Correspondance author. E-mail: letypsicologa@gmail.com
A substance user’s readiness to change is fundamental to the success of psychological interventions and treatments. Preserving neuropsychological functions is an integral part of moving towards readiness, yet few studies have evaluated the influence of cognition on a user’s motivation to change. Therefore, this paper aimed to verify the possible correlations between a user’s cognitive deficits and readiness to change through examining cocaine/crack users. This study analyzed a sample of 113 chronic cocaine/crack users’ performances on the WCST and WAIS-III subtests, the URICA, and the Readiness to Change Ruler. The results showed significant correlations between the presence of cognitive deficits and lower levels of motivation to change. Multiple regression analyses revealed the influence of cognitive test performance on the increase of readiness to change among the participants, suggesting a direct relation between the preservation of neuropsychological functions and a stronger willingness to change in cocaine/crack users.
La prontitud al cambio es un factor clave en el éxito de las intervenciones en los usuarios de drogas. Parte de este proceso está relacionado con la preservación de las funciones neuropsicológicas. Sin embargo, pocos estudios se han centrado en la influencia de estos en los procesos motivacionales. Este estudio examinó las asociaciones entre los déficits cognitivos y prontitud para el cambio en 113 usuarios de cocaína/crack, a los que se les aplicó el WCST , sub-tests del WAIS-III, la URICA y la Regla de prontitud para el cambio. Encontramos una correlación significativa entre los déficits cognitivos y menores grados de motivación. Tambien eran encontrados niveles de influencia del rendimiento en tests cognitivos en el aumento de la prontitud al cambio, lo que sugiere una relación directa entre la preservación de las funciones neuropsicológicas y una major prontitud para el cambio en los usuarios de cocaína/crack.
Alongside Brazil, where this study was carried out, many countries worldwide consider the use of cocaine/crack a public health issue (
According to the Transtheoretical Model of Change (
It is largely known that cocaine/crack users present important cognitive deficits (CF) due to the chronic substance use (
Cognitive deficits and treatment outcomes have been extensively explored in the literature (
Many studies showed that motivation and
cognitive status predict treatment success (
Participants were recruited from drug treatment facilities in the city of Porto Alegre, RS, Brazil. The sample was retrieved from a larger study that evaluated the effectiveness of a treatment intervention based on the TTM and Motivational Interviewing. The study was conducted on facilities that held an educational partnership with the Pontificia Universidade Catolica do Rio Grande do Sul (PUCRS), being advertised among the interns. Those who were willing to participate in the study were informed of its objectives and assured that all data would be de-identified. Participants consented participation by signing an informed consent form. This study was approved by the Research Ethics Committee of PUCRS, protocol number 11/05322.
One hundred and thirteen individuals of both genders, between 18 and 57 years old, participated in the study. All individuals were interns and had abstained from substance use for at least seven consecutive days by the time of the evaluation. In this sample, 40.7% were cocaine users, 21.2% were crack users, and 38.1% used both cocaine and crack.
Demographic data was collected by a social-demographic questionnaire and the clinical status of the sample was stablished by a semi-structured clinical interview based on the DSM-IV-TR (2004). Cognitive performance was assessed by the Wisconsin Card Sorting Test (WCST), the Rey Complex Figure Test (RCFT), and the cognitive screening subtests of the Wechsler Adult Intelligence Scale (WAIS-III).
The WAIS-III cognitive screening subtests
(
The RCFT requires the copy and further memory
drawing of a complex geometrical figure in three moments: immediately, three
minutes, and 30 minutes after the copy. We used only the copy and immediate
memory trials in the study to measure visual
perception and immediate memory damages (
The Wisconsin Card Sorting Test was used to track
EF deficits such as mental flexibility, categorization, sequencing, and problem-solving abilities (
Participants’ readiness to change was assessed by both the URICA (University of Rhode Island Change Assessment –
Data collection was performed within an overall period of 6 months throughout the year 2012. Assessments were given by research assistants of PUCRS trained to give and correct the cognitive tests and self-report measures. Training and supervision of the study staff were performed by a Psychologist specialized in both cognitive assessments and drug abuse treatment.
Assessment sessions were performed individually by the research assistants within the facilities. Sessions began with the demographic and diagnostic interview, followed by the self-report and the cognitive assessments. The assessments were completed in single sessions of 60-90 minutes of duration.
Continuous variables were described using average, standard deviation, median, interquartile range, and range of variation. Depending on variable characteristics, we applied either Pearson’s or Spearman’s coefficient correlations to assess the relationship between cognitive performance and the scores obtained on the URICA and the RCR scales. To verify the influence of cognitive performance on motivational stages, we performed a multiple linear regression analysis selecting variables systematically. All analyses were conducted with the use of the software SPPS version 18. The adopted significance level was 5% (p ≤ 0.05).
The sample was composed of young adults, mostly
single (69.6%), with an average age of 29.2 years (SD
8.06) (see
The WAIS-III subtests scaled scores were calculated and interpreted according to the proper age and educational level of participants. The sample presented overall low average scores on the VOC, BD, and DS tests, suggesting difficulties in long-term memory, inhibitory control, planning, and visual-motor skills. Scores on SC were classified within the low range (borderline), indicating major damages in working memory and processing speed in the sample.
On the RCFT, participants
achieved an average of 28.5 points (SD ± 6.3) in the copy, and 12.1 (SD ± 6.6)
in the memory reproduction trial, being classified as low average (
We found positive significant correlations between the RCR and scores on the VOC (r =-0.381, p<0.001) and BD subtests (r = 0.295, p<0.01) of the WAIS, as well as on the completed categories (rs = 0.201, p<0.05), learning how to learn (rs = 0.21, p<0.05), and failure in set maintenance indexes (rs =0.187, p<0.05) of the WCST. Although such correlations are weak (
No significant correlations were found between the RCFT and the URICA or the RCR.
*
Multiple linear regressions (step
by step model) verified the influence of each of the cognitive performance variables
on the RCR and the URICA subscales (
R2 = Percentage of variance explanation; * = p≤0.001; ** = p≤0.01; *** = p≤0.05. Effect size (f²) = small (0.2), medium (0.15), large (0.35), Cohen’s classification (
Changing addictive behavioral patterns requires the full awareness of the damages caused by the drug abuse as well as the ability to identify risky situations and to avoid relapses. In that sense, preserving cognitive functions such as attention, memory, and cognitive flexibility are necessary to help individuals throughout the changing processes towards quitting addictive behaviors (
In the pre-contemplative stage of motivation, the damage caused by the substance use isn’t clearly perceived by the user. Thus, behaviors related to the drug abuse are not a target of change. In our sample, about 33% of the participants were in the PC stage according to the URICA, and we found that low performances on the VOC and the SC tests predicted the PC stage in 13.8%, and 11.4% respectively. These results suggest that long-term memory, attention, and processing speed deficits are contributing to the lack of motivation to change in this percentage of the sample. Our results follow the findings of a previous study (
Our data also showed that performances on the WAIS-III VOC and BD subtests predicted the self-assigned readiness to change on the RCR. This finding reinforces the role of preservation of general verbal knowledge, planning, and processing speed skills over the self-reported level of motivation to change. The nature of the RCR instrument can help to address this finding. As an ideographic measure of motivation (
As the literature suggests, our participants also experienced difficulties in expressing EF, such as inhibitory control and cognitive flexibility, which we observed through their performance on the WCST. Succeeding on this task requires abilities related to sequencing, monitoring, and the flexibility to perceive and execute changes demanded by the environment. As the high scores of perseverative errors show, participants had a hard time in acknowledging the change in the rules and adequate their response accordingly to each trial. Our results showed positive correlations between scores on the CC, LHL, and FSM indexes of the WCST and the RCR, and a negative correlation between the latter and PE. It means that low levels of readiness to change according to the RCR, are related to low scores on CC, LHL, and FSM and high scores on PE, indicating that a lack of mental flexibility is directly linked to low motivation to change.
This paper aimed to verify to which extent cognitive performance is associated with and influences the readiness to change in cocaine/crack users. Although we found statistically significant correlations between readiness to change and cognitive measures, they were mostly weak to moderate. Our regressions, exploring the cognitive measures as predictors of readiness to change, showed a limited range of influence. Even though the correlations were statistically significant, the major predictors accounted only for a little percentage of the variances, also producing small effect sizes. These results are partially due to the lack of homogeneity of the sample, an important limitation of the study. The sample used in this study was retrieved from a larger research, addressing the validation of a treatment protocol based on the TTM and Motivational Interviewing in Brazil. For this larger study, variables such as educational level and cognitive status were not exclusion criteria. Therefore, the sample for the present analysis was highly heterogeneous, with participants diverging significantly regarding period of abstinence, duration of drug consumption, education, and age. Those differences lead to means with high SD in all the investigated measures, limiting better results and more specific conclusions. It is possible that a more homogeneous sample in terms of cognition, education, age, and periods of abstinence would have provided more robust results concerning the relationship between cognitive tasks and motivational levels.
Despite the low accountability of the cognitive predictors over the motivational levels and the small effect sizes, evidence of statistically significant relationships among these variables does imply that neuropsychological functions are important factors to be considered in the motivation for treatment among substance users. Active neuropsychological rehabilitation targeting the improvement of abilities such as learning from the context, judgment, and decision-making, as well as capacity to inhibit automatic behaviors can help substance users to build cognitive resources, facilitating the path throughout the motivational stages.
More studies focused on the impact of cognition on motivation to change are needed to provide more comprehensive and objective data. The exploration of cognitive training is also necessary to verify the efficacy of neuropsychological rehabilitation to promote the maintenance and success of treatments targeting cocaine and crack users.
The first author was awarded with a PhD scholarship from CAPES (Coordination for the Improvement of Higher Education Personnel) that supported her work during this research. The second author was awarded with a DTI/ FAPERGS grant that supported her work regarding this research. Currently, the 2nd author is supported by a fulltime PhD scholarship from the CNPQ/SWB program.
Research article.