Application of the Transtheoretical Model of Change to
Binge Eating and Smoking
Laura-Lee Clausen Oc
a thesis submitted to the Department of Psychology
in confomity with the requirements for
the degree of Master of Arts
Lakehead University
Thunder Bay, Ontario, Canada
Septemkr, 1 999 National Library Bibliothby nationale du Cana a uisitions ad Acquisitions et abgraphic SMvices semices bibliographiques
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Applicability of the stage of change and decisional balance constnicts for bingers and smokers was examined in a study of 191 participants; bingers (n = 47), smokers (n = 80). and conbols (n = 64). The Stage of Change Inventory (SCI) was cross-validated with the
University of Rhode Island Change Assessrnent (URiCA) sale and used to assign bingers and smokers to one of five stages of change; precontemplation, contemplation. action, maintenance, and recovery. Psychological distress, the characteristics of binge eating and smoking, and the pros and cons of behavioural change were evaluated as a function of the stages of change. Although an increase in the con scores fiom precontemplation to action did not support the weak principle of the decisional balance. an increase in the pros of behavioural change fiom precontemplation to action provided support for the strong principle for bingea and smokers. Results of the Brief Symptom
Inventory (BSI) indicated that psychological distress was not related to stage of change for bingers or smokers. However, bingers were found to score significantly higher than controls on the Global Seventy Index (GSI) of the BSI. Several measures were used to hinhet explore the phenomenology of binge eating and smoking. Results of the Binge
Eating Adjective Checklist (BEAC) and Smoking Adjective Checklist (SAC) suggested that both khaviom serve a fwction in reducing the amount of psychological distress experienced by participants. For bingers, degree of loss of control and negative affect were found to Vary as a function of stage of change, with precontemplators experiencing the least negative consequences associated with their behaviour and action-takea the most. The overail findings support the applicability of the transtheoretical mode1 for bingers and smokers and furthet suggest that stage of change is rclated to characteristics of binge eating such as negative affect and loss of control. Acknowledgements
First, 1 would Iike to express my most sincere uianks to my thesis supervisor, Dr.
Ron Davis, for his support, luiowledge, and understanding throughout the entire process of this study . 1 would also like to thank Dr. J. Jarnieson, Dr. D. Franko, and Professor K.
Ailan for their &ce and comrnents regarding this work. On a persona1 Ievel, 1 would like to thank Shannon Costigm and Kristim Isfeld for their understanding, patience, and encouragement thmughout the completion of this work, especiaily the last few months.
Lady, I would like to thank my parents and brocher, for without their continued encouragement and love 1 would not ôe who or where I am toàay. Table of Contents
Page
Abstract ...... i .. Acknowledgements...... 11
List of Tables ...... iv
Lia of Figures ...... v
Introduction...... 1 Stages'of Change ...... 1 Decisionai Balance ...... 2 Smoking ...... 4 The Strong and Weak hcipies of Change ...... 6 The Transtheoretid Model and Binge Eating ...... 7 Binge Eating and Psychopathology ...... 9 Phenomenology of Binge Eating and Smoking ...... 10 Purposes and Hypothcses of the Present Study ...... 11 .
Method ...... 12 Participants...... -12 Measures...... -12 Scmning instrument for Behaviours ...... -12 Stage of Change Invcntory ...... 13 University of Rhode Island Change Assessrnent Scalc - Reviscd ...... -13 Behaviourd Characteristics of Binge Eating and Smoking ...... 14 Decisional Balance for Binge Eating and Smoking...... 15 Brief Symptom Invcntory ...... 15 Bbge Eating Adjective Checklist and Smoking Adjective Checklist ...... 16 bdts...... -16 Chatacteristics of Participants...... 16 himilil Consistnicies of Maures...... 18 Cladfication of Participants into Stage of Change ...... 18 Stage of Change and Decisional Balance ...... 19 Bnef Symptom uivcntory Scores for Group and Stage of Change ...... 28 Pbenomcnology of the Behaviours ...... 31 Summiry of Findings ...... 40
Discussion...... 41 References...... 48 Appendices ...... 55
iii List of Tables
Table Page
1 Characteristics of Participants ...... 17
2 Distribution of the Number of Particijmts Acwrding to Group and the Stage of Change Inventory ...... -20 Decisional Balance Scores as a Function of Stage of Change for Bingers ...... 21 Decisional Baiance Scores as a Function of Stage of Change for Smokers..... 23
Difierences ktween Groups on the Bnef Symptom Inventory ...... 29 kief Symptom Inventory Global Severity Index as a Function of Stage of Change for Bingers and Srnoken...... 32
Behavioural Characteristics Scales (Part II) as a Function of Stage of Change for Bingea ...... 36
khavioural Characteristics Scales (Pari Il) as a Function of Stage of Change for Smokers...... 38
Behavioural Characteristics Scales (Part 1) as a Function of Stage of Change for Bingea ...... 39
khavioural Characteristics Scaies (Part 1) as a Function of Stage of Change for Smokers...... 41 List of Figures
Page
+ 1 Standerdized TScons for the pro and con desof the Decisional 1 Balance measure plotted as a hction of stage of change for bingers...... 24 I ... . i 2 Standardized Escores for the pro and con scales of the Decisional
I Balance measure plotted as a hction of stage of change for smokers...... 26
3 Binge Eating Adjective Checklist end Smoking Adjective Checkiist
1 composite scores for bingers and smokers plotted as a fùnction of time...... 3 3 Introduction
An increased awareness of health-related issues and behaviours has contributed to the development of programs and techniques to assist individuals in changing their behaviour
(Prochaska, Nmss, dé DiClemente, 1994). in 1982, Prochaska and DiClemente developed a therapeutic approach based on a synthesis of the processes of change fowid to be cornmon arnong 18 different therapy systems, known as the ~stheoreticalmodel. This integrative model of bchavioural change was extended to include addictive and problem behaviours such as smoking (Prochaska & DiClemente, 1983) and weight control (O'Connell, & Velicer,
1988). A Merconstruct of the model, decisional balance, has been found to Vary as a fùnction of an individual's motivation to change (Prochaska 1994).
The present study involved an evaluation of the applicability of the transtheoretical model and decisional balance to binge eating and smoking. Individuals at different stages of changing their binge eating and smoking were examined in ternis of the consequences affecting their decision to change their khaviour. Further, the psychological distress experienced by these individuals relative to participants that have never smoked or binged was examined overall and as a function of stage of change. Associated features that characterize binge eating and smoking were examined such as the affective experience of the behaviour, loss of control, frrquency, and age-related factors.
Based on research conceming how people intentionally change, the cote construct of the transtheoretical mode) is a series of stages reprcsenting various degrees of motivational readiness to change. The stages that have been identified by Prochaska, DiClemente, and
Norcross (1 992) include piecontemplation contemplation, action, and maintenance. Precontemplation is characterized by a lack of intention to change a behaviour in the fhture. individuals may be unaware of a problem or fcel that a behaviour is not problematic at ail.
Contemplation is characterized by an awareness that a problem exists and canful assessrnent of the pros and wns of khavioural change. Action represents an active modification of behaviour in order to overcome the problem. Maintenance is considered a continuation, not an absence of change in which individuals work to prevent relapse hm6 months deraction has taken place to tehination of the problem.
Thus far, evaluation of a stage of change bcyond maintenance has not occurred. In a study predicting smoking status, Velicer, DiClemente, Prochaska, and Brandenburg (1985) distinguish between ment and long-tenn quitters. A 6-month criticai pend was used to classify quitters as either ment or long-term, a distinction they equated with the action and maintenance stages of change. Prochaska and DiClemente (1982) note that for some individuals, change mults in the successfbl tennination of a problem behaviour. However, although long-temi abstinence and tennination have been discussed in the literatwe, the characteristics associated with such a stage have not been examined as a construct of the transtheomical model. Absolute recovery fiom a problem behaviour may warrant the identification of a stage beyond maintenance in which an individual is no longer actively working to prcvent relapse, and no longer considers the previous behaviour as a cumnt problem, or anticipates its mmergence in the future. A staging instniment developed for eating disorderrd behaviom by Davis (1 9%), includes an item to assess the movery stage of change in accordance with the abovementioned criteria. T~theoteticalModel 3
Decisional Balance
A Merconsideration in modifjing behaviour is the decision making process, or evaluation of the pros and cons of behavioural change. Janis and Mann (1977) proposcd a mode1 to identify the motivational and cognitive considerations of decision making known as the Decisional Balance Sheet of Incentives. The model categorizes decision making in terms of the anticipated gains and losses that will result for both the individual and hidher reference group with regarcho a particular choice. Furthcr, decisions arc evaluted in ternis of material or emotional impact that may result fiom a particular choice. Janis and Mann have identified the following categories as important considerations in the decision making process: (a) utilitarian gains and losses for self, (b) utilitarian gains and losses for others, (c) self-approval or self- disapproval, and (d) approval or disapproval from significant others. Thus, the model proposes that any decision made by an individual to change a given khaviour involves an examination of both the positive and negative effects that the change will have on the individual and others.
Further, a behavioural objective is viewed in ternis of either the physical or affective consequence, such as monetary gain or incdself~steem (Prochaska, Norcross, et al.,
1994).
Many aspects of the transtheoretical model have roots in psychothempeutic interventions (McConnaughy, Prochaska & Velicer, 1983). Fmm a clinical perspective, discovering an individual's dinessto change can prove advantageous to the timing and selection of intervention proceûuns. Howevcr, application of the transtheoretical model has evolved beyond the psychotherapeutic situation to include a wide range of behaviours
(Rochaska, Norcross, a al., 1994). Although diverse in scope, the types of khaviours to which the mode1 has most widely ken applied include those with consequences for physical and psychological well-king (Prochaska, Velicer, et al., 1994). Thus fa, the majority of research has focussed on applying the stages of change and decisional balance consînicts to smoking cessation (Prochaska, & DiClemente, 1984).
Srnoking
Smoking is the most frepuently investigated of dl health-related behaviours in relation to the tramtheoretical model Oijkstra, De Vries, Roijackers & van Bnukelen, 1998;
Prochaska & DiClemente, 1984). Initially, the stages of change concept developed as a result of an empincal investigation into the processes of change used by smokers who quit on their own compared to smokers involved in two different therapy programs (DiClemente &
Prochaska, 1982). Four stages of change were identified as important to the goal of smoking cessation and maintenance: (a) thinking about quitting (contemplation); (b) becoming deterrnined to quit (decision making); (c) actively moùifying the behaviour (action); and (d) maintaining cessation of the khaviour (maintenance). Subsequent investigation by Prochaska and DiClemente (1983) multed in sorne modification of the model ta include the addition of a precontemplative stage and a shifi in the emphasis placed on decision making. Refinement of the stages of change moàel in smoking cessation has continued as several studies have attempted to replicate thex early fmdings (Dijkstra, Bakket & De Vries, 1997; Prochaska,
Crimi, Lapsanski, Martel & Reid, 1982; Prochaska, DiClemente, Velicer, Ginpil & Norcross,
1985).
A study by Prochaska, Velicer, DiClemente, and Fava (1988) investigated the processes of change used by 970 smokers as they pmgressed through the various stages of change.
Results of this study confirmed the existaice of distinct stages of smoking cessation
(precontemplation, contemplation, action, maintenance, and relapse). Furthet validation of the stages of change model was achieved through an analysis of the stages of change for smoking
cessation @iClemente, Pmchaska, Fairhurst, Velicer, Velasquez & Rossi, 1991). The study
investigated the smoking khaviour and attitude towards smoking of participants in the
precontemplative, contemplative, and preparation stages of change. Results indicated stage of
change was highly correlated with nurnber of attempts to quit smoking, and successful
cessation at 1- and 6-month follow-up.
Decisional balance for smoking has been investigated as a predictive measure for
assessing smoking status (Velicer, et al., 1985). The relative importance assigned to the pros
and cons of quining smoking was found to successfùlly differentiate ktween the five stages of
change for al1 960 participants. As well, the decisional balance measure proved successful in
piedicting smoking status at a 6-month follow-up. Thus, support for the transtheoretical model
of change has been demonstrated through many investigations of smoking cessation. However.
evidence also suggests that a more universal application of the model to other problem
behaviours yields similar results (Prochaska, Velicer, et al., 1994).
Several studies have illustratecl the clinical utility of matching treatrncnt to the client's
stage of change (DiClmente et al., 1991 ; Velicer, et al., 1985). For exarnple, Levy (1 997)
foud in a study of bulimia netvosa that subjects prefernd matment approaches compatible
with their cmntstage of change. The application of the transtheoretical model to behavioural
change has been supported in dieson smoking (Prochaska, Velicer, Guadagnole, Rossi &
DiClemente, 1991), weight control (Rochaska, Norcms, Fowler, Follick & Abram, 1992),
alcoholism (DiClemente, & Hughes, 1990), opiate addiction (Tejero, Tnijols, Hernandez, de
1 1 los Cobos & Casas, 1997), and eating disorders (Frmko, 1997; Ward, Tmp, Todd & Treasure.
1 / 1996). Thus, the ability to detemine a subject's reaâiness for change has implications for Tmstheoretical Model 6
treaûnent as demonstrated in a weight loss study by O'Co~ell,and Velicer (1988). The results
of this study indicate the combination of stage of change and decisional balance provides an
effective instrument for undcntanding change and enhancing ûeatrnent planning.
The Stronn and Weak Princi~m
Prochaska, Velicer, et al. (1 994) investigated the relationship baween stage of change
and decisional balance for 12 problem behaviours; smoking cessation, cocaine cessation,
weight control, hiigh-fat diets, adolescent delinquent behaviours, safer sex, condom use,
sunxreen use, radon gas exposun, exercise acquisition, marnmography screening, and
physician's preventive practices with smokers. Results indicated the same pattern of pros and
cons at each stage of change for al1 12 khaviours. In the precontemplation stage, the cons for
changing a behaviour outweigh the pros. Progress to the action stage involves an increase in
the evaluation of the pros of changing a behaviour and a decrease in the cons. Thus. a
crossover occurs between the pros and cons with progress hmprecontemplation to action. A
decrease in the relevance of both pros and cons occurs with progression towards maintenance.
Based on the results of this study, Prochaska (1994) identified two principles of change:
The strong principle states that progression hmprecontemplation to action is a
function of approximately a 1 standard deviation increase in the pros of a health
behavior change. The weak pnnciple states that progression from precontemplation io
action is a function of appmximately a 0.5 standard deviation decrease in the cons of a
health behavior change. (Prochaska, 1994, p. 1)
Dijkstra, et al. (1 9%) conducted a study of smoking cessation in a Dutch population which
yielded results compatible with the pattern of pros and cons established by Prochaska (1 994). I / Further, Dijkstra, et ai. (1997) found that the progression hmprecontemplation to Transtheoretical Model 7 contemplation can be detemined by an individuals' perception of the advantages of modifying a behaviour.
The Transtheoretical Model and Binae Eating
Binge eating was identified by Stunkard (1959) as an eating disturbance occurring within a subset of obese patients who reporied consuming vast qmtities of food in a short period of time. More recently, the fourth edition of the Diamostic and Statistical Manual for
Mental Disorders (DSM-IV,American Psychiatric Association, 1994) has outlined a set of research critena pertaining to Binge-Eating Disorder (BED); recunmt episodes of binge eating characterized by the consurnption of large amounts of food, a sense of loss of control over intake, marked distress, and an absence of compensatory behaviours such as purging or exercising. Dixrepancies exia in the research regarding the use of the tenn "binge". This has resulted in considerable variability in the composition of samples studied and their findings
(Brody, Walsh & Devlin, 1994; Johnson, Carr-Nangle, Nangle, Antony & Zayfert. 1997). In a study of 243 women, kglin and Fairbwn (1992) detemined that a subject's perceived loss of control derthan the acnial quantity of food consumed was more important in defining a binge episode. Further, Niego, Pratt, and Agras (1 997) proposed that the amount of food should be considered secondary to the psychological experience in defining binge eating.
Although BED is primarily associated with overweight and obex individuals, evidence exists to support the occuncnce of binge eating episodes in subjects of varying weights (de
Zwann, 1997; Castonguay, Eldredge & Agras, 1995). A mview of binge eating by Wardle and
&inhart (198 1) concludecl thrit some form of binge eating is evident in okse, normal weight, and underweight groups. Reported pmalence rates of BED Vary hmapproximately 0.7% - 4% in nonpatient community samples, and 15% - 55% for people who attend weight-control Transtheoretical Mode1 8 programs (DSM-IV,1994; Telch, Agras, Rossiter, Wilfley & Kenardy, 1WO). A multisite field trial involving 1,984 participants detennined that severai patterns of episodic overeating exist, with fluctuations in prevalence rates depending on the set of criteria imposed on the sample
(Spitzer et al., 1992). For example, in a college sample, reported rates varied hm39% for episodic overeating to 2.7% for BED. Typically, females are approximately 1.5 times more likely to exhibit a pattern of binge eating behaviour than males according to DSM-IV (APA,
1994)..
Presently, the transtheoretical model hm not been applied to the distinct behaviour of binge eating in the absence of related eating disorder criteria for anorexia nervosa (AN) or bulimia nervosa (BN). Franko (1 997) studied a group of 16 subjects with BN during 12 weeks of cognitive-behavioural group therapy. Results of the shidy indicated that subjects who were able to decrease binge fmluency over the course of treatment were at more advanced stages of change at pretreatment compared to those with negative outcornes. Another application of the transtheoreticd model involved a sarnple of 35 AN subjects in a study conducted by Ward et al. (1 996). An examination of the stages and piocesses of change among AN subjects indicated that different processes of change characterized each stage, with patients nlying on certain processes throughout the course of treatment. Several limitations were dixussed by the authors regarding the applicability of the model to eating disorders. It appem that dixrepancy arose between clinician's impression of stage of change and the stage detennined as a function of the questionnaire administered to subjects. The complex nature of eating disorders may complicate stage assignment as some individuais may simultaneously engage in behaviours and attitudes reprrsentative of more than one stage. Fuither, the study of eating disorders compared to other problem behaviours may be complicated by the fact thet binge eating is subjective compared to
behaviours where abstinence is the fdgoal of ûeatment (Watd et al.). j A final study by Levy (1997) lends support to the application of the transtheoretical / model of change to BN. Stages of change. processes of change and treatrnent preferences were 1 assessed for 139 subjects with a pst or current diagnosis of BN. Results indicated that subjects i prefened treatment approaches that were compatible with their cumnt stage and process of change. Overall, etidence supports the application of the transtheoretical model of change to
eating disordes, specifically bulimia nervosa. Although binge eating as a distinct behaviour
has not been investigated, application of the stages of change to AN and BN lends support to
the investigation of the model in the absence of compensatory behaviours. Funher, research to
date has not been published on the decisional balance constnict of the transtheoretical model as
it might apply to the behaviour of binge eating.
A higher incidence of psychopathology among individuals diagnosed with BED has
ken demonstrated in several studies (Eldredge, Lockes, & Horowitz, 1998; Fairbum et al,
1998; Villejo, Humphrey & Kiisehenbaum, 1997; Wilfley et al, 1993). A cornparison of obese
binge eaters and obese nonbinge eaten noted an increase in psychiatrie symptomatology
among those who binge @e Zwann a al., 1994; Marcus, Wing & Hopkins, 1988). Similar
mults were rrported by Yanovski, Nelson, Dubbert & Spitzer (1993) as subjects with BED
were more likely than those without BED to -ive lifetime diagnoses of panic disorder, major
depression, borderline pemnality disorder, ad avoidant pmonality disorder. Contrary results
were reported by Brody et al. (1 994) in which measutes of psychopathology failed to
diffcrntiate ktween subjects with and without BED. Brody et al. proposed that a weight continuum may exist to explain the varying degrees of syrnptomatology exhibited among obese subjects, suggesting that those with the greatest weight problems experience the most distress.
Niego et ai. (1997) identified a positive relationship ktween binge eating severity and degree of psychopathology. Further studics have found similar nsults in the relationship between obesity, binge eating and psychopathology (Telch & Agras, 1994; Vendetti, Wing, Jakicic,
Butler & Marcus, 19%). While obesity was not found to relate to psychopathology, a positive relationship was identified between binge eating severity and symptoms of psychopathology.
Therefore, the psychological well-king of bingers may k related to additional characteristics of the binge eating experience (e.g.., fmluency, volume of food consumed, affective response, and sense loss of control). A study of substance addicts during the fust year of recovery indicates that psychological symptoms were fond to decrease as a function of substance-fiee time (Sutherland, 1997). Thus, the level of psychological distress experienced by bingea may relate to the stages of change and fkquency of the behaviour.
Phenomenolom of Binne Eatinn- and Smoking
Beyond the decision rnaking process and psychopathology, both binge eating and smoking can be identified through characteristics that are similar and unique to both behaviours. For instance, it has been demonstrated in the literatwie that prior to a binge episode, individuals with BN report a heightened level of negetive affect (Davis, Fmman &
Garner, 1988; Davis, Freeman & Solyom, 1985; Fdrbum & Cooper, 1993). Occumnce of a similar emotional experience among individuals who binge eat in the absence of a disorder remains to k seen. As well, the afféctive experience of srnokers in cornparison to binge eaters warrants evaluation to determine whether the khaviours serve a similar fùnction. Further chmcteristics such as age of onset and fkquency provide insight into the history of the
behaviour and ability and motivation to change. 1 Purposes and Hvwtheses of the Pment Study The main putpose of the prcsent research was to examine the applicability of the stage / consmict and decisional balance to individuals who binge eat or smoke. For smoking, applying
1 these constnicts involved a replication of previous research (Prochaska, & DiClemente, î983),
, while for binge eating, the pattern of results would help to detemine whether the mode1 can be
extended to include this behaviour. It was predicted that individuals in different stages of
change (precontemplation, contemplation, action, maintenance, and ncovery) would exhibit
different profiles on the decisional balance measure, with the relative weight assigned to the
pros and cons of modifjing the behaviour varying across the stages. Progression fiom
precontemplation to action was expected to involve an increase in the pros of eliminating a
khaviour and a decrease in the cons of eliminating the sarne behaviour. The profiles of
decisional balance scores were assessed for di fferences between subjects with a history of
either binge eating or smoking.
The second goal of the current study was to examine the psychological syrnptomatology
exhibited across the various stages of behavioural change. It was predicted that the amount of
psychological distress would vay accordhg to stage of change. Based on the results of the
study in which psychological symptoms decrrclsod as a function of substance-fke time
(Sutherland, 1997), individuals identifying with the maintenance and recovery stages were
predicted to report les psychological disüess than those at earlier stages of change (i.e..
precontemplation, contemplation, and action). Once again, sirnilaritia or differences between
people with smoking ot binge eating histories were explored. The finai goal was to explore the phenomenology of binge eating and smoking. Several exploratory measms were used to examine various characteristics of the khaviours such as the psychological experience, and historical factors such as age of onset and fiuency.
Cornparisons were also made between binge eating and smoking in tenns of the behavioural experience and as a function of the stages of change.
Methoâ
Particibants
Male and female participants were recniited through announcement and advertisement at Lakehead University @ = 21), Confederation College (o =34), the Thunder Bay Police Force
(n = 34). a national-level judo cornpetition (n = 2O), and rlected locations in the community (n
= 84). Recruitment of participants involved poster advertisements and public presentations.
Participants were read a description of the purposes and procedures of the study (Appendix A). and then asked to sign a consent fonn attesting to their voluntary, infomd consent to participate (Appendix B). Participants then cornpleted a one-page scmning instrument designed to categorize participants according to the bchaviour with which they self-identified; binge eating, smoking, or neither (Appendix C). Upon xlf-identifjing with a behaviour, each participant completed a corresponding package of measures that required approximately 20 minutes of their time.
Measures
Screeninn Instrument for Behaviours (SB). Participants cornpletcd a two-part series of questions desiped to gather peftonal information. Part 1 consisted of several items related to gender, age, ethic beckground, school employment status, height and weight. The second part seived as a xreening instrument through which participants decideci whether they Transtheoreticd Model 13
' exhibited the behaviour according to the description provided (se Appendix C). Participants then completed one of two questionnaire packages depending on the behaviour they identified
with, or a third package if they did not identify with the binge eating or smoking cntena.
Control subjects completed only the Brief Symptom lnventory (BSI); providing a cornparison
group for the bingers and smokers. Al1 merisures were completed by bingers and smokers, with
appropriate revisions made to reflect the respective behaviours.
Stage of Change Inventory KI). The SC1 (Davis, 1996) is a self-report instrument that
assesses cmnt stage of change for a variety of eating disordered behaviours including binge
eating. This instrument was adapted and used as the staging instrument for binge eaters and
smokers in the present study. Stage of change was exarnined through the endorsement of
statements reflecting the stage of change for each behaviour (see Appendix Dl and D2).
Statements were rated along a fivapoint xale, with each representative of a différent stage of
change fiom precontemplation through recovery. The recovery stage applied to individuals
who (a) wdto engage in the behaviour, (b) felt they had overcome the problem, and (c)were
cofident that they would not retum to the behaviour in the friture.
Universitv of Rhode Island Channe Assessrnent Scale (URICA) Revised. ûriginally,
lengthier staging questionnaires such as the URKA werc developed for use with clients in
outpatient psychothempy (Prochaska & DiClemente, 1982). However, shorter, adapted
instruments have been found to be as equally effective in staging subjects across a wide range
of problem beheviours including smoking cessation (Dijkstra et al., 1996). opiate addiction
(Tejem et al., 1997), weight conûol (Prochaska et al., 1992). and across 12 other problem
behaviours including condom use, exercise acquisition, high fat diet, mammography rreening,
and adolescent delinquency (Prochaska, Velicer, et al., 1994). The shorter stsging instruments have the advantage of decfeasing the arnount of misclassification that ofhresults hmtied scons or incomplete sale scores. The longer URICA was used in the present study as a measure to establish concumnt vaiidity for the SCI. Separate 40-item versions of the URiCA were used to assess the stages of change for binge eating and smoking (see Appendix El and
E2). A five-point likert format was useâ to score the items on each scale, with higher scores indicating greater agreement with t&e cognitions, attitudes and affect assaciated with each stage of change. Items on the binge eating version of the URICA were subjected to peer review and modified from the general form to more accurately reflect binge eating behaviour. In the case of tied scale scores, adjacent sale scores were evaluated and participants were assigned to the sale with the highest adjacent score. As this method of assignment is potentially problematic. the requirement of a simple, forced-choice staging instrument such as the SC1 becomes more apparent.
Behaviour Characteristics of Binne Eatinn IBCBE) and Smoking (BCS). A two-part questionnaire was administered in two foms to participants in each group to assess specific characteristics of binge eating and smoking such as fiequency and affective response to the behaviour (set Appendix Fland F2). Part 1 was used to gather information related to the duration over which the behaviour occumd, the age it began and the time span over which it was most ftequent. Part II involved a set of statements reflecting various physical, and psychological characteristics related to either bhge eating or smoking. Scales for each behaviour were created a priori based on the face validity of the items. For bingers, four scales were creatd to explore the behaviour in ternis of volume of fwâ, loss of contml, affective experience and psychological fùnction. Two scales were mateci for smokers to explore the affective experience and psychological funetion of smoking. Pmicipents were requird to evaluate each statement for petsonal devance along a five-point likert deranging fiom
"never" to "always."
The decisional balance
measme was onginslly designed to assess the decision-malring component of the
üanstheoretical model. Two fonns of the measure wete modifieci hmthe decisional balance
sale developed by Velicer et al. (1985) to assess and predict smoking status on the bais of the
pros and cons of quitiing. The 20-item self-report questionnaire evaluated 10 pros and 10 cons
of smoking and binge eating in accordance with the measun developed by Velicer et al. (see
Appendix Gl and G2). Potential items were subjected to peer review for content and
applicability and were deemed to adequately reflect the behaviom in question. Participants
rated each item for agreement along a five-point Likert sale, ranging fiom "not important at
all" to bbextremelyimportant". Raw scores for the pros and cons were then converted to
standard (T) scores with a mean of 50 and a standard deviation of 10. In a study of 12 problem
behaviours, Prochaska, Velicer, et al. (1994) found a consistent pattern in the relative
importance assigned to the pros and cons across the stages of change. Movement hm
precontemplation to action has bm found to involve an increase in the pros of changing a
khaviour, and a decmse in the cons; progressions referred to as the strong and weak
principles, respectively (Prochaska, 1994). Intemal consistencies were cakulated for the pro
. and con scales foi bingers and smokers in the pnsmt study.
bief Svm~tominventorv @Sn. The BSI @erogatiq 1993) was administereâ as a measure
of cumnt psychological distress within the cntire sarnple of self-identified binge eaters,
smokers, and controls. (see Appendix H). A 5-point sale wos used to rate each syrnptom in
tcmis of distress the individual !us experienced in the past 7 days, ranging hm'hot at dl" Transtheoretical Mode1 16 through "extremely." Scons on the BSI were calculated for the Globsl Sevcrity index (GSI), the nine primary symptom dimensions and additionel items. Reliability investigations indicate that the BSI has an interna1 consistency (Cronbach's alpha) ranging hm.7 1 on Psychoticism to .85 on the Depression âimension, bascd on a sample of 7 19 psychiatrie outpatients
(Nunnally, 1970). Test-tetest coenicients ranged hm.68 for Sornatization to .91 for Phobic
Amiety for 60 nonpatients rcassessed acmss a two-week intemal (Nunnally).
Binne Eatina Adiective Checklist [BEAC) and Smoking Adiective Checkiist (SAC). This checklist was wdto ascertain the foelings an individual experiences in relation to binge eating
(Davis & Jarnieson, 1999). A simiiar version of this checklist was adapted for use with smoken (SAC). The checklist contains 1O3 items. Participants were required to indicate the words that described the moods and feelings experienced immediately before or during an episode of binge eating or smoking (see Appendix Il and 12). A composite score was calculated to reflect the overail negative psychological experience aswciated with the behaviour before and duing the act.
Results
Characteristics of Particimts
A total of 193 participants completed the questio~akpackage. Two people were eliminated hmthe study for incomplete questionnaires. The remaining 19 1 participants were divided into 3 groups; controls @ = 64), bingers Q = 47) and smokers (D = 80). Table 1 provides the means and standad deviations of each gmup for the variables of gender, age, height, curent weight and ideal weight. The pupswere not significantly different on any of these variables. Table 1
Characteristics of Particimts
Group d
Controls Bingers Smokers Variable (n = 64) (n =47) (9 = 80) Statistic P
Gender: female YO Age (Y-) &M
Height (inches) M 0 Cumnt weight (pounds) M ldeal weight (pounds) M
--Note. F tests have dfs = (2, 188). Transtheoretical Model 1 8
Intemal Consistencies of Measures
Interna1 consistencies were calculated for the UiWA scales, the Decisional Balance scales, and the Behavioural Characteristics (Pari 11) desfor bingers and smokers. The
Cronbach's alpha coefficients for each &item URiCA scale were as follows: (a) precontemplation (items 1.5, 13, 1 5,28,32,36,38) a = .8 1 for bingers and .65 for smokers;
(b) contemplation (items 2,4,9, 14, 18,23,26,29) a = .91 for bingers and .90 for smoken; (c) action (items 3,8, 1 1,'16,21,24,31,37) a = .93 for bingers and .84 for srnokers; (d) maintenance (items 6,10, 19,22,27,33,35,39) a = .87 for bingers and .84 for smokers; and
(e) recovery (items 7, 12, 17,20,25,30,34,40) a = .94 for bingers and .95 for smokers.
The Decisional Balance measure consisted of two 10-item scales. For the pro scale (al1 even-numbered items) a = -91 for bingers and .84 for smokers. nie con sale (al1 odd- numbered items) had reliability coefficients of a = .82 for bingen and .85 for smokers.
Subscales for the ôehavioural characteristics measm were detennined a priori for bingers and smokers. Intemal consistencies for the four scales applicable to bingers were: (a) volume (items 6, 14, 15, 16) a = .8 1 ;(b) control (items 7,8,9, 10, 1 1, 13) a = .90; (c) affect
(items 12, 17, 19,20,22,23) a = .92; and (d) funetion (items 18,21) a = -65. For smokers. the two subscales were found to have the following intemal consistencies: (a) affect (items 6, 8,9,
1 1, 12) a = .83; and (b) function (items 7, 10) a = .76. 7
A cross-validation was perfomed between the URICA and the SCI. The single-item
SC1 cornlateci 1= 54 @ < .001) with the UNCA stage for bingers and 1 = .84 @ < .Ml) for 1 smokers. Table 2 displays the SC1 staging assignment of bingers and srnokers. For bingers, 47 I 1 participants identifiecl with the criteria for binge eating and 45 were assigned to one of the t stages of change. Two bingers did not complete the staging question and were treated as
) missing. Eighty participants identifml themselves as piesent or pst smokcrs and were
/ assigned to a stage of change based on their SC1 responses. The overall distribution of
! participants was bimodal, with a higher number of participants assigned to the contemplation
, and recovery stages:
Stages of Change and Decisional Balance
Separate one-way analyses of variance were conducted on the pro and con scale scores
for bingers and smokers to determine whether the Decisional Balance sales differed across the
stages of change. In order to control the farnilywise enor rate, a Bonferroni correction was
applied. The more conservative significance value was calculated at p = .OSR = .O25 for each
scale.
For bingen, the raw means and standard deviations for the five stages of change and the
two decisional balance scales are pnsented in Table 3. The pro scale was significant, E(4,38)
= 6.05, p <.O1, as was the con scale, E(4,38) = 5.3 1, p c.01, indicating differences in
decisional balance scores across the stages of change. To determine exactly how the decisional
balance scales differed acmss the stages, pst hoc Student-Newman-Keuls tests werc
conducted. Amongst bingers, precontemplators scored significantly lower on the pro scale than
action-taken and maintainers, while participants in recoveiy also scored lower than those in the
action and maintenance stages. The& results suggest that those individuals who are attempting
to change or who have recently changed their behaviour place gicater value on the benefits of
changing compmd to people in the other stages. A similar pattern ernerged on the con scale, as Transtheoretical Model 20
' Table 2
Distribution of the Numbcr W of Particwnts Accordinn to gr ou^ and the SUQCof
Gmup
Smokers -n Pncontemplation Contemplation
Action Maintenance
Recovcry
Missing
Total Table 3
Decisional Balance Scores as a Function of Stane of Change for Binaers
Decisional Balance Pmntemplation Contemplation Action Maintenance Rccovery -F e' *
Con sale M 10.01' 17.08 22.71 1 5.40 10.86' 5.3 1 .O02 (ci, (4.95) (7.32) (6.47) (3.OS) (9.1 2)
-Note. Groups with diffemt superscripts are signifieantly different @ < .OS) according to the Student-Newman-Keuls pst hoc andysis. F tests have &fs = (4.38). was evaluated againsi the Bonfemni sipiticance criterion of .O25 , / participants in the action stage were found to have significantly higher scores than those in
precontemplatioi! and rccovery, suggesting that individuals in the thmes of change are also
more aware of the negative aspects of changing their behaviour.
Table 4 presents the findings for smokers, with significant results for both the pro scale.
-F(4,72) = 4.32, e <.O1 and the con scalc, F(4,72) = 2.99, p c.025. Student-Newman-Keuls
testing revealed that precontemplatoa scored significantly lower on the pro scale thm
participants in the stages of contemplation, action, maintenance and recovery. These results
suggest that ptecontemplators placed the least value on the positive aspects of changing their
behaviour compared to individuals in any other stage of change. On the con scale,
contemplators were found to score significantly higher than precontemplators, indicating a
greater concern over the negative effects of behavioural change.
To place the cumnt findings in the context of previous research (Prochaska, 1994;
Prochaska, Velicer, et ai., 1994), raw scores for the pro and con scales were converied to
standardized 1scores with M = 50 and = 10. Figure 1 depicts the standardized means for
the pros and cons plotted as a f'unction of stage of change for bingers. Movemeni fiom the
precontemplation to action stage involved an increase of 1.60 on the pro de.This finding
is consistent with the strong principle of change (Prochaska, 1994). However, movement from
precontemplation to action also involved an increase on the con sale of 1.65 m.This finding
is contrary to the decrease that was predicted by the weak principle of change. The relative
emphasis placed on both the pros and cons of change was found to decrease fiom action
through neoveiy .
Standrvdized means for the pros and cons according to stage of change for smokers are
, pmented in Figure 2. The pros were found to incrcase by 2.55 hmthe precontemplation Table 4
Decisional Balance Scores as a Function of Staae of Chanee for Smokers
-- Stage of Change L Decisional balance Pmntemplation Contemplation Action Maintenance Recovery -F P
Con scale
-- - .. - - -. -- -Note. Groups with différent superscripts are sipificantly different @ < -05)accotding to the Shdcnt-Newman-kuls post hoc anal ysis. F îcsîs have &fs = (4.72).
OE was evaluated against the Bonfmni significance critenon of .025. Tmstheoretical Model 24 I mure 1. Standardized 1scores (EI = 50, = 10) for the pro and con scales of the Decisional Balance measun plotted as a fùnction of stage of change for bingers. Transthcoretical Mode! 2 5
/ - Pros -- -
Tramtheoreticai Mode! 26 mure 2. Standardized 1 scores = 50, = 10) for the pro and con scales of the Decisional
Balance measure plotted as a function of stage of change for smokers. + Pros + Cons to action stage. This result is consistent with the strong principle of change, although the
magnitude of the change was even greater than pndicted. For the con de,movement fiom
( precontemplation to action involved an increase h the cons of 1.57 m.An increase of 1.8 1
/ was found between pmontemplation and contemplation, while a dectease of -.24
occdbeâween the contemplation and action stages. The ovedl hcrease that occurred on
the con scale is contiary to the decrease that was predicted by the weak principle of change.
To swkmrize the mults thus far, suppon was found for the strong principle of change
for both bingers and smokea. The weak principle of change was not supported by the data for
bingers or smokers. The cons were found to increase fiom the precontemplation to action stage.
The relative importance placed on both the pros and cons of changing was found to
significantly decrease from action through recovery for bingers. although this pattern was not
replicated for smokers.
BSI Scores for gr ou^ and Staae of Channe
A one-way analysis of variance was conducted to determine if controls, bingers. and
smokers differed significantly on the BSI Global Severity Index (GSI). A sipificant difference
was found between groups, I32, 187) = 4.66, p <.O2 (see Table 5). Post hoc cornparisons using
the Student-Newman-Keuls test revealed that bingers scored significantly higher than controls
on the global measwe of psychological distress.
The nine BSI subscales and the composite of four additional items were testeâ using a
Bonferroni comction calculated as a = .OS110 = .00S. A significant difference was found
between groups on the Hostility scale, E(2, 185) = 5.87, g <.MM. The Student-Newman-Keuls
test revealed that controls scored significantly lowa than bingers and smokers on Hostility. A
Merdifference was found between groups on the Somatization scale, F(2.185) = 7.40, g - - Table 5
Dimerences ktween Grouos on the Brief S~mptomInventory (BSI)
BSI scale Controls Bingee Smokers -F P
Global Severity Index
Additional items
Anxiety
ûepression
Hostility
Interpersonal smsitivity
Obsessive-compulsion
Transtheoretical Model 3 1
c.002, with controls scoring significantly lower than bingers and smokers. No si gni ficant
differences were found between groups on the nmaining seven scales or on the additional
items.
Separate one-way analyses of variance were conducted to determine whether the GSI
differeâ significantly as a function of stage of change for bingers and smoken. Table 6 presents
GSI means and standard deviations as a function of stage of change and behaviour. GSI scores
wmnot found to Vary across the stages for bingers, E(4,39) = .86, p = .49, or for mokers, F
(4.74) = 1.46, g = .22. A Bonferroni correction calculated at a = .05/10 = ,005 was applied to
the 9 subscales and additional items of the BSI. The analyses of variance indicated that no
significant differences were found on the BSI subscales for bingen or smoken across the
stages of change.
Phenomenolow of the Behaviours
Several exploratory measures were utilized to examine various aspects of binge eating
and smoking behsviour. Areas of partirulu research interest included volume, control,
hction, and the psychological experiences associated with the behaviours. Additional
historical characteristics were also exarnined such as fkquency and age-related factors. 1 ihe BEAC was used to evaluate the psychologieal experience immediatcly before and while engaged in the khaviour for both bingers and smokers. A repeated-measuns anal y sis of
variance was conducted on the BEAC composite scores, with group as the between-subject
effect (binger versus smoker) and time as the within-subject effect (kfore versus during). The
main effeet of group was significant, E(1, 125) = 6.5 1, p c.05, as was the main effect of time.
-F( 1, 125) = 38.04, e ç.01. The Group X Time interaction was not significant, E(1, 125) = -00,g
= .W.Figure 3 dcpicts BEAC composite scores for bingers and smokers plotted as a huiction --- - - Table 6
Brief Svmptom lnventory (BSI) Global Severitv lndex [GSll as a Function of Staee of Change for Bingers and Smoken
# Stage of Change
BS1 Precontemplation Contemplation Action Maintenance Recovery -F E
Bingers
GSI
Smokers
GSI
Note. dfs = (4,39) for bingers and df = (4,74) for smokers. Transtheoretical Mode1 33
Adjective Checklist composite scores for bingers and smokers plotted 1 as a function of time.
Transtheoretical Mode1 35 of time. Bingen reported a greater magnitude of negative affective and somatic experience compared to smokers. Howevcr, both groups reportai signifiant mductions in these experiences when they were engagcd in binge eating or smoking. These nsults suggest that for both bingers and smokers, the act of engaging in the bchaviour serves a psychological fùnction.
Additional feams associated with binge eating adsmoking were examined according to responses on the Behavioural Characteristics scales (Part II). Mean totals, standard deviations, and analysis of variance results are displayed in Table 7 for bingers. The binge- eating items comptised four scales evaluating control, negative affect, volume of food, and function. A Bonferroni criterion for significance was calculated at a = .O514 = .O 125 for each test. A significant one-way analysis of variance found that bingers differed as a fùnction of stage of change, E(4,39) = 7.04, p <.001. A Student-Newman-Keulstest indicated that precontemplative bingers differed significantly ftom contemplators, action-takers, maintainers and recovered participants as they reported less loss of control than participants in al1 other stages.
The affect xde for bingers quantified the negative emotional experiences associated with binge eating. Significant differences were found ôetween stages on the composite of items reflecting distress, disgust, depression, guilt and helplessness towards binge eating, E(4.39) =
7.04, p c.001. Participants in pmntcmplation and ncovery nported significmtly lower aswiated etcompared to action-takea, and maintainers. Participants who have recently changed or are curmitly in the midst of changing their binge eating behaviour ~portedmore negative affect in relation to binge eating than those in mvery and pmnternplation.
Function and volume sale scores did not differentiate across the stages of change for bingers. Thercfore, the positive bction that bingc eating serves such as pleaswe and relaxation was the same for participants in al1 stages of change. Further, the volume of food and rate of consumption did not differentiatc among the stages. nius, observed differences between the stages of change in loss of control and negative affect were not significantly related to the volume of food consumed.
Table 8 presents the means and standard deviations for srnokers across the stages of change for the negative affect and hction scdes. No significant differences were found across the stages for either de,using the Bonferroni correction of a = .OS/2 = .O25 Thus, srnokers rrported consistent levels of negative affect and fiction, regardless of stage of change.
The Behavioural Characteristics questionnaire (Pari 1) exarnined the history of binge eating and smoking across the stages of change. Descriptive statistics for the items relating to age-related and kquency-nlated variables are displayed in Table 9 for bingers. Separate analyses were conducted with a Bonferroni critenon of a = ,0515 = .O 1.One-way analyses of variance were conducted on the two age-related variables and no significant differences were found for bingers. ffisl 28 days. Contemplators reporteci the highest numkr of binges with a median kquency of 8. No significant diffennces were found between groups on the two maximum frequency-related variables. Table 8 Behavioural Characteristics Scales (Part II) as a Function of Stage of Chans for Smokers 8 Affect Func t ion -Note. P = prnntemplation, C = wntmplation, A = action, M = maintenance, R = rrcovery. was evaluated against the Bonf-i signifiame criterion of .OîS. Table 9 Behiwioural Characteristics 4 Part 1) as a Function of Stage of Change for Binaers Age at first episode M 14.0 21.3 12.3 13.5 15.0 -F = 1.38 .26 (6, (3-2) (1 5.8) ( 1 -6) (3.0) (2.5) Age began rcgular episode M 16.0 24.4 16.8 15.5 17.2 -F = 1.32 .28 (ZIJ (4.7) (1 5.7) (4.2) (2.4) (3-2) Cumnt frosuency -Mdn 3 .O 8.0 2.0 O0 .O0 X2 = 20.08 .O0 1 over past 28 days Maximum fiequaicy -Mdn 3.0 10.0 12.0 15.0 7.5 x2 = 1.34 -85 ever over 28 &ys Months at maximum -Mdn 12.0 9.0 21.0 4.0 12.0 x2 = 5.28 .26 z- Note. P = prrcontmiplation, C = contemplation, A = action. M = maintenance, R = rexovery. aO > was evaluWd against the Bonfmni significancc criterion of .01. Transtheoretical Mode1 For smokers, a significant diffemice was found on the cumnt daily hquency item, X2( 1) = 6).W, g < .Oi (see Table 10). As expected, participants in recove y reported a 1 median fkquency of O. However, caution should be taken in the interpretation of fhquency 1 totals for both the precontemplation and maintenance stages as a result of small ce11 sizes. For example, in the maintenance stage, one participant reprted not smoking at al1 over the past 28 days, while the other reporied smoking 20 cigarettes during this time, contrary to the staging definition for maintenance. Thus, the current median fkquency was 10, above the expected fiequency for self-identified maintainen. No significant differences were found between groups on the age-related and maximum fkquency-nlated variables. -s -s Decisional Balance as a function of stage of chan= Partial support was found for Prediction 1, as the strong principle of change was evidenced for both bingers and smokers. Movement hmprecontemplation to action involved an increase greater than 1 for the pro scale. However, support was not found for the weak principle of change, as con scores actually increased hmprecontemplation to action, a finding opposite to that predicted. Psvcholo~icaldistress as a fùnction of suine of change. Support was not found for Prediction 2 as the index of distress did not decrease in the maintenance and recovery stages compared to the earlier stages of change. However, regardless of stage of change, group differences were found between controls, bingers, and smokers: (a) bingers scored higher than controls on the GSI, (b) bingers and smokers both scored higher than controls on the Hostility scale, and (c) bingers and smokers both scored higher than controls on the Somatization xale. Phenomenolonv of the behaviouis. The exploratory measuns revealed the following about binge cating and smoking: (a) Both khaviours mea psychological fwiction in Table 10 khavioural Characteristics (Part 1) as a Function of Stage of Change for Smokers O SC1 Age at first episode M 13.7 15.1 12.5 13.5 15.0 -F= 1.17 .33 (fi (3*2) (3.3) (4-1 (3.5) (3*3) Age began rrgular episode M 16.0 17.4 15.3 19.0 17.1 -F = .49 .75 (6 (4.9) (2.6) (2.8) (4.3) Current fquency -Mdn 14.0 280.0 252.0 10.0 .O0 x2=63.09 .00l0 over past 28 days Maximum kquency -Mdn 56.0 331 .O 406.0 700.0 420.0 x2= 8.25 .O8 ever over 28 days Months at maximum -Mdn 6.0 21 .O 12.0 139.5 120.0 x2 = 1 1.32 .O23 fros-cy -- Note. P = prrcontemplation, C = contemplation, A = action, M = maintenance, R = recovery. > was evaluateû againsi the Bonfemni signifieance criterion of .Ol . decreasing the level of affective and somatic distress. (b) Bingers in the precontemplative stage experience less loss of control and negative aitthan bingers in the other stages of change. (c) Bingers in the rnidst of change (i.e., action) report the greatest loss of control and negative affect asxniated with binge eating. (d) As expected, cumnt behavioural fnquency over the last 28 days differed as a function of stage of change for both bingers and smokers. Discussion ~everdlimitations of the present study must be noted. The mal1 sample sim calls for caution to be exercised in the interpretation of the msults. This problem is paiticularly evident in the smoking sample where the precontemplation and maintenance stages have very small nwnben. An additional limitation exists in the use of the staging instrument for bingen and smokers. DiRculties noted with the URiCA such as tied and missing scale scores has led to the creation of shorier staging algorithms such as the SCI. However, in the present study, the SC1 was not entinly accurate and resulted in a false-positive misclassification for 1 out of 80 smokers. Although the SC1 has good concurrent validity with the URICA, chere is a lack of collateral or biological meauws with which to furthet validate the instrument. Lastly, binge eating may be more ditricult to ciassify into distinct stages than other problem behaviours as binge eating is dependent upon an individual's subjective perception of food consumption versus complete abstinence hma behaviour such as smoking. In spite of the limitations discussed, the results of the study tend to support the utility of the stages of change mode1 and decisional balance for bingers and smokea. For both behaviouts, the pros of changing the behaviour were found to increase one or more standard deviations fiom precontemplation thugh action, as predicted by the strong principle of change. For bingers and smokers, the total con score was also found to increase hm precontemplation through action contrary to the weak principle. For bingers, the con sale continuously increased through the action stage, while for smokers an increase occmd from precontemplation to contemplation, followed by a decrease towatds action. For smokers, the lack of support for the weak principle of change may be a reflection of the very small nurnber of participants in the action stage. An altemative explanation may k that participants were misclassified in some cases, although similar results were found on the pro and con scores when the URICA was used to stage participants. For both khaviom, the pro and con scores decreased from action towards recovery, a pattern consistent with previous findings (Dijkstra et al., 1996; Velicet et al., 1985). For bingers and srnokers, the action stage appears to be the critical stage in the decision-making process: Participants in this stage evidence the greatest awareness of the pros and cons for changing their behaviour. The decrease in these scores towards recovery suggests that once the decision to change has been made, the reasons motivating the change decrease in importance. Further, participants in the precontemplation stage do not acknowledge their behaviour as a problem as evidenced by the low pro and con scale scores. These results are entirely consistent with the attitudes and beliefs characteristic of this stage of change. For bingers specifically, the results of the staging approach and decisional balance are of particular interest because the mode1 has not previously ken applied to a non-clinical binge eating sarnple. The heightened pro and con scores in the action stage correspond with an increase in the negative oiffcct and loss of control desthat was also found in this study. These findings suggest that jwticipants in the thioes of changing theu binge eating are most aware of both the negative and positive consequences and dso experience the greatest negative affect and loss of control regarding their behaviour. The effort required to change may k greatest at this stage as the individual is confronteci with the consequences of changing their behaviour thereby contributing to the loss of control and negative affect characteristic of this stage. The amount of psychological distress experienced by bingers and smokers did not differentiate between the stages of change as predicted. Based on addictions research with a drug and alcohol abusing sample (Sutherland, 1997), participants in the maintenance and recovery stages were predicted to exhibit less psychological symptomatology than the other stages of change as a function of the arnount of substance free time. Results of the study were not in support of this prediction. The lack of support may again be attributed to the previously discussed limitations, as it was found that one self-identifying maintainer had smoked at a fiequency comparable to participants in the other stages of change over the last 28 days. Therefore, the level of psychological distress experienced as a fiction of substance free time cannot be evaluated in this situation. However, differences were found between bingen, smoken and controls on the measuies of psychological distress regardless of stage of change. Bingers were found to experience more distress than smokers and controls as indicated on the Global Severity Index of the Brief Syrnptom Inventory. This finding is consistent with previous research indicating a positive relationship between binge eating severity and psychological functioning (Fairbum et al., 1998; Marcus et al., 1988; Spitzer et ai., 1993). Fherdifferences emerged between the groups on the Hostility and Somatization scales. Control subjects were found to exhibit less psychological distress than eithet bingers or smokeis. However, causality cannot be detennined in the relationship between ptoblem behaviours and psychological hctioning. Signifiicanly, it cannot k detennined whether engaging in the problem behaviour leads to psychological distress or whether the lcvel of distress experienced causes someone to 1 Transtheoretical Mode1 45 1 engage in the behaviour. Further questions temain ngarding the causal relationship across the \ 1 i stages of change and in relation to diffetent muencies and severity of the behaviour. i Regarding the phenomenology of binge eating and smoking, several interesting findings ' emerged through the use of the exploratory meames. In accordance with the lite~eon eating disorders, bingers and smokea nported a higher level of negative affect prior to engaging in the behaviour (Davis et al., 1985). Therefore, a psychological function is served by engaging in iither binge eating or smoking as detemined through the BEAC and SAC composite scores. Binge eating appears to have greater psychological consequences than smoking regardless of stage of change. For bingen, the amount of loss of control and negative affect experienced in relation to a binge eating episode was found to Vary across the stages of change. Pncontemplative bingers reported experiencing more control and less negative affect regarding their binge eating than did individuals in any of the other stages. However, these individuals were binge eating with a comparable fkquency and volume as the other bingers. Therefore, the psychological impact of binge eating for prccontemplators is much less than the othet stages. It is difficult to determine whether binge eating is less problematic for precontemplative bingers or whether they are denying the existence of a problem and inflating their sense of conml ovet the experience. However, the lack of significant differences on volume and fkquency scales suggests that these individuals arr minimizing or denying the existence of a problem behaviour. A similar pattern of responses was found by DiClemente and Hughes (1 990) in a study of aicoholic outpatients. In that study, preconternplative alcoholics consumed a comparable quantity of alcohol as the other stages although tbey reporteci a lower level of loss of control, detenoration and alcoholism. Thus, it appears that across behaviows, the precontemplation stage of change is Transtheoretical Model 46 1 unique in that these individuais engage in the same behaviour as others although they are either psychologicaily resistant to the expenence or minimize the psychological consequences. In contmt, bingers in the action stage were not binge eating any more kquently than the other stages although they reported the greatest arnount of negative affect and loss of control. Further, these individuals scored significantly higher than the others on both decisional balance measures. Thenfore, for individuals in the midst of change, both the positive and negative consequences of their behaviour are emphasized and they expetience the most distress in relation to their binge eating. Once again, the issue of causality can be raised in this situation: Either action-takers are moved to change their behaviour because of the amount of psychological distress caused by their binge eating, or the process of changing their binge eating behaviour impacts negatively on their psychological hctioning. Interestingly, individuals in maintenance and recovery report similar levels of loss of control as contemplators and action-takers when reflecting on their past behaviour. However. maintainers report a significantly higher amount of negative affect than those in recovery. For those in the maintenance stage, the persistent concem and effort requind to prevent a relapse may maintain the negative affect associated with their previous behaviour. In corn parison. individuals who consider themsclves recovereâ hmbinge eating hold a less negative view of their previous behaviour. Thenfore, the negative affect experienced by pest bingers may be attributed to the present level of concem and confidence related to maintaining the behavioural change. This distinction in negative affect provides support for the inclusion of a stage beyond maintenance as the two stages arc characteristically different. Additionaily, recovered binge eaten report significantly fewer pros of changing their behaviour than maintainers. Transtheoretical Model 47 While the results of this study support the extension of the tmnstheoretical mode1 and decisional balance to binge eat ing , Merexploration is certain1y warranted. A longitudinal study is nquired to determine the influence of the pros and cons of quitting and psychological distress on movement thiough the stages of change. Inclusion of an additional source of validation for the staging instnunent would be beneficial in reducing the misclassification of participants. For smokers, a test for nicotine dependence rnay provide an additional source of information bdfor bingers a food diary might prove fniitfbl. As well, for binge eating participants, a measure should k included to assess compensatory behavioun such as vomiting and/or laxative usage. Within the present study, it is possible that some of the bingers rnay be engaging in compensatory behaviours, indicating a disorder of a more serious pathoiogical origin. ldentibing these individuals rnay provide a fierunderstanding of binge eating in the presence and absence of an eating disorder. Questions regarding relapse and the number of attempts at change rnay be useful in Merunderstanding the change process among binge eaters. Lastly, including an opportunity for participants to provide an explanation of any intervention saategies they rnay have relied upon such as the nicotine patch for smokers rnay provide additional information regardhg movement towds recovery. I Amencan Psychiatnc Association. (1994). Diamostic and statistical manual of mental disorders(4' edition). Washington DC:Author. \ Beglin, S.J., & Fairburn, C.G. (1992). What is meant by the tem binge? AmeRcan Journal of Psvchiatrv. 149,123- 124. Brody, M.L., Walsh, T., & Devlin, M. J. (1994). Binge eating disorder: Reliability and validity ofa new diagnostic category. Journal of Consultinn and Clinical Psvcholo~v.62,38 1- 386. Castonguay, L. G., Eldredge, K. L., & Agras, W. S. (1995). Binge eating disorder: Current state and future directions. Clinical Pswholopv Review. 15,865-890. Davis, R. (1996). Stages of Change Inventory. Unpublished manuscript, University of Toronto, Davis, R., Freeman, R. J, & Garner, D. M. (1 988). A natudistic investigation of eating behavior in bulimia nervosa. Journal of Consulting and Clinical Psvcholonv. 56,273-279. Davis, R., Freeman, R., 8t Solyom, L. (1985). Mdand food: An analysis of bulimic episodes. Journal of Psvchiatric Research. 1 9,33 1-3 35. Davis, R., & Jarnieson, J. (1999). Develo~mentof the Binne Eatinn Adiective Checklist. Manuscript submitted for publication, Lakehead University. Demgatis, L. R. (1993). Bnef Svm~tomInventorv administration. scorinn. and procedures manual (3" ed.) U.S.A.: National Computing Services, Inc. De Zwann, M. (1997). Status and utility of a new diagnostic category :Binge eating disorder. EuromEatina Disorder Review.S,226-240. De Zwann, M., Mitchell, J. E., Seim, H. C., Specker, S. M., Pyle, R. L., Raymond, N. C., & Crosby, R B. (1 994). Eating related and general psychopathology in obese fmiales with binge eating disorder. Intemational Journal of Eatinn Disortiers. 15,43-52. DiClemente, C. C., & Hughes, S. 0. (1990). Stages of change profiles in outpatient alcoholism treatment. Journal of Substance Abuse. 2,2 17-23 5. DiClemente, C. C., & Prochaska, J. 0. (1982). Self-change and therapy change of smoking bchavior: A cornparison of processes of change in cessation and maintenance. Addictive Behaviors. 7, 133- 142. DiClernente, C. C., Piochaska, J. O., Fairhurst, S. K., Velicer, W. F. Velasquez, M. M., & Rossi, J. S. (1991). The processes of smoking cessation: An analysis of precontemplation. contemplation, and the preparation stages of change. 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Okse binge eaters: Anect cognitions, and response to khavioral weight control. Journal of Consultinn and Clinical Psvcholoq. 56,433439. Tmstheoretical Model 5 1 McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: measumnent and sample profiles. Psvchothera~v:Theorv. Research and Practice. 20.368-375. Niego, S. H.,Pratt, E. M., & Agras, W. S. (1997). Subjective of objective binge: 1s the distinction valid? Intemational Journal of Eatinn Disotden. 22.291-298. Nunnally, J. (1970). Introduction io ~svcholo~icalmeastuement. New York: McGraw- Hill. O'Connell, D., & Velicer, W. F. (1988). A decisional balance measure and the stages of change model for weight loss. The International Journal of Addictions. 23,729-750. Prochaska, J. 0. (1994). Strong and weak principles for progressing fiom precontemplation to action an the basis of twelve ptoblem behaviours. Health Psvcholoev. 13, 1-5, Piochaska, J. O., & Crimi, P., Lapanski, D., Martel, L., & Reid, P. (1982). Self-change processes, self-eficacy and self-concept in relapse and maintenance of cessation of smoking. Pswholonical Remrts. 5 1,983-990. Prochaska, J. O., & DiClemente, C. C. (1982). Tmstheoretical therapy: Toward a more integrative mode1 of change. Psychothera~v.19,276-288. Piochaska, J. O., & DiClemmte, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Jomal of Consultinn and Clinical J%vcholow. 5 1,390-395. Prochaska, J. O., & DiClemenie, C. C. (1 984). Self-change processes, selfsnicacy and decisional balance across five stages of smoking cessation. Advances in Cancer Control: JZ~idemiolonvand Resemh, 131-1 40. Prochaska, J. O., DiClemente, C. C., & Nomss, J. C. (1992). In search of how people change. Arnerican Psvcholo~ist.47,1102- 1 1 14. Prochaska, J. O., DiClemente, C. C., Velicer, W. F., Ginpil, S. T.,& Norcross, J. C. (1 98 5). Predicting change in smoking status for self-changers. Addictive Behaviors. 10,395- 406. Prochaska, J.O., Norcross, J. C., & DiClcmente, C. C. (1994). Chanann For Good. New ~ork:Avon Books. Prochaska, J. O., Norcross, J. C., Fowler, J. L., Follick, M. J., & Abram, D. B. (1992). Attendance and outcome in a work site weight conml program: Processed and stages of change as predictor variables. Addictive Behaviors. 17,354. Pmchaska, J. O., Velicer, W. F., DiClemente, C. C., & Fava, J. (1988). Measuring processes of change: Application to the cessation of smoking. Journal of Consulting and Clinical Psvcholotzv. 56,520-528. Prochaska, J. O., Velicer, W. F., Guadagnole, Rossi, J. S., & DiClemente, C. C. (1991). Patterns of change: Dynemic typology applied to smoking cessation. Multivariatc Behavioral Research. 26,83407. Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G.,Marcus, B. H., Rakowski, W., Fiore, C., Harlow, L. L, Rsdding, C. A., Rosenbloom, D., Rossi, S. R. (1994). Stages of change and decisional balance for 1 2 problem behaviors. Health Psvcholonv. 1 3,39- 46. Spitzer, R. L., Devlin, M., Walsh, B. Te,Hasin, D., Wing, R., Marcus, M., Stunkard. A., Wadden, T., Yanovski, S., Agras, S., Mitchell, J., & Nonas, C. (1992). Binge eating Tramtheoretical Model 53 disorder: A multisite field tnal of the diagnostic cnteria International Joumai of Eating Disordem. 22,191-203. Spitzer, R. L., Yanovski, S., Wadden, T., Wing, R., Marcus, M. D., Stunkard, A., Devlin. M., Mitchell, J., Hasin, D., & Home, R. L. (1993). Binge eating disurder: Its fùrther validation in a multisite study. Intemational Journal of Eatiniz Disorders. 13, 137-153. Stunkard, A.J. (1959). Eating patterns and obcsity. Pwchiaüic Ouarterlv. 33,284-292. ~utherland,1. (1 997). The development and application of a questionnaire to assess the changing personaliiies of substance addicts diiring the first year of recovery. Journal of Clinical Psvcholonv. 53,253-262. Tejero, A., Trujols, J., Heniandez, E., de los Cobos., & Casas. (1997). Processes of change assessrnent in heroin addicts following the Prochaska and DiClemente transtheoreiical model. Dnin and Alcohol De-pendence. 47,3 1 -37. Telch, C. F., & Agras, W. S. (1994). Obesity, binge eating and psychopathology: Are they related? International Journal of Eating Disorders. 1 5, 53-6 1. Telch, C. F., Agras, W. S., Rossiter, E. M., Wilflcy, D., & Kenardy, J. (1990). Group cognitive-behavioral trament for the nonpurging bulimic: An initial evaluation. Joumal of Consultinn and Clinical Psvcholonv. 58,629435. Velicer, W. F., DiClemente, C. C., Prochaska, J. O., & Brandenbwg, N. (1985). Decisional balance measure for assessing and predicting smoking statu. Joumal of Personalitv and Social Pwcholonv. 48,1279-1 289. Vcnditti, E. M., Wing, R R., Jakicic,-J. M., Butler, B. A., & Marcus, M. D. (1996). Weight cycling, psychological health, and binge eating in oben women. Jodof Consulting , and Clhical Psvcholonv. 64,400-405. Villejo, R E., Humphrey, L. L., & Kirschenbarn, D. S. (1997). Affect and self- regulation in binge eaters: E ffcct s of activating fmily images. International Journal of Eat ing Disorders. 2 1,237-249. Ward, A., Tmp, N., Todd, O., & Treasure, J. (1 996) To change or not to change- 'How' is the question? British Journal of Medical Psvcholow. 69, 139-146. Wardle, J., & Beinart, H. (1981). Bhge eating: A theoretical nview. British Joumal of Clinical Psvcholonv. 20.97-1 09. Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole, A. G., Sifford, L., & Raeburn, S. D. (1 993). Group cognitive-behavioral therapy and group interpersonal psychotherapy for the nonpurging bulimic individual: A controlled cornparison. Joumal of Consultinn and Clinical Psvcholonv. 6 1,296-305. Yanovski, S. Z., Nelson, J. E., Dubbert, B. K., & Spitzer, R. L. (1993). Association of binge eating disorder and psychiatrie comorbidity in obese subjects. Arnerican Journal of Psvchiatrv. 150,1472- 1479. Appendix A Cover Lctter Dear Participant: i am conducting a study on the attitudes, beliefs, and feelings that individuals have regarding binge eating and smoking. The purpose of this study is to investigate the dationship between the occumnce of specific behaviours and personal attitudes and feelings about those behaviours. Your participation in this nsearch will help to shed light on the comection between behaviour and attitudes. All information gathered will minconfidentid and secmly stored for a period of seven years at Lakehead University. The general results of the study will be made available to you at your request upon completion of the study. Thank you for you cooperation. Sincerely. aura-tee Clausen Appendix B Consent Form My signature on this form indicates that 1 agree to participate in a study on BEHAVIOURAL / ATTITUDES king conducted by Lam-Lee Clausen. 1 understand the following: 1. 1 am a volunteer and can withdraw at any time fiom the study. 2. There is no risk of physical or psychological hann. 3. The information 1 provide will be contikîential and stored for a pend of seven years. 4. 1 will receive a summary of the study, upon request, following the completion of the I have received explanations about the nature of the study, its purpose, and procedures. If 1 have any questions about the study after my participation, 1 may directly contact Laura-Lee Clausen (researcher) or Dr. Ron Davis (supervisor) in the Dept. of Psychology, Lakehead University, phone 343-844 1. Signature of Participant Date Transtheoretical Model 57 Appendix C -SIB PART 1 Please complete the following questions. Age: yrs Gender (check one): female, male Check one: college student, university student, employed full or part-time. other Ethnic Background: Height: fi.- inches (guess if you don? know) Current Weight : Ibs (guess if you don't know) Desired Weight: lbs PART 2 Please respond as honestly as possible to the following questions by circling your response. 1. Has there ever been a pend of time in your life when you engaged in binge eating? An episode of binge eating is characterid by eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is dcfinitelv limer than most people would eat during a similar period of time and under similar circumstances. (a) = yes If YES, please continue by completing Aimer Package II (skip questions 2 and 3: . (b) = no If NO, please continue with item #2. 2. Has then ever been a period of time when you engaged in smoking cigarettes? (a) = yes If YES, plcase continue by completing Anawer Package #2 (skip question #3). (b) = no If NO, plcase continue with item #3. 3. If then has never kcn a pend of time when you have engaged in either binge eating or smoking as dc~cribedabove plcase continue by completing Aaswer Package #3. Appendix Dl SC1 for Binne Eating Instructions: 1 1. Read BU of the statements within the box klow. I ( 2. Choose tbc letter beside the ou staternent that best descriks you. i 1 3. Circle this letter. 1 t ! Some people binne eat: characterizad by eating, in a discrete period of time (e.g., within any 2- i hour period), an arnount of food that is Pefinitel~ 1- than most people would eat during a 1 similar period of time and under similar circumstances. I 1 1 have binged within the past 3 months but 1 am not concerned about it. 1 just don't see it as a personal problem. 1 have binged within the past 3 months and it concems me. 1 would Iike to stop binge eating but 1 really haven't done anything about it so far. 1 have binged within the past 3 months and it concems me. 1 am dlyûying hard to stop binge eating but sometimes I still have this problem. 1 used to binge but 1 have completely stopped within the past 3 or more months. 1 am concemed that 1 could siarc binge eating again if 1 am not carefûl. 1 used to binge but 1 have completely stopped within the past 3 or more months. 1 believe that 1 have overcome this problem and 1 am confident that 1 will not start doing it again in the friture. Appendix D2 SC1 for Smokine Instructions: 1. Read &lof the statements within the box. 2. Choose the letter hide the statement that bcst describes you. ' 3. Circle this-letter. Some people gmoke: a period of time in their lives when they engage in smoking cigarettes. Select the following statement that best deseribcs you. a) I have smoked within the past 3 months but 1 am not concemed about it. 1 just don? see it as a personal problem. b) I have smoked within the pst 3 months and it concems me. I would like to stop smoking but 1 really haven't dom anything about it so far. c) 1 have smoked within the pa* 3 months and it concerns me. 1 am dlytrying hard to stop smoking but sometimes 1 still have this problem. d) 1 used to smoke but 1 have completely stopped within the past 3 or morc months. 1 am concemeâ thai 1 could start smoking again if 1 am not careful. t) 1 d to smoke but 1 have completely stopped within the past 3 or more months. I believe ùrat I have overcome this problem and 1 am confident that 1 will not start doing it again in the fùture. Transtheoretical Model 60 Appendix El CA Rcvised - BE Instructions: Each statement describes how a pemn might fetl about his or her binge eating. PIease indiate the cxtcnt to which you ACREE or DISAGREE with each statement. In each we,mike your choice in tcnns of how you feel d&t now, not how you would like to fcel. Rien arc FIVE possible responses to each of the quest ionnairc items. Please indicate the letter that kst descnks how rnuch you agree or disagree with each sutement by circling that letter on thc page. As far as 1 un concemcd, I do not hivc any problcms with binge uting that need chnging. 1 think 1 may k nrdy for rome self-improvement in rny binge eating. 1 am doing something about my binge cating that has km boihcrinp me. It mi@t k wonhwhile for me to work on my binge eating. 1 do not have a problmi with binge eating. It doesnvtmake much sensc for me to rnswer these questions. It woma me thrt 1 may slip back into binge uting like 1 uscd to, so 1 m mdy to work on it. 1 uwd to binge ut, h8ve stoppcd. Md it no ionpr conccms me. 1 am finrlly doing wme work to conod my bingc uting. 1 have ben thinking ihrt 1 miy want to stop binge uting. 10.1 have kcn sucrcufbl in controllin8 my binge eating but 1 am not sure 1 cm continue. I 1. At timcs, my binge ating is a dihltpmblem, but 1 un working on it. 12.1 have ben succesrnil in stopping my binge crting and 1 no longer tbuJr abut it. 13. Working on my bine athgis pntty much r wutc of thne for me Wuse it does no 2 1. Evcn though 1 am not alwrys succrsful in changing, I am at lcast working on my bingc cating. 22.1 thoughi once thai 1 had molved my problem wiih binge eating, 1 would k fm of ii, but somctimes I stillfind myself suuggling with it. 23.1 wish 1 had more ideas on how to stop binge cating. 24.1 have s~edto work on my binge ating but 1 would like some help. 25. Binge eating is romething 1 considei to be part of my put. 26. Maybe rorneonc will be able to hclp me with my binge eating. 27.1 may nced a boost nght now to help me maintain the changer 1 have alrridy mrde in my binge ating. 28.1 may k a part of my binp uting pmbkm, but 1 do not mlly think that 1 un. 29.1 hope chat someone will have wme good advice for me about binge cating. 30. Binpc eatinp uscd to trouble me, but now that 1 hvc stoppd 1 no longer wony about it. 3 1. Anyone cm ull< about chnging their binge eitiq; I'm rciuilly doing somethins about it. Transtheoretical Model 62 32. Al1 this elk about psychology is brinp. Why can8tpeople just forgct thcf bingc ating? 33. 1 am working to prcvent myself hmhaving a dapse of binge eating. 34. Since 1 have stopped binge cating, 1 un no longer concemed that 1 could start doing it again. 35. It is fmsmting, but I tee11 might k brving a ncurrence of the binge catin8 pmblcm I thought 1 hdmolved. 36.1 have womcs about my binge cating, but so does the next penon. Why spcnd timc thinking about it? 37. 1 am actively working on my binp cating problem. 38. 1 would nthcr cope with my binge ating than ty to change it. 39. After al1 that 1 have donc io stop binge eating. eveiy now and ihcn it comcs back to haunt me. 40.1 would Say that I am "cureci" of my binge eating. Tramtheoretical Model 63 Appendix E2 URiCA Rcvised - S Instrucdons: Each siaiemeni describcs how a pcaon might feel about his or her smoking. Pkase indicate the cxteni to which you ACREE or DISACREE with each sutement. In cach u~,malce your choice in ternis of how you feel &~t now, not how you would like to feel. Then ue FIVE possible responses to each of the questionnaip items. Plcau indicatc the letter that kstdescriks how much you agmor disagree wiih each siaiemeni by cjrclinp that letter on the page. As fu as 1 am concemed, 1 do not have any problcms with a) smoking that necd chrnging. 1 think 1 rnay k rcady for some sclf-improvement with a) my smoking. I am doing something about my smoking thei has ken a) bothcring me. Ir might k worthwhile for me io woik on smoking. a) I do not have a problem with smoking. Ii doesn't make a) much sense for me to answer these questions. Ir wonies me thai I may slip back into smoking like 1 used to. a) so I am ready to work on it. 1 used to smoke, have stopped, and it no longer conccms me. a) 1 am finally doin6 some work to control my smoking. a) 1 have been thinkiq that 1 may wrnt to quit smoking. a) 10.1 have ken succrsfbl in controlling my smoking but 1 am a) not sure 1 can continue. I 1. At times, my smoking is a dinicult problem, but 1 am working on it. 12.1 hw kcn ~cccufblin quitting smoking rad I no lon8er think about it. 13. Wodcing on my smoking is pmry much r wute of timc for me because it does not have rnything to do witb me. Transtheomical Model 64 14.1 am working on my smoking in order to fccl ktter about myself. 15.1 guess 1 do smoke. but ii is nothing that 1 nally necd to change. 16.1 am really working harâ to quit smoking. 17. I uscd to have to try really hard noi to smokc, but now 1 don't evtn have to think about it. 18.1 have a pmbltm with smoking and 1 mlly think 1 should work on it. 19.1 am not following ihrougb on the changes I have almdy made as well as I hsd hoped, and 1 am not working to pnvent rnyself from smoking. 20.1 am no longer even tempted to smokc now that 1 have stopped . 2 1. Even though 1 am not always succasful in changing. I am ai leart working on my smoking. 22.1 ihoughi once chat I had resolved my problem with smoking. 1 would be fret of it, but someiimes 1 still find mysclf stniggling with it. 23.1 wish 1 had more ideas on how to stop smoking. 24.1 have sisncd to work on rny smoking but 1 would like some help. 25. Smoking is something 1 consider to k part of my put. 26. Mayk someone will k able to help me wië my smoking. 27.1 may nad r boost right now to help me mintain the changes I have rlmdy mide in my smoking. 28.1 may k a pur of my smoking poblem but 1 do not dly think thrt 1 un. 29.1 hop chi wmeone will hrn wme good dvice for mc about smoking. 30. Smoking used to trouble me. but now ihu I have stoppcd 1 no longer wony abut it. Tramtheoretical Model 65 3 1. Anyone cm ulk about cbnging thcir smoking; I'm actually doing romethhg about it. 32. Al1 this ulk about pychology is boring. Why can't people just forgct Wr smoking? 3 3.1 am working to prevent myself fmm hving a relapse of smoking. 34. Sincc 1 have stopped srnoking, I am no longer concerned thai 1 could staut doing it again. 35. It is fnistrating, but 1 fcel 1 might k having a recumncc of the smoking problem 1 thought 1 had rcsolved. 36.1 have womes about my smoking, but so does the next person. Why spend timc thinking about it? 37.1 am activcly working on my smoking pmblem. 38.1 would nthcr cope with my smoking thiry to change it. 39. After al1 thai 1 have donc to stop smoking, evey now and thcn it comes back to haunt me. 40. 1 would say chat I am "curcd" of my smoking. Appendix F1 BÇBE L uw lnrtructianr: 1. Please mnemkr in answering the following questions that an eating binge onl'y =fers to an episode charactcriztd by eating, in a discnte paid of cime (cg. within any 2-hour period), an unount of food that is Pefinitelv han most people would cat during a similai period of time and under similar circumstances. 2. For each of the following items, plcase provide your bcst estimate in the spacc pmvided. 1. How oId were you when youfirst had an cating binp? yem old 2. How old wcre you when you kgan bhge eating on a reguIur basis? ycars old 3. During the luthm mdnths, how oAen have you typically haâ an eating binge? (check one item only and fil1 in comsponding fiuency) -Daily - 1 usually binge -timc(s) a day. -Weckly - 1 usually binge -time(s) a week. -Monthly - 1 usually binge -timc(s) a month. -1 have not binged in the Iast st months. 4. During the most fiq~entof tinus in yovr l@, how ofkn did you typically have an eoting binge? -Daily - 1 would usdly binge -tirnc(s) a day. -Walùy - 1 would dlybinge -time(s) a wweek. -Monthly - 1 would usually binge -timc(s) a month. 5. For how many months wmyou bingeing this fkquently? months Transtheoretical Model 67 PART II 1. Please read the statemaits below and indicate how characteristic each item idwas of your binge eating behaviour. 2. Circle the letter beside each statement that best reflects your answer. Sometimes Often 6. 1 would consume an unusually large amount of food during a binge 7. 1 would fccl out of control when 1 binge 8. 1 would feel that 1 could not stop eating once a binge started 9. 1 would fecl that 1 could not prevent a binge from starting in the first place 10. 1 would feel that 1 could not control my urges to eat large quantities of food 1 1. 1 would eat large arnounts of food when not feeling physically hungry 12. 1 would eat alone because of king embarrassed by how much 1 would binge upon 13. 1 would feel that I could not control what type of food 1 binge upon 14. 1 would feel that 1 could not conbol how much food I would binge upon 15. 1 would eat much more rapidly during a binge than normal 16. 1 would eat until feeling uncomfortably full Never Rmly Sometimes Often Always / 18. I would fmd bingeing pleasurabls a) b) C) 4 e) 22. 1 would fccl guilty about my bingeing a) b) C) 4 e) 23. 1 would fecl helpless about my bingeing a) b) C) d) e) Transtheoretical Model 69 Appendix F2 !!4!w Instructions: 1. Please rememkr in answenng the following questions that smoking refers to a period of time in which you engaged in smoking cigarettes. 2. For each of the following items, please provide your kst estimate in the space provided. 1. How old were you when youffrst began smoking? years old 2. How old were you when you began smoking on a reguiur basis? years old 3. During the lm thmmonths, how ofien have you typically smoked? (check one item only and fil1 in comsponding fiequency) -Daily - 1 usually smoke -time(s) a day. -Weekly - 1 usually smoke -time(s) a week. -Monthly - 1 usually smoke -time(s) a month. -1 have not smoked in the last three months. 4. During the most fient offimes, how ofien did you typically smoke? -Daily - I would usually smoke -time(s) a day . -Weekiy - 1 would usually smoke -time(s) a week. -Monthly - 1 would usually smoke -tirne@) a month. 5. For how many months wm you smoking this fkquently? months Transtheoretical Mode! 70 PART II Instnactionr: 1. Please read the statements klow and indicate how characteristic each item islwas of your smoking 1 2. Circle the letter beside each statement that kst rcflects your answer. ! I Never Rarely Sometimes Ofien Always i 6. 1 would fcel distressed by my smoking a) b) C) d) e) 1 I 1 7. 1 would find smoking pleasurable a) b) c) 4 e) 1 I / 8. 1 would fa1 disgusted about my smoking a) b) C) d) e) I 1 9. 1 would fecl depressed about my smoking a) b) c d) e) 1 1 10.1 would find smoking rclaxing a) b) C) 4 e) I 1.1 would feel guilty about my smoking a) b) C) d) e) : 12. 1 would feel helpless about my smoking a) b) f) e) ; 4 Transtheoretical Model 7 1 Appendix G I eaaE Instructions: The following statemcnts reprcsent dif'fcnnt opinions about binge eaiing. Please nte HOW IMPORTANT each statcment would k to you if you werc deciding whether or not ta binge eat. Circlc youi ccsponse io cach question on the page. 1. ïhc effort nceded for me to stop binge cating would k far too much. 2. 1 would feel more optimistic if 1 stopped binge ating. 3. 1 would k Icss productive. 4. 1 would feel kttcr aWmysdf if I stopped binge eating. 5. Binge eating makts me feel kner for a pcriod of time. 6. My self-respect would k pterif 1 stopped bine eating. 7. 1 think 1 would k mon moody towards othen if I stopped bingc ating. 8. My fmily would k poud of me if 1 stopped binge uting. 9. 1 would no longer be able io "binge out" when upset. 10.1 would be happicr if 1 stopped binge eaiing. 1 I . 1 am concemcd 1 mi@ fail if 1 try to change. 12. Others would have mon respect for me if 1 stoppcd binge ating. 13. Binge eating helps me O nlieve tension. 14.1 would worry leu if 1 quit binge uting. 1 5. By continuing to bingc mi 1 am making my own deeisions. 16.1 am emhssod aboui my binge uting and wouldn't have io fecl this way if l could stop. 17. Binge eatinp provider me Mme sort of "cornfort" when 1 necd it. 18.1 could save moncy if 1 didn't binge W. 19. Binge eating mws rome bction in my life. 20.1 would k hulthier if 1 stoppecl bine crting. The following statemenu rcprcsent differrnt opinions about smoking. Please rate HOW IMPORTANT each stattmcnt would k to you if you wen deciding whcthcr or not to smoke cigarettes. Cirele your nrponse to each question on the page. 1. The effort needed for me to stop smoking would k far too rnuch. 2. I would fcel mon optimistic if 1 stopped smoking. 3. 1 would k less productive. 4. 1 would fcel kttsabout myself if 1 stopped smoking. 5. Smoking mdces me feel ktter for a period of time. 6. My self-respect would be pater if Istopped smoking. 7. 1 ihink 1 would k more moody towards othen if 1 stopped smoking. 8. My family would k proud of me if 1 stopped smoking. 9. 1 would no lonpr k able to rmokc whcn upt. 10.1 would k happier if 1 stopped smoking. I 1. I am concernai 1 might fail if 1 try to chuyc. 12. Ohn would have mon respect for me if 1 stopped smoking. 13. Smoking helps me to relicve tension. 14.1 would wo y less if I quit smoking. 1 S. By continuing to smoke I un making my own decisions. 16.1 un cmbrmrsed aboui my smoking and wouldn't have to feel ibis way if 1could riop. II. Smoking provides me rome soii of "cornfort" whcn I nceû it. 18. !could rrve mony if I didn't smoke. 19. Srnolong serves romc funstion in my life. 20.1 would k halthia if 1.stopped smoking. Appmdix H -BSI Instruct~ons: Bclow is a list of problems people sometimes have. Please rad each one canfully, and indicate the nsponse that best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS MCLUDiNG TODAY. Record only one rcsponse for cach problem and do not skip any items. Circle your mponse on the page. Nervousness or shakiness inside Faintness or dizziness The idea that someone else can convoi your thoughts Feeling othm an to blarne for most of your troubles Trouble remembering things Feeling easily annoycd or irritated Pains in hem or chest Feeling afmid in open spaces or on the streets Thoughts of cnding your life 10. Feeling that most people camot k mûted 1 I . Poor appetite 12. Suddenly scarcd for no reuon 13. Temper outbunts that you could not conml 14. Feeling lonely even whcn you arc with people 15. Feeling blockeû in gening things done 16. Feeling loncly 17. Feeling blue 18. Feeling no interest in chings 19. Feeling fcuful 20. Your feelings uc cuily hurt Transtheontical Model 74 2 1 . Feeling that people are unfnendly or dis1ike you 22. Feeling inferior to others 23. Nausea or uset stomach 24. Feeling that you are watched or talked about by others 25. Trouble falling asleep 26. Having to check and doubletheck what you do 27. Difficulty making decisions 28. Feeling afmid to tmvcl on buses, subways, or trains 29. Trouble getting your bmth 30. Hot or cold spells 3 1, Having io avoid certain thinp, places, or activities kcause they fngbtm you 32, Your mind is going blank 33, Numbness or tingling in parts of you body 34, The idea that you should k punished for your sins 35. Feeling hopeless about the funirc 36. Trouble con cent rat in^ i 37. Feeling weak in parts of your body 38. Feeling tcnse of kcycd up 39. Thoughts of death or dying 40. Having urges to kat, injure, or hann sorneone 4 1 .Having urges to break or smash things 42. Feeling vcry self-conscious with others 43. Feeling uneuy in crowds, such as shopping or at the movie 44. Never feeling close to anothcr pcrson 45. Spclls of terrot or pmic 46. Getting into fiequent arguments 1 ; 47. ~eelingnervaus when you an lefk alone 48. Othen not giving you pmper credit for your achievements 49. Feeling so nstless you couldn't sic still : 50. Feelings of wonhlessness I I1 5 1. Feeling that people will take dvantagc of you if you let them 52. Feelings of yilt 53. The idea that something is wmng witb your mind Ttansthcoretical Model 75 1 Appendix Il I FAC - Mie 1) ; Inst~uctions: 10n this sheet you will find words which descrik différent kinds of moods and feeling. Mark an (X) ' in the boxes beside the wods which dcscrik how you tvaicallv fclt ri& bcfow binne eatinn. iust before vou benin to binae eat. Some of the words may xem alikc, but please çheck al1 the words that typically describe your feelings right befon you binge. Work rapidly. 0lighthtrdcd O I~Y D -Y 0lowd 0- 0moi mlid 0-Y Dnoarippowa 0nwnb O obw 0out of conml 0prihed O pdcily 0physicrl def 0nvawot 0-d ~dcual O- D=ilncd Dm- mtisflcd 0telf'spst 0self-h8te 0--pity O -ne 0- LJenjoymcnt - - 0siumt Transtheotetical Mode! 76 This time, mark an O() in the boxes ksidc the wards which dcscnbe how you micrllv felt rinht in titin~Work rapidly. 0lwcd Dd 0mol relief O~Y nnowiUpowcr 0nmb nobese O out of conad 0- Oppniely 0physial nlief 0nvenous 0-cd ~ftlc8sad O- O-@ 0muen otrrincd 0stlfdisgust 0oelf-h8ic O rtlf-P~V 0mIIe O sw 0s- Appcndix 12 On this shect you will find words which descrik diffmnt kinds of moods and fecling. Mark an (X) in the boxes beside the words which descrik how yftdcallvfc smoking. iust before you lit up.- Some of the words may seem aiike, but please check al1 the wods that typically describe your feclings right bcfore you smoke. Work rapidly. uck -PY tPlctY -8 stupid l mse teiriblt 'thiny w off tirtd udu UllCOmfmble 1 UnhrPPY 1 unloved 1 unmocivrted 1 unproducrive 1- opan l Wght 1 vikuit 1 Wonjed 1 wonhless go to next page., Transthtoretical Model 78 Appendix 12 SAC - (Side 2) 1nsttuctions: This time, mark an (X)in the bo~cskside the words which descnk how y-idlv felt rinht in the middle of smoking a cigant&. aAer vou bave lit un but before wu butt out. Worlc rapidly.