DiClemente 04

DISTINGUISHED SCHOLAR SERIES

Readiness and Stagesof Change in AddictionTreatment

Carlo C. DiClemente, Ph.D., Debra Schlundt, B.S.,

Leigh Gemmell, B.S.

Understanding the role of personal motivation in addiction treatment changedwith the advent of the Transtheoretical Model of intentional behavior change, abetter understanding of relapse, and a shift in focus from denial to readiness.Motivation is a complex concept that covers many diverse aspects of the processof intentional behavior change. This review examines current perspectives onreadiness and the stages of change, criticisms and measurement issues, andclinical applications and future research in this area. Although significantchallenges remain, properly incorporating the concepts of readiness and thestages of change into addiction treatment enables providers to address the di-verse needs of substance abusers and treatment seekers, supports more proactiveinterventions, creates a concentration on motivational enhancement, and helpsresearchers understand the larger process of change where addict and treatmentprovider meet. Better measurement, more frequent assessments, and a betterunderstanding of the stage subtasks and how they relate to readiness and suc-cessful change are needed to deepen our understanding of motivation and itsrole in the treatment of addiction. (Am J Addict 2004;13:103–119)

T he focus of addiction researchers andpractitioners has shifted from whether

addicted individuals change to how theychange. Understanding the process ofchange helps us ascertain key influencesthat promote change and increase recruit-ment, retention, and the successful ces-sation among substance abusers. Althoughcomplicated by physiological and psycho-

logical dependence, an abuser’s motivationand intentions represent a critical part ofthe process of recovery and healing. Thus,motivation plays an important role inrecognizing the need for change, seekingtreatment, and achieving successful, sus-tained change for all substance abusers. Ingeneral, motivation refers to the personalconsiderations, commitments, reasons, and

Received September 5, 2003; accepted November 21, 2003.From the Department of Psychology, University of Maryland, Baltimore County, Baltimore, Md. Addresscorrespondence to Dr. DiClemente, Department of Psychology, University of Maryland, Baltimore County(UMBC), 1000 Hilltop Circle, Baltimore, MD 21250. E-mail: [email protected].

The American Journal on Addictions, 13:103–119, 2004

Copyright # American Academy of Addiction Psychiatry

ISSN: 1055-0496 print / 1521-0391 online

DOI: 10.1080=10550490490435777

103

intentions that move individuals to performcertain behaviors. Addicted individuals ap-pear to be pushed or coerced at times bythese motivational forces, but at othertimes pulled or led by them. Nonetheless,intentional human behaviors are consideredto be motivated, whether one’s theoreticalperspective views behavior as shaped bycontingencies, driven by unconsciousmotives, or directed by self-regulation.1,2

Prior attempts to identify and assess themotivations that underlie both addictionand recovery reach back to the beginningsof psychological science3 and basic concep-tualizations of addiction.4–6 However, morerecent discussions of motivation have usedthe concepts of stages of change, readinessto change, and readiness for treatment.These concepts are related but not entirelyinterchangeable.

The stages of change represent one ofthe fundamental dimensions of the Trans-theoretical Model (TTM) of intentionalbehavior change, developed by Prochaskaand DiClemente.1,7–9 The underlying per-spective of the stages of change is thatthere is a multidimensional process of in-tentional behavior change that extendsfrom the establishment of a stable patternof abuse to the achievement of significantsustained change of the addictive behavior.1

The road that individuals traverse in orderto change an established addictive behaviorpattern is described in five stages, begin-ning with the Precontemplation stage, whereaddicted individuals have little or no cur-rent interest in considering change. Onceconcern and a sense of vulnerability reachthem, these individuals can move throughthe stages of Contemplation (a risk-rewardanalysis leading to decision-making), Prep-aration (involving commitment and plan-ning), and then to Action (taking specificsteps to implement the plan), before arriv-ing at the Maintenance stage, where thenew behavior becomes normative. Mainte-nance becomes the final stage in the tran-sition to recovery and establishes a new

pattern of behavior that ultimately can leadto the termination of the change process.10

Movement back and forth, as well as recy-cling through the stages, represents asuccessive learning process whereby the in-dividual continues to redo the tasks of vari-ous stages in order to achieve a level ofcompletion that would support movementtoward sustained change of the addictivebehavior.1

Motivation is viewed as an importantcomponent throughout the entire processof change. The stages of change specifymotivational demands by segmenting thechange process into specific tasks to beaccomplished and goals to be achieved, ifmovement toward successfully sustainedchange is to occur. Each of the multipletasks encountered on the road to recoveryrequire effort, energy, and ‘‘motivation’’on the part of the addicted individual. Suc-cessful change of an addiction represents aresolution of each stage’s tasks in a way thatsupports engagement in the tasks of thenext stage.1

Readiness is a more generic conceptthan stages. Readiness typically indicates awillingness or openness to engage in aparticular process or to adopt a particularbehavior and represents a more pragmaticand focused view of motivation as pre-paredness. Research has evaluated two dis-tinct but related aspects of readiness:readiness to change and readiness for treatment.Readiness to change has been conceptua-lized by some as a combination of thepatient’s perceived importance of the prob-lem and confidence in his or her ability tochange.11,12 Motivational readiness tochange has also been described using thetasks of the stages of change in order tosuggest intervention strategies13,14 andmeasure motivation to change drinkingbehavior.15–17 In fact, the specific measureof readiness to change used in ProjectMATCH consisted of a summary of scoresderived from separate subscales represent-ing the precontemplation, contemplation,

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action, and maintenance stages to form asingle readiness to change score.18,19

Readiness for treatment, on the otherhand, focuses on motivation to seek help,preparedness to engage in treatment activi-ties, and how they impact patient treatmentattendance, compliance, and outcome. Sev-eral studies have demonstrated the impor-tance of motivation for treatment amongsubstance-abusing patients in predictingtreatment participation and recovery.20–23

There is growing research both in thera-peutic communities and other treatmentsettings indicating that motivation orreadiness for treatment is related to atten-dance at treatment and positive out-comes.21,22,24,25 In fact, Simpson andcolleagues have identified motivation toseek help as an important predictor oftreatment outcome among a very hetero-geneous sample of substance abusing pa-tients.26,27 Generally, greater attendance atand compliance with treatment predict bet-ter behavioral change outcomes. However,the relationship between compliance andchange is not always significant, and notall treatment dropouts fail to change theiraddictive behaviors.28

It seems that readiness to engage in andcomply with treatment recommendationsas well as the motivational readiness of aclient to change are both important indica-tors for assessing treatment participationand outcomes. However, readiness orreceptivity for treatment and readiness tochange are not necessarily equivalent con-cepts in theory or practice. Individuals cancome to treatment and be open to partici-pating in treatment without being ready toabstain from alcohol and drugs. Several stu-dies have been able to identify individualsentering alcohol and substance abuse treat-ment with very different profiles on thestages of change measure in the Universityof Rhode Island Change Assessment scale(URICA).29–32 Other studies using a mea-sure called the Stages of Change, Readi-ness, and Treatment Eagerness Scale

(SOCRATES) have identified ProblemRecognition and Taking Steps as importantdimensions of personal motivation thatdiffer on entry to treatment.33–35 Thus,individuals entering treatment differ onimportant dimensions related to motivationand to the tasks identified in each of thestages of change, whether they are enteringresidential or outpatient drug treatmentprograms.21,23,24

Although logically assumed to be asso-ciated, readiness for treatment and readi-ness for change are not simply oppositesides of the same coin. In initial analysesof Project MATCH data, we found parti-cipants who appeared to have high scoreson the readiness to change measure butlow scores on a readiness for treatmentsubscale derived from the Alcohol UseInventory and vice versa. Although themajority of outpatients in this researchtreatment were consistent with higher orlower scores on both receptivity for treat-ment and readiness for change, 20% ormore showed some inconsistency betweenthese two types of readiness.36,37 Whencomparing the predictive ability of readi-ness for treatment with that of readinessfor change, it appeared that for outpatientparticipants, their readiness to change wasslightly more important as a predictor ofposttreatment drinking. However, parti-cipants who expressed more receptivity tohelp and greater readiness for change hadthe best outcomes. Although readiness fortreatment is an important motivation di-mension, the remainder of this article willfocus on the research related to the stagesof change and readiness for change.

MEASURING MOTIVATION IN TERMSOF THE STAGES OF CHANGE

Understanding motivation in terms of thestages of change is conceptually appealingand has been adopted by many cliniciansand researchers as a template throughwhich to view the change process.38

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THE AMERICAN JOURNAL ON ADDICTIONS 105

However, the measurement of stages ofchange poses some problems for the prac-titioner and researcher: how to assess stagestatus of individuals with different sub-stance abuse problems and in differenttypes of programs has created significantfrustration.39,40 Definitional and measure-ment problems have also led some to ques-tion the importance of the stages and theirrelevance to treatment outcomes and treat-ment behaviors.29,41–45 Some critics pointto inconsistencies in measurement acrossstudies; others have indicated that stagemeasures like the URICA yield varyingnumbers of profiles that do not reflectthe existence of the five stages of change.39

There is also a debate as to whether moti-vation or readiness to change is best con-ceptualized as a continuum or by discretestages.8

Critics have reason to be concernedand confused. The Transtheoretical Modelhas been developed over time and reflectsongoing thinking about the process ofbehavior change in addictions and in otherhealth behaviors. Segmenting this processinto discrete steps is by nature problematicbecause the specific tasks described in eachof the stages are linked and interactivethroughout the process of change. De-cision-making, for example, is primarily de-fined as a contemplation task that involvesa personal evaluation of the pros and consfor change. However, the strength of anindividual’s decision to change plays animportant role in the subsequent tasks ofcommitment and planning represented aspreparation stage tasks and in initiatingbehavioral changes that occurs in the actionstage. Moreover, once the change is madeand sustained over time, the nature of theinitial decision to change becomes less rel-evant and shifts from a primary focus onthe problem behavior to considerations ofthe benefits of the new lifestyle. Cognitiveprocesses of change also become lessimportant and behavioral processes moresalient as the individual moves from pre-

action stages to action and maintenance.There is both continuity and discontinuityin the process of behavior change,8,46,47

thus, the operational definition of stageswill always be to some degree arbitrary interms of where to draw the line and whichtasks to define as separable, distinct tasksthat support a separate step in the processof change.1 Could more stages or subdi-vided stages be identified? Without ques-tion, and some researchers have attemptedto do so.48–50 It is also clear that individualswithin a stage can be subclassified or cate-gorized.51,52 We have identified five stagesbecause these five seem to be steps thatwe could conceptually define and find someway to measure, and yet that also seemed todifferentiate among change activities andmarkers of change.1,8

Measurement of these five stages haspresented significant challenges across thevarious addictive and health behaviors.Multiple measures have been used toclassify individuals into stages, includingcategorical algorithms, ladders or rulers,self-reported stage on a multiple behaviorgrid, and multiple item=multiple subscalequestionnaires like the URICA,53

SOCRATES,33 and Readiness to ChangeScales.8,15,18 The good news is that manydifferent measures have been able to dividethe population of changers into subgroupsthat make sense and are consistent withthe description of the five stages.30,32,54–56

However, the bad news is that no consist-ent, single measure of stage status has beenused with even one addictive behavior likesmoking cessation, let alone across alladdictive behaviors. It is also significantthat the different measures do not alwayscross-classify the same individuals into theexact same stage of change.39,40,57–59

These multiple measures of stage statusare a mixed blessing. The fact is that thesedifferent measures have been used to dividepopulations of smokers, drinkers, and drugusers into subgroups that are alike onsome change dimensions and significantly



different on others. These findings providestrong support for the segmentation of theprocess of change and the existence ofsome underlying structure, like distinctstages or steps of change. These assess-ments create ways to identify whether theindividual is in earlier or later segments ofthe process of change. Some measures areused to create stage subgroups; others sim-ply identify individuals who are more orless ready to change. However, whetherone uses continuous measures or stage-based classifications, individuals earlier inthe process differ reliably from individualsin later stages on measures of change pro-cess activity, decisional considerations, andself-efficacy.19,30,31,54,60–64 Although mea-suring these stages for different behaviorshas proved challenging, different measureshave identified individuals at differentpoints in the process of change with manyaddictive and health behaviors and havecontributed to our understanding of theprocess of change.8 However, measures,measurement, and the quality and quantityof research vary greatly across differentaddictive behaviors. Examining measure-ment and predictions in different behaviorscan be instructive, so we will examine howstages and motivational readiness have beenoperationalized and what we have learnedabout the process of change with differentaddictive substances.

Nicotine Addiction

The earliest attempt to understandreadiness and segment the process ofchange into stages used smoking cessationas the target behavior change. This researchbrought together Prochaska’s attempt toidentify an integrative set of processes ofchange from psychotherapy and behaviorchange literature65 with DiClemente’s at-tempt to measure and use these changeprinciples to understand successful smok-ing cessation among self-changers and

treatment seekers.66,67 For over fifteenyears, subsequent joint research createdand evaluated various dimensions of thisTranstheoretical Model and developedassessments with smokers who were simplyassessed and followed through the processof unaided self-change7,61,68–74 and thosewho were given an intervention.54,75–77 Inall this research, stage status was assessedusing several questions that created an al-gorithm updated to accommodate researchfindings and the development of themodel.54 This simple and straightforwardmethod first asked lifetime smokers (100cigarettes or more) whether they weresmoking currently or not. If they were notsmoking, they were asked how long agothey had quit. If former smokers had quitfewer than six months in the past (a time-frame suggested by relapse curves acrossaddictive behaviors), they were classifiedinto the action stage. If they had quit morethan six months ago, they were classified asin the maintenance stage of change. If indi-viduals were smoking, on the other hand,they were asked several additional ques-tions, such as ‘‘are you seriously consideringquitting in the next six months,’’ ‘‘are youplanning to quit in the next 30 days,’’ and‘‘have you made an attempt to quit smokingfor at least 24 hours in the past year.’’ Smo-kers not considering quitting in the next sixmonths were placed in the precontempla-tion stage. Those who said yes to seriouslyconsidering and planning to quit in the next30 days and who had made a quit attemptin the past 6 months were considered inthe preparation stage. All others were con-sidered in contemplation. This rather sim-ple method of assigning stage worked wellto create categorical groupings of indivi-duals that differed in logical and consistentways on a number of related change con-structs, like self-efficacy to abstain fromsmoking across tempting situations,71,78

the pros and cons of decisional balance,63,79

and experiential and behavioral processesof change.73,80–82 Although some studies

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have been critical of the classification sys-tem and question the ability of stage statusto predict long term outcomes,83,84

others have supported its usefulnessand the psychometric soundness ofthis method of assigning stages ofchange.58,85–87

It became clear, however, that move-ment through the stages of smoking ces-sation was not linear. Although somesmokers could spend significant periodsof time in a single pre-action stage like con-templation, many moved back and forth,cycling and recycling through thestages.9,52,88 This complicated the assess-ment. Current stage status and the fre-quency and level of success the smokerexperienced when they cycled through thestages became important considerations. Ifmovement through the stages is viewed aslearning through successive approxima-tions, enabling an individual to completemore successfully the tasks of each of thestages as they recycle, then what they havedone in the past in terms of cessation suc-cess is important for understanding currentstatus and future success. This was therationale behind using a quit attempt inthe past year as part of the preparationstage assessment when studying veteransmokers,54 although this definition wouldbe illogical if used to define the preparationstage for individuals making their first at-tempt to quit smoking.8,44 Some research-ers have incorporated recycling successinto their definition of addiction and thencontrasted addiction with a baseline mea-sure of stage status to argue that addiction(measured by past attempts and length ofpast abstinence) predicted successful ces-sation after two years better than initialstage status.83,84 However, the argument isa bit circuitous because the current stagestatus of each individual is always influ-enced and tempered by prior attempts tomove through the stages and how well eachof the stage tasks has been or is being ac-complished.1,46,47,89 Knowing both where

an individual currently is in terms of stagetasks and how often and with what successhe has recycled through the stages is impor-tant clinically and for our understanding theprocess of change. Current stage statusrepresents a changeable state rather than astatic trait.

We have learned a great deal about thestages and the process of change in this re-search on smoking cessation. The initialstage status of a smoker who is simply fol-lowed over time or given self-help materialsdoes relate to probability of successfulchange.8,54,75 Stage status is changeableover time, and it is important to take bothshort-term and long-term longitudinal per-spectives when trying to understand andevaluate the process of change.9,74,88 Manyof these studies were done with largegroups of participants followed over signifi-cant periods of time, and they support thereality of recycling and the efficacy of re-peated attempts to quit for some smokers.We have also been able to see that smokingcessation is not necessarily the same as quit-ting in a sample of pregnant women whostopped smoking for the pregnancy,90 andthat shifting the process activity from cog-nitive to behavior processes as one movesinto action produces more abstinence.82

We have also demonstrated that it is pos-sible to recruit and engage smokers in earlystages of change into research projects andinterventions programs.8 However,although we have demonstrated that inter-ventions can reach and assist smokers fromall of the different stages of change, wehave not been able to demonstrate differen-tial effectiveness for any specific inter-vention with smokers in a single stage ofchange. Nevertheless, the stages have beenseen as a guide for talking about changefrom a practical perspective. Manyprograms and interventions use the stagesperspective to aid in the development ofself-help materials, counseling protocols,and healthcare-based smoking cessationprograms.10,91–93



Alcohol Abuse and Dependence

Applying the TTM and the stages ofchange to alcohol problems has producedan extensive series of studies and high-lighted other assessment problems andchange process issues. Attempting to assessreadiness and the stages of change in men-tal health and alcoholism treatment clinicsis more difficult than was true for smokingcessation. Unlike smokers, individuals withpsychiatric and=or substance abuse pro-blems who come to treatment programsoften are not as open about their intentionsto change, underestimate the existence andnature of the problem and their ambi-valence about change, overestimate theirreadiness to change, or simply tell treat-ment providers what they believe they mustin terms of where they are in the stages ofchange. For these reasons, more subtlemeasures were developed to assess stagestatus and evaluate patients entering mentalhealth53,94 and alcoholism treatmentclinics.31

The University of Rhode IslandChange Assessment Scale (URICA) con-sists of items reflecting attitudes and experi-ences related to the descriptions and tasksof the different stages of change. It wasdesigned for individuals entering treatmentand cast in a generic form so it could beused with a wide range of problem beha-viors.94 Although items were selected in-itially to represent five stages of change,including the determination=preparationstage, psychometric analyses of the measuresupported only four distinct subscales,labeled precontemplation, contemplation,action, and maintenance (These items re-flect a struggle to maintain a change.). Indi-viduals were asked to endorse these itemson a 5-point Likert scale that ranged fromstrongly agree to strongly disagree. Thisscale yielded four subscale scores that werethen used to assign stage status. In all stu-dies that use the URICA, the four subscalescores are significantly skewed so that con-

templation, action, and maintenance scoresare usually highly endorsed and precontem-plation scores are always underendorsed.Thus, it is not possible to simply use thehighest scale score to assign stage. A moresophisticated method of clustering indivi-duals based on their patterns of scoresacross the four subscales was used to createstage-based subgroups. These subgroupswere then labeled according to the patternof scores.30,31 The modified 28-item ver-sion of the URICA that targeted abstinencefrom alcohol identified five cluster sub-groups in the first study.31 The Carneyand Kivlahan30 study identified similar pat-terns but only found four cluster groups.The three largest groups seemed to alignwith the stages of precontemplation, con-templation, and preparation. The othertwo groups seemed to be variants of thesestage groups: one a group of precontempla-tors who seemed very discouraged aboutthe prospects of change (depressed=discouraged profile), and the other a groupthat could be either precontemplators orcontemplators who seemed very ambiva-lent about change (ambivalent profile).31

These subgroups related in logical andexpected ways to other variables in theseand a variety of studies focusing on sub-stance and alcohol abuse.29,95–97 However,many of these studies have not providedextensive support for predictive validity.Large samples are needed if clustering isto be used; otherwise subgroups have verysmall numbers of participants, and statisti-cal power to predict is compromised.

Miller and colleagues33 took a similarassessment approach to evaluate moti-vation in creating the SOCRATES (Stagesof Change, Readiness, and TreatmentEagerness Scale). They used items similarto the URICA, made them alcohol- ordrug-specific, and again added items thatcould represent a subscale for determi-nation (the preparation stage precursor).The factor structure for this measure,however, did not support all the stage

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subscales, and currently this measure isused to assess problem recognition(precontemplation and determinationitems), taking steps (action items), and am-bivalence (contemplation). Although notclearly identifying stage status, this scaleidentifies subtasks related to the stage tasksand finds them related to other variables ina logical and consistent manner.33,35,98 Todate, support for predictive validity hasbeen modest.34,99

Groups formed by clusters are interest-ing but make for complicated data analysis.The information is also difficult to accessand use in clinical settings because profilesof scores must be interpreted and com-pared to those of some larger group. To ad-dress this concern and create a single scorewith which to measure motivation for Pro-ject MATCH, we evaluated the secondorder factor structure of the URICA andcreated a motivational readiness scorebased on the URICA subscales thatreflected this second order factor.18,19 Sum-ming the average contemplation, action,and struggle to maintain subscale scoresand subtracting the precontemplation aver-age score created a motivational readinessscore that could range from �2 to þ14,with higher scores indicating greater readi-ness to change. These scores paralleledthe profiles found in prior research, withthe lowest scores representing the discour-aged precontemplator and the highestscores the preparation=participation profilegroups.18 This was the metric that was usedin the primary motivational hypothesis inProject MATCH. These motivational readi-ness scores were predictive of drinking out-comes at the one- and three-year follow-upamong outpatients but not amongaftercare patients.16,17 It also predicted pa-tients’ working alliance scores100 and wasrelated to patient processes of change19 aswell as outpatient outcomes. Of all the out-patient characteristics measured, patientmotivational readiness was one of thestrongest predictors of frequency and in-

tensity of drinking outcomes.101 A secondmeasure of alcohol-specific readiness tochange derived from the SOCRATESyielded similar findings102 for outpatients.Motivation to change, as measured bystage-based assessments at baseline, provedto be a robust predictor of quantity and fre-quency of drinking at the one- and three-year follow-up period.

An in-depth analysis of this readinessscore and its relation to changes in drinkingindicated that patient endorsement of thefour subscale scores of the URICA shiftedfrom the beginning to the end of treatmentbut not in totally expected ways. As indivi-duals moved through treatment and intothe post-treatment period, many achieveda substantial modicum of abstinence.19,64

On entry to treatment and prior to achiev-ing significant reductions in drinking,URICA scores that represented a prepara-tion stage profile with individuals havinglower precontemplation scores along withhigher scores on the contemplation, action,and struggle to maintain subscales indicatedgreater readiness to change and predictedtherapeutic alliance and drinking outcomes.However, as drinkers gained some measureof abstinence and progressed in treatment,their attitudes related to the tasks of thestages of change and their alcohol problemshifted. At the end of treatment, patientswith high action scores and low scores onthe struggle to maintain subscale had thebest outcomes.64 These patients also hadhigher abstinence self-efficacy and lesstemptation to drink, and they used morebehavioral processes of change than com-parison patients with poorer outcomes.19,64

Thus, the readiness score derived from theURICA can be used prior to treatment topredict drinking outcomes. However, whenthe scores from the URICA are being usedto indicate progress during treatment or asend-of-treatment predictors of drinkingoutcomes, action and maintenance subscalescores and not the readiness score shouldbe used.19 It is important to remember that



these subscales scores represent attitudesand activities related to the stages of changeand not precisely stage status. Items inthese subscales, however, tap into impor-tant dimensions of the process of change.The shifts in subscale scores, with some in-creasing and decreasing over time, supportthe notion that motivation and the processof change is not represented accurately by alinear, continually increasing, singlevariable. As individuals successfullyaccomplish the tasks of the different stages,they shift focus and change attitudes andactivities related to the process ofchange.1,8,9,64

Another interesting discovery that wasmade while using the URICA to assessreadiness in Project MATCH was that base-line readiness scores were more predictivewhen assessed in the outpatient arm com-pared to the aftercare arm of thetrial.16,17,102 For patients who were assessedduring their inpatient or intensive out-patient treatment prior to their entry intoaftercare, the motivational readiness scoresderived from both the URICA and theSOCRATES were not predictive of drink-ing outcomes. It appears that the evaluationof motivation and stage of change wasmore difficult to obtain when patients werein restricted environments, where absti-nence was supported by the setting andthere was a lack of access to alcohol.1,19

Once these patients completed their after-care treatment, however, they appeared tobe very similar to the outpatients at theend-of-outpatient treatment in how theirscores on the URICA, self-efficacy, andprocesses of change related to stoppingdrinking predicted their drinking outcomesduring the post treatment year.19,64,103

Accurate self-assessments of patient motiv-ation were more difficult to obtain in theserestricted settings and seemed to be skewednot simply from social desirability but alsofrom a genuine difficulty that patients hadin accurately evaluating their readiness andpersonal efficacy in these settings.

Using the stages of change and motiva-tional readiness in alcoholism treatment toaccurately and definitively place patients inparticular stages of change is challenging.One way is to use subscale scores of theURICA or the SOCRATES in combinationto create groups based on profiles and as-sign an individual to a stage based on thesimilarity of profiles. Another is to usereadiness scores calculated from URICAsubscale scores to assign stage or level ofreadiness based on cutoff scores derivedfrom prior research. For example, in Pro-ject MATCH, motivational readiness scoresof outpatients at entry to the treatmentwere trichotomized yielding three equalgroups: a low readiness group with a meanreadiness score of 8.7, a medium groupwith a mean of 10.5, and a high readinessgroup with a mean of 12.4.19 These groupsloosely parallel the precontemplation, con-templation, and preparation=participationprofiles. Thus, scores could be used to as-sign stage status with those individuals,with scores below 8 considered precontem-plation, scores of 8 to 11 in contemplation,and scores above 12 in preparation. Themore elegant way to do this would be to de-velop cutoff scores based on patients whowere in a setting that was the same or verysimilar in order to develop norms used tocreate stage assignments. Again, thesescores predict best when assessing patientsat the beginning of treatment and in out-patient settings.

Although the findings that support theconcurrent, construct, and predictive val-idity of the motivational readiness scoresin Project MATCH do not directly supportdistinct stage classifications, they do indi-cate that patient’s stage-based attitudes atthe beginning of treatment have importantimplications for the process of treatmentand drinking outcomes. More importantlyfor the transtheoretical model is that moti-vational readiness scores are related in waysthat are compatible with the process per-spective of the model. Readiness scores

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were consistent with patient scores on cog-nitive and behavioral processes of changeand abstinence self-efficacy and were re-lated to problem recognition, workingalliance, and behavioral change.19,64,101

Drug Abuse and Dependence

Assessment of motivation and readi-ness with drug abusers has been even moredifficult and suffers from problematic ap-plication of measures, small samples, andmultiple targeted behaviors. Despite thesedifficulties, a number of studies with sub-stance abuse patients have supported someof the basic psychometric properties ofURICA and SOCRATES scales with find-ings similar to those with alcohol patients.However, predictive validity has beenmore elusive.29,35,95,96,104,105 The biggestproblems for interpretation with many ofthese studies has been inadequate samplesto represent the range of stages95,106 andthe fact that most have attempted to evalu-ate multiple substance use behaviors.29,35,105

Motivation for change among sub-stance abusers is most often substance-specific. Individuals usually arrive intreatment focused on the primary drugabuse problem, be it heroin, cocaine, mari-juana, or some other substance. However,many come to treatment as polydrug abu-sers who, in addition to the primary drugof abuse, use or abuse other illegal drugsand alcohol, and smoke cigarettes. Drug-free treatment programs usually demandabstinence from all drugs as well as anyproblematic alcohol use. Methadone main-tenance programs often require abstinencefrom all ‘‘unauthorized’’ drugs. However,individuals who apply to and participate inthese programs often are ready to changeonly one or two of the drug abusebehaviors that they are engaging in andnot all unauthorized drugs.1,95,107 Stage ofchange can be very different for eachdrug or drug class. However, measures ofmotivation and stages of change in the

studies cited are often quite generic, usingterms that refer to substance use behavior,unauthorized drugs, alcohol and drugs,drug use, or illegal drug use.

More sensitive measures targeting spe-cific drugs of abuse are needed to accu-rately reflect the stage status of individualsentering substance abuse treatment. How-ever, increasing accuracy is difficult becauseentry into the program is often contingenton individuals being assigned to or optingfor the drug-free program and=or beingmandated to treatment by the legal system.Most individuals entering treatment experi-ence a combination of negative and positivepressures.108 Pressures to enter and be ac-cepted into programs can make accurateself-evaluations problematic. Moreover, intreatment settings, it is often problematicfor staff if patients report any lack of mo-tivation, lack of conviction that their drink-ing or drug use is problematic, orambivalence about changing drug use.Thus, assessment of readiness and stagesof change with illegal substances of abusepresents greater challenges than did assess-ments of motivational readiness for alcoholproblems and stage status for nicotine de-pendence. Additional research that specifiessubstance and tracks process variables overtime is needed to evaluate how best to useand evaluate the stages of change and readi-ness with drug abuse problems.

READINESS, STAGES OF CHANGE,AND ADDICTION TREATMENT

Despite the difficulties in measuring stagestatus with evaluation instruments and thecriticisms of the stages, the success of sta-ging and assessing motivational readinessamong smokers and drinkers and the intuit-ively appealing stage-based description ofthe process of change have made asignificant impact in designing and deliver-ing interventions for a range ofabused substances and health beha-viors.1,8,12,13,65,109,110 Clinicians have found



the identification of stage subtasks and theidea that individuals are in different stagesof change on entering treatment both in-formative and helpful. Other conceptualcontributions have included placing the re-sponsibility to work through the tasks ofeach of the stages on the substance abuser,helping the treatment provider specify theirrole in facilitating accomplishment of thetasks, and highlighting the fact that relapseis often part of learning process, whichmakes movement through the process ofchange not linear but cyclical and requiresrecycling through the tasks of the variousstages.1,9

Clinicians have been using the stagesdespite not having a simple measure toevaluate stage status. The most recent re-vision of the ASAM Placement Criteria111

requires an evaluation of patient readinessto change as an important part of place-ment decision making. Most evaluatorsand clinicians are using sensitive and moti-vational clinical interviews to establish stagestatus and how to help patients movethrough the process of change.13,46,110 Re-cent efforts to apply the stages of changeto substance abuse treatment have usedboth stages and processes of change, out-lined in the Transtheoretical Model ofChange, to guide interventions efforts. Anew group therapy manual developed forsubstance abuse treatment has created spe-cific intervention modules and group activi-ties utilizing both the stages and theprocesses of change.14 In fact, this ap-proach encourages therapists to teach pa-tients the stages so that they canunderstand better stage tasks and evaluatethemselves as to where they are andwhether they are ready to move forward.Obviously, patients need to feel comfor-table and safe in self-disclosure if they areexpected to acknowledge to the groupwhere they are in the process of change.To apply and assess stage status and moti-vational readiness to change in clinical set-tings, a collaborative and non-judgmental

approach that will allow the patient to ac-knowledge ambivalence, lack of commit-ment, and their personal evaluation oftheir own stage status is needed.

Motivation for change is best viewed asbehavior- and goal-specific, meaning thatmotivation to change can differ for eachsubstance (alcohol, cocaine, marijuana, ni-cotine, heroin) and for different goals (re-duction of alcohol and other drugs versusabstinence from these substances). Moti-vation to change can be specified not onlyby substance but also by the method of in-gestion. In one survey of blue-collar work-ers, we found that many individuals whosuccessfully had quit smoking cigarettesand were in maintenance for smoking ces-sation were in early stages of change(precontemplation, contemplation, prepara-tion) with respect to quitting their useof smokeless tobacco. Programs thatrequire freedom from all drugs will certainlyhave to struggle with differing levels ofmotivation and variable stages status withabusers of multiple substances.

Although the stage of change modelsupports the notion that interventions andtreatment must be individualized and tai-lored to the stage status of the individual,there are many ways to accomplish this.One approach is to develop common pro-gram elements that address the needs ofdifferent patients and have the flexibilityof moving patients and shifting program-ming to meet their changing needs as theymove forward in the process of change. Anumber of very concrete suggestions fortreatment programming that would addressspecific stages, and stage tasks havebeen provided in several recentpublications.1,13,14,46

READINESS, STAGES OF CHANGE,AND ADDICTION RESEARCH

Although there has been a great deal of re-search on the stages of change and readi-ness to change over the past twenty years,

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there are still important and basic questionsto be answered. The face validity and heu-ristic value of the stage conceptualizationhas fueled its popularity. However, researchstudies with a variety of addictive behaviorssupport subdividing the process of changeinto different steps and tasks. They furtherindicate that groups of individuals sub-divided according to stage tasks or withdiffering levels of readiness vary in predic-table ways. However, not all studies havebeen able to find these differences, andmany have not found stage status to predictparticipation in treatment and behaviorchange outcomes. Assessment of the stagesand translating that assessment into a readi-ness to change metric offers some benefitsbut also poses problems for assigning stagestatus. In addition, assessment problemsand challenges vary by substance of abuseand setting.

The problems encountered in assessingstage status in various studies appear to berelated to four key issues:

1. the target goal of the behavior changeis often poorly specified

2. measures have been poorly constructedand inadequately evaluated in theirapplications

3. measures are setting-sensitive becausethey must rely on self-report and theaccuracy and honesty of the individual

4. stage status is difficult to capture be-cause it represents a changeable stateand not a static trait.

However, some important considerationshave been identified that could assist in im-proving the accuracy of assessing the stagesof change, including having a clear beha-vioral target in terms of substance andchange goal; assessing problem recognition;identifying attitudes, evaluations, and inten-tions toward changing that behavior nowand in the future; finding accepted indica-tors of actual behavior change; and measur-ing the length of time the change has been

sustained.8 All of these elements can behelpful in creating sensitive stage assess-ments. However, it is important rememberthat any measure attempts to operationalizea construct in a satisfactory manner, but nomeasure ever achieves a complete represen-tation of a construct.

The evaluation of stages is more com-plicated when the target behavior is com-plex and multi-faceted or when there aremultiple potential goals with regard to thetarget behavior. Reducing drinking andabstaining from drinking represent two dif-ferent potential goals for an alcohol abuser.Stage status related to these two distinctgoals often are very different and inverselyrelated because drinkers who successfullycut down often become more resistant toabstinence goals. Specificity of behaviorand the change goal is critical for accurateassessment.

A stage of change represents the cur-rent state of the individual with respect tochanging a single behavior or constellationof behaviors. Stage status can persist for along time or could change in a very shorttime. An individual who is in precontem-plation about quitting smoking today couldbe in preparation or action tomorrow afterlearning about the death of his best friendfrom lung cancer. Assessing this movingtarget and then using a single assessmentat one point in time to predict change out-comes is problematic. Considering this in-stability, the research findings describedabove are all the more astounding as stagevariables have been very potent predictorsin many studies despite the problems ofassessment.

Some researchers point to these pro-blems and lack of consistency in findingsand conclude that the ‘‘stage model doesnot work’’ and should be set aside.43 How-ever, a model is a heuristic to assist inunderstanding a phenomenon. In this case,the phenomenon is the process of inten-tional behavior change. This review of theliterature indicates that there is substantial



support in demonstrating that the stageshave assisted in creating research that hasadvanced our understanding of the processof change in recovery from an addictivebehavior. However, both positive and nega-tive findings should be examined. What isneeded is not simply model testing to seeif the model is supported, but, more impor-tantly, what each piece of research revealsabout motivation, the process of change,and the phenomenon of intentional beha-vior change.

CONCLUSIONS ANDRECOMMENDATIONS

Understanding motivation in terms of thestages of change and patient readiness toengage in and complete the tasks of eachstage has enriched our understanding ofthe process of change and increased ourability to reach and influence substanceabusers. An evaluation of the current statusof the research indicates that there are flaws

in application, problems in measurement,and variable support for some expectedpredictions derived from the construct ofthe stages of change and the Transtheoreti-cal Model. However, there is solid evidencethat when measured adequately, the stagesof change provide a meaningful way to seg-ment the process of change, increase ourunderstanding of motivation as a multifa-ceted dimension of change, and offer a dif-ferentiated and rich view of the process ofchange to aid our understanding of self-change and treatment-assisted change. Inthe areas of alcohol abuse and smokingcessation, both stage status and stage-basedreadiness to change measures are better de-veloped than with other drugs of abuse.Overall, the data and the insights providedby this differentiated, stage-based view ofmotivation continue to support additionalexploration and evaluation of its applicationin clinical treatment and its use in researchthat explores the process of intentionalbehavior change.

REFERENCES

1. DiClemente CC. Addiction and Change: HowAddictions Develop and Addicted People Recover.New York: Guilford Press; 2003.

2. DiClemente CC, Bellino LE, Neavins TM. Mo-tivation for change and alcoholism treatment.Alcohol Res Health. 1999;23:86–92.

3. Miller WR. Motivation for treatment: a reviewwith special emphasis on alcoholism. PsycholBull. 1985;98:84–107.

4. Jellinek E. The Disease Concept of Alcoholism. NewHaven, CT: Hillhouse; 1960.

5. Klingemann H. The motivation for changefrom problem alcohol and heroin use. Br JAddict 1991;86:727–744.

6. Lettieri DJ, Sayers M, Pearson HW, eds. The-ories on Drug Abuse: Selected Contemporary Perspec-tives. NIDA Research Monograph No. 30,DHHS Publication No. ADM 80–967. Rock-ville, MD: National Institute on Drug Abuse;1980.

7. Prochaska JO, DiClemente CC. The Transtheore-tical Approach: Crossing the Traditional Boundaries

of Therapy. Malabar, FL: Krieger PublishingCo.; 1984.

8. DiClemente CC, Prochaska JO. Toward a com-prehensive, transtheoretical model of change:stages of change and addictive behavior. In:Miller WR, Heather N, eds. Treating AddictiveBehaviors. 2nd ed. New York: Plenum; 1998:3–24.

9. Prochaska JO, DiClemente CC, Norcross J. Insearch of how people change. Am Psychol.1992;47:1101–1114.

10. Prochaska JO, Norcross J, DiClemente CC.Changing for Good: The Revolutionary Program thatExplains the Six Stages of Change and Teaches YouHow to Free Yourself from Bad Habits. New York,NY: William Morrow & Co., Inc.; 1994.

11. Miller WR, Rollnick S. Motivational Interviewing.2nd ed. New York: Guilford Press; 2002.

12. Rollnick S, Mason P, Butler C. Health BehaviorChange. London: Churchill Livingstone; 1999.

13. Center for Substance Abuse Treatment. En-hancing Motivation for Change in Substance Abuse

DiClemente et al.


Treatment. Treatment Improvement ProtocolNumber 35, DHHS Publication No. SMA 99-3354. Washington, DC: U.S. GovernmentPrinting Office; 1999.

14. Velasquez MM, Gaddy-Maurer GG, Crouch C,DiClemente CC. Group Treatment for SubstanceAbuse: A Stages of Change Therapy Manual. NewYork: Guilford Press; 2001.

15. Heather N, Rollnick S, Bell A. Predictive val-idity of the Readiness to Change Questionnaire.Addiction. 1993;88:1667–1677.

16. Project MATCH Research Group. Matchingalcoholism treatments to client heterogeneity:Project MATCH post-treatment drinking out-comes. J Stud Alcohol. 1997;58:7–29.

17. Project MATCH Research Group. Matchingalcoholism treatments to client heterogeneity:Project MATCH three-year drinking outcomes.Alcohol Clin Exp Res. 1998;22:1300–1311.

18. Carbonari JP, DiClemente CC, Zweben A. Areadiness to change scale: its development, vali-dation, and usefulness. In: DiClemente CC, ed.,Assessing Critical Dimensions for Alcoholism. Sym-posium conducted at the annual meeting ofAssociation for the Advancement of BehaviorTherapy, San Diego, CA; 1994.

19. DiClemente CC, Carbonari J, Zweben A,Morrel T, Lee RE. Motivation hypothesis cau-sal chain analysis. In: Longabaugh R, WirtzPW, eds. Project MATCH: a Priori Matching Hy-potheses, Results, and Mediating Mechanisms.National Institute on Alcohol Abuse and Al-coholism Project MATCH Monograph Series.Vol. 8. Rockville, MD: National Instituteon Alcohol Abuse and Alcoholism; 2001:206–222.

20. DeLeon G, Melnick G, Kressel D. Motivationand readiness for therapeutic community treat-ment among cocaine and other drug abusers.Am J Drug Alcohol Abuse. 1997;23:169–189.

21. DeLeon G, Melnick G, Thomas G, Kressel D,Wexler HK. Motivation for treatment in aprison-based therapeutic community. Am JDrug Alcohol Abuse. 2000;26:33–46.

22. Avants SK, Margolin A, Kosten TR. Influenceof treatment readiness on outcomes of twopharmacotherapy trials for cocaine abuseamong methadone maintained patients. PsycholAddict Behav. 1996;10:147–156.

23. Simpson DD, Joe GW. Motivation as a predic-tor of early drop out from drug abuse treat-ment. Psychotherapy. 1993;30:357–368.

24. DeLeon G, Melnick G, Kressel D, Jainchill N.Circumstances, motivation, readiness, and suit-ability (the CRMS scales): predicting retentionin therapeutic community treatment. Am J DrugAlcohol Abuse. 1994;20:101–106.

25. Mattson ME, Del Boca FK, Carroll KM, et al.Compliance with treatment and follow-up pro-tocols in Project MATCH: predictors and re-lationship to outcome. Alcohol Clin Exp Res.1998;22:1328–1339.

26. Joe GW, Simpson D, Broome KM. Effects ofreadiness for drug abuse treatment on client re-tention and assessment of protocols. Addiction.1998;93:1177–1190.

27. Simpson DD, Joe GW, Rowan-Szal G,Greener J. Client engagement and change dur-ing drug abuse treatment. J Subst Abuse.1995;7:117–134.

28. DiClemente CC, Scott CW. Stages of change:interaction with treatment compliance and in-volvement. In: Onken LS, Blaine JD, BorenJJ, eds. Beyond the Therapeutic Alliance: Keepingthe Drug-Dependent Individual in Treatment. Rock-ville, MD: National Institute on Drug Abuse;1997.

29. Blanchard KA, Morgenstern J, Morgan TJ,Labouvie E, Bux DA. Motivational subtypesand continuous measures of readiness forchange: concurrent and predictive validity.Psychol Addict Behav. 2003;17:56–65.

30. Carney MM, Kivlahan DR. Motivational sub-types among veterans seeking substance abusetreatment: profiles based on stages of change.Psychol Addict Behav. 1995;9:1135–1142.

31. DiClemente CC, Hughes S. Stages of changeprofiles in outpatient alcoholism treatment.J Subst Abuse. 1990;2:217–235.

32. Willoughby RW, Edens JF. Construct validityand predictive validity of the stages of changescale for alcoholics. J Subst Abuse. 1996;8:275–291.

33. Miller WR, Tonigan JS. Assessing drinkers’ mo-tivation for change: the stages of change readi-ness and treatment eagerness scale(SOCRATES). Psychol Addict Behav.1996;10:81–89.

34. Isenhart C. Pretreatment readiness for changein male alcohol-dependent subjects: predictorsof one-year follow-up status. J Stud Alcohol.1997;58:351–357.

35. Carey KB, Maisto SA, Carey MP, Purnine DM.Measuring readiness-to-change substance mis-use among psychiatric outpatients: I. reliabilityand validity of self-report measures. J StudAlcohol. 2001;62:79–88.

36. DiClemente CC. Motivation for change: Impli-cations for substance abuse treatment. PsycholSci. 1999;10:209–213.

37. DiClemente CC, Lee RE, Whyte SR. Treatmentreceptivity versus motivational readiness tochange in alcohol treatment. Presented at the32nd annual convention of the Association



for the Advancement of Behavior Therapy.Washington, DC; 1998.

38. Mallin R. Smoking cessation: integration ofbehavioral and drug therapies. Am Fam Phys-ician. 2002;65:1107–1114,1117.

39. Carey KB, Purine DM, Maisto SA, Carey, MP.Assessing readiness to change substance abuse:a critical review of instruments. Clinical Psy-chology: Science and Practice. 1999;6:245–266.

40. Joseph J, Breslin C, Skinner H. Critical perspec-tives on the Transtheoretical Model and stagesof change. In: Tucker JA, Donovan DM,Marlatt GA, eds. Changing Addictive Behavior:Bridging Clinical and Public Health Strategies.New York: Guilford Press; 1999:60–190.

41. Bandura A. Toward a unifying theory of beha-vior change. Psychol Rev. 1977;84:191–215.

42. Davidson R. Prochaska and DiClemente’smodel of change: a case study [editorial]. Br JAddiction. 1992;87:821–822.

43. Littell JH, Girvin H. Stages of change: a cri-tique. Behav Modif. 2002;26:223–273.

44. Sutton S. Can ‘‘stage of change’’ provide guid-ance in treatment of addiction? A critical exam-ination of Prochaska and DiClemente’s model.In: Edwards G, Dare C, eds. Psychotherapy,Psychological Treatments, and the Addictions.New York: Cambridge University Press;1996:189–205.

45. Sutton S. A critical review of the Transtheore-tical Model applied to smoking cessation. In:Norman P, Abraham C, Conner M, eds. Under-standing and Changing Health Behavior: FromHealth Beliefs to Self-regulation. London: HarwoodAcademic Publishers; 2000:207–225.

46. Connors GJ, Donovan DM, DiClemente CC.Substance Abuse Treatment and the Stages of Change:Selecting and Planning Interventions. New York:Guilford Press; 2001.

47. Prochaska JO, DiClemente CC, Velicer WF,Rossi JS. Criticisms and concerns of the Trans-theoretical Model in light of recent research. BrJ Addiction. 1992;87:825–828.

48. Crittenden KS, Manfredi C, Lacey L, WarneckeR, Parsons J. Measuring readiness and motiv-ation to quit smoking among women in publichealth clinics. Addict Behav. 1994;19:497–507.

49. Crittenden KS, Manfredi C, Warnecke R, ChoYI, Parsons J. Measuring readiness and motiv-ation to quit smoking among women in publichealth clinics: predictive validity. Addict Behav.1998;23:191–199.

50. Dijkstra A, DeVries H, Roijackers J, van Breu-kelen G. Tailored interventions to communi-cate stage-matched information to smokers indifferent motivational stages. J Consult Clin Psy-chol. 1998;66:549–557.

51. DiClemente CC, Velasquez M. Motivationalinterviewing and the stages of change. In:Miller WR, Rollnick S, eds. Motivational Interview-ing: Preparing People for Change. 2nd ed.New York: Guilford Publications, Inc;2002:201–216.

52. Velicer WF, Prochaska JO, Rossi J, et al. Aempirical typology of subjects with stages ofchange. Addict Behav. 1995;20:229–320.

53. McConnaughy EA, DiClemente CC, ProchaskaJO, Velicer WF. Stages of change in psycho-therapy: a follow-up report. Psychotherapy: Theory,Research and Practice. 1989;4:494–503.

54. DiClemente CC, Prochaska JO, Fairhurst S,Velicer WF, Velasquez M, Rossi J. The processof smoking cessation: an analysis of precon-templation, contemplation, and preparation.J Consult Clin Psychol. 1991;59:295–304.

55. Biener L, Abrams DB. The contemplation lad-der: validation of a measure of readiness toconsider smoking cessation. Health Psychol.1991;10:360–365.

56. Isenhart C. Motivational subtypes in an inpati-ent sample of substance abusers. Addict Behav.1994;19:463–475.

57. Belding MA, Iguchi MY, Lamb RJ. Stages ofchange in methadone maintenance: assessingthe convergent validity of two measures. PsycholAddict Behav. 1996;10:157–166.

58. Etter J, Perneger TV. A comparison of twomeasures of stage of change for smoking cess-ation. Addiction. 1999;94:1881–1889.

59. Rothfleisch J. Comparison of Two Measures of Stagesof Change among Drug Abusers. Unpublished doc-toral dissertation, University of Houston; 1997.

60. DiClemente CC, Prochaska JO, Gibertini M.Self efficacy and the stages of self change ofsmoking. Cognitive Therapy and Research.1985;9:181–200.

61. DiClemente CC, Prochaska JO. Processes andstages of change: coping and competence insmoking behavior change. In: Shiffman S, WillsTA, eds. Coping and Substance Abuse. New York:Academic Press; 1985:319–342.

62. Prochaska JO, DiClemente CC. Common pro-cesses of change in smoking, weight control,and psychological distress. In: Shiffman S, WillsTA, eds. Coping and Substance Abuse. New York:Academic Press; 1985:345–362.

63. Prochaska JO, Velicer WF, Rossi JS, et al.Stages of change and decisional balance for12 problem behaviors. Health Psychol.1994;13:39–46.

64. Carbonari JP, DiClemente CC. Using trans-theoretical model profiles to differentiate levelsof alcohol abstinence success. J Consult ClinPsychol. 2000;68:810–817.

DiClemente et al.


65. Prochaska JO. Systems of Psychotherapy: A Trans-theoretical Analysis. Homewood, IL: DorseyPress; 1979.

66. DiClemente CC. Perceived processes, changeon the cessation of smoking, and the mainte-nance of that change. Unpublished doctoraldissertation, University of Rhode Island;1978.

67. DiClemente CC, Prochaska JO. Self changeand therapy change of smoking behavior: acomparison of processes of change in cessationand maintenance. Addict Behav. 1982;7:133–142.

68. Prochaska JO, DiClemente CC. Stages andprocesses of self change of smoking: towardan integrative model of change. J Consult ClinPsychol. 1983;51:390–395.

69. Prochaska JO, DiClemente CC. Self changeprocesses, self efficacy, and decisional balanceacross five stages of smoking cessation. In:Epstein PF, Anderson PN, Mortenson LE,eds. Advance in Cancer Control. New York: AlanR. Liss, Inc; 1984:131–151.

70. Prochaska JO, DiClemente CC. Toward a com-prehensive model of change. In: Miller WR,Heather N, eds. Treating Addictive Behavior: Pro-cesses of Change. New York: Plenum Press;1986:3–27.

71. DiClemente CC, Prochaska JO, Gibertini M.Self efficacy and the stages of self change ofsmoking. Cognitive Therapy and Research.1985;9:181–200.

72. Prochaska JO, DiClemente CC, Velicer WF,Ginpil SE, Norcross JC. Predicting change insmoking status for self changers. Addict Behav.1985;10:395–406.

73. Prochaska JO, Velicer WF, DiClemente CC,Fava J. Measuring processes of change: appli-cation to the cessation of smoking. J ConsultClin Psychol. 1988;56:520–528.

74. Prochaska JO, Velicer W, DiClemente CC,Guadagnoli E, Rossi J. Patterns of change:dynamic typology applied to smoking cessation.Multivariate Behavioral Research. 1991;26:83–107.

75. Prochaska JO, DiClemente CC, Velicer WF,Rossi JS. Standardized, individualized, interac-tive, and personalized self-help programs forsmoking cessation. Health Psychol. 1993;12:399–405.

76. Velicer WF, Prochaska JO, Bellis JM, et al. Anexpert system intervention for smoking cess-ation. Addict Behav. 1993;18:269–290.

77. Velicer WF, Prochaska JO, Rossi J,DiClemente CC, Guadanoli E, Redding C. Aempirical typology of subjects with stages ofchange. Addict Behav. 1995;20:229–320.

78. Velicer WF, DiClemente CC, Rossi J, Pro-chaska JO. Relapse situations and self-efficacy:

an integrative model. Addict Behav. 1990;15:271–283.

79. Velicer WF, DiClemente CC, Prochaska JO,Brandenburg N. A decisional balance measurefor assessing and predicting smoking status.J Pers Soc Psychol. 1985;48:1279–1289.

80. Kristeller JL, Rossi JS, Ockene JK, Goldberg R,Prochaska JO. Processes of change in smokingcessation: a cross-validation study in cardiacpatients. J Subst Abuse. 1992;4:263–276.

81. O’Connor E, Carbonari JP, DiClemente CC.Gender and smoking cessation: a factor struc-ture comparison of processes of change. J Con-sult Clin Psychol. 1996;64:130–138.

82. Perz CA, DiClemente CC, Carbonari JP. Doingthe right thing at the right time? Interaction ofstages and processes of change in successfulsmoking cessation. Health Psychol. 1996;15:462–468.

83. Farkas AJ, Pierce JP, Zhu S, et al. Addictionversus stages of change models in predictingsmoking cessation. Addiction. 1996;91:1271–1280.

84. Abrams DB, Herzog TA, Emmons KM, Lin-nan L. Stages of change versus addiction: a rep-lication and extension. Nicotine Tob Res.2000;2:223–229.

85. Keller S, Nigg CP, Jaekle C, Baum E, Basler H.Self-efficacy, decisional balance, and the stagesof change for smoking cessation in a Germansample. Swiss Journal of Psychology. 1999;58:101–110.

86. Morera OF, Johnson SF, Parsons J, CrittendenKS, Flay BR, Warnecke RB. The measure ofstage of readiness to change: some psycho-metric considerations. Psychol Assess. 1998;10:182–186.

87. Schorling JB. The stages of change of ruralAfrican-American smokers. Am J Prev Med.1995;11:170–177.

88. Carbonari JP, DiClemente CC, Sewell KB.Stage transitions and the transtheoretical stagesof change model of smoking cessation. SwissJournal of Psychology. 1999;58:134–144.

89. Velicer WF, DiClemente CC. Understandingand intervening with the total populationof smokers: an editorial. Tob Control.1993;2:95–96.

90. Stotts A, DiClemente CC, Carbonari JP, MullenP. Pregnancy smoking cessation: a case of mis-taken identity. Addict Behav. 1996;21:459–471.

91. Glynn TJ, Boyd GM, Gruman JC. Essentialelements of self-help=minimal interventionstrategies for smoking cessation. Health EducBehav. 1990;17:329–345.

92. Zimmerman GL, Olsen CG, Bosworth MF. A‘‘stages of change’’ approach to helping patients



change behavior. Am Fam Physician.2000;61:1406–1416.

93. Fiore MC, Jorenby DE, Baker TB. Smokingcessation: principles and practice based uponthe AHCPR Guideline, 1996. Ann Behav Med.1997;19:213–219.

94. McConnaughy EA, Prochaska JO, Velicer WF.Stages of change in psychotherapy: measure-ment and sample profiles. Psychotherapy: Theory,Research, and Practice. 1983;20:368–375.

95. Belding MA, Iguchi MY, Lamb RJ. Stages andprocesses of change as predictors of drug useamong methadone maintenance patients. ExpClin Psychopharmacol. 1997;5:65–73.

96. Pantalon MV, Nich C, Frankforter T, CarrollKM. The URICA as a measure of motivationto change among treatment-seeking individualswith concurrent alcohol and cocaine problems.Psychol Addict Behav. 2002;16:299–307.

97. Greenstein DK, Franklin ME, McGuffin P.Measuring motivation to change: an examin-ation of the University of Rhode IslandChange Assessment Questionnaire (URICA)in an adolescent sample. Psychotherapy.1999;36:47–55.

98. Dermen K, Koutsky J, Connors G, CzarneckiD. SOCRATES scores of alcoholic inpatients:factor structure and relationship to pretreat-ment characteristics and treatment compliance.Poster presented at the annual meeting of theAssociation for the Advancement of BehaviorTherapy, Miami, FL; 1997.

99. Maisto SA, Chung TA, Cornelius JR. Factorstructure of the SOCRATES in a clinical sam-ple of adolescents. Psychol Addict Behav.2003;17:98–107.

100. Connors GJ, DiClemente CC, Dermen KH,Kadden R, Carroll KM, Frone MR. Predictingthe therapeutic alliance in alcoholism treatment.J Stud Alcohol. 2000;61:139–149.

101. DiClemente CC, Carroll KM, Miller WR, Con-nors GJ, Donovan DM. A look inside treat-ment: therapist effects, the therapeuticalliance, and the process of intentional behaviorchange. In: Babor T, DelBoca F, eds. TreatmentMatching in Alcoholism. Cambridge UniversityPress; 2003:166–183.

102. Project MATCH Research Group. ProjectMATCH secondary a priori hypotheses. Addic-tion. 1997;92:1671–1698.

103. DiClemente CC, Carbonari JC, Daniels JW,Donovan DM, Bellino LE, Neavins TM. Self-efficacy as a matching hypothesis: causal chainanalysis. In: Longabaugh R, Wirtz PW, eds. Pro-ject MATCH: A Priori Matching Hypotheses,Results, and Mediating Mechanisms. National Insti-tute on Alcohol Abuse and Alcoholism ProjectMATCH Monograph Series. Vol. 8. Rockville,MD: National Institute on Alcohol Abuse andAlcoholism; 2001;239–259.

104. Siegal HA, Li L, Rapp RC, Saha P. Measuringreadiness for change among crack cocaineusers: a descriptive analysis. Subst Use Misuse.2001;36:687–700.

105. Pantalon MV, Swanson AJ. Use of the Univer-sity of Rhode Island Change Assessment tomeasure motivational readiness to change inpsychiatric and dually diagnosed individuals.Psychol Addict Behav. 2003;17:91–97.

106. Abellanas L, McLellan AT. ‘‘Stage of change’’by drug problem in concurrent opioid, cocaine,and cigarette users. J Psychoactive Drugs.1993;25:307–313.

107. DiClemente CC, Carbonari JP, Velasquez MM.Alcoholism treatment mismatching from a pro-cess of change perspective. In: Watson RR, ed.Treatment of Drug and Alcohol Abuse. Towota, NJ:Humana Press; 1992:115–142.

108. Marlowe DB, Merikle EP, Kirby KC, FestingerDS, McLellan AT. Multidimensional assess-ment of perceived treatment-entry pressuresamong substance abusers. Psychol Addict Behav.2001;15:97–108.

109. Miller WR, Heather N, eds. Treating Addictive Beha-viors. 2nd ed. New York: Plenum Press; 1998.

110. Miller WR, Rollnick S. Motivational Interviewing:Preparing People to Change Addictive Behavior.New York: Guilford Press; 1991.

111. Mee-Lee D, Shulman GD, Fishman M,Gastfriend DR, Griffith JH, eds. ASAMPatient Placement Criteria for the Treatment of Sub-stance-related Disorders. 2nd ed, revised. (ASAMPPC-2R). Chevy Chase, MD: AmericanSociety of Addiction Medicine, Inc.; 2001.

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