We examined the factor structure of the SOCRATES questionnaire in a population of adult men and women with unhealthy alcohol use identified by opportunistic screening, who were hospitalized in a general hospital and not attending specialized alcohol treatment.
We found a 2 component structure. We propose that the first component be named “Perception of Problems” (PP)(consisting of 10 items) and the second component be named “Taking Action” (TA)(consisting of 6 items). PP includes 3 items originally classified by Miller & Tonigan as Ambivalence, 6 as Recognition and one as Taking Steps. This component reflects the cognitive dimension of acceptance and recognition of alcohol problems. Item 14, “I want help to keep from going back to the drinking problems that I had before,” originally classified as Taking Steps, is part of PP. This could reflect that the acceptance of needing help is more a recognition of an underlying problem than an action statement. PP appears to reflect both the perception of problems related to alcohol drinking and a need for help. TA consists of 6 items originally described as Taking Steps, and appears to report actions that individuals are already doing in order to address their drinking problem. The desire to get help appears to be separate from taking actions to change drinking behavior.
In the PCA, 3 of the 19 items had component loadings ≥0.4 with a factorial complexity of one. Item 19 (“I have made changes in my drinking and I want some help to keep from going back to the way I used to drink”), originally classified as Taking Steps, is a composite question made of two statements, one on changes already made in drinking and the other on the desire to get help. It loaded ≥0.4 on both components, consistent with what the 2 factors appear to capture. Item 1 loaded ≥0.4 on both components, and item 11 did not load ≥0.4 on any component.
The assessment of concurrent validity indicates that PP (the first component) is correlated with alcohol consumption level (drinks per day and heavy drinking episodes). PP has stronger associations with the presence of alcohol-related consequences than TA (the second component). This is consistent with the interpretation that PP reflects perception of alcohol problems, but suggests also that PP could reflect the severity of the problems related to alcohol use.
The exploratory analysis results were reinforced by the comparative analysis. In comparative and confirmatory analyses, the most appropriate structure in our data was similar to that found by Maisto et al. and less similar to that found by Miller & Tonigan.
Our data support the evidence that the factor structure of the SOCRATES questionnaire may be dependent upon the population and the therapeutic setting in which the questionnaire is administered. The use of a 3 factor solution seems to be appropriate in specialized addiction and psychiatric settings, especially with alcohol dependent patients, even if this remains questionable since Figlie and colleagues demonstrated a 2 factor solution in a mixed population of patients from specialized setting and from a gastroenterology clinic (Demmel et al., 2004
; Figlie et al., 2005
; W.R. Miller & J.S. Tonigan, 1996
). On the other hand, the use of a 2 factor solution seems more appropriate for patients screened opportunistically in general health settings such as primary care clinics, community samples or hospitals (Maisto et al., 1999
) (Burrow-Sanchez & Lundberg, 2007
). Among adolescents and young adults, published data are inconsistent in favor of one or the other structures (Maisto, Chung, Cornelius, & Martin, 2003
; Vik, Culbertson, & Sellers, 2000
). Contrary to the ambivalence and recognition constructs that the originally described Ambivalence and Recognition factors intended to capture, the concept captured in the factor called “Taking Steps” (measure of actions taken towards change, or change-related actions) in both the Maisto et al. and Miller and Tonigan studies is consistent across populations and settings.
The main strength of our study was the examination of the SOCRATES in a large sample of medical inpatients, adding to the literature on readiness to change in patients who are identified opportunistically, and are not seeking treatment (in contrast to studies in specialty addiction treatment settings). This is the first study to our knowledge investigating the factor structure in this population. Nevertheless, the generalizability of these results should be limited to hospitalized medical patients. The results are particularly applicable to those who agreed to participate in a clinical trial where they could receive alcohol counseling. It is possible that the subjects included in our sample were more motivated to change than were those who refused to participate. However, individuals who agreed to participate had similar readiness scores on a 1 to 10 visual analog scale compared to eligible subjects who refused participation.
In conclusion, our findings support the likelihood that the SOCRATES can assess and measure two important motivational constructs in patients identified by screening, who are not necessarily seeking nor receiving specialty alcohol treatment. One of these constructs, change-related actions, was consistently found across settings and populations. The first component identified in our sample (PP) reflects perception of problems and need for help, and the second taking action or change-related actions (TA). Nevertheless, identification of these two readiness-to-change constructs is of interest primarily as potential predictors of change or determinants of behavior change. The predictive validity of the 2 components and their relationship with behavior change need to be further explored. Since only about 5% of individuals with alcohol dependence seek and receive treatment, having tools that help researchers to better study the 95% who do not seek help is important and relevant, particularly when it is assumed that seeking treatment is related to motivation and problem recognition.