Motivational subtypes and continuous measures of readiness for change: concurrent and predictive validity

Treatment retention in a prison-based residential sex offender treatment program

This study assessed the role of static factors, a dynamic factor (motivation to change sexually deviant behavior), and an administrative factor in predicting treatment retention within a prison-based sex offender treatment program. The analyses also included assessing differences in initial levels of motivation and differences in beginning-versus end-of-treatment motivation scores for various types of program discharges. The sample consisted of 251 individuals who were admitted to a residential prison-based sex offender treatment program where 46% completed the program. Paired comparison t-tests showed higher motivation scores at the end of treatment only among treatment completers. Multivariate analyses showed that treatment retention was associated with higher initial motivation scores, higher levels of education and admission to treatment within 3 months of initial commitment to prison. Implications for motivational enhancement programming as well as for changes in admission criteria are discussed.

Association of baseline characteristics and motivation to change among patients seeking treatment for substance dependence

BACKGROUND

The current study evaluated the bottoming out hypothesis by determining the extent to which composite measures of motivation to change are associated with baseline characteristics among patients seeking treatment for substance dependence.

METHODS

Two hundred treatment-seeking substance-dependent veterans were assessed. Motivation to change was assessed using the composite measures of Readiness to Change (RTC) and Committed Action (CA) derived from the University of Rhode Island Change Assessment. Baseline characteristics included recent life stressors, addiction severity, depression, anxiety and hostility. Linear regression was used to determine the association between baseline characteristics and the composite measures of motivation to change while controlling for age, gender and race.

RESULTS

Linear regression indicated that RTC and CA were associated with different baseline characteristics. RTC was associated with anger expression (B=-.28; 95% CI=-.6, -.01) and recent life events (B=1.1; 95% CI=.01, 2.2). CA was associated with alcohol problems (B=-.33; 95% CI=-.62, -.05) and state anxiety (B=-.13; 95% CI=-.21, -.04).

CONCLUSIONS

Our findings suggest that motivation to change was negatively, not positively, associated with greater emotional distress and problem severity. With the exception of recent life events, these findings are contrary to the notion of hitting bottom. Composite measures of RTC and CA also appear to represent different types of motivation to change.

Does progressive stage transition mean getting better? A test of the Transtheoretical Model in alcoholism recovery

AIMS

To test two central assumptions of stage movement in the Transtheoretical Model (TTM) vis-à-vis alcoholism recovery: (assumption 1) individuals making a forward transition to the action-oriented stages (i.e. preparation/action) will manifest relatively greater drinking improvements than their counterparts remaining in the pre-action stages (i.e. pre-contemplation, contemplation); and (assumption 2) individuals remaining in the pre-action stages across time will not demonstrate clinically relevant improvement in drinking outcomes.

DESIGN AND SETTING

Secondary data analyses of data from Project MATCH, a large multi-site alcoholism treatment-matching study.

MEASUREMENTS

At baseline and 3 months post-treatment, the following variables were measured: stage-of-change (based on the University of Rhode Island Change Assessment measure and the most recent stage assignment algorithm), drinks per drinking day (DDD) and percentage days abstinent (PDA).

FINDINGS

Six of the eight tests of assumptions 1 and 2 failed to support the basic tenets of the TTM. Our study demonstrated that individuals making a progressive stage transition to the action-oriented stages (i.e. preparation/action) do not necessarily manifest greater improvements in drinking-related behavior than individuals remaining in the pre-action stages (i.e. pre-contemplation, contemplation), and that individuals remaining in the pre-action stages over time actually do manifest statistically significant and clinically important improvements in drinking-related behavior.

CONCLUSIONS

Our findings challenge not only the criterion validity associated with stage movement in the TTM account of alcoholism recovery, but also recent TTM-based substance abuse treatment approaches which systematically promote forward stage transition as a primary clinical goal and marker of therapeutic success.

Reducing Past Harm Appraisals During Treatment Predicts Worse Substance Use Outcome

BACKGROUND

Appraisals of the past harm from substance use have been associated with increased motivation and treatment seeking behaviors. Harm appraisals are subjective evaluations of the harm caused by substance use and differ from traditional consequences measures which assess the occurrence of adverse events related to substance use. Although influencing these appraisals is a central component to most treatments, no studies have examined how changes in these appraisals during treatment influence outcome. The present study examined how changes in appraisals of the past harm from substance use over the course of treatment influence short- and long-term substance use outcomes.

METHODS

Participants were 252 individuals seeking outpatient treatment for a substance use problem. Participants were assessed at treatment entry, end of treatment (13 weeks), and 9 months post-baseline. All participants were given a battery of measures that assessed substance use, consequences, self-efficacy, motivation, treatment intensity, 12-step affiliation, and appraisals of harm. Past harm change scores from baseline to end of treatment recoded into 3 groups: increased, remained the same, and decreased (reduced their perception of the harm from substance use).

RESULTS

Reductions in appraisals of past harm from baseline to end of treatment predicted lower PDA and higher objective consequences at end of treatment and 9-month follow-up. There were no significant differences in outcome between those who increased versus maintained harm appraisals from baseline to end of treatment. Higher treatment intensity and 12-step affiliation were associated with fewer reductions in past harm appraisals.

CONCLUSIONS

Results of the present study suggest subjective appraisals of the past harm from substance use wane for some people during treatment and that helping clients maintain or increase their perceptions of the past harm from substance use over the course of treatment is associated with better short- and long-term outcomes.

A structural equation modeling approach to the concepts of adherence and readiness in antiretroviral treatment

OBJECTIVE

The objective of this secondary analysis of data from a cross-sectional, nation-wide survey, was to test a hypothesized model with two latent concepts (readiness and adherence), based on the theory of trigger events. A secondary objective was to compare this model with two simpler models, without the concept of readiness.

METHODS

Data consisted of a consecutive sample of 828 HIV patients > or = 18 years on antiretroviral treatment at 30 out of 32 HIV Clinics in Sweden (response rate 97.5%). Structural equation modeling (SEM) was used to test the models against the empirical data. Chi2 test was used to compare fit between models.

RESULTS

The hypothesized model, with two latent concepts (readiness and adherence), fitted the data best (chi(2)=223.508, d.f.=129, p-value<0.0001, GFI=0.970, CFI=0.913, RMSEA=0.030), and significantly better than the models with adherence as the only latent concept.

CONCLUSION

Although the SEM technique could not rule out that other models might also fit the data equally well, the hypothesized model, where readiness and adherence were two separate latent concepts, fitted data the best. This supports readiness as a distinct factor that influences adherence and hence treatment outcome. Increased attention should therefore be attached to interventions that focus on the individual' readiness for behavioural change, i.e. factors amendable to change and that can be addressed by the patients themselves.

PRACTICE IMPLICATIONS

Based on these results it seems necessary to shift focus from adherence to readiness, especially in conditions where treatment can be postponed such as antiretroviral treatment.

Stages of change and stuttering: a preliminary view

As a way to better understand the process of change that occurs in stuttering, Craig [Craig, A. (1998). Relapse following treatment for stuttering: a critical review and correlative data. Journal of Fluency Disorders, 23, 1-30] compared the behavioral changes that people who stutter often experience with and without treatment to those that have been observed for certain (non)addictive behavior disorders such as smoking, overeating, phobia and anxiety disorder. The process underlying these behavioral changes has been described by the transtheoretical or "stages of change" model, which is a model of behavior change that can illuminate "where" a person is in the process of change, and how this may relate to the outcome of either treatment or self-change attempts [Prochaska, J. O., & DiClemente, C. C. (1986). The transtheoretical approach. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy. New York: Brunner/Mazel]. The purpose of the present study was to analyze the extent to which the responses of adults who stutter on a modified Stages of Change Questionnaire yield interrelations among questionnaire items that are consistent with a stage-based interpretation. Results of both confirmatory and exploratory factor analyses indicated that while the modified questionnaire was a relatively good fit for participant responses, the structure derived from the exploratory analysis provided a significantly better fit to the observed data. Results suggest that a questionnaire incorporating items that better reflect the unique behavioral, cognitive and affective variables that characterize stuttering may better discriminate stages of change in people who stutter as they move through therapy, or are engaged in self-directed change.

EDUCATIONAL OBJECTIVES

After reading this paper, the learner will be able to: (1) describe the transtheoretical or "stages of change" model; (2) describe the various processes that are associated with different stages of change; (3) summarize research findings in stages of change as they apply to a variety of clinical populations; (4) discuss the applicability of the findings from the present study to stuttering treatment, and (5) relate conventional strategies and techniques used in stuttering therapy to different stages in the process of change.

Assessing and achieving readiness to initiate HIV medication

OBJECTIVE

To summarise published HIV-specific research on readiness theories, factors influencing readiness, instruments to measure readiness and interventions to increase readiness for treatment.

METHODS

Medline and PsychInfo were searched until August 2004.

RESULTS

Two HIV-specific readiness theories were identified. Fear of side effects, emotions emerging from the diagnosis and lack of trust in the physician were some barriers to overcome in order to reach readiness. Of the three measurement instruments found, the index of readiness showed the most promise. Multi-step intervention programs to increase readiness for HIV treatment had been investigated.

CONCLUSION

Readiness instruments may be useful tools in clinical practice but the predictive validity of the instruments needs to be further established in the HIV-infected population.

PRACTICE IMPLICATIONS

Readiness instruments and practice placebo trials may serve as complements to routine care, since health care providers currently have no better than chance probability in identifying those patients who are ready to adhere.

Does contingency management affect motivation to change substance use?

Although substantial evidence favors the efficacy of contingency management (CM) for substance use disorders, few studies have examined the effect of CM on one's motivation to change substance use. One way of conceptualizing motivation to change is by using the stages of change model [Prochaska, J.O., DiClemente, C.C., 1983. Stages and processes of self-change of smoking: toward an integrative model of change. J. Consult. Clin. Psychol. 51, 390-395]. We assessed motivation to change substance use as conceptualized by the stages of change model using the University of Rhode Island Change Assessment (URICA [McConnaughy, E.A., Prochaska, J.O., Velicer, W.F., 1983. Stages of change in psychotherapy: measurement and sample profiles. Psychother. Theor. Res. 20, 368-375]) in 115 patients in community treatment clinics before they were randomized to receive standard treatment or standard treatment plus CM. Motivation was also assessed 3 months later. Patients in both conditions evidenced significant decreases in their motivation scores from pre- to post-treatment. CM neither increased nor decreased motivation relative to the standard treatment condition. Pre-treatment motivation scores were also not related to treatment outcome. Assignment to the CM condition was associated with better treatment outcome as defined by longest duration of abstinence during treatment (LDA). Higher post-treatment motivation was also modestly associated with LDA, but not in all analyses. These findings suggest that CM neither increases nor decreases motivation to change substance use in outpatients receiving treatment at community-based drug-free clinics. Future studies should further examine motivation change in CM treatment using different assessment tools and conceptualizations of motivation, extending these effects to other treatment settings and populations.

Treatment motivation in drug users: a theory-based analysis

Motivation for drug use treatment is widely regarded as crucial to a client's engagement in treatment and success in quitting drug use. Motivation is typically measured with items reflecting high treatment readiness (e.g., perceived need for treatment and commitment to participate) and low treatment resistance (e.g., skepticism regarding benefits of treatment). Building upon reactance theory and the psychotherapeutic construct of resistance, we conceptualized these two aspects of treatment motivation - readiness and resistance - as distinct constructs and examined their predictive power in a sample of 1295 drug-using offenders referred to treatment while on probation. The sample was 60.7% African Americans, 33.5% non-Hispanic Whites, and 21.2% women; their ages ranged from 16 to 63 years old. Interviews occurred at treatment entry and 6 months later. Readiness (but not resistance) predicted treatment retention during the 6-month period. Resistance (but not readiness) predicted drug use, especially among offenders for whom the treatment referral was coercive. These findings suggest that readiness and resistance should both be assessed among clients entering treatment, especially when the referral is coercive. Intake and counseling protocols should address readiness and resistance separately.

The Readiness Ruler as a measure of readiness to change poly-drug use in drug abusers

Readiness to change is a crucial issue in the treatment of substance use disorders. Experiences with methadone maintenance treatment (MMT) has shown that continuous drug and alcohol use with all its consequences characterize most MMT programs. In a prospective study of drug abusers seeking opiate agonist maintenance treatment in the City of Copenhagen, subjects were administered the Addiction Severity Index, and the Readiness Ruler for each of 11 different licit and illicit drugs by research technicians. Data was collected upon admission to the program and at a 18 month follow-up. Subjects who indicated they wanted to quit or cut down upon admission, reported less drug use at 18 month follow-up, after controlling for severity of drug problems at intake. Subjects who expressed readiness to change their drug use upon admission decreased their drug use. It is concluded that the Readiness Ruler measures a construct related to actual readiness, supporting its use in the clinical context.

Predicting sex offender treatment entry among individuals convicted of sexual offense crimes

This study examined what factors were predictive of who volunteers for sex offender treatment (self-selection) as well as who enters treatment after volunteering (administration selection). Research participants included 404 treatment volunteers and 387 nonvolunteers to treatment who were convicted of a sexual offense involving minors within the federal prison system. Maximum likelihood probit estimation procedures indicated that when compared with nonvolunteers, treatment volunteers were more likely to be recommended by a judge to receive treatment at the time of sentencing, had received prior treatment for sexually deviant behavior, reported higher levels of motivation to change their sexually deviant behavior, and had lower rates of a substance use disorder in the year prior to incarceration. Of those persons who initially volunteered, 62% were accepted and entered treatment, 16% were denied entry to treatment by program staff, and 22% refused treatment after being accepted to the waiting list. When compared with those who were accepted and entered treatment, motivation was the only predictor of being denied admission into treatment by program staff and for refusal of treatment once accepted. The findings emphasize the need to control for selection bias in treatment outcome studies and the importance of examining the role of motivation in treatment volunteerism and treatment entry for sexual offenders.

Contrasting predictors of readiness for substance abuse treatment in adults and adolescents: a latent variable analysis of DATOS and DATOS-A participants

Although readiness for substance abuse treatment is a potent predictor of short-term clinical response, predictors of readiness are still poorly understood. Predictive models are customarily not predicated on dependence or abuse, but usually focus instead on intrapsychic motivational change or external contextual incentives. Based on a secondary analysis of the drug abuse treatment outcome studies (DATOS) data set for adults and a similar data set for adolescents (DATOS-A), latent variables were constructed to represent readiness for treatment, various psychosocial and behavioral features of substance use, substance-related problems and specific substance use frequency. Identical measures were used for each group. The two groups were then directly compared using a series of constrained covariance structure models. A path model using all hypothesized latent variables, treatment modality and demographics predicted Readiness for treatment in each separate group. Substance problems, a latent variable reflecting cross-substance symptoms of dependence and abuse, was the strongest predictor of Readiness for treatment in both age groups. Health problems and deviant family/peers were also strong predictors of readiness in both age groups. Demographic variables and specific substances used predicted readiness directly and indirectly in an age-specific manner. This study links readiness for substance abuse treatment to the core disorders targeted by that treatment in adults and adolescents for the first time.

Does stage-of-change predict dropout in a culturally diverse sample of adolescents admitted to inpatient substance-abuse treatment? A test of the Transtheoretical Model

The Transtheoretical Model (TTM) () proposes that the stages-of-change construct can serve as useful tool for identifying those most at-risk of treatment dropout [Prochaska, J. O. (1999). How do people change, and how can we change to help many more people? In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change (pp. 227-255). Washington: American Psychological Association]. While researchers have found mixed support for this claim in adult samples, studies have not yet tested this issue in adolescent substance-abuse treatment settings. This paper reports findings from a Canadian study of adolescents (n = 130: 80 Caucasians, 50 Aboriginals) admitted to a hospital-based, residential substance-abuse treatment program. Two approaches were used to test the TTM's claim: (1) a hierarchical logistic regression model of dropout was developed using the subscales of the University of Rhode Island Change Assessment instrument (URICA), demographic variables, and subscales of the Addiction Severity Index (ASI); and (2) a chi-square analysis was employed to test the hypothesized relation between stage-of-change and dropout status. The findings demonstrated that the best predictive model of dropout included only the Precontemplation subscale of the URICA (OR: 4.3; 95% CI: 2.0-9.0). In addition, adolescents assigned to the Precontemplation stage manifested significantly higher rates of treatment attrition than individuals in the Contemplation or Preparation/Action stages. This study provides important empirical support for the predictive utility of the stage-of-change construct among a culturally diverse sample of adolescents admitted to an inpatient substance-abuse treatment program.

READINESS FOR CHANGE AND READINESS FOR HELP-SEEKING: A COMPOSITE ASSESSMENT OF CLIENT MOTIVATION

AIMS

To investigate the correspondence between readiness for behaviour change in general and readiness for alcohol related help-seeking in particular. A related aim was to examine how, if at all, measures of dependence severity, use, and consequences were related to a composite measure depicting agreements and disagreements between general change readiness and help-seeking readiness.

METHODS

Non-treatment seeking alcohol-dependent patients, numbering 549, from general hospitals in Germany were interviewed.

RESULTS

When taking into account both dimensions of motivation, findings indicate 42% of the subjects were characterized by different motivation levels regarding readiness for change and readiness for help-seeking. Higher help-seeking readiness was associated with higher alcohol problem severity. Readiness to change was not affected by alcohol problem severity.

CONCLUSIONS

Findings underscore the need to evaluate both motivational constructs in determining clients' need and receptivity to formal help.

Identification of subgroups of persons with chronic pain based on profiles on the pain stages of change questionnaire

This study sought to identify reliable subgroups of patients with chronic pain based on profiles of subscale scores on the Pain Stages of Change Questionnaire (PSOCQ), a reliable and valid measure of individuals' readiness to adopt a self-management approach to chronic pain. The PSOCQ was administered to 633 people seeking treatment for chronic pain. Participants were predominantly White, averaged 48 years of age, about half were men, and about half reported back pain as the primary complaint. In a first study, cluster analysis was applied to 250 respondents. Five clusters were identified and named Precontemplation (11.0% of the sample), Contemplation (18.0%), Noncontemplative Action (12.4%), Participation (25%), and Ambivalent (33.6%). Results of a discriminant function analysis (DFA) on this sample, using the solution from the cluster analysis yielded a total error rate of 0.036. In a second study, the results of the first DFA were applied to an independent sample of 383 respondents in order to cross validate the solution from the first study. Cluster assignment proportions were very similar to the first sample and the posterior probability error rate for the second DFA was 13%. As predicted, clusters did not differ on measures of pain, disability, or demographics. Moreover, clusters differed significantly in theoretically consistent directions by scores on the Survey of Pain Attitudes, thus demonstrating criterion related validity for the clusters. Future research should examine the utility of PSOCQ profiles, relative to individual PSOCQ scale scores alone, in predicting response to self-management treatment approaches.

Stages of change in treatment-seeking pathological gamblers

The transtheoretical model has been applied to many addictive disorders. In this study, psychometrics properties of the University of Rhode Island Change Assessment (URICA) scale were evaluated in 234 pathological gamblers initiating treatment. Four components were identified--reflective of precontemplation, contemplation, action, and maintenance stages--with internal consistency from .74 to .88. Cluster analyses identified 4 patterns of responding, ranging from ambivalent to active change. The 4 clusters differed with respect to baseline gambling variables and treatment engagement and outcomes assessed 2 months later. A continuous measure of readiness to change was also correlated with gambling severity and predictive of reductions in gambling. This study provides initial support for reliability and validity of the URICA in treatment-seeking gamblers, and it suggests that stage of change may have an impact on outcomes.

Motivational enhancement and coping skills training for cocaine abusers: effects on substance use outcomes

AIMS

This clinical trial investigated effects of motivational enhancement treatment (MET) and group coping-skills training (CST) tailored for cocaine dependence. Effects of MET were hypothesized to be greater with CST and for less motivated patients.

DESIGN AND INTERVENTIONS

A 2 x 2 design investigated two individual sessions of MET compared to meditation-relaxation (MRT), followed by four group sessions of CST versus drug education (ED), as daily adjuncts to intensive treatment.

SETTING

The substance abuse program provided full-day treatment with a learning-theory and 12-Step orientation.

PARTICIPANTS

Cocaine-dependent patients were recruited.

MEASUREMENTS

Assessment included treatment retention; change in cocaine-related urge, self-efficacy, pros and cons, and motivation; substance use and problems during 12-month follow-up. Findings Of 165 patients, follow-up status is known for 90% (n = 149). Patients in MET with low initial motivation to change reported less cocaine and alcohol relapse and use days and fewer alcohol problems than MET patients with higher initial motivation. MET produced more employment improvement than MRT, with no other significant benefit for MET. Patients with higher motivation had more cocaine use and alcohol problems after MET than MRT. Group CST reduced cocaine and alcohol use during follow-up for women only and reduced alcohol relapse for men and women.

CONCLUSIONS

MET is more beneficial for patients with lower initial motivation than for patients with high initial motivation. CST reduced cocaine and alcohol use for women only and reduced alcohol relapses, in contrast to results with lengthier individual CST.

The transtheoretical model and motivational interviewing in the treatment of eating and weight disorders

The transtheoretical stages of change model suffers from conceptual and empirical limitations, including problems of stage definition, measurement, and discreteness. Sequential transition across stages has not been established. The model lacks strong predictive utility, and there is little evidence that therapeutic interventions must be matched to stage to facilitate change. Initial tests applying the model to weight and eating disorders have been negative. Although the model is frequently associated with motivational interviewing (MI), no theory links the two. MI should be evaluated independently as a treatment for weight and eating disorders, to be used either alone or prior to treatments not explicitly addressing motivation. The conceptual compatibility and procedural overlap between cognitive behavioral therapy (CBT) and MI are analyzed.

Convergent and concurrent validity of the Contemplation Ladder and URICA scales

This study examined the convergent and concurrent validity of the Contemplation Ladder and the University of Rhode Island Change Assessment (URICA). Intake data of participants recruited into two concurrent studies were analyzed. One group (n=77) had no plans to quit smoking within the next 6 months, while a second group (n=106) had definite plans to quit. The groups did not differ on any demographic variables except employment status. Contemplation Ladder scores for the entire sample (n=183) correlated positively with the URICA Contemplation and Action subscale scores but negatively with Precontemplation subscale scores. The Contemplation Ladder also correlated positively with the URICA Composite score. Additionally, participants seeking to quit within the next 6 months had significantly higher Contemplation Ladder and URICA Contemplation, Action, and Composite scores, but lower Precontemplation scores than participants not seeking to quit. Controlling for employment status did not change the pattern of results. Our findings provide support for the convergent and concurrent validity of these two measures and suggest that the single-item Contemplation Ladder may be a practical alternative to the URICA in certain situations.