Scale 164
. . . . . . . Four-factor Items Listed by Subscales 171 . . . . . . Eight-factor Items Listed by Subscales 173
. . . . . . . . . . . . . . . . . . . . . Appendix B: Demographic Information 175
. . . . . . . . . . . . . Appendix C: Alcohol Use Questionnaire (ADS) 178
Appendix D: Stages of Change Readiness and Treatment . . . . . . . . . . . . . . . Eagerness Scale (SOCRATES-SA) 189
Appendix E: Marlowe-Crowne Social Desirability Scale . . . . 195 (xii)
Appendix F: Outcome Expectancy Scale (OES) . . . . . . . . . . . . . . 197
Appendix G: Alcohol Expectancy Questionnaire ( A E Q ) . . . . . . 203
Appendix H: Drinking-Related Locus of Control Scale (DRIE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Appendix 1: Situational Confidence Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (SCQ-39) 211
. . . . . . . . . . . . . . . . Appendix J: Perceived Stress Scale (PSS) 217
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix K: Consent Foms 220
. . . . . . . . . Appendix L: Summary of Prediction of Hypotheses 226
T a b l e s
Table Table T a b l e Table T a b l e Table Table Table
Characteristics of sample in study 1 . . . . . . . . . . . . 84 RCD Confirmatory Factor Analysis . . . . . . . . . . . . . . . . 95
. . . . . . . . Correlations among 8 First-Order Factors 97 . . . . . . . . . . . . . . Fit Indices of Second-Order Models 98
Second-Order Confirmatory Factor Analysis . . . . . . . 98 . . . . . . Interna1 Consistency & Reliability of RCD 100
Gender Differences i n RCD . . . . . . . . . . . . . . . . . . . . . . 101 . . . . . . . . . . Characteristics of sample in study II 105
(xiv)
Figures
Figure 1 . A single motivational control loop . . . . . . . . 16 Figure 2 . A priori and empirical mode1 of
motivational sources . . . . . . . . . . . . . . . . . . . . . . 89 . . . . . . . . . . . . . . . . Figure 3 Factor structure of the RCD 93
CHAPTBR 1: INTRODUCTION
Motivation and change in addictive behaviour have
frequently been associated (Cox & Klinger, 1987; Klinger &
Cox, 1986; Marlatt, Curry & Gordon, 1988; Miller, 1989; Miller
& Rollnick, 1991; Saunders & Wilkinson, 1990) with reports of
this association dating back to the early days of
psychoanalysis (Appelbaum, 1972) . Clinical experience
suggests that motivation is an essential component of change
in addictive behaviour . Drinkers who successf ully al ter their drinking habits are believed to be more motivated than those
who fail to change or who relapse back to substance use.
Early motivational studies examined this clinical
impression. Studies documented that alcohol counsellors
viewed motivation as essential to treatment success (Beckman,
1980; Lemere et al., 1958; Stem & Pittrnan, 1965).
Counsellors frequently reported that, without motivation,
there was nothing they could do for the client. This thinking
implied that clients had to enter treatment motivated and
ready to commence change and, if they were not so prepared,
there was little point in their becoming involved in
treatment . The emphasis on low motivation as an impediment to
treatment is still f a i r l y widespread.
Viewed in this manner, motivation is conceived as a
static quality that clients either possess or lack. The
implication is that motivation cannot be created or
manipulated. If a client is without motivation to change,
treatment will be ineffective.
This view of motivation and addictive behaviour is now
being challenged (Saunders & Wilkinson, 1990). Counselling
techniques known as motivational interviewing, developed by
Miller (1983, 1985), have dernonstrated that motivation can be
enhanced in clients who present as lacking in this domain.
The techniques involve encouraging the clients to explore the
costs or negative consequences of their drinking behaviour
relative to the benefits of continued consumption, with the
intent of helping clients understand the need to reduce or
refrain from abusive drinking behaviour. Such techniques are
intended to generate in the client a robust resolution to
alter drinking habits in the belief that only a major
c o r n m i t m e n t will lead to sustained effort. Motivat ional
interviews have successfully influenced the initial decison-
making process and strengthened the resolut ion and commitment
to habit change (Saunders & Wilkinson, 1990) . Research has
also demonstrated that motivational counselling has been
influential in more successful treatment outcome relative to
cornparison groups (McGowan, 1985; Stockwell et al., 1989;
2
Allsop, 1990).
At present, a comprehensive understanding of the
association between motivation and habit change is generally
lacking. The understanding of this association deserves
examination for a number of reasons. From a clinical
perspective, readiness to change and progress through the
stages of change, as described by Prochaska & DiClemente
(1982 ; 1986) , would obviously be inf luenced by motivation and
thus an understanding of one's motivational structure during
these processes may be helpful in developing more effective
motivational counselling procedures. In addition, maintaining
the goal of abstinence or controlled drinking may be
facilitated by maintaining a focus on the motives that led to
that decision. As people increase their "vocabulary of
motivesn, they become more certain of the nature of their past
problems. This increased understanding serves to increase and
sustain cornmitment over time (Becker, 1963; Ludwig, 1985).
From a research perspective, very little is understood about
the motivational sources that influence cessation or reduction
in abusive drinking behaviour. Very little is also understood
about treatment attrition, which is generally high between
initial assessment and entry into treatment' as well as
following the first treatment session2. An understanding of
one's motivation to alter drinking consumption patterns may be
useful i n determining who f ollows through with treatment a£ ter
the initial con tac t .
At present, there are few methods of identifying and
measuring motivation to alter drinking habits. The
predominant procedure measures motivation indirectly by
assessing the stage of change presently experienced (SOCRATES:
Miller et al., 1990; URICA: McConnaughy, Prochaska & Velicer,
1983; the Readiness to Change Questionnaire: Rollnick et al.,
1990) . This approach, however, only assumes the presence of
motivation from beliefs and behaviours believed to be
indicative of motivation but gives no information about the
actual motives driving the behaviour change. The main problem
with the stages of change measurement approach to motivation
is that the majority of clients present in more than one stage
of change rather than a solitary stage as the mode1 predicts
(Rollnick et al., 1992). While this may or rnay not have
In sorne clinical settings, it is estirnated that approxirnately 35% either never complete the initial assessment phase or drop out prior to treatment entry (Graham, 1992).
The dropout rate following the first session of treatment has been documented as well over 50% (Miller & Rollnick, 1991) .
serious implications for treatment, research becomes
problematic.
Currently, the only direct method of measuring motivation
is to ask clients why they want to stop or reduce their
drinking. However, there are inherent limitations to this
approach. While it is true that some clients are tremendously
articulate about their reasons for habit change, others are
less eloquent or less clear themselves about why they desire
change, Clients rnay also not be fully aware of the complete
range of their reasons for change. Still others may be
reticent to offer persona1 reasons because of the private
nature of the concern, guilt surrounding certain behaviours or
humiliation about circumstances or personal states.
Another interesting consideration is the report by
drinkers of seemingly trivial events that trigger change
(Fillmore, 1988; Klingemann, 1991; Knupfer, 1972) . It is not
uncornmon for drinkers to identify apparently insignificant
happenings as precursors to change initiation. Without a more
global picture, an undue weight might be assigned these
reasons and, therefore, distort a more comprehensive
understanding of the motivation to change.
Thus, a well-validated, objective measure of motivation
for habit change would have some obvious advantages over an
idiographic approach. The use of an objective approach would
also have research advantages in that responses would allow
consistency and comparability.
Since the motivation to alter abusive drinking habits has
important implications for treatment and no objective measure
of motivation currently exists for the purposes of research or
clinical practice, the objectives of the present study were
to : (1) develop and validate a Reasons for Change in Drinking
(RCD) Scale; (2) explore gender differences in reasons for
change; and (3) determine the utility of the RCD scale for
predicting treatment attrition. In the following chapters, a
comprehensive framework for understanding habit change is
initially outlined; the study hypotheses are presented along
with the study methodology; the data analyses are described
followed by a discussion of the findings; and finally,
suggestions are offered for the possible future clinical
application of the Reasons for Change in Drinking Scale.
MOTIVATION
Historically, the concept of motivation in the addictions
field has been viewed as a trait that a person either
possesses or lacks. Clients approaching treatment have been
characterized as having a particular level of motivation. If
they are unsuccessf ul at reaching treatment goals, they are
said to be "not very motivated" while those who demonstrate
treatment gains are viewed as "more motivated".
More recent formulations have conceived of motivation as
a willingness to change behaviour (Miller & Rollnick, 1991).
Because a key dimension of motivation in this view is
adherence to or compl iance wi th a change programme, proponent s
of this formulation have defined motivation as "the
probability that a person will enter into, continue, and
adhere to a specific change strategy" (Council of
Philosophical Studies, 1981; Miller, 1985; Miller & Rollnick,
1991) .
Both of these approaches irnply that motivation exists in
degrees. The greater the intensity or magnitude of motivation
that a person possesses, the more likely they are to initiate
change in maladaptive, addictive behaviour. Houston (1985)
even suggests that it is the strength or intensity of
7
motivation that has the most important consequences for
behaviour change.
There is, however, a second dimension of motivation that
is equally important for, without it, no magnitude of need
exists. This dimension entails the forces that initiate,
direct and sustain behaviour (Buck, 1988; Deci & Ryan, 1985;
Kleinginna & Kleinginna, 1981; Petri, 1981; Young, 1961).
This dimension of motivation focuses on the reasons or sources
of motivation that produce the need to alter behaviour. In
the case of alcohol abuse, these are the problems (e.g.,
physiological, psychological or social), resulting from
chronic misuse of alcohol, that necessitate a change in
behaviour.
In addition to the dual-dimensionality of motivation, it
is important to recognize that motivation fluctuates over
time. A person's motivation is limited to current
circumstances and time parameters (Miller & Rollnick, 1991).
Both the sources and the intensity of motivation alter with
t ime .
In summary, motivation for change in addictive behaviour
is a dual-dimensional construct which involves both a source
or reason for behaviour change as well as an intensity of need
8
- - a duality that interacts to produce behaviour in any
particular circumstance at any particular time.
MOTIVATIONAL THEORIES OF HABIT CHANGE
There are several current theoretical approaches to
understanding the motivation for change in addictive
behaviour. Cognitive-behaviour theory as presented by Bandura
(1978) and Kanfer (1971; Kanfer & Busemeyer, 1982; Kanfer &
Hagerman, 1981 ; Karoly & Kan£ er, 1982) purports that behaviour
change involves the self-imposition of persona1 standards, the
monitoring of onest actions and the evaluation of those
actions by comparison with persona1 standards (Mischel. 1973;
Meichenbaum, 1977) . The belief that self -ref lection is an
important aspect of this process has also been emphasized by
Kanfer (Kanfer & Karoly, 1972) and Bandura (1978). These
theorists emphasize the importance of a personf s expectancies
of being able to alter behaviour in the direction of the
standard. These expectancies are seen as an important
determinant of whether a person continues to strive for
behaviour change or gives up the attempt. The importance of
expectancies as mediators of the behaviour change process has
also been verified empirically (Bandura, Adams & Beyer, 1977;
Bandura, Adams, Hardy & Howells, 1980; Chambliss & Murray,
1979).
9
Marlatt (1985a) proposes that the motivation for change
in addictive behaviour entails both the salience of one's
reasons for change and the importance of surpassing a
threshold value before action ensues. In his description of
habit change, Marlatt proposes that the initiation of change
stage or what he has metaphorically referred to as a journey
to freedom is the preparation for departure. Marlatt proposes
that motivation at this stage involves two components: the
reasons why one wishes to make the journey and the overall
strength of the motivation to change. For each individual, a
hypothetical threshold of motivation exists such that a
commitment to behaviour change only occurs whenthat threshold
is exceeded. This threshold of action is highly individual
and may have to be fairly high for habit change to occur.
Marlatt (1985a) certainly suggests this, although it has not
been validated empirically. He also suggests that for each
individual, there is a hypothetical threshold beyond which
action ensues.
Millerf s approach to motivation for change in substance
use suggests that motivation for change is created when
substance abusers perceive a discrepancy between their present
behaviour and their important persona1 goals (Miller, 1983,
1985) .' The critical element for enhancing motivation to
change substance use patterns is to create and amplify, in the
user's mind, a discrepancy between where s/he is and where
s/he wants to be (Miller & Rollnick, 1991). For example,
believing that one is a caring parent is not consistent with
the action of embarrassing a child in front of friends with
drunken behaviour or forgetting to pick up a child £rom
school. When conflict between one's self-image and one's
behaviour occurs, discomfort follows. If this discomfort is
suf f iciently strong, it overrides attachment to the present
behaviour.
The Transtheoretical Mode1 (prochaska & DiClemente, 1982,
1986) of behaviour change proposes that change is effected in
£ive sequential stages: precontemplation, contemplation,
preparation, action and maintenance (Prochaska & DiClemente,
1983, 1984, 1992; Prochaska, DiClement & Norcross, 1992).
These stages of change provide a rough ranking of the degree
of motivation for addictive behaviour change being experienced
at a given tirne. The mode1 assumes the presence of motivation
In the original exposition of motivational interviewing, Miller (1983) described this as creating "cognitive dissonancetf about drug use, borrowing from the concept introduced by Festinger (1957). Miller used the term 'cognitive dissonance' to describe the situation where beliefs about oneself are not congruent (are dissonant) with one's behaviour.
from beliefs and behaviours considered to be indicative of
motivation.
Decisional balance theory borrows £rom work in the area
of decision-making processes (Janis & Mann, 1977). Decision
theory conceptualizes the decision-making process as a
sequence of stages starting with attitude changes that are
brought about by challenging the information that motivates
the person's current stance or position. The balance sheet or
decision rnatrix is employed in the early stages of decision-
making as a means of analyzing the benefits and costs that
enter into decisional conflicts (Janis & Mann, 1968).
Within the addictions, decisional balance theory purports
that people make decisions regarding substance use by weighing
the benefits and the costs of use (Oppenheimer & Stimson,
1982; Orford, 1985, 1986; Saunders & Wilkinson, 1990) . If the
benefits of substance use surpass the costs, then use
behaviour is maintained. On the other hand, if the costs of
continuing use outweigh the benefits, then change in use
ensues. Thus, a cessation or reduction in use will only occur
when a person becomes aware that the behaviour is increasingly
not 'paying offt . Relapse is also explained by this approach.
If the costs of use are minimized ( e - g . , through lack of use)
and the perceived benefits of use are viewed as outweighing
12
the costs, then a return to use can ensue,
These various approaches to understanding motivation for
change in addictive behaviour, although seemingly disparate,
are actually complementary approaches when viewed within a
larger framework, known as motivational control theory. In
this context, the theories can be viewed as focusing on
different aspects of a single underlying process (Souter, in
review) .
MOTfVAT30NAL CONTROL THEORY
Motivational control theory, named by Hyland (1988),
derived £rom engineering control theory which is a branch of
engineering that was developed to enable machines to do things
previously done by people (Powers, 1978) . Its application
from machines back to people is not new (Ashby, 1952; Wiener,
1948) but its utility within psychological domains has only
begun to manifest itself in the last decade. The basic
principles of control theory are self-regulatory precepts
which are applicable to any self-regulating system be it
electronic, biological, or psychological. In terms of
addictive behaviour change, the theory provides a framework
for understanding the motivation for change in addictive
behaviour and the intensity or commitment to that change. The
13
central tenet of the theory is the negative f eedback loop. It
is termed a negative loop because "its overall function is to
reduce or eliminate any perceptible discrepancy between a
sensed value and some standard of cornparison" (Carver &
Scheier, 1982a, p . 9 5 ) . In a control system. a reference
criterion is compared with environmental conditions i e a
comparator) and the difference between the two generates a
signal called detected error. The amplification (i-e., error
sensitivity) of the detected error determines whether or not
corrective action ensues.
The basic principles of control theory are well
recognized. Within engineering. the common thermostat
exemplifies the process. Once a thermostat value is set, a
sensor in the thermostat detects the difference between the
desired temperature (reference criterion) and the room
temperature by means of a device called a comparator. The
detected error, either above or below the ref erence criterion,
determines whether a heating or cooling mechanism is turned on
or off. As the error correction device (e.g., furnace or air
conditioner) operates, new temperature signals return to the
comparator. Eventually, the negative f eedback signal is
reduced to zero, the room temperature is maintained at the
desired temperature and the operating system turns off.
Within human behaviour, people who look at their
reflections in a mirror also exemplify the process (Carver &
Scheier, 1983). People use mirrors to examine the present
state of their appearance. The image perceived is compared to
a standard of how the person believes he or she should look.
If there is a discrepancy, there is generally an adjustment
which brings the standard and the appearance into closer
proximity.
Motivational control theory shares the basic elements of
engineering control theory but the various components of the
system are replaced by psychological terrns. Motivational
control theory also adds expectancies as an external factor
influencing the continuance of the loop and the direction of
one of the elements of the loop, as explained below.
Although the process can begin at any point in the loop,
for explanatory purposes, the discussion will begin at
perceptual input.
Perceptual Input :
As presented in Figure 1, the control loop sequence can
begin with the occurrence of some event that causes the person
to focus attention in that direction (Carver, 1979; Carver &
Scheier, 1981a, 1981b) . This attentional focus does not refer
15
Expectancies 1 I I I v
~erce~iual Input A Corrective , Action
Figure 1. A single motivational control loop
to a lengthy examination of the self/environment nor the
attainment of dramatic insight into oners motives, character,
or relationships. The term simply connotes a momentary
shifting of attention to the present state (Caner & Scheier,
1982b) . This momentary shifting of attention provides
perceptual input about the present condition.
Personal S tandard :
The perceptual input is then compared with a personal
standard of h o w the person wishes to be. These standards are
learned criteria that are adopted from parental, societal, and
persona1 values. They constitute the manner in which the
person chooses to think of him or herself or how a person
wishes to present to others or interact with the environment.
If the present perceptual input matches the standard, then no
change in behaviour occurs or no new action is activated. If,
however, the perceptual input does not match the standard, a
discrepancy is created.
Di screpancy/Threshold of Action :
The existence of a discrepancy necessitates a binary yes-
no decision regarding discrepancy-reduction. The decision,
however, is based on the analysis of the condition. The
presence of a discrepancy constitutes the existence of a
problem but this in itself is insufficient to instigate
action. 1 t is only when the problem reaches a significant
magnitude of concern to the person that corrective behaviour
occurs. This means that a threshold must be reached for the
discrepancy to move from the domain of a problem into the
realm of sufficient concern for action to result-
Fxpectanci es :
Once the discrepancy reaches sufficient saliency,
corrective action ensues. The direction of this action,
however, depends on the person's expectancy of successful
discrepancy-reduction between the standard and the present
condition. Expectancies represent a learned component within
the control loop. Expectancies are based on prior experience
or on in£ ormat ion f rom various sources that enables the person
to anticipate discrepancy-reduction. This information rnay
derive £rom a person's perceptions or attributions of the
causes of success or f ailure (i . e. , outcome expectancy) . This
process implies an extensive memory system that can be
accessed for the decision-making process. Self-efficacy or
the individual's perceived ability to successfully perform a
coping response e efficacy expectancy) is also an
important expectancy that feeds into the selection and
execution of corrective action.
Carver & Scheier (1982b3 suggest that the expectancy-
assessment process is separate and distinct from the
discrepancy-reduction process . It may occur either bef ore or
during a discrepancy-reduction attempt and involves an
integration of information from several potential sources
including physical and social constraints on behaviour and the
quantity and quality of one's resources. The expectancy-
assessment process also constitutes a binary, yes-or-no
decision whereby further attempts are undertaken or there is
a disengagement £rom the attempt.
Corrective Behaviour:
Corrective behaviour to reduce or eliminate the
discrepancy constitutes coping behaviour by which the person
attempts to deal with the prevalent concern. This would
entai1 either behavioral or cognitive strategies or a
combination of the two depending on the person' s expectancy
and the nature of the concem. The intensity with which the
strategy is pursued would relate to the salience of the
concern. If the concern takes on a magnitude of extreme
gravity, then corrective behaviour would be engaged in with
greater dedication than in instances where the concern
rnanifests less urgency.
Perceptual input would then provide feedback to the
system regarding changes in the present state, and thus
complete the control loop. If the discrepancy remains or is
only minimally reduced, then the loop would react ivate with
alternate corrective action coping strategies employed. The
control loop process would continue until the discrepancy was
eliminated and the concern was no longer present. At this
point the person returns to homeostatic balance and functions
on "normal ff, or in other words, retums to below threshold
value.
Motivational control theory thus provides an
19
understanding of the source of behaviour change, the threshold
for initiating action, and the intensity or commitment to
change. The persona1 standards explain the sources or reasons
for change. The threshold of acceptable discrepancy from
one's persona1 standard explains the necessity for change and
suggests the intensity by which one pursues the change.
Motivational control theory is a value-driven meta-theory
involving a need to maintain oneself according to persona1
values or standards. If one's current state becomes too
discrepant £rom a desired state, then corrective action ensues
to bring one back into balance with one's standards. The main
function of the motivational control loop is to create and
maintain the perception of a present state in close
approximation to some standard or value. As such it is a
homeostatic model. Within this perspective, human behaviour
is seen as a continual process of establishing goals
(reference standards) and altering present states so as to
correspond more closely to them. This is accomplished by
utilizing informational feedback as a guide to adjustment
(Caner & Scheier, 1983; Locke, Shaw, Saari & Latham, 1981) .
It should be noted, however, that, even when a threshold
is exceeded, corrective action such as reduction in substance
intake or abstention f rom use may not follow. If expectancies
20
are held that a particular corrective behaviour will not lead
to a reduction in discrepancies, then that behaviour will not
be chosen as a method of coping with the concern. This rnay
occur with someone who has not been able to successfully
reduce alcohol consumption or abstain from use and who is thus
not able to attribute the absence of alcohol to the
alleviation or reduction of the concern. However , other
situations may also occur. A person may be fully aware of the
discrepancy but have no conception of how to reduce the
dispari ty . This might occur with someone w h o has not
identified alcohol as the cause of the problem. In other
situations a person may chose inappropriate or inefficient
corrective behaviour. For instance, s/he might chose to
continue to drink in order to overcome concerns because s/he
still attributes the use of alcohol to the palliation of the
concern.
Any break in the closed-loop control system will cause
the informational circuit to "openM and the system to cease
functioning, due to the interruption of the flow of
information and control. This occurs primarily when there is
a lack of self -f ocus which prevents the comparator process
(Diener, 1979, 1980; Ickes, Layden & Barnes, 1978) or when
expectancies do not provide corrective action. Anxiety has
also been found to interrupt the self-regulation process
21
(Carver & Scheier, 1988) . In addition, the system can operate
maladaptively by utilizing an inappropriate standard or
erroneous or irrelevant perceptual input (Leventhal, Meyer &
Nerenz, 1980; Schwartz, 1978, 1979a, 1979b) . Another
possibility is that a person may alleviate the discornfort of
a discrepancy between one' s self - image and one' s behaviour by
making one's self-image congruent with onefs behaviour -
alcohol is disgusting and I ' m disgusting too. For someone
with a long history of not being able to stop drinking, this
may be a very normal manner of being able to live with
oneself, albeit one that inherently creates a whole new set of
problems .
Hi erarchi cal Organization of Con trol Loops :
Powers (1989; Robertson & Powers, 1990) suggests that
control loops are organized in a hierarchical fashion into 11
levels, ranging £rom higher-level cognitive loops (labelled
system concept, principle and program) that influence the
physiological, action-related loops (sequence, category,
relationship, event, transition, configuration, sensation and
intensity). The organization of the loops is believed to be
from the top down rather than from the bottom up. In this
systemic approach, a discrepancy detected at a higher order
loop activates standards or values at lower level loops
(Hyland, 1986, 1988; Powers, 1973). Control loops within any
2 2
of the levels can also occur singly or several at a time,
competing for attention (Souter, in review) .
MOTIVATIONAL SUBSYSTEMS
Motivational control loops can be dichotomized into loops
pertaining to intrinsic sources of motivation and those
pertaining to extrinsic sources (Hyland, 1988). It should be
emphasized that this dichotomy refers only to the original
source of motivation. The distinction will be used here for
clarity of ref erence. In actuality, the distinction is
somewhat artif icial . Intrinsic and extrinsic motivation do
not probably exist in pure forms. Intrinsic motivation would
have elements of extrinsic influences. For instance, the
desire to exert more control over one's life may actually be
due to extrinsic forces such as a loss of employment or
spousal desertion. Extrinsic motivation even in the sense of
coercion (such as court-mandated treatment) has an intrinsic
element in that the person may choose to comply with or defy
the edict. Intrinsic and extrinsic motivation is probably
more related in a temporal sense i , early-later) than a
spatial sense {i . e . intemal-external) . Motivation may
originate in an extrinsic source (e . g . , spousal nagging) but it must translate into an intrinsic source for action to occur
(e .g., a desire to reduce pressure f rom spouse in order to
23
create more desirable living conditions for oneself) . A more
succinct terrninology would probably involve intrinsic-
intrinsic and extrinsic-intrinsic categorization but that
becornes cumbersome to reference. Therefore, for ease of
discussion, the intrinsic/extrinsic distinction will be
retained and will refer only to the or ig in of the motivational
source -
Intrinsic motivation concerns loops that relate to the
self. Intrinsic motivation compares standards relating to the
ideal self with present conditions and attempts to bring the
experienced self in line with the ideal self. The standards,
the perceptual input, and the discrepancies al1 pertain to
emotions, thoughts, and sensations experienced by the private
self. For example, an alcoholic would be intrinsically
motivated if s/he chooses to abstain f rom alcohol consumption
becauçe of a personal desire to regain control of a life
dictated by alcohol. The desire for self-control is an
interna1 standard expressing an ideal self-image. The
corrective behaviour for a lack of such control in one' s life
might be the pursuit of abstinence in substance use. Mastery
of alcohol control would provide feedback that one can indeed
control one's behaviour and thus bring the experienced self in
line with the ideal self.
Extrinsic motivation concerns loops that relate to the
external environment of the person. Extrinsic motivation
compares standards relating to the ideal environment with
present conditions and attempts to bring the experienced
environment in line with the ideal environment. The
standards, the perceptual input. and the discrepancies would
al1 pertain to onef s public self and would involve social and
environmental relationships. As an example, an alcoholic who
chooses to alter drinking behaviour because of employment
problems is extrinsically rnotivated because the reason for
participation originates in the person's environment and not
within the person. The stimulus to action thus has an
external source.
Relationship to Concept of Locus of Control:
Intrinsic and extrinsic motivation should not be confused
with a similar appearing concept called locus of control
(Rotter, 1966 ; Weiner et al. , 1971) . Locus of control (LOC)
is a unidimensional personality construct that developed out
of a social learning perspective. The term LOC refers to
whether outcomes are believed to be contingent on one's
behaviour or, in other words, to whether people believe that
outcomes are controllable. Behaviour is conceived as
controlled by expectancies about reinforcements so that the
25
essential concems of LOC theory are who or what is believed
to control these reinforcements or outcornes. The range of
beliefs extends £rom internal to external locus of control.
With an internal locus of control, a person expects that a
contingent relationship exists between persona1 actions and
outcome or reinforcements while no such relationship is
expected by a person who is oriented to an external locus of
control (Lefcourt, 1966; Phares, 1976). Thus ability and
effort are internal controls whereas luck and task difficulty
are external controls.
Within motivational control theory, the intrinsic and
extrinsic subsystems are two distinct subsystems of motivation
that account for the perceived source of the initiation and
regulation of behaviour . The source can either be internal to
the person or external but in both instances the behaviour is
self-regulated and not a result of uncontrolled elements
(i.e., fate, luck, or the unpredictable whims of some outside
agent) . Both the intrinsic and extrinsic motivational
subsystems of motivational control theory would be subsumed
within the internal locus of control concept. This makes
intuitive sense since drinkers do not alter their drinking
habits because of fate, luck or the unpredictable whims of an
outside agent. It is self-directed behaviour.
SOüRCES OF MOTIVATION
Individuals who change their use of alcohol or other
drugs report common motivational sources as salient to the
process. The attribution literature provides evidence of some
significant concerns that lead individuals to change their
alcohol consumption. One part of this literature has examined
spontaneous remission (or natural recovery) f rom alcohol abuse
in a population of drinkers who recovered from their problem
without the help of formal treatment while another has
explored remission in a population of drinkers who recovered
with the help of treatment intervention. Similarities in the
findings between these literatures suggest similar
motivational sources among clients recovering on their own and
those exposed to treatment programs.
The literature provides support for both intrinsic and
extrinsic sources of motivation for change. The studies,
however, are based on qualitative analyses which suffer f r o m
a lack of uniformity in eliciting responses and in reporting
the findings, both of which complicate comparability.
However, in many instances actual examples of subj ects'
responses are reported and this allows a clearer understanding
of the content, irrespective of the terminology used to
summarize the responses.
The literature reports four general areas of concern
dichotomized into intrinsic and extrinsic sources of concern.
Intrinsic Sources of Motivation:
Intrinsic sources of motivation for habit change involve
factors interna1 to the drinker: namely, concern about one's
present psychological state (Self Concerns) and about one' s
state of health (Health Concerns) .
Self Concerns: Concerns about one's psychological well-
being have been reported as salient issues creating a need for
change in alcohol consumption patterns (Amodeo & Kurtz, 1990;
Brill et al., 1972; Curry et al., 1990; Guydish & Greenfield,
1990; Klingemann, 1991; Ludwig, 1985; McBride et al., 1994;
Thom, 1987 ; Tuchf eld, 1981) . Individuals f requently report
that their substance use has led to a negative self-image that
differs from their ideal image, creating a desire for change.
The perceived inability of many substance abusers to control
their life and their desire to "get on with life" is also a
frequently-reported source of motivation for change. In the
study by Ludwig (1985), drinkers reported sensing a "loss of
control over the direction of their lives and decided, almost
in an existential sense, to do something about it1I (p. 54) . Low self-esteem, shame, helplessness and insecurity, and the
28
need to overcome these feelings and regain self-respect were
precipitants of change. Inappropriate behaviour such as
violence or belligerence, enacted while under the influence,
leading to a negative self-image also presented as a salient
concern related to the need for habit change (Thom, 1987).
Despair leading to suicide attempts was reported by
Tuchfeld (1981). Tuchfeld gives no indication as to the
frequency of this concern and, as no other study mentions
this, it may be that suicide attempts may relate to a
specialized group, possibly a group experiencing other
clinical disorders.
Spiritual experiences (Ludwig, 1985) and religious
experiences (Tuchfeld, 1981) were reported as sources of
motivation for change. These experiences, however. were only
reported in studies £ r o m the Bible Belt in the Southern United
States and may also not generalize to other populations.
Health Concerns: Health concerns have been frequently
reported as reasons for change in dririking habits (Amodeo &
Kurtz, 1990; Curry et al., 1990; Edwards et al, 1987;
Klingemann, 1991; Ludwig, 1985; McBride et al., 1994; Saunders
et al., 1979; Smart, 1976; Stall, 1983; Tuchfeld, 1981).
Alcohol-related physical illness/incapacitation/allergy, or
29
the impression that alcohol was harming one's health were the
most frequently reported concerns. Alcohol-related accidents
that resulted in physical problems were also related to
change. Several people also reported receiving a physician's
advice to stop drinking. Alcoholic q1blackoutsq8 and the fear
of losing one's mind as well as memory loss, feelings of
anxiety or depression, and mood swings were also mentioned as
salient concerns.
Education about alcoholism was mentioned in one study by
12% of the subjects (Tuchfeld, 1981) . However, education by
itself would not constitute a concern. Only the resultant
awareness of alcohol-related physical problems or the threat
of such problems would constitute a concern.
Extriasic Sources of Motivation:
Extrinsic sources of motivation for habit change involve
factors that are external to the drinker and entai1 both a
concern for family and friends (Social Influence) and a
concern for one's current financial, employment or legal
situation (Situational Influence).
Social Influence: Social forces have been reported to
influence the decision to alter drinking behaviour (Amodeo &
3 0
Kurtz, 1991; Curry et al., 1990; Edwards et al., 1987;
Klingemann, 1991; Ludwig, 1985; McBride et al., 1994; Saunders
et al., 1979; Stall, 1983; Tuchfeld, 1981) . Drinkers often
reported a concern for loved ones (spouse, children, parents,
girlfriend/boyfriend, friends) as a salient concern that
influenced their change in alcohol consumption. Drinkers
reported concerns about what their drinking was doing to their
family and friends. Loved ones were often deeply upset with
the drinker, resulting in a great deal of anger within the
social unit and, in some cases, the spouse (or partner) had
threatened or enacted separation or divorce. Interventions,
both positive and negative, by loved ones and suggestions to
stop or reduce drinking were not uncornmon. Drinkers were
often concerned that loved ones held an unacceptable image of
them as an nalcoholic" or a "drunk". The desire to rectify
and maintain a relationship was also an important precipitant
to change. Thus, valued relationships whether i n t ac t or
dysfunctional were influential to habit change, with the
drinker attempting to reinstate him or herself as a valued
member of the s o c i a l unit.
Situational Influence: The situation in which the
drinker has found him or herself as a result of abusive
drinking behaviour has been reported as influential to habit
change (Arnodeo & Kurtz, l99O ; Brill et al. , 1972 ; Curry et
31
al., 1990; Edwards et al., 1987; Kiingemann, 1991; Ludwig,
1985; M c B r i d e et al., 1994; Saunders et al., 1979; Smart,
1976; Stall, 1983; Tuchfeld, 1981). The lack of finances as
a result of alcohol consumption was the most frequently
reported situational influence in altering drinking behaviour.
Employment problems both in terms of job functioning, job
loss, absenteeism, lateness and new employment were also
precipitant to change. In some cases alcohol-related legal
problems or problems with the Children's Aid Society had
prompted the alteration in drinking behaviour.
A FOUR FACTOR APPROACH TO MOTIVATION FOR CHANGE
Support for the four subareas of motivation can be
derived from several empirical sources across various fields
of addiction, including the smoking, drug and alcohol
literature. Extrapolation of the findings from one field of
addiction to another seems appropriate as Stall & Biernacki
(1986) and Klingernam (1991) have found evidence for
comparable motivational concerns for habit change across
addictions.
One of the studies that supported the four subareas of
motivation derived from the factor analytic study by Curry,
32
Wagner & Grothaus (1990). These researchers examined the
intrinsic and extrinsic motivation of people who wanted to
stop smoking.
Curry and her associates evaluated two samples (ns=1217
and 151) of smokers who requested self-help material for
quitting smoking. Exploratory and confirmatory factor
analyses of the Reasons for Quitting Questionnaire (RFQ)
produced a 2-dimensional motivational model, with 2 intrinsic
and 2 extrinsic subdimensions. The intrinsic dimensions
revealed concems about health and a desire for self-control.
The self-control dimension included items that related to
self-determination and psychological incongruency. The
extrinsic subscales were grouped according to source of
contingency. The social influence dimension reflected both
positive and negative influences from other people while the
imrnediate reinforcement dimension related to financial savings
and situational betterment.
McBride, Curry et al. (1994) also investigated intrinsic
and extrinsic motivation in marijuana smokers and cocaine
users. The study confirmed only three of the four dimensions
from the tobacco study. Imrnediate reinforcement in terms of
saving money was not replicated in the 1994 study.
The study of spontaneous remission from cocaine
dependency by Toneatto and associates (1993) provides support
for the four subareas. The most frequently reported reasons
for resolution were : 1) social influences (external factors
such as family, 46%; observation of negative ef fect of cocaine
on others, 18%; departure of signif icant other, 14%) ; 2)
situational influence (poor financial situation, 38%; legal
problems, 16%) ; 3) health problems (30%) ; and 4) self concerns
(negative self -evaluation, 22%) .
Klingemannts (1991) study of spontaneous remission from
substance abuse provides further support for the four
subareas. His study indicated that feelings of helplessness
and insecurity (self-control) were experienced by 83% of
remitters, health problems (health concerns) by 73%' family
tensions (social influence) by 73%, and financial problems
(situational influence) by 47%. These four categories were
the highest reported percentages of stressful life events and
feelings preceding the natural recovery of alcoholics in the
study.
Thom's (1987) exploration of problems influential to
addiction treatment entry also determined four subareas of
concern: 1) psychological and emotional problems, 2) health
problems, 3) relationship problems, 4) practical issues
34
(unemployment , f inancial problems , coping wi th j ob) .
It would thus appear that both intrinsic and extrinsic
motivational concerns emerge as salient to habit change.
Intrinsic sources O motivation for habit change involve
factors interna1 to the drinker. These appear to involve both
a concern about one s present psychological state (Self
Concerns) and one's state of health (Health Concerns) . Self
Concerns involve a need to experience more control of one's
life and psychological issues reflect a need to regain one's
ideal self-image, usually regain one's self-respect. Health
Concerns involve one's present experience of alcohol-related
physical or mental health problems or the threat of such
problems .
Extrinsic sources of motivation for habit change involve
factors that are external to the drinker. It seems to entai1
both a concern for family and friends (Social Influence) and
a concern for oner s current f inancial, employment or legal
situation (Situational Influence) . Social Influence involves
input from family members and friends or the perceived input
that indicates a lessening or a loss of the existing
relationship because of the drinking behaviour. If the
relationship is valued by the drinker, then change behaviour
becomes important. Situational Influences seem to involve
35
both employment issues and financial concerns. These issues
are often interrelated and can create a need for change. if
one's ideal self-image relates to a lifestyle that requires
more accumulated income than drinking behaviour allows. Legal
issues may also be influential.
CHANGE MAINTENANCE
Research has shom that habit change maintenance is
related to the intrinsic and extrinsic sources of motivation.
Within the addictions field, Curry et al. (1990) found
evidence that extrinsic sources of motivationwere detrimental
to sustained abstinence £rom smoking. Smokers with higher
levels of extrinsic motivation relative to intrinsic
motivation were more likely to return to smoking 3 months
following treatment. The association between extrinsic
motivation and failure to quit smoking is supported by the
motivational literature that suggests that extrinsic
motivation is detrimental to sustained performance (Deci &
Ryan, 1985) . This also parallels the f indings of Harackiewicz
and her associates (1987) who determined that extrinsically
orientecl treatment was iess effective than intrinsically
orienteci programs in maintaining abstinence from smoking.
Change maintenance may thus be attributed to greater
36
intrinsic sources of motivation, Successful abstainers from
smoking in the Curry et al. (1990) study were those who
differentiated between intrinsic and extrinsic motivational
sources and who demonstrated significantly higher levels of
intrinsic motivation relative to extrinsic motivation.
CHANGE INITIATION
Research on the intrinsic and extrinsic dimensions of
habit change initiation has been less conclusive. Deci (1975;
1980), in his work within the educational s y s t e m , suggests
that extrinsic sources of motivation rnay be related to
behaviour change while intrinsic sources may be related to
behaviour maintenance. He uses the example of a math major
who would never have considered taking a French literature
course until forced to do so but, once involved in the course,
became fascinated with the subject. Extrinsic sources of
motivation rnay be necessary to induce a behaviour but
intrinsic sources may be more likely to ensure the maintenance
of the behaviour.
Within the field of addictions, this is not generally
supported. While the research by Tuchfeld (1981) reported
that disengagement from any deviant behaviour was related to
extemal social conditions (Le., extrinsic motivation), the
37
behaviours that he reported as preceding habit change had a
strong intrinsic component. These behaviours included
personal illness/accident and extraordinary events such as
persona1 humiliation, exposure to negative role models, events
during pregnancy, attempted suicide and personal identity
crises. Ludwig (1985), in his study of 29 spontaneous
remitters. found that the initiation of change related more to
a person's state-of-mind and to his or her perception of the
situation e intrinsic motivation) than to specific life
events or external circumstances . The majority of subj ects
reported initiating recovery at the lowest point in their
lives. This "personal bottom" referred to the experience of
profound persona1 humiliation, shame, despair or meaningful
loss.
Thus, it would appear that intrinsic sources of
motivation play a major role in habit change initiation, as
well as habit change maintenance.
CHAPTER 2: PURPOSES OF THE STUDY
In a survey taken in 1987/88 there were an estimated
467,800 alcoholics in Canada (Adrian, 1993) . Attributional
research has demonstrated that treatment is seldom given by
recovered addicts as the major cause of recovery £rom
alcoholism (Edwards et al. , 1987; Klingemann, 1991) ; Knupfer,
1972; Ludwig, 1972, 1985; Orford & Edwards, 1977; Saunders et
al., 1979; Sobell et al., 1991, 1992, 1993; Vaillant, 1983) . Indeed, there is extensive 1 i terature, reviewed by Edwards and
his colleagues (Edwards & Grant, 1980; Orford & Edwards,
1977), suggesting that the recovery process in alcoholism may
depend almost entirely on factors other than specific
treatment interventions. For those who do enter treatment,
failure rates are fairly high, ranging from 55 to 70%
(Baekeland, 1977). If the common pathway to habit change is
motivational ( C o x & Klinger, 1988), then it would seem
beneficial to explore the motivational structure of such
change. If, as maintained by motivational control theory
presented above, change is only induced when a personal
threshold of need is exceeded, then it would seem beneficial
to understand what constitutes a personal threshold and what
concerns are involved.
The aim of the present research was to examine the
motivational structure of people who were attempting to stop
39
or reduce drinking. An intrinsic/extrinsic model of change in
drinking behaviour was tested on subjects entering treatment
for alcohol abuse. A two-dimensional scale comprised of two
intrinsic (self concerns and health concerns) and two
extrinsic (social in£ luence and situational influence)
subscales was explored by confirmatory factor analysis.
Reliability and validity of the scale and its subscales were
examined. The research hypotheses were tested in two separate
studies .
DEWZLOPMENT OF THE REASONS FOR CHANGE IN DRINKING (RCD) SCALE: Intrinsic and Extrinaic Sources of Motivation
People who present with an alcohol problem that requires
an adjustment in consumption patterns usually present with a
multitude of discrepancies/concerns (Amodeo & Kurtz, 1990;
Marlatt, 1985 ; Tuchf eld, 1981) . The sources of these concerns
relate to the self (intrinsic motivation) and the environment,
both social and situational (extrinsic motivation). Despite
the differential emphasis on either intrinsic or extrinsic
sources of motivation, both dimensions of motivation will
usually be present (Curry et al., 1990; Edwards et al., 1987;
fiuper, 1972; Ludwig, 1985; Saunders et al., 1979; Smart,
1976; Tuchfeld, 1981) .
Intrinsic Sources of Motivation:
Research has shown that an individual may be motivated
to change his/her substance use when a perceived lack of self -
control is experienced in the use of the substance. A key
factor in the recovery of the Core City alcoholics in the
study by Vaillant (1983; Vaillant & Milofsky, 1984) , for
example, was the recognition that they were no longer
consciously in charge of their drinking and that their use of
alcohol was no longer under voluntary control. The
spontaneous remitters in the Klingernann (1991) study reported
similar feelings of helplessness and insecurity preceding
natural remission. Curry and her associates (1990 ; McBride et
al., 1994) and Guydish & Greenfield (1990) have also
demonstrated that self-control is a valid concern associated
with habit change. Related psychological incongruencies have
also been established as important to the change process.
Psychological concerns demonstrating a discrepancy between the
ideal self and the real self have related to a lack of self-
respect (Edwards et al., 19871, low self-esteem ( C o x &
Klinger, 1987) , experiencing an absolute low point in a
person's life (Amodeo & Kurtz, 1990; Klingernann, 1991; Ludwig,
1985; Tuchfeld, 1981) , and undesirable behaviour enacted while
under the influence, leading to a poor self-image (Guydish &
Greenfield, 1990).
One of the standards by which people live is to remain
healthy. Research has shown that people typically act in ways
whereby they maintain themselves in healthy states (Leventhal,
1980; Leventhal, Meyer, & Nerenz, 1980; Schwartz, 1978, 1979a,
1979b). As alcohol has been linked to physiological disease'
and neuropsychological dysfunction5, there may be a point in
a drinker's life where the presence of alcohol-related disease
or neuropsychological dysfunction or even the threat of such
conditions can reach sufficient proportions that corrective
action in the form of reduction or cessation in alcohol
consumption will be necessitated. The following hypothesis
is, therefore, offered:
Hypothesis 1 : The i n t r i n s i c dimension of the scale
w i l l involve a subscale for se l f
concerns invol ving i tems r e l a t i n g to
self-control and self-esteem issues
' Alcohol has been associated with heart disease, cirrhosis of the liver, pancreatitis, ulcers, gastritis, and dehydration due to water loss from the kidneys (Kahan, 1993; Wartenberg & Liepman, 1987) .
Over time, alcohol can produce cerebral atrophy i n the frontal lobes which produces impairment of the higher executive functions such as decision-making, organizational abilitv, abstract reasoninq, and the implementation of appropkate cognitive skills - (~iller & ~audeco, 198 3 ; Laberg, 1986) . Alcohol impairment can also involve periods of memory loss and exacerbated emotional states.
and a subscale for heal th concerns,
both physical and mental.
Extrinsic Sources of Motivation:
People are influenced by external as well as interna1
forces. Family, friends, physicians, and other professionals
can impact on a person's decision to alter drinking habits by
facilitating the self-focus process (Curry et al., 1990;
Klingemann, 1991; Edwards et al., 1987; Ludwig, 1985;
Tuchf eld, 1981) . Situationai influences such as employment
problems, financial issues, court decisions, changes in
residence, etc. can also create a need for self -focus which
can impact on the necessity for habit change (Klingernann,
1991; Edwards e t al., 1987; Ludwig, 1985; Tuchfeld, 1981).
The following hypothesis is, therefore, proposed:
Hypothesis 2: The ex t r ins ic dimension of the scale
w i l l involve a subscale f o r socia l
influence and a subscale for si tuational
i n f 1 uence .
Gender Differences in Sources of Motivation:
The attributional literature presented thus far has been
predorninantly a study of male responses to cessation or
43
reduction attempts. Only two studies included a significant
proportion of f emales . Tuchf eld (198 1) included 16 women
(32%) and Klingemam (1991) included 15 (50%). However,
neither author reported the findings as a function of gender,
so it is unknown whether males and Eemales differ
systematically in regard to the salient concerns that
influence habit change.
A small body of literature has examined alcohol-related
problems as a function of gender (Drummond, 1990; Miikelii &
Simpura, 1985; Thom, 1987; Wilsnack et al., 1984) and some
gender differences have emerged. Although problems do not
equate to concems, the existence of a problem is generally a
prerequisite for a concern. In order for a concern to
manifest itself, there is generally some form of problem that
presents itself first. However, this is not always the case.
Concerns can be unfounded in actual circumstances.
Drummond (1990) examined the total number of alcohol-
related problems experienced by clients and found no gender
dif ferences. Makelâ & Simpura (1985) likewise found no gender
differences in terms of total number of alcohol-related
problems experienced. Differences only emerged in problem
patterns.
Wilsnack et al. (1984) found that almost none of the
drinking women in their study reported social problems such as
threats of desertion £rom their husbands or warnings from
friends because of their drinking habits. The support system
in general was less likely to apply pressure to alter alcohol
consumption as the key supports, including husbands and best
friends, also tended to be drinkers (Perodeau & Kohn, 1989).
MZkelà & Simpura (1985) also found that women drinkers were
less likely than male drinkers to be criticized by family or
friends. Males on the other hand were significantly more
likely to report marital disruption and the threat of
separation as problems influential to treatment entry for
alcohol problems (Thom, 1987) .
Wilsnack et al. (1984) reported that almost none of the
women drinkers reported their drinking had harmed job
opportunities while Thom (1987) reported that men were
significantly more likely than women to have experienced job
loss because of their drinking. MâkelB & Simpura (1985)
reported that women were less likely to be arrested for
drunkemess .
Health problerns were reported by only 9% of the women in
the Wilsnack et al. (1984) study and only 6% reported that
physicians had suggested that they might have a drinking
45
problem. There were no gender differences in the report of
health problems in the study by MakelZ & Simpura (1985) but
males were more likely than fernales to receive a physician's
advice about altering their drinking habits. Thom (1987) also
found no significant differences in reported health problems.
MakelZ & Simpura (1985) reported no difference in
psychological problerns (Self Concerns) . They did, however,
indicate that women more frequently reported belligerent
behaviour e . quarrelling, nagging) connected to their
drinking while men often reported more reckless behaviour
(i . e. , driving while drunk) but that these dif f erences were
not significant. They also reported that control issues did
not differ by gender. Wilsnack et al. (1984) reported that
17% of the women drinkers reported driving while feeling drunk
or high at least once during the preceding year. Many
reported belligerent behaviour after drinking. While 34% had
started fights with their husbands or partners while drinking,
11% had started fights with people outside the family unit.
Depressive symptoms, involving low self-esteem, were reported
by 61% of the women but there was no report about the
incidence of depression among males. In the study by Thom
(1987) , women were more likely than men to report feeling
depressed but the difference did not reach significance. Men
were also as likely as women to need help for emotional
4 6
dif f iculties (Thom, 1987) .
Based on the literature, it is proposed that the
following gender differences in motivation will manifest
themselves:
Hypothesis 3 : M e n w i l l present w i th f e w e r concerns
on the Social Influence and the
Si tua tional Influence subscal es.
There w i l l be no gender differences i n
the Se l f Concerns and the Heal th
Concerns subscal es.
CONSTRUCT VAtIDITY OF THE RCD SCALE: Relationship of the RCD to Stages of C h a n g e Motivation
Prochaska & DiClemente (1982; 1986) have proposed that
change is effected in a number of stages. While a habit such
as alcohol consumption is still producing the desired effect
without substantial negative consequences, a person is said to
be in a precontemplation stage in which there is no perceived
need for change and thus no interest in such. At some point,
the negative consequences of drinking may emerge and outweigh
the benefits of use. If such a situation occurs, a person rnay
begin to contemplate that a problem exists and that an
alteration in drinking habits may be necessary. This process
47
has been referred to as the contemplation stage. When a
person decides to take corrective action, the determination
stage6 occurs and when change behaviour is actually enacted,
the person is said to be in the action stage. The final stage
is maintenance, during which the person has accomplished
initial change and is seeking to maintain it. The motivation
for habit change would be greatest during the determination,
action and maintenance stages of change and lowest during the
precontemplation and contemplation stages (Miller et al.,
1990). Convergent validity of the Reasons for Change in
Drinking Scale could thus be established by matching high
motivators with the determination, action and maintenance
stages of change and low motivators with the precontemplation
and contemplation stages, as per the following hypothesis:
Hypothes is 4 : Drinkers w i th a higher aggrega te
motivation score w i l l be i n the
de temina t ion , ac t i on a n d / o r
maintenance s t ages of change
In a recent revision of the model, DiClemente et al. (1991) have reformulated the determination stage to be a latter phase of the contemplation stage and have renamed it the preparation stage. The determination or preparation stage e , recognizing that a problem exists) would be the first step in effecting change according to Motivational Control Theory. In light of that, the determination or preparation stage would actually be the early phase of the action stage rather than the contemplation stage, contrary to DiClemente e t al.
while drinkers wi th a lower
aggregate m o t i v a t i o n score will
be in the precontempla t ion or
contemplation stages of change.
PREDICTIVE VALIDITY OF TBE RCD SCALE: Treatment Conpliance
Treatment programs typically experience a high rate of
attrition and missed appointments ranging from 25 to 80
percent (Jones, 1985). For treatment to have any beneficial
effect, the programs must obviously be completed. Treatment
dropouts have been associated with less motivation (Baekeland
et al, 1973) while treatment completers have been associated
with a stronger motivation for habit change (Marlatt, Curry &
Gordon, 1988). Research has examined the dimensions of
motivation and has shown that extrinsic motivation is
detrimental to sustained performance and that individuals who
score high on extrinsic motivation are less likely to maintain
behaviour (Deci & Ryan, 1985; Harackiewicz et al., 1987;
Jones, 1985). Research on withdrawal against medical advice
(AMA) £ r o m treatment for alcoholism has demonstrated that
alcoholics exhibiting more internality are reliably associated
with more days in treatment (Jones, 1985). The attributional
literature also indicates that intrinsic attributions are
reported more frequently as a cause of remission from alcohol
4 9
abuse than extrinsic causes (Curry et al., 1990; Klingemann,
1991; Tuchfeld, 1981). The following hypothesis is,
therefore, oifered:
Hypothesis 5 : Individuals who score higher on
the intrinsic subscale w i l l be
more likely to enter and complete
treatment than those who score
higher on the extrinsic subscal e .
Motivational control theory purports that habit change is
effected only when a threshold of discrepancies is exceeded.
The natural resolution literature has suggested that a
threshold may be exceeded by a single, significant occurrence
but more often it represents an accumulation of events that
tip the balance in favour of change (Klingemann, 1991; Sobell
et al. , in press) . Problematic concerns are also typically
interrelated. Once concerns in one area of a drinkerrs life
are manifested, concerns tend to emerge in other areas. For
example, loss of employment due to drinking could result in
financial problems which might create a problematic familial
relationship. Tuchfeld (1981) indicated that, for his
autoremitters, no single factor was a sufficient condition to
create change. Sobell and her associates (1992) found that
the naturally recovered subjects in their study experienced an
50
average of eight to ten alcohol-related consequences (out of
16 possible) antecedent to their recovery. Likewise, in a
sample of people who had received treatment for their alcohol
problem, Amodeo & Kurtz (1990) found that subjects reported an
average of four out of f ive precipitants to recovery. The
following hypothesis is, therefore, proposed:
Hypothesis 6 : People w i t h a higher aggregate
motivation score w i l l be more
likely t o enter and complete
treatment than those wi th a
lower score.
STUDY II
DKVELOPMENT OF THE REASONS FOR CHANGE IN DRINKING (RCD) SCALE: Socially Desirable Response Style:
Because clients present for treatment under legal or
employment coercions, it is important to establish whether or
not clients are presenting in a socially desirable fashion in
order to gain acceptance to a treatment program and thus
fulfil their legal obligations. If items on the Reasons for
Change in Drinking Scale are answered predominantly in a
socially desirable response style as measured by the Short-
Form Marlowe-Crowne Social Desirability Scale (SDS) , then the
measure would lack validity and its utility would be negated.
If items on the RCD scale demonstrate a socially desirable
response style, they will be deleted from the scale. The
criterion for deletion of items f r o m the RCD will be that the
corrected item-total correlation for the item is lower that
the correlation between the item and the SDS score As part of
study 1 in the development of the RCD Scale, it is proposed
t h a t :
Hypothesis 7: T h e items on the RCD scale w i l l not
demonstrate a socially d e s i r a b l e
response s t y l e -
Emectancies :
Within motivational control theory, the choice of
corrective behaviour employed to reduce experienced
discrepancies is influenced by a person's expectancies (see
Figure 1) . Bandura (1986) distinguishes between two types of
expectancies that influence behaviour choice: efficacy
expectancy which is the belief or confidence one has in being
able to successfully perform a specific behaviour and outcome
expectancy which is the belief one has about the consequences
that will follow successful performance. There are also
various types of outcome expectancies related to habit change:
the expectancies related to the use of a substance (alcohol
52
expectancies) , the expectancies associated with abstaining
f rom the substance (change outcome expectancies) and the
expectancies about the behaviour control source (drinking-
related locus of control expectancies) . In relation to the
control loop, expectancies are an external element that
influence corrective behaviour.
Efficacy expectancyor confidence in achieving one's goal
should not demonstrate a systematic relationship to
motivational sources of behaviour change. However, outcome
expectancies or beliefs about the consequences of behaviour
change should have a relationship to motivation. Thus,
outcome expectancies should provide evidence of convergent
validity and efficacy expectancies should produce evidence of
discriminant validity.
C O N V E R G m VALIDITY OF THE RCD SCALE:
Outcome Emectancv:
a) Change Ou tcome Ekpec tancy:
The motivational sources of behaviour change and the
expectations that a corrective behaviour will produce the
desired results should demonstrate a systematic relationship.
If problems/concerris exist and the expectation is that change
53
in drinking behaviour will reduce or alleviate the concerns
and thus produce benefits, then the corrective behaviour will
more likely ensue than if the change in drinking produces
negative effects or costs. Therefore, a higher motivation
should be related to a belief that change in drinking patterns
would produce more benefits than costs, with the converse also
being true. The following hypothesis is, therefore, proposed:
Hypothesis 8 : The benefi ts of changing alcohol
use should r e l a t e to higher
motiva ti on to change drinking
behaviour while the cos t s of
changing use should r e l a t e
to lower motivation for drinking
change.
b) A l cohol Expectanci e s :
There should be a direct relationship between one's
perception of the benefits of alcohol use and the need to
alter use. If use of alcohol produces desired rewards (Brown
et al., 1987), then motivation to alter the use should be
relatively low . In the initial stages of use, alcohol
generally does produce beneficial effects which reinforce
future use. It is only with continued or abusive use of
alcohol that t h e negative effects may begin to dominate,
54
leading to salient concerns that can motivate a need for
change in drinking behaviour. Thus, as long as positive
rewards are associated with use, motivation for altering use
of alcohol will probably remain low. Therefore, the following
hypothesis is suggested:
Hypothesis 9: The motivation to al ter drinking
patterns will be inversely related
to the perception of the positive
effects of alcohol.
C) Drinking-Related Locus of Control:
Drinking-related locus of control (Rotter, 1966; Weiner
et al., 1971) refers to whether or not a person believes that
outcornes are controllable or subject to forces beyond a
persont s influence i e . , f ate, luck, or the unpredictable whims of some outside agent). The concept, as it relates to
the ability to control drinking, represents an expectancy that
behaviour change is or is not within a persont s control. With
an interna1 locus of control, a person expects that a
contingent relationship exists between personal actions and
outcome while no such relationship is expected by a person who
is oriented to an external locus of control (Lefcourt, 1966;
Phares, 1976). Within motivational control theory, the
intrinsic and extrinsic subsystems are two, quite distinct
55
dimensions of motivation that account for the perceived source
of the initiation and regulation of behaviour. The source can
either be internal to the person or external but in both
instances the behaviour is self-regulated and not a result of
uncontrolled elements (i.e., fate, luck, or the unpredictable
whims of some outside agent) . Both the intrinsic and
extrinsic motivational subsystems of motivational control
theory would be subsumed within the internal drinking-related
locus of control concept. The following hypothesis is,
therefore, proposed:
Hypothesis 10: Motivation will be more related
to an internal drinking-rela ted
locus of control than an external
1 ocus of con trol .
DISCRIMINANT VALIDITY OF TBZ RQ3 SCALE:
Efficacy Expectancv:
The mot ivat ional sources of behaviour should di£ f er
conceptually from feelings of self-efficacy or confidence in
being able to enact a behaviour. The reasonç for changing
56
one's drinking patterns are conceptually distinct from a
person's confidence that s/he will be able to successfully
effect the change. The motivational sources of change derive
£rom salient concerns, experienced or perceived. The presence
and degree of motivation is thus related to a problem/concern
continuum. Confidence, on the other hand, derives £rom past
experiences of success and failure and represents an
expectancy about future successful behaviour enactment. The
expectancy of successfully being able to effect habit change
should not have any systematic relationship, therefore, to a
person' s actual reasons for change. Motivation and con£ idence
may be present to a similar degree for some but that does not
necessarily hold across the population. Many drinkers report
that they are rnotivated to alter their drinking behaviour but
are not confident that they will be able to do so successfully
while others report that they are quite capable of altering
their drinking patterns but they are not really certain that
they want to. The f ollowing hypothesis is, theref ore,
of fered:
Hypothesis 11 : The conceptual distinctiveness
between motivation and confidence
i n being able t o successful ly
resis t the urge to drink heavily
in various s i t u a t i o n s w i l l be
57
established by the intercorrelation
between the two concepts being
significantly 1 ower than the square
root of the product of the reliabili t i e s
of the measures of these concepts.
Perceived Stress:
Motivation, as assessed by the Reasons for Change in
Drinking (RCD) Scale, should be conceptually different from
the perceived stress one is experiencing. Stress relates to
the inability to cope with life events, which can reçult in
various 1evels of experienced emotion (e.g. anxiety,
distress) . The life events or concerns that create the
necessity to utilize coping mechanisms are distinctly separate
constructs that rnay or may not produce levels of stress,
depending on the person's coping abilities. Therefore, the
Reasons for Change in Drinking Scale should not be interpretad
as a measure of stress. That is not to Say that stress and
motivation are unrelated. They may very well be related but
they are not seen as conceptually identical. Lt is expected,
however, that the intercorrelation of the two concepts would
be significantly less than the square root of the product of
their reliabilities (Jaccard & Becker, 1990) - In the study by
Curry et al., (1990) , perceived stress was found to be
unrelated to any of the intrinsic or extrinsic subscales
58
established in her study of motivation and smoking cessation.
The following hypothesis is, therefore, proposed:
Hypothesis 12: The non-equivalent relationship
between perceived stress and
motivation will be established
by the intercorrela tion between
the two concepts being significantly
lower than the square root of the
product of the reliabili ties of the
measures of these concepts.
CHAPTER 3 : METHOD
The purpose of study 1 was to develop the Reasons for
Change in Drinking (RCD) Scale for measuring drinkers'
motivation to alter their drinking behaviour (hypotheses 1-2).
Gender differences in motivational sources were explored
(hypothesis 3). Convergent validity in terms of the degree of
motivation and its relationship to the stages of change as
presented by Prochaska & DiClemente (1982; 1986) were also
investigated (hypothesis 4 ) and the capacity of the scale to
predict treatment attrition was examined (hypotheses 5 - 6 1 .
The subjects were adult clients entering treatment on the
Behaviour Change Unit (BCU) of the Addiction Research
Foundation and the Jean Tweed Treatment Centre in Toronto.
Only clients who presented with alcohol as their primary
substance of abuse were included in the study. A total of 486
subjects (342 males and 144 fernales', which roughly ref lects
' The females sample consisted of 94 subjects from the Addiction Research Foundation and 50 subjects from the Jean Tweed Treatment Centre.
the 3:l ratio normally reported in the treatment literature)
participated in the study. Subjects on the Behaviour Change
Unit were the first consecutive alcohol clients who presented
for treatment at the unit. The Jean Tweed subjects
volunteered to participate in the study.
SAMPLE SIZE JUSTIFICATION:
The RCD Scale is composed of 48 items. For the
confirmatory factor analysis, a sample size of 486 exceeds the
recomrnended minimum of £ive times as many subjects as
variables suggested by Gorsuch (1983) and Tabachnick & Fidell
(1989). It also surpasses recornrnendations made by Guadagnoli
& Velicer (1988) who suggest that a sample size of 300 is
generally adequate even for models with a low variable to
factor ratio and factor loadings of less than . 40 .
A sample size of 486 also provides adequate power for the
gender cornparisons (342 males, 144 fernales), the correlational
analysis examining the construct validity of motivational
sources with the stage of change motivational concept and the
ANOVA analyses exploring the motivational predictors of
treatment attrition (the subj ect to predictor ratio exceeds
the optimal 20:l ratio in each incidences).
Data on the Behaviour Change Unit were gathered on three
separate occasions: the intake interview, the clinical
assessment interviews and the conclusion of treatment (or
before, in the case of early dropouts who did not enter
treatment) .
During the intake interview, subjects were asked to
cornplete the following measures: (1) demographic information,
(2) the Reasons for Change in Drinking (RCD) Scale and (3) the
Stages of Change Readiness and Treatment Eagerness Scale for
alcoholics (SOCRATES; Miller et al., 1990) .
The Reasons for Change in Drinking (RCD) Scale and the
Stages of Change Readiness and Treatment Eagerness Scale
(SOCRATES) were administered during the intake interview so as
to avoid any confounding from motivational counselling that
could occur during the subsequent interviews. The early
mot For example, the analysis of intrinsic and extrinsic
ivational sources and treatment completion has a subject to dictor ratio of 486:1. The early dropouts analysis has a :1 ratio, the late dropouts analysis has a 3 4 3 ratio and
the treatment completers analysis has a 150:l ratio.
administration of the RCD was also necessary to avoid losing
data on the early dropouts.
Drinking history over the three months prior to seeking
treatment was obtained during the clinical assessrnent
interviews.
Following treatment completion or earlier, subjects were
coded as either early dropouts (i.e, subjects who dropped out
during the intake assessment process prior to treatrnent
entry) , late dropouts i . e . , clients who dropped out during treatment) or treatment completers.
Data £rom the Jean Tweed group were gathered at one
interview. These subjects completed only the demographic
information and the Reasons for Change in Drinking (RCD)
Scale .
1) Demoqraphic In£ ormat ion provided a descript ion of the
study population. The information included age, gender,
education, marital status, employment status, social stability
and legal status (see Appendix B) as well as information on
alcohol dependency as measured by the Alcohol Use
63
Questionnaire (ADS; Skinner & Horn, 1984) (see Appendix C) .
Whether subjects presented with alcohol as the solitary
problem or with primary aicohol and secondary drug problems
was also indicated. Data were also collected on number of
years that drinking had been a problem, number of previous
attempts at abstinence, longest period of abstinence and prior
treatment involvement.
Drinking history over the three months prior to treatment
intake i e - , frequency of drinking in the three months,
maximum quantity consumed on a drinking day and average
quantity consurned per drinking day) were reported for those
subjects who completed assessment. If the 90-day drinking
history prior to treatment-seeking was atypical, then the most
recent , typical 90 -day period was reported .
2) Reasons for Chanqe in Drinkinq (RCD) Scale is a 48 -
item scale designed to measure the type and salience of
motivation involved in altering drinking habits (see Appendix
A). The scale was developed for this study to assess four
subaxeas of concems believed to influence a change in
drinking behaviour. The four subareas were categorized into
two ma j or dimensions : (a) intrinsic motivation involving
concerns that are interna1 to the individual; and (b)
extrinsic motivation involving concerns that impinge on the
64
individual from an external source. Intrinsic motivation was
subdivided into two subscales of 12 items each: Self Concerns
and Health Concerns. Extrinsic motivation was also subdivided
into two subscales of 12 items each: Social Influence and
Situational Influence. The two-dimensional classification is
based on the intrinsic/extrinsic subsystems of mot ivational
control theory. Subscale categories arose £ r o m empirical
reports in the literature on reasons for change in recovery
£rom alcohol abuse. In addition to reported empirical
findings, item-scale development was assisted by extensive
interviewing of alcohol clients entering treatment and the
advice of a number of addiction therapists.
3) Stases of Chanqe Readiness and Treatment Eaqerness
Scale (SOCRATES-SA; Miller et al., 1990) is a 40-item scale
designed to assess readiness for change in alcohol abusers
(see Appendix 1)) . The scale yields scores on five subscales:
precontemplation (P), contemplation (C), detemination (D),
action (A) , and maintenance (M) . The subscales correspond to
the five conceptual stages of change as described by Prochaska
& DiCiemente (1982; 1986) . Higher scores on scales P and C
suggest uncertainty or ambivalence about change. Higher
scores on scales D and A are consistent with a greater current
cornmitment to change. Elevation on the M scale indicates a
person who has accomplished initial change and is seeking to
65
maintain it. Scales P and D are highly negatively correlated,
representing inverse reflections of a single motivational
construct (precontemplation is measured indirectly by items
similar to the determination stage but scored in the reverse
direction). The measure has been found to have adequate
interna1 consistency and test-retest reliability.
DATA ANALYSES:
Sample Statistics
Descriptive statistics were employed to describe the
characteristics of the sample.
Confirmatow Factor Analyses of the RCD:
Confirmatory maximum likelihood factor analysis was used
to test the adequacy of the proposed structure of the Reasons
for Change in Drinking Scale. The analysis was performed
using the LISREL 8 program developed by Joreskog and Srjrbom
(1993).
The data on the measure were examined prior to analyses
for elements that could pose problems for multivariate
analyses - - missing values, entry errors, nonnormality of the
66
sampling distributions, univariate and multivariate outliers,
nonlinearity, multicollinearity, and singularity.
As several authors (Jereskog & S6rbom, 1993; Marsh, Balla
& McDonald, 1988) have suggested that various goodness-of-fit
indices (as well as parameter estimates) should be considered
in a collective fashion when assessing model fit, assessrnent
of the overall goodness-of-fit for the first-order factor
model, which tested the adequacy of fit for the four-factor
solution (Le., the four subscales of the RCD), was estimated
using three indices: (1) the Tucker-Lewis Index (TLC) also
referred to as the non-nomed index (Tucker & Lewis, 1973) ;
(2) LISREL'S 'Goodness-of-Fit Indexf (GFI); and the ratio of
the chi-square to its degrees of freedom. In addition,
parameter estimates were examined.
Marsh, Balla & McDonald (1988) have suggested that one of
the major problems with many of the current goodness-of -fit
indices used in confirmatory factor analyses is that they are
influenced by the size of the sample. Thus large samples (400
or greater) are likely to produce indices that are inflated
and not true representations of the actual fit between the
proposed and the target model . These authors have examined
stand-alone indices (e.g., GFI, AGFI, X ) and incremental fit
indices (e.g., the Bentler & Bonett Index, the Tucker-Lewis
Index) in relation to sample size. Of the more than 30
indices considered in the study , the Tucker- Lewis Index (an
incremental fit index) was the only widely used index whose
magnitude was relatively independent of sample size . 9 The GFI
by LISREL was found to perform better than any of the other
stand-alone indices.
The chi-square goodness-of-fit test, although generally
reported, was not used to assess the data fit because there
are several problems with the test. First, the chi-square
likelihood ratio, for a true model, has an expected value
equal to the degrees of freedom and does not Vary
systematically with sample size (Tucker & Lewis, 1973) .
Bentler & Bonett have warned, however, that the probability of
detecting a false model with a X' value increases with N even
when the model is trivially false. Thus for very large
samples, nearly al1 rnodels are rejected. Second, chi-square
is highly sensitive to violation of various model assumptions
(multinormality, additivity, linearity) . Third, in large
complex problems in which there are many variables and degrees
These findings contradict prior claims (Bentler & Bonett, 1980; Hoelter, 1983; Jôreskog & S6rbom, 1993) that the BBI and various stand-alone indices are not biased by sample size.
of freedom, the observed X' will nearly always be
statistically significant, even when there is a reasonably
good fit to the data. Because of the relatively large sample
size in the present study, the complexity of the problem and
the slight issue with normality of distribution in item
scores, the X statistic was, therefore, not used in the
assessrnent of model fit.
The ratio of X 2 / d f , like the X likelihood ratio, does not
Vary with sample size for a true model, but is related to
sample size when a model is false. As a consequence of this
dependence on sample size, different researchers have
recommended using ratios as low as 2 or as high as 5 to
indicate a reasonable fit, with smaller ratios representing a
better fit (Carmines & McIves, 1981; Marsh & Hocevar, 1985)-
Thus to assess the association between the proposed model and
the observed model, the above three indices were used, T-
values were also exarnined.
To test the intrinsic/extrinsic dichotomy of the
subscales, a second-order factor model was assessed. In this
rnodel , the correlations among the f irst -order factors were
expected to be explained in terms of the dual categories.
Because the second-order model is attempting to explain the
f irst -order model in a more parsimonious manner, the goodness-
of -fit of the higher order model cannot exceed that of the
f irst-order mode1 on which it is based. Therefore, the f irst-
order model provides a target or optimum fit for the second-
order model (Marsh & Hocevar, 1985) . The ' Target Coefficient ' (T) proposed by Marsh & Hocevar (1985) was used to assess the
goodness-of-fit of the second-order model. This index is the
ratio of the chi-square of the first-order model to the chi-
square of the second-order model . The TLI, GFI and X2/df were
also reported.
Another single second-order factor model was also
assessed to determine if a general motivational factor was
reflected in the data.
Psvchometric Evaluation of the RCD:
Cronbach's alpha coefficient (Anastasi, 1976; Cronbach,
1951) determined the intemal consistency of the motivational
subscales and the total scale. The contribution of individual
items to the scale and the subscale reliabilities were
obtained £rom the corrected item-scale total correlations.
Items displaying a higher corrected correlation ( .2 0 or
greater as suggested by Nunnally, 1978) are believed to
enhance the scale's reliability.
Evaluation of Gender Differences
Because the sample size for the females was too small to
produce a stable solution (n=144), factorial invariance
procedures could not be employed to evaluate the factor
structure of the RCD as a function of gender. Instead,
separate ANOVA analyses were used to evaluate gender
differences between the subscales of the RCD, the
intrinsic/extrinsic dimensions and the aggregate score.
Construct Validity of the RCD
Construct validity of the RCD as a measure of motivation
for change initiation was hypothesized to be established by
its relationship with the stage of change motivational
concept. Because subjects generally do not present as clearly
in only one stage of change (Rollnick et al., 1992) , subj ects
were classified according to raw score responses on the Stages
of Change Readiness and Treatment Eagerness Scale for
alcoholics (SOCRATES) categorically as either non-change
initiators (precontemplation or contemplation stage) or change
initiators (determination, action or maintenance stage).
Correlational procedures determined the relationship between
71
the aggregate score of the RCD and the change versus non-
change motivational concept.
Predictive Validity of the RCD
The predictive validity of the RCD was assessed by its
ability to predict attrition £rom the treatment process.
Validity was established by ANOVA analyses. The intrinsic and
extrinsic dimensions of the RCD (predictor variables) were
used to distinguish between treatment completers and
noncompleters. A second analysis examined the ability of
these predictor variables to distinguish between early and
late dropouts. The aggregate score of the RCD was also used
to ascertain its ability to distinguish between treatment
completers and noncompleters and a final analysis examined its
ability to distinguish between early and late dropouts.
The purpose of study II was to aid in the development of
the Reasons for Change in Drinking (RCD) Scale and to
establish evidence of convergent and discriminant validity.
The study, therefore, tested hypotheses 7-12.
The subjects were a subsample of the subjects from study
1. A total of 196 subjects volunteered to participate in the
study, 160 males and 36 fernales. Demographic information for
participants in study II was the same information as reported
by the subjects in study 1.
Appendix K contains the consents forms for both study
locationf;,
SAMPLE S I Z E JUSTIFICATION:
A sample size of 196 exceeded the optimal ratio of 20
subjects per variable and thus provided ample power for the
convergent and discriminant validity analyses. The study
analyses examined the relationship between the items on the
RCD scale and the aggregate score on the Marlowe-Crowne Social
Desirability Scale. Analyses also examined the correlational
relationship between the aggregate score on the RCD scale and
the aggregate score on each of the three convergent validity
measures (Outcorne Expectancy Scale, Alcohoi Expectancy Scale,
Drinking-Related Locus of Control Scale) and the two
discriminant validity measures (Situational Confidence
Questionnaire and Perceived Stress Scale) as outlined in a
73
following section.
PROCEDURE :
Subjects were asked to complete various measüres to
establish the discriminant validity of the RCD. These
measures were administered at the Addiction Research
Foundation during the clinical assessrnent interviews prior to
treatment entry and at the Jean Tweed Centre during the single
interview period.
Subj ects at the Addiction Research Foundation were asked
to complete the six study measures. T h e subjects a t the Jean
Tweed C e n t r e only completed the Outcome Expectancy Scale and
the demographic information as described in Study 1.
T h e following six measures were employed in the study:
Developxnent of the Reasons for Change in Drinking (RCD) Scale:
1) The Short-Fom Marlowe-Crowne Social Desirabilitv
Scale (M-C SDS; Reynolds, 1982) measures social desirability.
This concept is defined broadly as the need of subjects to
obtain approval by responding in a culturally appropriate and
74
acceptable rnanner. Respondents are requested to signify
whether a staternent concerning personal attitudes and traits
is true or false as it pertains to them personally. The
shortened version (Reynolds, 1982) containing 13 items was
employed in the study for expediency of administration and
scoring. The short form has an acceptable interna1
reliability of .76 and correlates .93 with the longer 33-item
original measure (Crowne & Marlowe, 1960) . Of the 13 items,
8 are keyed false and 5 true. See Appendix E. This measure
was employed as part of Study 1 in the development of the RCD
Scale. For ethical reasons, it could not be justif ied for
inclusion in the intake interview and was thus administered to
the volunteers in Study II.
Convergent Validity of the R O Scale: Outcome Expectancy
2) Outcome ExDectancv Scale (OES-Alcohol ; Solomon &
Annis, 1989) is a 34-item scale designed to assess the
consequences expected by clients once they alter their
drinking behaviour (see Appendix F) . The scale consists of
both a valence and a strength measure. However, because of
recent debates concerning the original scoring procedure, only
the strength aspect of the measure was employed in the study.
The strength measure of the OES measures the expectancy of how
strongly the subject anticipates various consequences
occurring, if a change in drinking takes place. The scale
75
consists of two subscales: a 21-item measure of the advantages
expected should a change in drinking behaviour occur (BENEFITS
Scale) and a 13-item measure of the disadvantages expected
with a change in drinking behaviour (COSTS Scale) . Summed
scores on the subscales indicate the expected costs and
benefits as a result of changes in consumption.
3) Akohol Emectancv Ouestionnaire (AEQ; Brown et al. ,
1987) is a 90-item scale designed to rneasure the degree to
which individuals expect alcohol to produce a variety of
general and specific positive effects (see Appendix G). The
items are in a forced-choice agree-disagree format:
Respondents answer "agreen if they sometimes or always
experience the ef f ect and "disagree" if they never experience
the effect (see Appendix 1). The questionnaire measures six
alcohol-related expectancies : (1) global positive changes, (2)
sexual enhancement, (3) physical and social pleasure, ( 4 )
increased social assertiveness, (5) relaxation and tension
reduction, and (6) arousal and aggression. The interna1
consistency of the 6 subscales ranges from -72 to -92 with a
mean coefficient of .84 (Brown et al., 1987) . Construct,
discriminant and concurrent predictive validity have been
demonstrated.
4) Drinkincr-Related Locus of Control Scale (DRIE; Donovan
& OtLeary, 1978) is a 25-item scale measuring locus of control
(LOC) in relation to controlling drinking behaviour (see
Appendix H). The items are presented in a forced-choice
format pairing a response indicative of an internal LOC with
a response indicative of an external LOC. Respondents choose
the alternative that most closely represents their beliefs or
behaviour. The DRIE scale is controlled for an acquiescent
response style by virtue of the forced-choice format. The
external items appear 10 times as the f irst response option
and 15 timeç as the second. The correlation between the DRIE
and Rotter's Internal-Extemal (I-E) Scale (Rotter, 1966) has
been reported at .52 (Oziel et al. , 1972) . The Kuder-
Richardson 20 coefficient of internal consistency has been
reported as .77 (Donovan & OILeary, 1978). Adequat e
concurrent, discriminant and construct validities have been
demonstrated (Donovan & O'Leary, 1978).
Discriminant Validity of the RCD Scale:
5) Situational Confidence Questionnaire (SCQ-39; m i s &
Graham, 1988) is a 39-item self-report questionnaire developed
to assess clients' confidence (or self-efficacy) in their
ability to resist the urge to drink in various situation-
specific high-risk circumstances (see Appendix 1) . The
drinking situations are classified into eight categories based
77
on the work of Marlatt and Gordon (1980; 1985). Three
categories represent negative states (Unpleasant Emotions,
Physical Discornfort, Conflict with Others), three represent
positive states (Pleasant Emotions, Pleasant Times with
Others, Social Pressure to Use) , with the two remaining
categories representing control issues (Urges and Temptations
to drink, Testing of Personal Control). Clients are asked to
indicate how confident they are that they will be able to
resist the urge to drink heavily in various situations on a 6-
point scale ranging £rom O (not at al1 confident) to 100 (very
confident) . The eight subscores const itute a con£ idence
profile. Summation of the subscores indicates an aggregate
confidence index.
Reliability of the overall mean score for the 39 items
has been reported at .98 with subscale alphas ranging from .81
to -97 (Annis & Graham, 1988) . Construct and predictive
validity has been demonstrated. S e x differences were found on
only one subscale. Male clients demonstrate lower confidence
on average in the area of Pleasant Emotions than females.
Younger clients also tend to report lower levels of confidence
in their ability to resist the urge to drink heavily across a
variety of situations than older clients e . Unpleasant
Emotions, Pleasant Emotions, Urges and Temptations, Testing
Persona1 Control , Social Tension, and Positive Social
78
Situations) .
6) The Perceived Stress Scale (PSS; Cohen, Kamarck &
Mermelstein, 1983) is a 14-item scale designed to measure the
degree to which situations in onef s l i f e are appraised as
stressful. It is a nonspecific measure of a person's
perceived current effectiveness in coping with stress. Higher
levels of perceived stress have been found to be indicative of
relapse following smoking cessation attempts (Cohen et al.,
1983). Perceived stress w a s also found to be unrelated to any
of the intrinsic or extrinsic subscales established by Curry
et al., (1990) in her study of motivation and smoking
cessation. Respondents on the PSS are asked to indicate how
often they felt or thought a certain way in the last month.
The responses are indicated on a 5-point frequency scale
ranging from never (O) to very often (4) . A PSS score is
obtained by reversing the scores on the seven positive items
(i . e. , 4,5,6,7,9,10,13 ) and then summing across al1 14 items.
Scores can range £rom O to 56. Interna1 consistency of the
scale has been reported at -85. Test-retest reliability was
reported at .85 for a college sample retested after two days
but at only .55 for subjects in a smoking study retested after
six weeks, thus suggesting that perceived stress fluctuates
over time and is not static. The scale has been validated
with no gender or age differences. See Appendix J.
79
DATA ANALYSES:
Development of the RCD Scale:
The response styles of the individual items of the RCD
w e r e assessed by rneans of correlations between items and the
score obtained on the Marlowe-Crowne social desirability
measure, If items dernonstrated a socially-desirability bias
L e . coefficients w e r e significant at o r below the .O5
level), then the items w e r e considered for deletion from the
RCD scale.
Convergent Validity of the RCD Scale:
The relationship between the three outcome expectancies,
change outcome expectancies (OES) , alcohol expectancies (AEQ)
and drinking-related locus of control (DRIE) , and motivation
were established through correlational procedures.
Discriminant Validity of the RCD Scale:
The non-equivalent relationship between efficacy
expectancy (SCQ) and stress (PSS) on one hand and motivation
on the other hand was evaluated by individual analyses of the
correlations between each measure and the aggregate score of
the RCD compared with the square root of the product of the
reliabilities of the two scales. If comparisons yielded
significantly lower correlations than the square root of the
80
product of the reliabilities, the scales were assumed to
measure diiferent concepts.
SAMPLE CHARACTERISTICS:
The sample consisted of 486 subjects (342 males, 144
fernales). The characteristics of the sample are presented in
Table 1.
The majority of the subjects were single (38 -9%) or in
married or common-law relationships (30.9%). They had a
moderate level of social stability (M=7.4, SD=3.1)1° with an
average age of 38.1 (SD=9.0) . Most had a secondary school
education (rnean of 12 years of schooling, SD=2.8) . Almost
half (47.7%) were unemployed or on welfare and about one-third
(32.7%) reported legal o r CAS problems.
With respect to their recent alcohol use, the majority
were moderately dependent drinkers (mean ADS score of 20.1,
SD=9.3) who had experienced only O to 3 consecutive months of
'O The Social Stability Index (Skinner, 19) was composed of current legal status , current employment status , present accomodation, frequency of family contact and ability to live with family. Scores of 6 or more on the Index (range 0-12) are considered to reflect a reasonable level of social stability.
abstinence at any given time". Drinkers consumed an average
of 10.1 drinks per day over a typical 90-day drinking period,
with t h e average maximum quantity per day reported at 18.6
drinks. On average, they reported drinking on about 60% of
the days .
Subjects had considered their alcohol use to be a problem
for an average of 12.3 years (SD=8.69) and had made several
quit attempts (M=4.4, SD=7.8) prior to seeking treatment. The
majority of the subjects (58.9%) had also previously sought
help for their alcohol problem.
Alcohol was the primary substance of abuse for a l 1
subjects but approximately 26% of subjects also reported
concurrent drug abuse.
" The mean l eng th of consecutive abstinence was actually 9.3 (SD=17.7) months at anygiven tirne. However, most (56.4%) of the subjects had experienced only O to 3 consecutive months of abstinence at a given time (the rnost frequently reported response was O months of abstinence). One subject reported 180 months of abstinence and this response influenced the magnitude of the mean, producing a misleading statistic.
Gender Males Females
Marital Status single, never married married, common- 1aw divorced separated widowed
Employment not employed/welfare full time part time self-employed s tudent homemaker ret ired
~ e g a l /CAS Problems
Previous Treatment Other Problematic Use
cocaine cannabis benzodiazapines heroine prescription drugs
Years of Education Social Stability'
M (SD) Range
Years of Alcohol Problem 12.3 (8.69) 0 -44 Quit Attempts 4.4 (7.79) 0-100 Longest Abstinence Period (months) 9.3 (17.77) 0-180 Dependence (ADS ) 20.1 (9.34) 0 - 4 5 Typical Drinking Pattern (90 days) Maximum daily quantitp 18.6 (9.34) 2-50 Average daily quantitp 10.1 (5.93) 1-45 Percentage of drinking daysC 59.8 (30.79) 2.2-100
marp loynn i t - ,P= - bAlfobd Depmdarr Scrlt (Skimrra H m 1984). Rtnet: W7: biw depmdaia(1-13); m x k a t ~ (14-21); nibrpnoll(2i-30); (3147).
c T i Fdfoarbui: (Saki] & SoWI. 1992).
Table 1. Characteristics of sample in study 1
DEVELOPMENT OF THE REASONS FOR CIIANGE IN DRINKING ( R a ) SCALE :
The data were examined for elements that could pose
problems for analysis - missing values, entry errors,
nonnormality of the sampling distributions, univariate and
multivariate outliers, nonlinearity, multicollinearity and
singularity. There were no missing values in the data and
none of the other issues posed a problem for analysis with the
exception of the distribution of the scores. The distribution
posed a minor problem in that 21% of the items demonstrated a
slight skewness and 33% showed slight kurtosis. Because of
problems in interpretation. the data were not transformed.
Consequently, correlations may be weakened by the distribution
pattern.
Socially Desirable Response Style:
The Short-Form Marlowe-Crowne Social Desirability Scale
(SDS) was completed by 196 subjects. Responses were normally
distributed with a mean of 5.83 (SD = 3.20) and a range of O
to 13.
Correlations between subjects' scores on the SDS and the
individual items of the RCD Scale produced five significant
coefficients at the .O1 level (with r's ranging from -.19 to
-30) and six significant coefficients at the .O5 level (with
r's ranging from - .15 to - .18) . However, only two of the
correlations exceeded the corrected item-total correlation for
that item. These items were: "1 have legal charges related to
my drinking and I need to satisfy the courts (32) and Ilthe
courts have said that I have a drinking problemfl (48). These
items were not considered for deletion because it was
important to retain items related to legal influence.
Confirmatory Factor Analyses
To determine how well the hypothesized factor structure
fit the data, confirmatory maximum-likelihood factor analysis
was employed. The analyses were performed using the LISREL 8
program developed by Joreskog and S8rbom (1993). The inter-
item correlation matrix was entered for analysis.I2
First-Order Models
The proposed four factor mode1 (representing self
concerns, health concerns, social influence and situational
influence) involving 12 items per subscale was tested against
l2 For models that do not include invariance constraints, analyzing the variance-covariance or the correlation matrix produces the same goodness-of-fit (Long, 1983).
the 48 x 48 data matrix. The model was specified in the
following manner: a) factor loadings were restricted so that
each item was allowed to load on only the factor it was
hypothesized to represent: b) al1 other factor loadings were
set to zero: and c) the factor correlation matrix and the
error matrix were free to be estimated. There were 48 factor
loadings, six coefficients in the factor correlation matrix
and 48 error components to be estimated - a total of 102
parameters.
Goodness-of-fit indices suggested that the data provided
a poor approximation of the hypothesized mode1 (TLI=.672;
GFI=.704; X/df=3.84). Freeing of parameters as suggested by
the modification indices (automatic LISREL selection) produced
an improved but still unacceptable fit to the data (TLI=.754;
GFI=.754; X/df=3.12). It also produced uninterpretable
factors . The individual freeing of parameters based on
theoretical reasoning produced only slight improvement in fit
(TLI=.681; GFI=.714; X/df=3.65) . Thus, an alternate model to
explain the data was investigated.
Exploratory analysis of the data (principal components
analysis with varirnax rotation) indicated that the data could
be represented by eight factors resulting f rom an expansion of
the four factor model (see Figure 2). The loading of items
indicated that the Health Concems scale could be divided into
physical health and mental health items. The Social Influence
scale could be split into the influence of significant others
and the influence of children. Situational Influence could be
separated into legal/CAS issues, employer influence and a
factor that seemed to rneasure the need to get ahead
financially. Self Concerns remained as a single factor.
Three items did not load on any of the eight factors. These
items were: "1 could then get away £rom my current
relationship (15) ; "1 want to develop a proper relationship
with someoneI1 (23) ; and "my doctor has advised me ton (26) .
The exploration of the data, theref ore, suggested that
the original four subscales could be further subdivided to
produce eight theoret ically meaningf ul subscales . A post hoc
conf irmatory analysis ( B y r n e , 1989) using LISREL was conducted
to test the validity of an eight-factor model. Prior t o
analysis, the three items that did not contribute to the
exploratory factor solution were deleted from the scale. The
45 remaining items were examined for face validity and an
eight-factor first-order model was
FIGURE 2
A PRIORI & EMPlRlCAL MODEL OF MOTIVATIONAL SOURCES
A Priori 4 Factor Mode1
HEALTH CONCERNS
SELF CONCERNS
Emplrlcal 8 Factor Model
SOCIAL INFLUENCE
Conbol
SITUAWONAL INFLUENCE
specif ied. The eight factors were labelled: (1) Control ; (2)
Finances; (3) Self; (4) Health; (5) Others; (6) Children; (7)
Legal; and (8) Work. The Control subscale contained 11 items
that involved issues of regaining control of one's life.
Finances was a 6-item subscale involving financial concerns
and the need to get ahead financially. The Self subscale had
8 items that measured concerns about cognitive and emotional
functioning (mental health issues). Health involved 4 items
that dealt with physical problems resulting £rom drinking.
The Others subscale measured the influence of significant
others and contained 8 items. The Children subscale contained
only 2 items and measured the influence of one's children on
the decision to alter drinking habits. The Legal subscale
contained 4 items measuring the influence of the legal system
or the CAS on motivation. Lastly, the Work subscale rneasured
the influence of one's employer on the decision and involved
2 items. See Appendix A for a list of the items by subscale.
The mode1 (see Figure 3) was tested against the 45 x 45
data matrix and was specified in the same manner as the first
analysis with items restricted to load only on the factor they
were hypothesized to represent and al1 other factor loadings
set to zero. The factor correlation matrix and the error
matrix (theta delta) were free to be estimated.
The Tucker-Lewis Index (TLI) for the eight factor model
was .844. LISRELrs 'Goodness-of-Fit Indexf (GFI) for the
model was .820. The ratio of chi-square to the degrees of
freedom resulted in a value of 2.49. Taken together, the
goodness-of-fit indices suggest that the eight factor model
provides an acceptable fit to the data. The magnitude of the
factor loadings and the significance of parameter estimates
provided further support for the eight-factor model. The
factor loadings (standardized solution) presented in Table 2
were al1 statistically significant. Parameter estimates had
T-values ranging from 10.3 to 21.0 (T-values greater than 2.58
are statistically significant at the .O1 level). The values
strongly suggest that the results would replicate in a similar
sample.
The first-order factor correlation matrix is presented in
Table 3. Correlations ranged from -.O5 to -82.
Second-Order Factor Models
A two-factor, intrinsic versus extrinsic second-order
model (Mode1 2) was tested with four first-order factors
loading on each second-order factor (see Figure 3). Control,
Self, Finances and Health factors were hypothesized to load on
the intrinsic scale while the Others, Children, Legal and Work
factors were predicted to load on the extrinsic scale. For
91
the sake of parsimony, a second mode1 containing a single
second-order factor , was a lso tested (Mode1 1). As shown in
FIGURE 3
Second-Order Factom
FACTOR STRUCTURE OF RCD
First-brdar Factors Control
RCD Teut Item
Table 4, Model 2 containing the intrinsic/extrinsic second-
order factors provided the better fit of the two models
[X(1) =106.58, p<. 0011 . The TL1 and the GFI indices were
slightly higher and the chi-square/df w a s lower. The target
coefficient for Model 2 was .93.
The second-order loading matrix (standardized solution)
is presented in Table 5. The T-values of the parameters in
Model 2 ranged £ r o m 8.58 to 28.44. The first-order factor
loading matrix and the factor inter-correlation matrix f o r
Model 1 are not given as they are essentially the same as
those for the first-order mode1 (see Tables 2 and 3 ) .
The intercorrelation between the intrinsic and extrinsic
factors was .54 .
TABLE 2 RCD C O N F I W T O R Y FACTOR ANALYSIS
FACTOR
RCD Control Self Finances Health Others Children Leqal Work ITEM
TABLE 2 (CONTI RCD CONFIRMATORY FACTOR ANALYSIS
RCD C o n t r o l Self Finances Health Others Children Legal Work ITEM
TABLE 3
CORRELATIONS AMONG 8 FIRST-ORDER FACTORS
FACTOR
Control Self Finances Health Others Children Legal Work
Control 1.00
Self - 8 2 1-00
Finances .70 .67 1.00
Health - 6 0 .63 .53 1.00
Others .S7 .53 .37 .36 1.00
Children .27 -31 .ll - 16 .60 1.00
Legal -.OS .O2 .12 - . 02 .24 ,351 1.00
Work .26 . 3 4 . 4 9 - 2 4 .24 .13 .17
TABLE 4
FIT INDICES OF SECOND-ORDER MODELS ... . - - - -- - - --
MODEL TL1 GFX X2/df T
1. 1 Second- Order Factor
2. 2 Second- Order Factors (Intrinsic & Extrinsic)
TABLE 5
SECOND-ORDER LOADING MATRIX OF MODEL 2
SECOND-ORDER FACTORS
Intrinsic Extrinsic
Control Self Finances Health
Others Children Legal Work
Interna1 Consistency and Reliabilitv of the RCD
Cronbachf s coefficient alpha (Cronbach, 1951) , an
internal consistency measure, was used to estimate the
reliability of the eight subscales. These analyses, as well
as means and standard deviations for each subscale, are
presented in Table 6. Alphas for the eight subscales ranged
£rom .70 to 3 0 which indicates substantial internal
consistency. Cronbach's coefficient alpha for the RCD Scale
as a whole was .93 indicating the overall consistency of the
measure .
A gauge of an item's contribution to scale reliability
can be obtained f rom the corrected item-scale total
correlations. Items having a higher corrected correlation
(.20 or greater as indicated by Nunnally, 1978) will enhance
the scalefs reliability. For the RCD, the corrected item-
scale total correlations ranged from .45 to .79 for the 45
items. The ranges and average item-scale total correlations
for each subscale are presented in Table 6. Since the lowest
of these correlations was - 4 5 and most were substantially
higher, this indicates high correlations between items
comprising the scales and supports the reliability of the RCD
scale .
Subjects appear to respond in a consistent marner to the
items within each subscale and to the scale as a whole.
Consequently, the eight RCD subscales should show substantial
reliability for clients seeking treatment for an alcohol
problem.
TABLE 6
INTERNAL CONSISTENCY & RELIABILITY OF RCD
RCD # of Item-Scale Total C o r r e l a t ions Subscale items MEAN SD ALPHA MEAN RANGE
Control
S e l f
Finances
Health
O t h e r s
Children
L e g a l
Work
Gender Differences in Motivation
Three nundred and forty two males and 144 females
completed the Reasons for Change in Drinking Scale. As
100
indicated in Table 7, females scored significantly higher on
the Self and Children subscales while males scored
significantly higher on the Finances, Legal and Work
subscales. The intrinsic and extrinsic dimension of the RCD
did not Vary signif icantly as a function of gender nor did the
aggregate score. The individual differences in the eight
subscales would have cancelled out differences at the higher
levels .
TABLE 7 GENDER DIFFERENCES ON RCD
t P Males Fernales
Self
Finances
Health
O t h e r s
Children
L e g a l
Work
Intrinsic
Extrinsic
Aggregate
Construct Validity of the RCD
The Stages of Change and Treatment Eagerness Scale
(SOCRATES) was completed by 396 subjects. Change initiation
scores were calculated by adding subjectsr responses on the
determination (D), action (A) and maintenance (M) subscales.
Scores on change initiation were normally distributed with a
mean of 96.8 (SD=13.5) and a range of 32 to 120. Scores on
non-change initiation were calculated by adding subjects'
responses on the precontemplation (P) and the contemplation
(C) subscales. Scores were normally distributed with a mean
of 34.7 (SD=8.7) and a range of 16 to 56. The correlation
between the aggregate score of the RCD and change initiation,
pooled scores on D,A and M, was .46 (pc . 01) . The correlation
between the aggregate score of the RCD and non-change
initiation, pooled scores on P and C, w a s - .27 ( p c . 01) . Sub jec ts with higher motivation, therefore, tended to be in
change initiation stages. The relationship accounted for 21%
of the variance between the measures . The analysis
dernonstrated a negative relationship between the two measures
as they related to non-change initiation. The higher the
motivation, the less likely they were to be in a non-change
stage. This relationship accounted for 7% of the variance
between the measures.
Predictive Validity of the RCD
Treatrnent completion status for the Jean Tweed sample w a s
not available. For the Addiction Research Foundation sample,
the treatment cornpliance status of thirteen subjects could not
be detemined at the time of analysis; forty-five additional
subjects were not included because they had indicated at
intake that they were shopping around for programs or they
were known to have entered other treatment facilities.
This left a sample of 378 subjects for the predictive
validity study. One hundred fifty subject (39.7%) completed
the treatment programme on the Behaviour Change Unit. Thirty-
four (9.0%) dropped out during treatment and were classified
as late dropouts. They were either discharged from the
program for nonattendance, lack of abstinence or left of their
own volition before the sessions were completed. One hundred
ninety-four (51.3%) failed to return following the initial
intake interview or did not follow through with treatment
entry. These subjects were classified as early dropouts.
ANOVA analyses indicated that neither the intrinsic
[F (2,368) =.861, pc . 4231 nor the extrinsic scale
[F (2,368) = .O71, p< .93 11 signif icantly distinguished the early
dropouts £ r o m the treatment completers. Neither the intrinsic
103
[F(1,181)=1.886, pc.1711 nor the extrinsic scale
[F(1,181)=.136, pc.7121 significantly distinguished the late
dropouts £rom the treatment completers.
The aggregate score of the RCD was also unable to
distinguish between the early dropouts (F=.645 df=2,368
pc.526) and the treatment completers nor between the late
dropouts (F=1.379 df=1,181 pc-241) and the treatment
completers.
A further unplanned analysis examined the relationship
between the eight subscales of the RCD and treatment status.
None of the eight subscales distinguished treatment completers
from early or late dropouts.
It would, therefore, appear that specific sources of
motivation to change alcohol use are unrelated to treatment
compliance.
Sample Characteristics
The sample consisted of 196 subjects (160 males and 36
fernales) who volunteered to participate in the study. These
subjects were a subsample of study 1. The sample in study II
differed from the sample in study 1 in that there were
104
Gender Males Females
Marital Status single, never married married, common- 1aw divorced separated widowed
Employment not employed/welfare full tirne part tirne self-employed student homemaker retired
~egai/CAS Problems
Previous Treatment Other Problematic Use
cocaine cannabis benzodiazapines heroine prescription drugs
Age Years of Education Social Stabilitp
Years of Alcohol Problem 12.8 (9.19) O - 4 4 Quit Attempts 4.4 (8.79) 0-100 Longest Abstinence Period (months) 8.8 (19.62) 0-180 Dependence (ADS) 20.4 (9.12) 1-45 Typical Drinking Pattern (90 days) Maximum daily quantitf 19.5 (9.64) 2-50 Average daily quantitv 10.3 (6.21) 1-45 Percentage of drinking daysC 63.5 (30.29) 2.2-100
c T i ï FoUowkk (SoWI & SoWI. 1992).
Table 8. Characteristics of sample in study II
slightly more males than females ( 4 :1 ratio in study II vs.
3 : l ratio in study 1) and that more s u b j e c t s were employed
( 40% in study II vs 31% in study 1). There were also no
homemakers who volunteered for study 11 and only one student.
The demographics of study II did not differ significantly on
any other dimension from study 1 (see Table 8).
Convergent Validity of the RCD:
Convergent validity was established by examining the
relation between motivation and three outcome expectancies.
Chanqe Outcome Expectancies:
Change outcome expectancy, as measured by The Outcome
Expectancy Scale (OES) , was completed by 246 subjects . On the
benef its scale, scores ranged from O to 42 with a mean of 26.7
(SD=lI.S). On the costs scale, scores ranged from O to 23
with a mean of 5.7 (SD=4.4). Scores on both scales were
normally distributed.
The intercorrelation between t h e benefits of altering
drinking habits and overall motivation a s measured by the RCD
Scale was .42 (pc .O11 . This accounted for 18% of the variance
between the two measures. The correlations between t h e costs
of altering alcohol use and overall motivation was .O3 (ns).
106
Therefore, higher motivation is related to a belief that
change in drinking patterns will produce more benef its than
costs.
Alcohol Expectancies:
Alcohol expectancy, as measured by The Alcohol Expectancy
Questionnaire (AEQ) , was completed by 196 subjects. Scores
were nonally distributed with a mean of 123.3 (SD=17.5) and
a range of 91 to 178.
The intercorrelation between the expected positive
effects of alcohol use and overall motivation as measured by
the RCD Scale was - . 2 6 (pc.01). This accounted for 7% of the
variance between the rneasures. Analysis, therefore, indicated
that motivation to alter drinking patterns was inversely
related to the perception of the positive effects of alcohol.
Drinkinq-related Locus of Control:
Expectancies related to locus of control over drinking,
as measured by The Drinking Related Intrinsic/Extrinçic Scale
(DRIE), was completed by 246 subjects. Scores were normally
distributed with a mean of 7.7 (SD=3.9) and a range of -3 to
15. One hundred seventy-six subjects (96%) had positive
scores, representing a more interna1 than external drinking-
related locus of control , two subj ects (1%) demonstrated no
107
difference between the internal and external scores, and six
subjects (3%) had negative scores, indicating a more external
than internal locus of control. The intercorrelation between
the RCD Scale and the DRIE was .28 (pc.01) and this accounted
for 8% of the variance between the measures. Analysis,
therefore, indicated that motivation was moderately related to
an internal drinking-related locus of control.
Discriminant Validity of the RCD
The discriminant validity of the RCD was established by
differentiating motivation £rom the concepts of efficacy
expectancies and stress.
Efficacy Emectancies:
Self-efficacy, as measured by The Situational Confidence
Questionnaire (SCQ), was cornpleted by 188 subjects. The
scores were normally distributed with a mean of 2389.8
(SD=856.6) and a range of 400 to 3900. The correlation
between the RCD Scale and the SCQ was .O3 (ns). The product
of the reliabilities of the two scales (RCD=. 93; SCQ=. 97) was
. 90 . The square root of the product was .95. The
intercorrelation between the two scales was significantly
lower than the square root of the product of the reliabilities
of the two scales (2-19.49, p c . 001) . Analysis, therefore,
108
supports the conceptual distinctiveness of confidence and
motivation.
Perceived Stress:
Perceived stress, as measured by the The Perceived Stress
Scale (PSS) , was cornpleted by 195 subjects. Scores on the PSS
Scale were normally distributed with a mean of 31.3 (SD=9.6)
and a range of 7 to 51. Scores on the RCD Scale were also
normally distributed with a mean of 99 - 4 (SD=15.3) and a range
of 52 to 135. The correlation between the PSS and the RCD
Scales was .14 (ns) . The product of the reliabilities of the
two scales (RCD=. 93 : PSS=. 86) was .79. The square root of the
product was -89. The intercorrelation between the two scales
was signif icantly lower than the square root of the product of
the reliabilities of the two scales (2=17.83, pc.001).
Analysis, therefore, supports the non-equivalence of perceived
stress and motivation.
CHAPTER 5: DISCUSSION
An intrinsic/extrinsic conceptual mode1 of types of
motivational sources related to initiation of change in
drinking behaviour was evaluated. Conf irmatory factor
analysis confirmedthe overall intrinsic/extrinsic distinction
and indicated four subdimensions of each type. The four
intrinsic motivational dimensions (control issues, self
concerns, finances, physical heal th) and the four extrinsic
dimensions (others, children, legai/C~S problems and employer
pressures) were defined by a 45-item Reasons for Change in
Drinking (RCD) Scale .
The empirically derived motivation rnodel w a s an expansion
of the a priori model. The items on the a priori Health
Concerns dimension dichotornized into physical and mental
health components. The a priori Social Influence dimension
partitioned into items measuring the influence of others and
the influence of children as motivational sources. The a
priori Self Concerns dimension was renamed control issues in
the empirical model (the self concerns label was shifted in
the empirical model to refer t o the emotional and cognitive
conditions that describe the mental health issues related to
habit change). The Situational Influence dimension split into
legal/CAS issues, work and financial concerns. It is
interesting to note that several items in the a priori mode1
designed to measure employment influences formed a separate
dimension. This dimension involved a need to get on with lif e
financialiy and was labelled financial concerns in the
empirical mode1 .
Several studies provide support for the expanded sources
of motivation derived in the present study. Klingemann (1991)
reported feelings of helplessness (Control) , mental distress
(Self) , physical health (Health) , f inancial problems
(Finances) , f amily tension/separation/divorce (Others) , f ear
of trouble with the police or the authorities (Legal/CAS) and
job di£ f iculties (Work) . Thom (1987) reported feeling
powerless (Control) , depression/low self -
esteern/anxiety/meaninglessness (Self). physical health
(Health), financial problems (Finances), marital breakdown
(Others) and problems with children (Children) . The study by
Toneatto et al. (1993) found evidence of negative self-
evaluation (Self) , health problems (Health) , poor f inancial
situation (Ficances) , f amily/departure of signif icant
other/observation of negative effect of cocaine on others
(Others) and legal problems (~egal/CAS) . Finally , McBride ,
Curry et al. (1994) reported evidence of a legal motivational
dimension for marijuana and cocaine users.
Although the intrinsic/extrinsic dimension of motivation
was conf irmed, concurring with the research of Curry et al.
(1990) and McBride et al. (1994), the specific nature of some
of the intrinsic and extrinsic factors differed. As was
expected, control issues (Control) , physical concerns (Heal th)
and mental health concerns (Self) were conf irmed as intrinsic
motivational sources of change. However, the financial
concern items (Finance) , derived from the a priori situational
influence subscale, were found to measure an intrinsic
motivational source. These items actually measured self-
regulated employment action rather than pressure £rom an
employer and, as such, constituted an intrinsic motivational
source. The expected extrinsic sources (Others, Children,
Legal, Work) were confirmed by the study.
By expanding upon the motivational sources, the present
study counters the trend of Curry and her colleagues (1990) in
their analysis of motivation to alter smoking behaviour. They
factor analyzed a 36-item pool and moved from a larger a
priori six-factor motivation mode1 to an empirically derived
20 -item four4 actor modelt3. Parsimony and equal subscale
size (i . e . , f ive items per subscale) may have been a priority
l3 The empirical mode1 accounted for only 39% of the variance (Curry, 1991) . The subscaleç demonstrated poor to good interna1 consistency (Cronbach's alphas ranged from .53 to .81) .
in this research. However, it is evident from the present
study that a four factor motivation mode1 is too restrictive,
at least for a population of clients seeking alcohol
treatment.
Examination of gender differences in motivational sources
revealed that males and females did not differ in terms of
intrinsic or extrinsic sources of motivation, nor did they
differ in terms of overall motivation. They did, however,
differ in terms of the specific nature of the intrinsic and
extrinsic sources. Fernales appeared more motivated by
cognitive and emotional problems . e t the mental health
issues of the Self subscale) resulting from use patterns than
their male counterparts. Specifically, females were more
likely to report sources of motivation for change relating to
blackouts, memory problems, mood swings and unpleasant or
disagreeable behaviour while drinking. While the previous
motivational literature has not reported findings as a
function of gender, a small body of literature has examined
alcohol-related problems as a function of gender (Drummond,
1990; Makelà & Simpura, 1985; Thom, 1987; Wilsnack et al.,
1984) and provides some support for the current findings.
Màkela & Simpura (1985) found that women more frequently
reported belligerent behaviour i . e , quarrelling, nagging) connected to their drinking than men. Wilsnack et al. (1984)
113
also reported more belligerent behaviour in women than men
during drinking bouts. They indicated that 34% started fights
with their husbands or partners while drinking and 11% started
fights with people outside the family unit. They also
reported depressive symptoms related to drinking in 61% of t h e
women .
Females also tended to be more motivated by their need to
be better parents. A contributing factor rnay be that women
are more likely to be the primary caregivers to their
children. Thom (1987) also found that women were more likely
than men to feel under threat of losing a child or to be
suffering problems arising £rom t he recent loss of a child.
Males appeared to be more motivated by financial concerns
as well as legal/CAS and employment issues. The desire to
improve one's financial condition rnay be more socialized into
the male population than into females and may, therefore,
account for its greater importance in tems of motivational
sources for males. Males are also likelier to be involved
with alimony/child-support.
The finding that more males (39%) than females (17%)
reported l e g a l / ~ ~ S problems is consistent with previous
reports. The gender literature on alcohol-related problems
114
has consistently indicated that women are less likely to have
legal problerns arising from their drinking than males. For
instance, Mâkela & Simpura (1985) reported that women were
less likely to be arrested for dnirikemess than males. There
are no previous research reports on CAS problems. However, it
should be noted that in the present sample, only 5 women (3%)
reported CAS problems while none of the male sample reported
such problems .
It is possible that employment issues were less salient
as a motivational source for women in the present study
because more of the women (61%) than men (51%) reported
support either by their spouse or the welfare system.
However, even among employed women. previous research (e.g.,
Wilsnack et al, 1984) has indicated that few employed women
drinkers report that their drinking is harmful to job
opportunities. Similarily, there is evidence that men are
significantly more likely than women to have experienced job
loss because of their drinking (Thom, 1987). The present
findings on the greater importance of employment issues as a
motivational source for men is consistent with this
literature.
The present motivational concept received some construct
validation by relating it to the stage of change motivational
115
concept (Prochaska & D i C l e u t e n t e (1982 ; 1986) . Motivation,
measured by the Reasons for Change in Drinking (RCD) Scale,
was correlated with motivation as measured by the Stages of
Change Readiness and Treatment Eagerness Scale (SOCRATES).
Analysis confirmed the construct validity between the two
measures. Findings revealed that individuals with a greater
degree of motivation (higher aggregate score on the R O ) were
in a change-initiation stage (Le., determination, action or
maintenance stage of change) while those with a lesser degree
of motivation were in a nonchange-initiation phase ( i . e . , the
precontemplat ion or contemplation stage) . This is consistent
with the theorizing of Miller et al. (1990) . Miller suggested
that motivation for habit change would be greatest during the
determination, action and maintenance stages of change and
lowest during the precontemplation and contemplation stages.
The predictive ability of the intrinsic and extrinsic
motivational sources of the RCD Scale to identify individuals
who were not likely to follow through with treatment was not
supported by the study findings. Contrary to prediction,
intrinsic motivation failed to predict both early and late
dropout from treatment.
Part of the inability of the intrinsic dimension to
predict treatment attrition in the early dropouts may have
been the result of a lack of clear separation in the retention
classes chosen for analysis. The early dropouts were defined
as clients who dropped out of treatment during the intake
assessment period prior to treatment entry. However, it is
known that clients tend to "shop aroundm and explore treatment
entry at more that one facility. Consequently, many subjects
who were classified as early dropouts may actually have
proceeded to treatment at other facilities. Unfortunately, no
data were available on this possibility.
One of the problems with measuring motivation is that it
is not a stable construct. It can fluctuate greatly over
time. In the present study, motivation was measured at
treatment seeking when it is likely to be at a peak. The
timing of the measurement may have reduced rnotivational
variability between subjects making any differences between
dropouts and treatment completers harder to detect.
It is also possible that motivation measured at treatment
seeking may not be the same as motivation rneasured during the
various phases of treatm~nt. The salience of a rnotivational
source can alter with time. If, according to rnotivational
control theory, corrective action reduces the discrepancy
between the observed self and the ideal self, then the
motivational source will lessen in importance. For instance,
117
individuals who are able to change their drinking patterns on
their own and thereby lessen experienced discrepancies, may
feel that self-initiatives are able to deal with the problem
and that formal treatment is not necessary. Similarily, brief
counselling during the early stages of contact with a
treatment facility may also be sufficient to initiate change
and lessen the need for extended treatment.
The f ailure of the overall motivational measure to
predict treatment completion could also suggest that degree of
motivation or the threshold to action is somewhat specific.
The threshold to action may not be related to an overall
measure or composite of motivational sources but rather to a
threshold of a unique configuration of motivational sources.
The only configuration tested in the present study was
intrinsic vs . extrinsic sources and no evidence of a threshold along this dimension was evident in relation to treatment
dropout . Research on natural remitters (Fillmore, 1988;
Klingemann, 1991; Knupfer, 1972; Sobell et al., 1993) suggests
that an action threshold may be exceeded by a single,
significant event but is more likely to be exceeded by a
gradua1 accumulation of negat ive events that eventually tip
the scales in favour of change. The present research
indicated that no single motivational source predicted
treatment completion. Thus, the threshold to action may entai1
118
a unique configuration of sources. For instance, one person
could be motivated to alter alcohol use because of health
problems, control issues and family tension while another may
be motivated by financial concerns and employment issues.
Other motivational sources may be present but only certain
sources are sufficiently troublesome to warrant change in
drinking behaviour. From this prespective, the threshold to
action would be highly individualized and would not be
reflected in a composite score.
It is also possible that the motivation to initiate
change in drinking patterns rnay not equate to the motivation
to engage in formalized treatment. Motivation to change
drinking may only be related to drinking status at some future
point in time, not the method of achieving abstinence.
Adherence to formalized treatment is only one method of
achieving change in drinking. Many people are able to resolve
their drinking problem on their own without treatment
intervention. The motivation to engage in a formal treatment
programme may be more related to a lack of wi11 power or
pref erence for prof essional help (Cunningham et al. , 1993 ;
Klingernam, 1990; Thom, 1986) .
Evidence of the convergent validity of the Reasons for
Change in Drinking (RCD) Scale was found in relation to three
119
outcome expectancy concepts: change outcorne expectancies,
alcohol expectancies and drinking-related locus of control.
Motivation was found to be related to change outcome
expectancy as measured by the Outcome Expectancy Scale (OES) . Overall motivation to alter alcohol consumption was found to
be positively related to the perception that benefits would
ensue £rom a change in alcohol use. The higher the
motivation, the more likely drinkers were to report the
expectation of greater benefits £rom changing their drinking
patterns. However, the relat ionship between motivation and
the costs of altering drinking behaviour was weak and non-
significant. The findingç concur with research by Prochaska
(1994) in which progression £rom the precontemplation stage of
change to action in smoking and cocaine cessation was found to
be related to an increase in the perceived benefits of
behaviour change. He also found a slight decrease in the
perceived costs of change, which did not emerge in the present
research. The literature on decisional balance theory also
supports the relationship between motivation and the perceived
benefits of change. Research has shown that cessation or
reduction in addictive behaviour will only occur when the
perceived benefits of behaviour change outweigh the perceived
c o s t s of change (Oppenheimer & Stimson, 1982; Orford,
1985,1986; Saunders & Wilkinson, 1990) . 120
The positive rewards of drinking, as measured by the
Alcohol Expectancy Questionnaire (AEQ) , appear to be inversely
related to the motivation to alter drinking behaviour. The
motivation to alter the use of alcohol is lower in those
drinkers who perceive more positive rewards associated with
drinking. Thus, drinkers who are still 'romanticizing' the
use of alcohol are not as likely to be motivated to change
their use patterns as those who perceive fewer positive
rewards from use. Research by Brown et al. (1987) supports
the findings by indicating that greater expectancies of
drinking-related rewards are associated with continued alcohol
use while lower expectancies are associated with total
abstinence and number of days without drinking problems. It
should be cautioned, however, that the relationship determined
by the present study is rather weak and accounted for only 7%
of the variance.
Evidence was presented that both intrinsic and extrinsic
motivational sources are related to an intrinsic drinking-
related locus of control. The present study examined the
intercorrelation between scores on the Drinking-Related
Intrinsic/Extrinsic Locus of Control Scale (DRIE) and the
Reasons for Change in Drinking (RCD) Scale . Findings provided evidence that motivational sources are more related to an
interna1 drinking-related locus of control than an external
locus of control. Locus of control refers to whether or not
a person believes that outcornes are controllable or subject to
forces beyond a person's influence (i.e., fate, luck, or the
unpredictable whims of some outside agent). This concept, as
it relates to the ability to control drinking, represents an
expectancy that behaviour change is or is not within a
person's control. Within motivational control theory, the
intrinsic and extrinsic subsystems are two, quite distinct
dimensions of motivation that account for the perceived source
of the initiation and regulation of behaviour. The sources
can either be internal to the person or extemal but in both
instances the behaviour is self-regulated and not a result of
uncontrolled elements. Both the intrinsic and extrinsic
motivational subsystems of motivational control theory would
thus be more related to an internal drinking-related locus of
control than an external locus of control. The findings of
the present study provide support for this aspect of
motivational control theory.
Evidence of the discriminant validity of the Reasons for
Change in Drinking (RCD) Scale was found in relation to the
concept of self-efficacy (efficacy expectancies) and stress.
Motivation was found to be conceptually distinct £rom
efficacy expectancies. The finding that self-efficacy or
122
confidence in achieving one's dririking goal, as measured by
the Situational Confidence Questionnaire (SCQ), had no
systematic relationship to motivational sources of behaviour
change supports motivational control theory in which efficacy
expectations are viewed as exerting a separate influence on
behaviour. Curry et al. (1990) also found that confidence in
relation to quitting smoking was unrelated to motivation to
stop smoking.
Motivation was also found to be distinct from the concept
of stress. Paralleling the findings of Curry et al. (1990) in
which type of motivation was found to be unrelated to stress
as measured by the Perceived Stress Scale, motivation measured
by the Reasons for Change in Drinking Scale in the present
study was also unrelated to stress as measured by the
Perceived Stress Scale. By definition, stress refers to the
pressure or tension experienced during life events while
motivation refers to the sources and intensity of the drive to
make desired changes in one's behaviour. Stress and
motivation may CO-occur but they do not appear to be measures
of a single concept.
To surnmarize the findings of the present study, eight
sources of motivation to change drinking patterns, loading
equally on an intrinsic and an extrinsic dimension, were
123
supported. The factor structure of the motivational model, in
terms of the factor loadings and the intercorrelation between
the factors, suggests that the eight sources are actual
dimensions measuring intrinsic and extrinsic motivation for
change. The analytic methodology, the theoretical
orientation, the relatively large sample size and the sample
characteristics enhance the credibility of the motivational
model. Each of these study strengths is discussed below.
One of the major strengths of the present research was
the application of the confimatory factor analysis using
LISREL. This analyticaf procedure has improved upon
exploratoryprincipal components factor analyses more commonly
reported in the literature (e-g., Curry et al., 1990). There
are serious limitations with exploratory principal components
analysis. The procedure specifies the number of comrnon
factors and observed variables to be analyzed but does not
specifythe structure of the relationships among the variables
in the model. The researcher must assume that:
a l 1 common factors are correlated;
al1 obsenred variables are directly af fected by al1
common factors ;
unique factors are uncorrelated with one another;
al1 observed variables are affected by independent
unique factors ;
124
(5) al1 common factors are uncorrelated with the unique
factors .
These assumptions are made regardless of their
appropriateness. The inability of this factor analytic rnodel
to incorporate meaningful constraints and its necessary
imposition of possibly meaningless constraints has earned it
the derogatory label of a garbage in/ garbage out rnodel (Long,
1983). Such models are not theory-driven. Consequently,
results are open for interpretation and this can pose
problems .
The limitations of the exploratory factor analytic
approach have been largely overcome by the development of the
confirmatory factor procedure (Jôreskog, 1967, 1969; J6reskog
and Lawley, 1968). In confirmatory factor analysis, the
researcher imposes theoretically based constraints which
determine: (1) which pairs of cornmon factors are correlated,
( 2 ) which observed variables are affected by which common
factors , (3 ) which observed variables are af f ected by a unique
factor, and (4) which pairs of unique factors are correlated.
Statistical tests can be performed to determine if the sample
data are consistent with the imposed constraints or, in other
words, whether or not the data conf i n the generated model.
It is in this sense that the model is thought of as
confirmatory. By utilizing this technique, the present study
125
has produced a more theory-driven and possibly more rneaningful
analysis of motivational sources than previous literature.
Another strength of the present study is its theoretical
orientation. The work of Curry and her colleagues (Curry et
al., 1990; McBride et al., 1994) most closely parallels the
current study in its development of a measure to assess
motivation to change addict ive behaviour . Curry et al. (1990) employed an intrinsic-extrinsic motivation mode1 that borrows
f rom the intrinsic motivation theories of Deci and Ryan (Deci,
1975: Deci & Ryan, 1985) and the extrinsic motivation theories
£rom operant models of reinforcement. While these models
certainly have merit, they also have limitations. These
behavioral models focus on the intrinsic and extrinsic sources
of reinf orcement resulting f rom behaviour . However, a true
intrinsic/extrinsic dichotomy probably does not exist . Intrinsic motivation would have elements of extrinsic
influences and vice versa. For instance, the desire to exert
more control over one's life may actually be due to extrinsic
forces such as loss of employment or spousal desertion.
Extrinsic motivation even in the sense of coercion (such as
court -mandated treatment ) has an intrinsic element in that the
person rnay choose to cornply with or defy the edict. Thus
intrinsic and extrinsic motivation rnay be more related in a
temporal sense i e , early-later) than a spatial sense (i . e . , 126
interna1 -external) . Therefore, behavioral models of
motivation in their intrinsic and extrinsic focus present
conceptual di£ f iculties in terms of interpretation of
f indings .
By utilizing a larger theoretical framework, known as
motivational control theory (Hyland, 1988 ; Souter & Annis,
1995) , the present study has improved upon previous studies of
motivation in several ways, First, it recognizes that
motivation is a dual-dimensional construct. Motivation is
comprised of both a source and a magnitude dimension. The
present study has distinguished between these two dimensions
and reported results accordingly. Secondly, the intrinsic and
extrinsic dimension in the present study refers only to the
or ig in of the motivational source and thus does not imply a
spatial relat ionship between the intrinsic and extrinsic
dimensions of motivation. This overcomes the interpretation
problems of the behavioral approach. Thirdly, employing a
meta- theory has expanded the research approach and resul ted in
more extensive findings. In the present study, results
indicated that a four-factor motivational approach was too
restrictive for alcohol clients and that an eight-factor mode1
more accurately reflected the motivational sources for
changing dririking patterns.
Further strengths of the present research are the size
and characteristics of the sample. The 486 subj ects provided
a creditable sample size for the confirmatory factor analyses.
The characteristics of the sample appear comparable to the
general population of drinkers seeking treatment for their
alcohol abuse. Both of these factors suggest that the
motivational sources established by the research are valid and
generalizable.
Interpretation of the motivational sources must, however,
be qualified by some methodological limitations of the
research. First and foremost, the present results should be
considered preliminary. There is always the possibility that
current findings are limited to the study sample, so results
cannot be firmly established until they have been confirmed
with another sample. Un£ ortunately, the present sample was
insufficient to allow cross- validation of the findings.
There is also the possibility that the apparent fit of the
data in the present study may be somewhat inflated by the
prior exploratory analysis and, theref ore, a second
confimatory analysis is needed to establish support for the
f indings .
The loadings of the Work and Legal subscale on the
extrinsic dimension w e r e problematic in that they were
12 8
comparatively low, despite being statistically significant.
Subjects tended to endorse items on these two subscales either
highly or not at all, thus producing a distribution pattern of
high peaks at both ends of the distribution (negative kurtosis
and bimodality) . Correlations were probably weakened by this
distribution pattern. Further refinement of these subscales
may help to enhance loadings on the extrinsic dimension.
Increasing the number of items on the work subscale might
prove beneficial.
The internal consistency of seven of the motivational
sources ranged from good to excellent. However, the internal
consistency of the Work subscale was relatively low
(Cronbachrs alpha = .70) and requires further refinement.
Again, increasing the number of items on the subscale would
probably enhance its reliability.
Gender differences were found on five of the eight
mot ivat ional dimensions, based on variation on the mean scores
of the individual dimensions. Stronger evidence of
differences would involve factorial invariance procedures
comparing factor structures on the RCD scale for each gender.
Sample size considerations prevented such an examination in
the present study.
The atteinpt to establish predictive validity evidence for
the Reasons for Change in Drinking Scale in relation to
retention in treatment was unsuccessful. Unfortunately, the
data collection did not control adequately for precise
categorization of outcome status and this resulted in a
problematic early dropout category.
Motivational sources may differ as a function of
addiction. McBride et al. (1994) found evidence that
motivational sources varied among cocaine users, marijuana
smokers and cigarette smokers. The present resul t s ,
therefore, are limited only to an alcohol population. Data on
the motivational sources of drug users requires a separate
analysis to establish the motivational sources of drug users
with factorial invariance analyses to establish differences
among different types of drug users.
Future Research
Along with the further development and refinement of the
RCD Scale, future research should focus on further validation
of the measure.
In terms of construct validity, there is a promising new
measure of motivational stage of change (Schober & m i s ,
130
1995) . The Cornmitment to Change Algorithm (CCA) is a
behavioral approach to determining stage of change in relation
to change in drinking behaviour. Stage of change is
determined according to actual behaviour enacted in terms of
stopping or reducing drinking. Thus, the measure produces a
mutually exclusive stage of change categorization of sub j ects
which is behaviorally based, thus minimizi~g confounding with
cognitive appraisals. In contrast, the stage of change
concept as measured by the Stage of Change and Treatment
Eagerness Scale (SOCRATES) measures the belief s and attitudes
a drinker has about his or her drinking and produces non-
mutually exclusive categorical assignments which have produced
problems £rom a research perspective. If the CCA is found to
be a more accurate measure of stage of change than the
SOCRATES scale, then analysis between the RCD ~ i l d the CCA
scales could help to further establish the construct validity
of the motivational dimensions.
Research on the predictive validity of the RCD should
focus on the ability of the motivational sources to predict
treatment outcome following discharge, at three and six
months .
Because motivational sources may Vary over the, future
studies should monitor changes in motivation across treatment
1 3 1
seeking, early, mid and late phases of treatment and treatment
completion as well as treatment outcome at three to six months
post discharge.
Future research should also examine motivational sources
as they relate to addiction to drugs and a drug-related scale
developed for use with drug abusers.
In conclusion, the present study has pioneered the
development of a direct measure of motivational sources that
initiate change in drinking behaviour and suggested that the
sources of motivation may Vary between males and fernales.
Analyses have provided some support for the construct,
convergent and discriminant validity of the motivational mode1
and suggest that f urther development and ref inement of the
Reaçons for Change in Drinking (RCD) Scale is warranted.
CHAPTER 6 : POSSIBLE CLINICAL APPLICATION OF THE REAsONS FOR CHANGE IN DRINKING ( R a ) SCALE
The RCD Scale:
The Reasons for Change in Drinking Scale purports to
measure the type and salience of motivational sources that
influence habit change related to alcohol abuse. The sources
are based on client reports and empirical literature that has
explored reasons for change in alcohol abuse in both natural
remitters and treatment successes (Amodeo & Kurtz, 1990 ; Brill
et al., 1972; Edwards et al., 1987; Guydish & Greenfield,
1990; Klingemann, 1991; Ludwig, 1985; Saunders et al., 1979;
Sobell et al., 1993; Smart, 1976; Stall, 1983; Tuchfeld,
1981) . The instrument measures four intrinsic sources of
motivation (Self, Control, Finances, and Health Concerns) and
four extrinsic sources (Others, Children, Legal, and
Ernployment Influences). The 45-item RCD is self-administered
and can be completed typically in 5 to 10 minutes. The RCD
was developed for both clinical and research purposes.
Scorinq of the RCD:
The client is asked to indicate how important each item
is for him or her at that particular time on a 6-point
intensity scale ranging from not important (O) to very
important (5) . Eight subscores are initially calculated, one
for each subscale, by simple addition of the scores obtained
for each item within the subscale (see Appendix A for the
scoring f o m ) . Each client would receive 11 scores : eight
separate subscale scores; an intrinsic score; an extrinsic
score; and a total score (aggregate of al1 eight subscales
scores) .
Possible Clinical Application:
The Reasons for Change in Drinking (RCD) Scale would be
administered during the assessment process. The resulting
responses would provide a profile of the client ' s motivational
sources and would provide an indication of the magnitude of
motivation presently experienced. Motivational scores
predictive of treatment attrition would target clients for
motivational interviewing sessions for the purpose of
enhancing motivational states prior to treatment entry.
Following f ormal treatment, prof iles could be reviewed to
ascertain the attainment of goals or the shifting of
motivational incentives following treatment. By maintaining
the focus on desired outcornes, the client may be better able
134
to maintain a comrnitment to change and experience the rewards
of achieving his or her goals. If goals have shifted, it is
important to understand current incentives to again maintain
the focus on change. If goals have not been attained, then
needed changes could be addressed. If further treatment is
required, referrals would be made available to the client.
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Appandix A: 48-Item Reasons f o r Change in ~rinking Scale
W O N S FOR CHANGE IN DRINKING
What are your reasons for wanting to change your drinking habits at this time? Below is a list of reasons that drinkers may have for wanting to change their drinking.
Would you kindly read each reason and decide how important it is for you at this moment. Then circle one number for each reason.
If the reason is not true for you at this time, then circle "O".
Remember, there are no ' right' or 'wrong' reasons for wanting to make changes in your drinking habits.
1 want to change my drhkhg because:
not important
1 need to feel more in control of my life than 1 do when I'm drinking O 1
1 have physical symptoms that indicate that alcohol is hurting my health O 1
People 1 reafly care about w a n t me to change my drinking O 1
1 could hold dom a job better O 1
1 don't like the person Irve becorne as a result of my drinking O 1
Blackouts (lost memory) f rom drinking worry me O I
I want to maintain my current relationship
Aicohol is draining my finances
v e r y important
I want to change my drinking because:
9. My life is out of control because of my drinking
10. 1 think that drinking is harming my health
11, My family/friends will get off my back
12. When I f m working, 1 take too many days off or 1 am late too many times because of m y drinjcing
not important
VerY important
13. 1 am ashamed of sorne of the things 1 do when 1 drink O 1 2 3 4 5
14. 1 need to clear my head of alcohol so that 1 can think better
15. 1 could then get away from my current relationship
16. Alcohol has caused me serious problems with Children's Aid or with the law (legal charges, - loss of driver's licence, jail) O 1 2 3 4 5
17. 1 want to get my life back on track
18. 1 am afraid that drinking will shorten my life
19. People 1 really care about are upset about my drinking O 1 2 3 4 S
1 want to change my d r i d h g because:
not important
ve=Y important
20. 1 want to improve my current financial situation O 1 2 3 4 5
21. 1 get pretty unpleasant with others when 1 drink O 1 2 3 4 5
22. 1 am concerned about what alcohol is doing to my mind
23. 1 want to develop a proper relationship with someone
2 4 . Drinking seriously iimits my ability to get a decent place to live and enjoy normal leisure activities
25. 1 need to get on with my life without being held back by my drinking
26. My doctor has advised me to
27. 1 am afraid of what drinking is doing to my family
28. My employer wants me to
29. 1 will like myself better
30. 1 am beginning to forget too many things because of my drinking
31. 1 need to for the sake of my children
32. 1 have legal charges related to my drinking and 1 need to satisfy the courts
1 want to change my drinking because:
not important
v = r Y important
33. 1 am missing out on things because alcohol is too large a part of my life O
34. My body cantt handle the alcohol anymore O
35. 1 don't want people 1 care about to think of me as a drunk or an alcoholic O
36. 1 want to get back to work O
3 7 . 1 am feeling very alone and unloved because of my drinking O
3 8 . My moods seem to swing back and f o r t h too much as a result of my drinking O
39. 1 am worried about what kind of parent 1 am when I drink O
40. 1 want to avoid problems with the law o r Childrents Aid O
41. So that 1 can regain my self-respect O
4 2 . 1 dontt feel as energetic as 1 used 0
43. So that 1 can improve my relationship with those 1 care about O
4 4 . So that 1 wont t lose my job 0
45. Because nothing gets done in my life when 1 drink O
1 want to change my drinking because:
4 6 . Because 1 feel that 1 am losing m y m i n d
47. So that 1 can do more for my family
4 8 . The courts have said that 1 have a drinking problem
no t important
v e w important
What is your most important reason for wanting t o change your drinking at this tirne? If any of the above reasons 1 through 40 is your most important reason, then simply write the number of the reason i n the space below. Otherwise, write your o m reason.
My most important reason for wanting to change my drinking at this time is:
Cücrir Nmac:
Cliart No.:
Reasons for C h a n g e in Drinking Scale
Il - -
Scorins Form
Fil1 in the client's response to each item where indicated:
Health Concerns
Social Influences
Situational Influences
Self Concems
Extrinsic = Intrinsic =
(aum of Social Influence Situational Influence)
(sum of Self Concerns and Health Concerns )
Motivational Index = (Total Intrinsic and Extrinsic)
REASONS FOR CHANGE IN DRINKING SCALE
Four-Factor Items Listed by Subscales
INTRINSIC :
SELF CONCERNS :
My life is out of control because of my drinking. 1 need to get on with my life without being held back by my
drinking . I need to feel more in control of nry life than 1 do when I'm
drinking . 1 am missing out on things because alcohol is too large a
part of m y life. 1 want to get my life back on track. 1 don't like the person Irve become as a result of my
drinking . Irm ashamed of some of the things 1 do when 1 drink. 1 get pretty unpleasant with others when 1 drink. 1 will like myself better. 1 am feeling very alone and unloved because of my drinking. So that 1 can regain m y self-respect Because nothing gets done in my life when 1 drink
HEALTH CONCERNS :
I have physical symptorns that indicate that alcohol is hurting my health.
My doctor has advised me to. 1 think that drinking is harming my health. My body can't handle the alcohol anymore. 1 am afraid that drinking will shorten my life. Blackouts (lost mernory) from drinking worry me. 1 need to clear my head of alcohol so that 1 can think
better . 1 am concerned about what alcohol is doing to my mind. 1 am begiming to forget too many things because of my
drinking . My moods seem to swing back and forth too much as a result
of my drinking. I donOt feel as energetic as 1 used to. Because 1 feel that 1 am losing my mind.
SOCIAL INFLUENCE:
People I really care about want me to change my drinking. 1 am afraid of what my drinking is doing to my family. My family/friends will get off my back. 1 donft want people I care about to think of me as a dnuik
or an alcoholic. People 1 really care about are upset about my drinking. 1 need to maintain my current relationship. 1 could get away from my current relationship. 1 want to develop a proper relationship with someone. 1 need to for the sake of my children. 1 am worried about what kind of parent 1 am when 1 drink. So that 1 can improve my relationship with those I care
about. So that 1 can do more for my family.
SITUATIONAL INFLUENCE :
1 could hold d o m a job better, My employer wants me to. When I'm working, 1 take too many days off or 1 am late too
many times because of my drinking, 1 want to get back to work. 1 want to improve my current financial situation. Alcohol is draining my finances. Alcohol has caused me serious problems with Children's A i d
or with the law (legal charges, loss of driver's licence, - jail)
Drinking seriously limits my ability to get a decent place to live, and enjoy normal leisure activities,
1 have legal charges related to my drinking and 1 need to satisfy the courts.
1 want to avoid problems with the law or Children's Aid. So that 1 won' t lose my job. The courts have said that 1 have a drinking problem.
REASONS FOR CHANGE IN DRINKING SCALE
Eight-Factor Items Listed by Subscales
INTRINSIC:
CONTROL ISSUES:
1 need to feel more in control of my life than 1 do when 1 'm drinking . 1 don't like the person Itve become as a result of my drinking . My life is out of control because of my drinking. 1 need to clear my head of alcohol so that 1 can think. 1 want to get my life back on track. 1 need to get on with my life without being held back by my drinking. 1 will like myself better. 1 am missing out on things because alcohol is too large a part of my life. So that 1 can regain my self-respect. 1 don't feel as energetic as 1 used to. Because nothing gets done in my life when 1 drink.
SELF CONCERNS:
Blackouts (lost memory) from drinking worry me. I'm ashamed of some of the things I do when I drink. 1 get pretty unpleasant with others when 1 drink. 1 am concerned about what alcohol is doing to my rnind. 1 am begi~ing to forget too many things because of my drinking . 1 am feeling very alone and unloved because of rny drinking . My moods seem to swing back and forth too much as a result of my drinking. Because 1 feel that 1 am losing my mind.
FINANCIfi CONCERNS :
1 could hold dom a job better. Alcohol is draining m y finances. When I'm working, 1 take too many days off and 1 am late too many times because of my drinking. 1 want to improve my current financial situation. Drinking seriously limits my ability to get a decent place to live and enjoy normal leisure activities. 1 want to get back to work.
HEALTH CONCERNS:
2. 1 have physical symptoms that indicate that alcohol is hurting my health.
10. 1 think that drinking is harming my health. 18. 1 am afraid that drinking will shorten my life. 3 4 . My body can't handle the alcohol anymore.
People 1 really care about want me to change my drinking. I want to maintain my current relationship. My family/friends will get off my back. People 1 really care about are upset about my drinking. 1 am afraid of what my drinking is doing to my family. 1 don't want people 1 care about to think of me as a drunk or an alcoholic. So that 1 can improve my relationship with those 1 care about. So that 1 can do more for my family.
CHILDREN' S INFLUENCE :
31. 1 need to for the sake of my children. 39. 1 am worried about what kind of parent I am when I drink.
LEGAL INFLUENCE:
16. Alcohol has caused me serious problem with Children's Aid or with the law (legal charges, loss of driver's licence. - jail) .
32. 1 have legal charges related to my drinking and 1 need to satisfy the courts.
4 0 . 1 want to avoid problems with the law or Children's Aid. 48. The courts have said that 1 have a drinking problem.
WORK INFLUEEJCE:
28. My employer wants me to. 4 4 . So that 1 won' t lose my job.
Appandix B: Demographic Information
Appendix C: Alcohol Use Questionnaire (ADS)
SAME DATE
ALCOHOL USE QUESTIONNAIRE
(ADSI
The questions in rhis b k l e t are about -oui. uje of î lcohd duiing the pc-r 12 n i o r i t h ~ .
If you have dificiilty with a que-siion or have any problems. please a.ik the questionnaire administrator.
These questions mfir ta the past 12 month
1 . Ho% much did yt~u drink the Iast trnir y u di-tink"
6. When you drink. do you stumble about. stagger. and ararr. '
a. SO b. Sametimes c. Often
a S n b Once c Several timec
3 $ 4 1
b Once T S v t d tlmec
a. No b. Yes. but un!! for ;i ku hours C. Yes. for cine or iuct da!% d Yb. for manu
;1 Si) h Once c. Sevcrd tirnces
MORE - - - -
21. As a result ddrinking. have ?ou "felt things" ctawling on !ou rhat w r e n a really there te.g bugs. spidefil!
a. 'io b. Once c. Svera l times
22. With respect to blackouts 1 l o s of mumoc 9:
a Have nevet- had a blackout b. Have had blackout that lasr le+ than :in houi- c. Have had blackauts rhar h t for w-et-al h iw i - -
d. Have had blackout3 thrit I;i.;t 101' ri da! t i r n iwc
25. Afrei- tditng one or r wo di-rnks. can 'ou u+ua!l! stop'
AIS25 ~dministratian: Give the ADS25 questionnaire to the
client and insttuct him/her t o carefully consider each
question and circle the answer that most accurately
r e f l e c t s his/her response.
The assessaent worker should be available to answer any questions that the c l i e n t may have while eompleting the
questionnaire.
Scorinq: When the client has completed the
questionnaire, use the table e n t i t l e d ADS Scorino Key to
determine the value of the circled responses to each
question. The rav score is obtained by adding the scores
for ail 15 quuasstions.
Interprotation: Use the AD- Interpretation Guide t a b l s
for the suggested interpretation of the client's score.
It is tecornendad that t h i s infornation should be
discussed with the clieat durinp the assessment summary portion of t h e i n c ? r - ~ i e u .
Item Option Score
ADS SCORfNG KEY
Item Option Score Item Option Score
ADS INTERPRETATION GUIDE
ADS RAW SCORE
O
1 - 13 (1st quartile)
SUGGESTED INTERPRETATION
No evidence of alcohol dependence was
reported by the client.
Low level of alcohol dependence. Such . dependence as exis ts is probably
psychological, rather than physical.
Controlled drinking strategiss may be of use
if there are no contraindications. Clients
are more likely to comply with controlled
drinking and reject abstinence goals. Check
for seriousness of intentions to comply with
treataeat.
Hoderate level o f alcohol dependence.
Psychosocial problems telated to drinking are
likely. Psychological dependence may still
be characteristic, but look for increasing
signs of physical dependence, and withdraw'al
symptoms. Controlled- drinking strategies may . *
be consider'ed if there are no
contraindications . Clients may be more
likely to comply with controlled drinking and
reject abstinence goals.
22 - 30
(3rd quartile)
31 - 47
(4th quartile)
Substantial level of alcohol dependence.
Physical dependence is l i k e l y . Physical
disorders and psychosocial problems related
ta alcohol abuse a r e probable. Abst inence .
treatment goals should be very seriously
considered. Clients may be more l i k e l y to
recognize that abstinence is the only way to
improve.
Severe leoel of alcohol dependence. Phys ica l
dependence is highly likely. Serious
physical disorders related to drinking, such
as liver dis tase , are likely. Abstinence i g
probably the onlr reasonable treatment goal.
Clients sbould generally .grec w i t h total abstinence as the focus o f treatment.
Appendix D: Stages of Change Readiness and Treatrnent Eagerness Scale (SOCRATES - SA)
RBCOOjO FORM
1. f d l y want to Puke rome changes in my driPkiag. 1 2 3 4 5 - Dirqar UidaQdaa 4- -
Dirlripr œ b l r A p
3. 1 dcfinirdy have somc ptoblam dasd go my dlinking. 1 2 3 4 5
"1; D&= a US lbrr SLiaiJr
S. Iw+rdrinkiagroomuchrto~ tirne, but I've minigd to change my cîhking. 1 2 3 4 5
s-w Di-#= UodsEidod MF- w Dingtœ or Unan8
1 1. 1 bave serious problears with dtinking. 1 2 3 4 5 m b Udœi&d AC-
or U m m -ir
D- Am=
12. Somairaes 1 wonder if my drinking is burting otha ~ p l e . t 2 3 4 5 - D i Y m Apoc
=u= œ UM E?
14. l un activeiy doin tbings mw to f cut down or stop rinit;nn. 1 2 3 4 - - uadocidod œ Uiuun
4- 0-
15. 1 usai to have problems with alcobol, but not mymore. 1 2 3 4 5
0" - a U m m
4= ZP
17. 1 question wbcther drinlring is goud f9r me. 1 2 3 4 "?: a Undocidcd Unu* M-=
18. If 1 don't change my dtinLing m a , my pmblems ue gohg to ga W . 1 2 3 4 5
Siirub D i n g s M= or Uarin
StmnCIy D m Apac
19. 1 bave Jrudy beea trying to change my drintting, and 1 am bere to ga some more help with it. 1 2 3 4 5
-Wb =4= UaQti6sd AUrsr -ab Din- or 11- Ac=
20. Now tbat t have changai m drinking,
tbe change th& I've mdc. I it Y irnpurîant fbr me to bo d oato
1 2 3 4 5 D k - U d œ a d AFa Q-Zb
DYym ar unui. At=
24. 1 h m mai to crrry out a plan to cut dowu or stop my driniciag. 1 2 3 4 5 - - U a k a d Assr sl<aa3r
or Uavrr Di@w- e-
27. Sometimes I wda if 1 am in conml of my drinliog. 1 2 3 4 5
Srionlly D w udaidod At= or Uairrr
- w J Y Diuw Am-
30. I am w o m d tbat my prcvious probIems with drintiag dgbt cume back. 1 2 3 4 5
SLiayl>. D i r t r a U a k a d 4- - a Uarrr Di=&= At=
31. I've bd more trouble b s e of my drinLiog than most people do. I 2 3 4 5
-b Dimgzw U d o d d At- or umrn
w Ding. At=
36. My probletas art I l a partiy due to my owa dtiakiag. 1 2 3 4 5 - Divqa Uadocissd Mt- -
a Uarrm D e 4-
1-1 A D S TOTAL SCORE = sum of di itam; whete, PO; b e l ; c=2; d=3.
3) D m - 1-1 . DAST TOTAL SCORE = nim of 'ya' 194 ~ ~ ~ = l ) , a c ~ f i r f i ~ f i .
wbae ycs=O.
Appendfx E t Marlowe-Crowne Social Desirability Scale
1 - 1 - 1 - 1 SUBNO
LLrted k l o w are a numkr of statements amenhg personal attitudes. Read cach item and eWc whether the statement is frme or fslsc as il pertains to you personally.
T / F It is sowtimes hard for me to go on with my work if I am not encouragd.
T 1 F 1 sometimes feel melitfui when 1 don't get my way.
T 1 F On a few occasions, 1 have given up doing sometbing b u s e 1 thought too littk d my abüity.
T 1 F Thir have been times wben 1 felt liLc rebebg againiît people in authority tven though 1 knew tbcp wtre a h t .
T 1 F No matter who I'm talking to, I'm phrays a gooà Mener.
T 1 F Tbete haPt been oecarions when I took advantage of someoue.
T 1 F I'm aiways wüliog to admit it when I makc a mistake.
T / F 1 somethes try to get even, mtbv than forgive or forpet.
T 1 F 1 am dways wurteous, even to people who are disagreeable.
T / F 1 have never been irked wben people exprossed ideas very difEerent fmm my own.
T 1 F There have been h e s when 1 was quite jeaious of the good forhine of others.
T / F 1 am sometimes lrritated by people who ask favours of me.
T / F I have never deiiberately said somethiog that hurt someone's feelings.
Appendix F: Outcome Expectancy Scale (OES)
Nunc:
OUTCOME EXPECI'ANCY SCALE - PART 1 OES-ALC
Listsd below are a number of situations dich psople report happa to thun oace tbey stop drinlùng or change the way they d m . Indicise how_mufhYou would Jike it if each of the following situations happ«iad to you. Circle the rpproprUtc numba.
1.
2.
3.
4.
5.
6.
7.
8.
9.
IO.
Il.
12.
13.
14.
15.
16.
you were eaing bcüa
pu felt god about youndf
you were bord
pu hiul more eaergy to & tbiags
you wae bappier
you were fiiudly lad outgoing
you w a e withdrawn whta pu were witb ohen 1
p u were tense and a n x h
the world lookd good to you
you felt in conml of thin@
you were beau at your job
you w a e huithier
you had sudden urges to drink
HOW MUCH WOUU) YOU LIKE IT IF
17. you w a c prtssu~ad by your fntnds to drink
2û. you bai urges to drink if you went to your usuai drinLing spotr
21. you had more seif-nspa
23. you were selfanfident
27. you eajoyed sex more
28. you h d urge to &ïnk whca you saw dahot or tbought rbout rlcobol
29. p h n d it eiisict to express yout fdings to &ers
30. you were o h o f f a d dnnlrs by fri&
31. pu fdt Id out when othen were drinlriag
32. things wue beaer at work witb your basJ lad co-worka /
33. you w a e rnoody
34. p u w a e more relaxcd and confident with othas
OUTCOME EXPECTANCY SCALE - PART II OESALC
Listed Wow are r numbet of situations wbicb p p l e report happa to than once they change the way they driaL. Indiaîe or th a& of the followiag situniom wül happa m you if you change the way pu d r u , or if pu stop dtinking.
IF 1 CHANGE MY DRIMUNG/IF 1 m P DRIM<INC
1 will catbeacr
1 will f d good about mysdf
1 will be bord
1 d l have mott m q y to do things
1 d l be bppiet
1 d l fal dqmsed
1 will enjoy life more
1 will be fiiendly and outgoing
I will bc withdrawn when 1 un witb arhers
I wifl be tense rnd uuious
Somc of my drinking fritnds will avoid w
The w r l d wilt'look g d to me
1 will f d in conml of thhgs
I will be bctter at my job
1 will be healthicr
I will bave sudden urges ta d m
I will f d prtssured by my frieads to drink
I wül f d lonely
0th- papk ml1 respect me
1 wiit have urges m drink if 1 go to my usuai drinking spots
1 will b a ~ e more self-respaa
M y job wil1 bc reaue
1 will f d selfanfident
My mind will be cleu
My h r e will look gooâ
I will be sted'm on my fat
1 will ftod it evia ta express my facliags to otben
1 will often be offad drinks by friends
Tbings will k beaer at work with my b rnd co-workas
1 wiil be moody
Appendix O: Alcohol Expectancy Questionnaire (AEQ)
RESPOND TO THESE ITEMS ACCORDING TO YOTm EXSONAL BELIEFS ABOUT DRINKING
A l d o l lets my m i e s flow more easily.
Dtirrlring gives me more ooafidencc in mysdf.
1 feel more d v e ?Atr 1 have ban chking.
Hnring a fm drinLs U a nice way a cclebnte special occasious.
After a fcw QinLs, 1 Qa't wcq as rmch &uut m b c da people think of me.
Whm drinking. 1 & mt amida n m todly urnmoble or responsibie for my behrviur. - - -
L - 3
Alcobol enable me oo have a beaer time at parties.
Anyihing dich capires a relaxed s!yle could be fadiotsd by Jsohol.
Drinking maka the future sani brigbtcr.
1 oftea fed sexicr ifter 1 have a ample of drinla.
Having a few d r b b helps me relu in a sociîl siaiation.
1 dfink w h e ~ 1 am fding mad.
Drinlcing Jone or with just one other person makes me fed d m d sacrie.
Aftm a fcw drinks, 1 feel brave aad more capable of fighthg.
Drhkhg can make me more satisfid with myself.
There is mbre camaraderie in a gnntp of people who have been drinki. .
My fali- of isolaibn and d i e d o n decte;zpe whea I drink.
A few drhks milrcs mt fed less in toucb with wb! U going oa d me.
Alcobol makes me more tolcnat of people 1 don't enjoy.
Aloohol hdps me sieep beaer.
Women are f n d i a a f k they have a few drinks.
1 am a beaet lover idter a few drinh.
Women talk more a f k they have a few drinls.
AIcohol d a e a s e muscular tension.
A l d o l &CS me worry Iess.
A few drinb makes it easia to caik to people.
AAer a fcw drinks 1 am usuaily in a betier maod.
Alcohoi jains lilce magic.
Womea can have orgasms more easily if they have been drinking.
At times, drinking is like permission to forga probtems.
2 0 6
Drhkhg bdps me ger out of a degtessed mood.
After 1 have a couple of drialrs, 1 fed 1 am more of a uring, sharingpason.
Alcobol d i e s me to f?)l asieep more asily.
1 feel more d i n e iffer a few m.
Mar I am feeling antisocial, drinking mites me more gregarious.
1 f a l like more of a happy-gducky persaa whea 1 drink.
After a few drinict, I am more sexdly rspusive.
If I am cold, haviag a few drinLs gives me a seme of warmth.
It is easier to act on my falings afkr 1 have a few dtinLs,
207
Appendix H: Drinking-Related Locus of Control Scale (DRIE)
1-1-1-1 SUBNO
Ou this questionniah are groups of stltementt. P l a s e r a d ca& group of stmcments carcfully. Then pick out the one smunent in erb group that you lgrre with. For example, on question i l . &ere are two puts, a and b. Wbich one do you agra witb mm. Plcase c W e that one.
Be sure to read botb statements in each qucstf;on befom mikiry yout Wce.
A. 1 - One of the major reasons wby p p l e drink is because thq cannot handle th& problems.
2. People drink because ciramtanas fora thcm to.
B. 1. The idea thît men or women are driva to drinlr by their spouses is aonsense. 2, Most paople do wt realize t&î dnnLiag problans are inûuamd by accidentai
h-.
D. 1.1 have the streagth to witûstand pressurés at wort, 2. Trouble iia work or home drives me to W.
E. 1. Without the right breaks one lrnmt stay s o k . 2, Ateoholics who are mt succesfiil in curbiog their dfinking ofken have mt taken advantage
of help bat is available.
F. 1. Tbere is w such thing as an irresistible temptation to driok. 2. Many times there are circumstances that force you to drinl.
G. 1. 1 get so upset over smail arguments, th% they cause me to drink, 2. I can usually bandle arguments without taking a drinlr.
H. 1. S u d l y licking alcoholism is a mattu of hard work, lu& has littie to do with it.
2. Staying sober d e p d &y on things going right for you.
1. 1. Whea I sa a bottle, 1 cannot resist taLing a d M . 2. It is no more d i f f id t for me to resist drinkiDg when 1 am near drugs than
d e n 1 am mt.
3. 1. The average person has an influence on whctba he drinb or not. 2. O h times, 0 t h people drive one to drinir.
K. f.WhenIun~aprrty.wtrereodienuedr~,Icînrvoidhir;ngadtink. 2. It Ù impossible tbr me to resist drinlring if 1 am at a puty whae othtts are d W n g .
L. 1. Tbose who are successfiil in quiaing drinkiog are the ones who are just pllin IucLy.
2. Qsitting drinking deperds upon lots of effort and bard work (iuck has littie or M i n g to & with It).
N. 1. It is not easy fOr me to have a good time d e n 1 am Jober. 2. 1 lrnmt f a good unless 1 am d r W g .
0. 1. As fu as drinking W concemal, m t of us are viaims of forces we a n ncither undefstaad or control.
2. By taking an active part in our treatment programs, we can contrai out d*g.
P. 1. 1 have control over my drinking bdnviout. 2 .1 fa l completely heipless when it cornes to tesisting a drinlr.
Q. 1. If people want to WIy enough, they a n &ange their &inLing bchaviouf. 2. It is impossible for some people to ever stop drinüng.
R. 1. Witb aougb *art wo cui lick our drialllog. 2. It is diffidt for ricoholics to have mu& mnml over their drinking.
S. 1. If somane offus me a dtink, 1 cannot refwe bim. 2. 1 bave the stragth to refuse a drink.
T. 1. Sometimes 1 canna understand how people can conml their drinluag. 2. There is a direct cumtctioa becween how hard people try md how successful they are in stopping th W drinkiog .
U. 1. 1 can overcome my urge to drirJr. 2. Once 1 start to drinlr 1 can't stop.
V. 1. Drinking isn't necessary iri ordet to solve my problems. 2. 1 just ruimt h d l e my probluas udess 1 takt a drink first.
W. 1. Most of the time 1 caanot unâerstand why 1 continue drinking. 2. In the long nip. 1 am responsible fbr my d r W g problems.
X. 1. If I make up my mind, 1 can stop drinking . 2. 1 bave no will power whea it cornes to drinkbg.
Y. 1. Drinking is my favorite form of entertainment. 2. It wouldn't botha me if 1 auid nava hyppmtùa W.
Appemdix 1: Situational Confidence Questionnaire (SCQ-39)
Addlttlon Fondation Rasoarch de ta rmcherche Foundrtlan sur la toxicornsnte
SITUATIONAL CONFIDENCE QüESTIONNAIRE
Lts t e= beh? zrn a n m b e r of situations or even t s In which some people exper iecce 5 Cr:nking problec,
lrnaginc yourself as you are right nov in each of these ~ituütioris . Indicate on the s a l e provided hou. conf ident )ou a r e tha t ).ou would b e abIe to res is t the urge t a drmk heauily ir. tha t situation.
Circle 100 if you a r e 100% confident right now t h a t you could resist the urge to drink hea.rily; 80 if you a r e 30% confident; 60 if you are 60% confident, If you are more unconfident than con fiden t , circle 40 to indicate t h a t you are only 40% con fiden t tha t you could resist the urge to drink hea.rily; 20 for 20% confident; O i f you have no confidence at al1 about t h a t situation.
1 would k able to resist the urge to Qink heavily
1. If 1 f e t t t ha t 1 had let rnyseIf down
2. I f t h e r e a c r e f ights a t home
3. If 1 Sad t iauble sleeping
4. [f f :ad 3n arguaen t w i th a friend
S. I f o t h e r p q i e didn't scem to like m e
6. If I f c l t confident and relaxed
7. I f I were o u t with friends and they stopped by a bat for a drink
- 8. If 1 w e r e enjoying myself a t a party and wanted to feel even bet ter
9. If I rernernbered how good it rasted
10. If 1 convinced myself t ha t 1 was a new person and could take a few drinkr
no t at al1 confident
very confident
0 20 4 0 60 SO LOO
O 20 1 O 60 SO 100
O 20 (1 0 60 80 LOO
1 would be able to res is t thc urge t o drink heavily
11. If 1 w e r e afraid to work out
12. If other people
that things weren't going
nterfered with my pians
13. If 1 f e l t drowsy and wanted ta stay alert
14. If there were problems wi th people at work
15. If 1 felt uneasy in the presence o f someone
16. If everything were going weil
17. If 1 w e r e a t a party and other people w e r e drinking
18. If 1 wanted t o ce lebrate with a friend
19. I f 1 passed by a liquor store
20. If 1 wondered about rny self-controt over a lcoho l and f e l t like having a drink to try it out
not at aU con fiden t
ver y confident
1 would bc able to resist the urge to drink heavily
21. I f i were angr). at tfie way things had turnea ou:
22. If o t h e r people t rea ted me unfairty
23. If I. f e l t nauseous
24. if pressure built up at work because of the demands of rny supervisor
25. If xrrneone cr i t ic ized me
26, If 1 feit satisfied w'ith something 1 had done
27. I f I Ixere relaxed with a good friend and wantec! to hzve 3 good time
ZS. If 1 were in a res tauran t and the people w i t h me ordered drinks
29. I f I unexpecredly found a bo t t l e of my favor i te booze
36. If 1 s t a r t ed to think t ha t just one drink could cause no harrn
not at al1 confident
ver y con fiden t
1 , - - 4 6 SC) LOO
k C 65 SO 100
$5 6C Sri lC)3
&$ 65 SC) 100
I would be able to resist the urge to drink heavily
31. If 1 f e l t confused about what 1 should d o
32. If I f e l t under a Iot of pressure f r o m f a m i l y m e m b e r s a t home
33. If my s t o m a c h f e l t Iike i t was t ied in kno t s
34. If I were not g e t t i n g along well with o t h e r s at work
35. If o t h e r people around m e made m e t e n s e
36. If 1 w e r e o u t wi th friends "on t h e town" and w a n t e d to increase my enjo) men t
37. If I m e t a f r iend and he/she suggested t h a t we have a drink together
38. If 1 suddenly had a n urge to drink
39. If I wanted to prove to rnyself t h a t f cou id t a k e a f e w dr inks without becoming drunk
not at aîi confident
very con fiden t
Appendix J: Perceived Stress Scale (PSS)
The quest ions below ask you about your f e e l i n g s and thoughts dur ing t h e l a s t month. I n each case, you a r e asked t o i n d i c a t e how often you f e l t o r thought a c e r t a i n way. Although some of t h e ques t ions a r e s i rn i la r , there a r e d i f f erences between them and you should t r e a t each one as a separate quest ion. The b e s t approach is t o answer each ques t ion f a i r l y quick ly . That is, d o n ' t try t o count up t h e number of times you f e l t a p a r t i c u l a r way, but r a t h e r i n d i c a t e what s e e m s l i k e a reasonable e s t i m a t e .
1. I n t h e last month, how o f t e n have you been upse t because of something t h a t happened unexpectedly?
never very often O 1 2 3 4
2 . I n t h e l a s t month, how o f t e n have you f e l t t h a t you were unable t o cont ro l t h e important things i n your l i f e ?
never very often O 1 2 3 4
3 . In t h e l a s t month, how o f t e n have you f e l t nervous and s t r e s s e d u ?
never very often O 1 2 3 4
4 . I n t h e last month, how o f t e n have you d e a l t s u c c e s s f u l l y with i r r i t a t i n g l i f e h a s s l e s ?
never very often O 1 2 3 4
5 . I n t h e l a s t month, how o f t e n have you f e l t t h a t you were e f f e c t i v e l y coping with important changes t h a t were
occurr ing i n your l i f e ?
never very often
6 . I n t h e l a s t month, how o f t e n have you f e l t conf iden t about your a b i l i t y t o handle your persona1 problems?
never very often O 1 2 3 4
7 . I n the l a s t month, how o f t e n have you f e l t t h a t t h i n g s w e r e going your way?
never very often O 1 2 3 4
8 . I n the l a s t month, how of t en have you found t h a t you could not cope with a l 1 t h e things t h a t you had t o do?
never very often
I n the l a s t month, how often have you been a b l e t o con t ro l i r r i t a t i o n s i n your l i f e ?
never very often O 1 2 3 4
I n t h e l a s t month, how o f t e n have you f e l t t h a t you were on t o p of things?
never very often O 1 2 3 4
I n t h e l a s t month, how of t e n have you been angered because of t h i n g s t h a t happened t h a t were ou t s ide of your con t ro l?
never very often O 1 2 3 4
I n the l a s t month, how of t e n have you found yourself thinking about th ings that you have t o accomplish?
never very often O 1 2 3 4
In t h e l a s t month, how of t en have you been a b l e t o control t h e w a y you spend your t i m e ?
never very of ten O 1 2 3 4
In the last month, how o f t e n have you f e l t d i f f i c u l t i e s were p i l i n g up s o high t h a t you could not overcome them?
never very often O 1 2 3 4
Appendix K: Consent Forms
f , , hereby consent to participate in the research project entitled Reasons for Change in Drinking, which is taking place at the ~ddicti~n Research Foundation, Toronto, under the direction of Dr. Kelen Annise The purpose of this project and the procedures t o be followed have been explainad to me by . Zn consenting to participate, I understand M a t :
The purpose of this project is to validate the Reasons for Change in Drinking (RCD) Scala. The RCD is a 40-item questionnaire vhich asks how important particular reasons are for changing i y drinking at this tirne.
1 vill be asked to fil1 out six questionnaires. The session should last approximately one hou.
The data 1 provide will be kept strictly confidential and secure, and w i l l be protacted i n the same way as other hospital records.
The resu l t s of this project w i l l be reported in such a manner that 1 will not be identifiable in any way. Published reports will refer to group data and not to any particular individual.
During this project, 1 may decline to answer any particular questions asked of me. 1 niay withdraw from this project at any tirne and for any reason. If 1 should withdraw from the project, this vill not in any way jeopardize my right to present for treatment at the Addiction Research ~oundation.
1 vil1 be given a copy of this consent form at the t i m e 1 sign it.
1 have been given an opportunity to read this form and ask questions. Any questions that 1 have raised have been answered to my satisfaction.
Dated this day of , 19 -
This consent forn vas read and signed in my presence by
Researcher/Staff Signed : (print name)
flOrtinp Ttestmeot Rctention and outcorne, which is W n g phcc at the Addiction Rcsarrb Foudation unda the direction of Dr. Rtnatt Schoba and Dr. Helen ANLU.
1. nie porpos~ of this pmj- is to examine whether genda, m g hiffory, cornmitmat to change, uid health kliefs influaice dropout fimm t r a x m t and drinking behaviour aAtr mmcnt.
2. Prior to mirnuit, 1 will be aPhd to aimplcîc sevcral qwslionnahcs to provide Uiformation about the following yar:
a. the c a b and b a ~ f i t s usociatcd with Jianging rny m g bchavbur (Ou- Expeetoicy -1;
b. the Suiousness of Eeaith Effcds Asociated with AIcohd Use; c. my h c e i v e à Susceptmillty to the Negaüve Eealth Encetr of Alcohol Use; d. my abüity to rcsist the urge to drink under high ri& dtuaîicms
(Situaîional Conftdence Questionnain); te my kliefs about barriers that intcrferc wiih my cornmitment to change
(Baniers to Cam for D r h b g Qestionnak); and f. ~ t - m m m t of my cornmitment to change
(Cornmitment to Change Questionnnlre). This &on will take a p p c o r i d y 2 to 3 houn to complecc.
3. 1 agne ta k contaaed for a foilow-up i n t c ~ e w at appmimatdy 90 days a f k the in* auessrnuit. In this telephone interview, 1 will provide information about my d M n g patterns and adjustmcnt during the time pcriod wia intake assesmat . and the mle of the treatment expuiaice in my rccovay.
4. The data 1 provide wili be kept stricily confidcntial and recure, and wii i be protscted in the ~ame way as other hospital records:
5. The results of this project wiîl k rcported in such as manna that I wi. not k identifiable in any way. PubIished reports will rcfu to gmup data and not to any parriaiiar individuais.
6. During this poject, 1 may always dcche io answer any particular quesrions askcd to me. 1 may withdraw fiom thb projcct at any tirne and for my r r a ~ ~ . If 1 should withdraw from the p r o j e this wiU not in any way j- my right to rrcPve treatnmt at the Addiction Rtstarch Foundation,
8. 1 have ken givm an opporhinity to nzd this fonn and ask questions. Any questions thu I have misui have beni lhnvtred to my satisfkdon.
D W Ulis da yof ,19-.
Signed: Addms: .
' I b i s c o o w a t f a m w u r c d y d s g n e d i n r n y p ~ b y (name of participant)
1, , hereby consent to participate in M e research rirofect entitled Gender Differences in Drinking, - - cornmitment to Change and Haalth Belief s af f ecting haatmant Retention and Outcome, vhich is taking place at the Jean Tweed Centre and the Addiction Research Foundation under the direction of Dr. R a Schober and Dr. 8. Annis.
The purpose of this project and the procedures to be followed have b e n explained to me by . In consenting to participate, 1 understand that:
1. The purpose of this project is to examine whether gender, drinking history, commitment to change and health beliefs influence dropout trom treatment and drinlcing behaviour after treatment .
2 . 1 will be asked to coinplete several questionnaires to provide information about the folloving areas:
a) reasons for changing my drinking behaviour (Reasons for Change in Drinking Scale)
b) the costs and benefits associated vith changing my drinking (ûutconie Expectancy Scale)
c) the seriousness of health effects associated with alcohol use
d) my perceived susceptibility to the negative haalth affects of alcohol use
a) my beliefs about barriers that interfere vith my cornnitment to change (Barriers to Care for Drinking Questionnaire)
f) assessment of my commitment to change (Conunitment to Change Questionnaire)
This session vil1 take approximately 60 to 90 minutes t o complete.
3. The data 1 provide vill be kept strictly confidential and secure, and vill be protected in the same vay as other hospital records.
4 . The results of thfs project vil1 be reported in such a manner that 1 vill not be identifiable in any vay. Published reports vill refer to group data and not to any particular individuals.
5 . Durinq this project, 1 may always decline to answer any particular questions asked to me. 1 may vithdraw from this project at any tirne and for any reason. If 1 should vithdraw from the project, this vil1 no+ Ln any way jeopardize my right to receive treatment at the Jean Tveen Centre or the Addiction Research Foundation.
6 . 1 vil1 be given a copy of this consent form at the time 1 sing it.
7 . 1 have been given an opportunity to read this tom and ask questions. Any questions that 1 have raised have been answered to my satisfaction.
8. 1 will be paid $10 to acknowledge my participation.
Date this day of 1 1 9 -
signed:
Address :
This consent form was read and signed in my presence by
(name of participant)
Printed Name: (Researcher/staf f)
S igned :
Appendix L: Surnmary of Predicticz af Hypotheses
I : The intrinsic dimension of the sale will involve a subsc.de for self conferos involving items relating to self-control and self-esteem issues and a subscale for heaith concems, both physicai and mental.
2: The ext+insic dimension of the sale will involve a subscaie for social influence and a subscale for situational influence.
3: Women will present with fewer concem on the Social Influence and the Situational Influence subscales. There w u be no gender ciifferences in the Self Concerns and the Health Concerns subscales.
4: Drinken with a higher aggregate motivation score will be in the detemination, action andor maintenance stages of change while dniakers with a lower aggregate motivation score will be in the precontemplation or contemplation stages of change.
5: Individuals who score higher on the intrinsic subscale will be more Likely to enter and complete treatment t)ian those who score higher on the exainsic subscale.
Outcorne
not confirmeâ
not confirmed
not confirmeci
not confimed
6: People with a higher aggregate motivation score will be more likely to enter and complete treatment than those with a lower score.
7: The items on the RCD sale will not demonstrate a socially desirable response style.
8: The benefits of changing alcohol use should relate to higher motivation to change drinlang behaviour while the costs of c b g i n g use should relate to lower motivation for drinking change.
9: The motivation to alter drinking patterns wili be inversely related to the perception of the positive effects of alcohol.
10: Motivation will be more related to an interna1 dri&ing-related locus of control than an extemal locus of control.
11: The concepnial distiactiveness between motivation and confidence in king able to successfully resist the urge to drink heavily in various situations will be established by the intercorrelation between the two concepts king significantiy lower than the square root of the produd of the reliabilities of the measures of these concepts.
Outcome
not confirmed
HYPOTHESES SUMMARY Cont 'd
12: The non-equivalent relationship between perceived stress and motivation wiil be established by the intercorrelation between the two concepts king significantly lower than the square root of the product of the reliabilities of the measures of these concepts.
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