This questionnaire is designed to give us a better understanding of what strategies you are using in your treatment. Each statement describes a situation or thought that a person might try to help them not use cocaine. Please indicate how often you might make use of a particular situation or thought to help you at the present time.
There are FIVE possible responses to each of the items in the questionnaire:
1 = NEVER
2 = SELDOM
3 = OCCASIONALLY
4 = FREQUENTLY
5 = REPEATEDLY
| 1. | I keep things around my home or work that remind me not to drink. | |
| 2. | I engage in some physical activity when I get the urge to drink. | |
| 3. | I do something nice for myself for making efforts to change. | |
| 4. | I can talk with at least one special person about my drinking experiences. | |
| 5. | I get upset when I think about illnesses caused by drinking. | |
| 6. | I tell myself that I can choose to change or not to change. | |
| 7. | I take some type of medication for my drinking problem. | |
| 8. | I change personal relationships which contribute to my drinking. | |
| 9. | I see signs in some public places trying to help people not to drink. | |
| 10. | I stop to think about how my drinking is hurting people around me. | |
| 11. | I consider that feeling good about myself includes changing my drinking behavior. | |
| 12. | I think about information from television and radio on how to quit drinking. | |
| 13. | Someone in my life helps me to face my drinking problem. | |
| 14. | I remove things from my home or work that remind me of drinking. | |
| 15. | I calm myself when I get the urge to drink. | |
| 16. | I reward myself when I don't give in to my urge to drink. | |
| 17. | I have someone to talk with who understands my problems with drinking. | |
| 18. | Warnings about the health hazards of drinking have an emotional effect on me. | |
| 19. | I use will power to keep from drinking. | |
| 20. | I take some type of drugs to help me not drink. | |
| 21. | I avoid people who encourage drinking. | |
| 22. | I notice that people with alcohol problems are making known their desire not to be pressed to drink. | |
| 23. | I am considering the idea that people around me would be better off without my problem drinking. | |
| 24. | I get upset with myself when I think about my problem drinking. | |
| 25. | I read newspaper stories that may help me quit drinking. | |
| 26. | Someone in my life lets me know about how my drinking is affecting me personally. | |
| 27. | I avoid situations that encourage me to drink. | |
| 28. | I try to think about other things when I begin to think about drinking. | |
| 29. | Others make life difficult for me when I drink. | |
| 30. | I have someone who listens when I want to talk about my drinking. | |
| 31. | Stories about alcohol and its effects upset me. | |
| 32. | I make myself aware that I can choose to overcome my drinking if I want to. | |
| 33. | I use tranquilizers to help me keep from drinking. | |
| 34. | I avoid people who are heavy drinkers. | |
| 35. | I find society changing in ways that make it easier for me to overcome my drinking problems. | |
| 36. | I have strong feelings about how much my drinking has hurt the people I care about. | |
| 37. | I become disappointed with myself when I depend on alcohol. | |
| 38. | I look for information related to problem drinking. | |
| 39. | I have someone who tries to share their personal experiences of alcohol with me. | |
| 40. | I use reminders to help me not to drink. | |
| 41. | I do something else instead of drinking when I nedd to deal with tension. | |
| 42. | I don't let myself have fun when I drink. | |
| 43. | I have someone whom I can count on to help me when I'm having problems with drinking. | |
| 44. | I read newspaper stories that can affect me emotionally about my drinking. | |
| 45. | I tell myself that if I try hard enough I can keep from drinking. | |
| 46. | I take antabuse to help me not drink. | |
| 47. | I leave places where people are drinking. | |
| 48. | I seek out social situations where people respect the rights of others to not drink. | |
| 49. | I stop and think that my drinking is causing problems for other people. | |
| 50. | I feel more competent when I decide not to drink. | |
| 51. | I seek out groups of people who can increase my awareness about probles of drinking. | |
| 52. | I have someoine who helps me "see through" my excuses for drinking. | |
| 53. | I stay away from places generally associated with my drinking. | |
| 54. | I find that doing things is a good substitute for drinking. | |
| 55. | I spend time with people who reward me for not drinking. | |
| 56. | Someone in my life tries to make me feel good when I don't drink. | |
| 57. | I attend meetings that help me express how emotionally destructive drinking has been in my life. | |
| 58. | I make commitments to myself not to drink. | |
| 59. | I change my diet to help me overcome drinking. | |
| 60. | I go places where drinking is not generally accepted. | |
| 61. | I see advertisements on television about how society is trying to help people not drink. | |
| 62. | I stop and think that drinking and driving causes many problems for other people. | |
| 63. | I thikn about the type of person I will be if I am in control of my drinking. | |
| 64. | I think about information that people have personally given me on the benfits of quitting drinking. | |
| 65. | My physical reactions to alcohol help me to realize that alcohol is a problem for me. |
Scoring
Process of Change |
Items |
||||
Stimulus Control |
1 |
4 |
27 |
40 |
53 |
Contingency Management |
3 |
16 |
29 |
42 |
55 |
Counterconditioning |
2 |
15 |
28 |
41 |
54 |
Helping Relationships |
4 |
17 |
30 |
43 |
56 |
Social Liberation |
9 |
22 |
35 |
48 |
61 |
Environmental Reevaluation |
10 |
23 |
36 |
48 |
62 |
Consciousness Raising |
12 |
25 |
38 |
51 |
64 |
Dramatic Relief |
5 |
18 |
31 |
44 |
57 |
Self Liberation |
6 |
19 |
32 |
45 |
58 |
Physical Interventions |
7 |
20 |
33 |
46 |
59 |
Interpersonal Systems/ |
8 |
21 |
34 |
47 |
60 |
Feedback |
13 |
26 |
39 |
52 |
65 |
Self Reevaluation |
11 |
24 |
37 |
50 |
63 |