Using Decision Tree Procedures to Understand Readiness to Change and Treatment Referrals

PURPOSE: The Trans-Theoretical Model of Change (Prochaska, DiClemente & Norcross, 1992) and the concept of readiness for change have been posited to increase engagement, retention and positive outcomes for substance abuse treatment among incarcerated populations (Simpson & Joe, 1993; Hiller et al, 2009). SOCRATES (Miller& Tonigan, 1996) yields three stages of readiness for treatment: Ambivalence, Recognition and Taking Steps. However, there is reason to question if these three stages are distinct (Littell & Girven, 2004; West, 2005), to explore how a controlled environment may influence readiness estimates (Muesser, Noordsy, Drake & Fox, 2003) and to explore the relationships among these three stages to improve assessment and treatment referrals in the criminal justice system (Prendergast,2009).                                                                                                

METHODS: Decision Tree Procedure in SPSS was used to examine the patterns of SOCRATES-8 scales.  Data were collected from a screening sample for a jail-based in-reach and re-entry intervention.  Participants were between 18 and 24 years old, expected to return to the community post-adjudication, and had been flagged at booking for the possibility of a mental health problem. Mental health disorders, alcohol and other drug disorders were determined by responses to the Mini International Neuropsychiatric Interview (MINI).  Participants who indicated alcohol use or drug use completed the SOCRATES-8; separate forms were used for alcohol and for other drug use. The forms were identical except for the terms “alcohol” or “drinking” or “drugs” or “drug use” in the questions. A total of 118 participants completed SOCRATES.   

RESULTS: 69 participants (59%) indicated they used both alcohol and drugs; 41(35%) indicated they used drugs only and 8 (7%) indicated they used alcohol only. 76 completed the SOCRATES-ALCOHOL; of these, 60 (79%) met DSM-IV-TR criteria for alcohol dependence and 16 (21%) met criteria for alcohol abuse. 110 participants completed the SOCTRATES-DRUG form; of these, 90 (82%) met criteria for drug dependence and 20 (18%) met criteria for drug abuse. Marijuana was the drug of choice (70%) followed by street opioids (11%), hallucinogens (5%) and other drugs of abuse (14%).  For the SOCRATES-ALCOHOL, 6 separate patterns, using decile scores, were identified. 54% of the sample fell into the two patterns in which Ambivalence was the highest decile score.  32% of the sample was classified into the pattern of Ambivalence, followed by Taking Steps in the middle decile and Recognition in the lowest decile. 22% were classified into the Ambivalence-Recognition-Taking Steps pattern. Similar findings emerged for the SOCRATES-DRUGS.  Two patterns classified Ambivalence in the highest decile score (64%). The two patterns were Ambivalence-Taking Steps-Recognition (42%) and Ambivalence-Recognition-Taking Steps (22%). Taking Steps was classified in the highest decile for two patterns in the alcohol group (26%) and in two patterns in the drug group (22%).                                                                                                              

IMPLICATIONS: Taking Steps implies readiness for action, a common assumption of alcohol treatment.  In this sample Ambivalence was classified in the highest decile by a larger proportion of both alcohol and drug groups.  Examination of middle decile groups can be useful as a guide to develop more effective staged assessments and treatment referrals.