Psychology of Addictive Behaviors Copyright 2002 by the Educational Publishing Foundation

2002, Vol. 16, No. 4, 299 –307 0893-164X/02/$5.00 DOI: 10.1037//0893-164X.16.4.299

The URICA as a Measure of Motivation to Change Among Treatment-

Seeking Individuals With Concurrent Alcohol and Cocaine Problems

Michael V. Pantalon, Charla Nich, Tami Frankforter, and Kathleen M. Carroll

Yale University School of Medicine

The original 4-factor structure of the University of Rhode Island Change Assessment (URICA; C. C.
DiClemente & S. O. Hughes, 1990) was replicated, and the scale’s internal consistency was found to be
acceptable in a sample of 106 cocaine- and alcohol-dependent participants receiving either disulfiram or
no medication in a psychotherapy trial. In addition, participants categorized as having high Committed
Action (CA), a new URICA composite, had a significantly greater percentage of days abstinent from both
alcohol and cocaine (85.6%) than low-CA participants (72.7%, p ⬍ .01). Furthermore, a significant
Treatment ⫻ CA interaction emerged, suggesting that low-CA participants had better outcomes than
those with high CA when assigned to medication, whereas high-CA participants fared equally well with
or without medication.

The importance of assessing motivation in individuals seeking
substance abuse treatment has been demonstrated in several recent
studies. Findings from these studies suggest that there are positive
associations between motivation to change problem substance use
and a variety of indicators of treatment outcome, including, for
example, treatment engagement and retention among methadone-
maintained participants (Joe, Simpson, & Broome, 1998; Simpson,
Joe, Rowan-Szal, & Greener, 1997), quit attempts in cigarette
smokers (DiClemente et al., 1991) and reductions in alcohol con-
sumption among alcohol-dependent individuals (Project MATCH
Research Group, 1997).
One of the most commonly used multidimensional question-
naires to assess motivation to change in non–tobacco-related sub-
stance use disorders is the University of Rhode Island Change
Assessment (URICA; DiClemente & Hughes, 1990), a 32-item
scale based on one of the central constructs of the transtheoretical
model (TTM) of behavior change in the addictions, namely, the
stages-of-change model of motivation (Prochaska & DiClemente,
1985; Prochaska, DiClemente, & Norcross, 1992). In its original
form, the TTM’s stages-of-change model hypothesizes that indi-
viduals go through four distinct stages while addressing problem-
atic behavior: (a) precontemplation (when an individual believes
he or she does not have a problem), (b) contemplation (when the
pros and cons of change are being considered), (c) action (when
efforts to change are underway), and (d) maintenance (when ef-
forts are focused on sustaining improvements). The scale yields
four discrete stage/subscale scores. It should be noted, however,
Michael V. Pantalon, Charla Nich, Tami Frankforter, and Kathleen M.
Carroll, Department of Psychiatry/Division of Substance Abuse, Yale
University School of Medicine.
The research reported in this article was supported by National Institute
on Drug Abuse Grants P50-DA09241, R18-DA06963, and K05-DA00457
to Kathleen M. Carroll.
Correspondence concerning this article should be addressed to Michael
V. Pantalon, Department of Psychiatry, Yale University School of Medi-
cine, CMHC/SAC-S209, 34 Park Street, New Haven, Connecticut 06519.
E-mail: michael.pantalon@yale.edu
that the current iteration of the TTM stages-of-change model now
includes an additional stage between Contemplation and Action:
the preparation stage, in which an individual is preparing to take
steps toward change but has not yet done so.
The URICA’s psychometric properties have been evaluated in
individuals with a wide variety of substance-related disorders,
including nicotine (Prochaska & DiClemente, 1985; Prochaska,
DiClemente, & Norcross, 1992), alcohol (Carbonari & Di-
Clemente, 2000; DiClemente & Hughes, 1990; Edens & Wil-
loughby, 2000; Project MATCH Research Group, 1997), heroin
(Belding, Iguchi, & Lamb, 1996; McCusker et al., 1994), cocaine
(Lamb, Belding, & Festinger, 1995; Roberts, Shaner, & Marlatt,
1996; Rosenbloom, 1991), and polydrug dependence (Abellanas &
McLellan, 1993; Carney & Kivlahan, 1995; El-Bassel et al., 1998),
as well as with dually diagnosed populations (Velasquez, Carbon-
ari, & DiClemente, 1999). Its internal consistency has been found
to be in the acceptable-to-good range in a number of studies,
although its test–retest reliability has been rarely studied (Carey,
Purnine, Maisto, & Carey, 1999). Though also infrequently stud-
ied, the concurrent validity of the URICA was shown to be good
in one published report, which suggested that, among dually di-
agnosed participants, alcohol use severity in the past 90 days was
positively correlated with two of its subscales (i.e., the Mainte-
nance score and the Readiness to Change composite score), sug-
gesting that heavy alcohol use at baseline is related to readiness to
change (Velasquez et al., 1999).
Support for the URICA’s four-factor solution has been mixed.
The most common analytical strategy used in evaluating the factor
structure of the URICA is a principal-components analysis, a form
of exploratory analysis. To our knowledge, only one study used a
confirmatory factor analysis (CFA) strategy, in which fit indices
were presented for each of the four original factors. Four of the six
studies supported a four-factor solution (excluding the preparation
stage), ranging in variance accounted for from 39% to 58% (Car-
ney & Kivlahan, 1995; DiClemente & Hughes, 1990; McCon-
naughy, DiClemente, Prochaska, & Velicer, 1989; McConnaughy,
Prochaska, & Velicer, 1983). Of the other two studies, one dem-
onstrated a better fit with a five-factor solution (including the

299
300 PANTALON, NICH, FRANKFORTER, AND CARROLL
preparation stage), which accounted for 47% of the variance (El-
Bassel et al., 1998), whereas the other, which used CFA, failed to
confirm the a priori specified four-factor model (Belding et al.,
1996). This study found that none of the items thought to be
associated with the maintenance stage had factor loadings greater
than .60 and thus prevented the confirmation of a four-factor
(stage) model. Three other studies that evaluated populations of
illicit substance users (e.g., cocaine, opiates, cannabis) have failed
to support the URICA’s original four-factor solution (Belding,
Belding, Lamb, & Lakin, 1995; Lamb et al., 1995; Rosenbloom,
1991).
Findings regarding the URICA’s predictive validity have also
been mixed. For example, results from Project MATCH, a large
multisite study of patient–treatment matching for three psychother-
apeutic approaches to treating alcohol dependence, indicated that
pretreatment motivation, as measured by the URICA, was a sig-
nificant predictor of drinking behavior in a 1-year follow-up,
where higher motivation was associated with less alcohol use
(Project MATCH Research Group, 1997). In contrast, for individ-
uals receiving motivational enhancement therapy (Miller, Zweban,
DiClemente, & Rychtarik, 1992), lower pretreatment motivation
on the URICA was associated with lower alcohol use. However,
this held true only at the 15-month follow-up point (Project
MATCH Research Group, 1997). Recent additional analyses
from this sample used a different methodology to investigate the
URICA’s predictive validity by using all four URICA subscales
simultaneously (e.g., profile analysis). These analyses suggested
that motivational profiles, or the shapes of graphic displays of
baseline and end-of-treatment URICA subscale means, differenti-
ated among participants who were abstinent, moderate, and
heavier drinkers, on the basis of their 1-year outcomes (Carbonari
& DiClemente, 2000). However, it appeared that participants who
were abstinent had lower end-of-treatment Maintenance scores,
which indicate low motivation, than those in the other two groups
of drinkers. A study that used another type of profile analysis,
namely, cluster analysis, indicated that alcohol-dependent partici-
pants who were in a contemplation–action cluster completed res-
idential treatment at a significantly higher rate (75%) than those in
a precontemplation cluster (54%; Edens & Willoughby, 2000).
Although several studies that have evaluated the URICA appear
to support the TTM’s stages-of-change construct, other studies
seem to contradict the model’s predictions. For example, Abella-
nas and McLellan (1993) reported that, in a sample of polydrug-
dependent methadone participants, URICA scores were not related
to current level of drug use. In addition, Carney and Kivlahan
(1995) found less drug use among participants they had catego-
rized as precontemplators (those who presumably had the lowest
motivation for change) than among those in the three other cate-
gories, whereas El-Bassel et al. (1998) found no differences in
level of drug and alcohol use among clusters of participants,
derived from cluster analysis, representing different levels of mo-
tivation. Finally, a small study of the URICA with cocaine-
dependent schizophrenic participants suggested no relationship
between stage of change and cocaine use (Roberts et al., 1996).
The above findings appear inconsistent with the stages-of-change
model, which posits that higher motivation should be associated
with less substance use within treatment, longer treatment reten-
tion, and greater treatment adherence.
The discrepancy between URICA studies that have versus have
not demonstrated good predictive validity with alcohol- or drug-
abusing participants may pertain to at least two issues: (a) the
URICA score or scores with which validity is established and (b)
the outcome measure. Although the most robust predictive validity
finding was based on the Readiness composite score (Project
MATCH Group, 1997), one that was consistent with the TTM
model positing that higher motivation should be associated with
lower alcohol use, most of the other studies used either individual
subscale scores, or cluster or profile analysis, to predict alcohol or
drug use; the latter studies have led to some of the most contra-
dictory findings (Carbonari & DiClemente, 2000; Carney & Kiv-
lahan, 1995; El-Bassel et al., 1998). Although DiClemente and
Hughes (1990) did demonstrate the predictive utility of the URICA
based on cluster analysis, they predicted the various purposes for
which individuals used alcohol (e.g., social, mental, mood bene-
fits), not amount of alcohol use.
In summary, the support for the URICA’s factor structure and
utility as a predictor of substance use has been mixed, especially
with regard to illicit– drug-using samples. With regard to such
samples, these inconsistent findings may in part be due to the fact
that most of the studies evaluating the URICA’s predictive validity
have used single stage scores (e.g., precontemplation, contempla-
tion) versus a summary or composite score that takes into account
more than one of the URICA’s stage scores.
Thus, a major potential advantage of composite scores is that
they allow for a more complete picture of an individual’s motiva-
tion than any single stage score alone. For example, consider the
case of two individuals with identical high Precontemplation
scores (which suggests low motivation). They may have very
different Action scores and, thus, very different motivational pro-
files. A composite score, such as the Readiness score (Carbonari,
DiClemente, & Zweben, 1994; Velasquez et al., 1999), which
sums the Contemplation, Action, and Maintenance scores and
subtracts the Precontemplation score, would indicate different
levels of motivation for these two individuals and thus may be
more predictive of severity or outcome. For this reason, a single
composite score may have comparative advantage in evaluating
the association between motivation and outcome over discrete
stage scores. In addition, composite scores could be useful to
clinicians attempting to categorize participants in terms of high
versus low motivation for treatment-planning purposes or to re-
searchers wishing, for example, to use motivation as a randomiza-
tion or stratification variable. Furthermore, the ease with which
composite scores could be calculated and interpreted may have
advantages over common, but more complicated and sometimes
arbitrary, procedures used to classify individuals with different
URICA profiles based on cluster analysis (Carey et al., 1999).
Critics of the TTM have suggested that, even without the above
inconsistent and contradictory findings, the URICA may not nec-
essarily be measuring discrete stages of change; they cite the
illogicality of (a) measuring four different stage scores if individ-
uals actually progress from one stage to the next or back, (b)
summing stage scores (as in the calculation of composite scores),
and (c) finding that individuals have high scores in more than one
stage at any given point in time (Sutton, 1999, 2001; Weinstein,
Rothman, & Sutton, 1998). These critics also suggest that positive
or large negative correlations between adjacent and nonadjacent
stages is actually evidence that the stages proposed by the TTM are
 MOTIVATION TO CHANGE
neither discrete or qualitatively distinct (Sutton, 2001). Yet another
issue that further confuses the idea that the URICA measures
stages of change is that URICA stage scores have not been dem-
onstrated to correlate with stage membership determined by
stages-of-change algorithms (DiClemente et al., 1991). Thus, as
one report concluded, the URICA and the stages-of-change algo-
rithm, both of which are said to be measuring stage of change, may
be measuring different dimensions of motivation to change (Beld-
ing et al., 1996). It also appears that use of the staging algorithm
has led to results that are inconsistent with the TTM (e.g., Belding
et al., 1995).
To date, there are no published reports on the psychometric
properties of the URICA or its concurrent or predictive validity
among individuals with both alcohol and cocaine problems. Be-
cause of the prevalence of such patients (Anthony, Warner, &
Kessler, 1994; Brady, Sonne, Randall, Adinoff, & Malcolm, 1995;
Carroll, Rounsaville, & Bryant, 1993), we evaluated the psycho-
metric properties of the URICA for measuring motivation to
change in participants with comorbid alcohol and cocaine prob-
lems drawn from a randomized clinical trial evaluating pharma-
cotherapy and behavioral treatments (Carroll, Nich, Ball, Mc-
Cance, & Rounsaville, 1998; Carroll et al., 2001; Carroll et al.,
2000).
In this report we also describe the development of a novel
composite score, Committed Action (CA). In this composite score,
the Contemplation score is viewed as a measure of ambivalence
and, as such, it is subtracted from the Action score. The rationale
for this score is threefold. First, all but one of the URICA Con-
templation subscale items are related to doubts about one’s self-
efficacy, where one hopes, rather than knows, that change is
possible (e.g., has few ideas about how to change), or feels
ambivalence about the need for change (e.g., “I’m hoping this
place will help me to better understand myself”; “I wish I had more
ideas on how to solve the problem”; “I think I might be ready for
some self-improvement”; “It might be worthwhile to work on my
problem”). Therefore, it appeared logical to consider high endorse-
ment of such items as something that could potentially lessen the
chances of action toward change. In fact, a motivational assess-
ment, based on the URICA and used widely in Italy, is scored in
a similar manner, where its Precontemplation and Contemplation
totals are subtracted from the Action and Maintenance total to
arrive at an overall indicator of readiness to change (Scaglia et al.,
1995).
A particular benefit of the CA score is that it may more accu-
rately measure motivation in treatment-seeking populations, as
treatment-seeking samples tend not to endorse either Precontem-
plation (“I don’t have a problem”) or Maintenance (“I have made
significant changes in my problem, but I’m afraid of slipping
back”) items. Composite scores that incorporate both the Precon-
templation and Maintenance scales, such as the Readiness score
(Carbonari et al., 1994), may not fare as well in predicting outcome
among treatment-seeking patients simply because they include
these two less relevant subscales. Furthermore, most of the con-
tradictory results regarding the URICA’s predictive validity have
revolved around these two scales, and factor analytic studies have
suggested that the Maintenance subscale may be weakest (Belding
et al., 1996).
Given these considerations, in this study we evaluated the
URICA as a multidimensional assessment of motivation to change,
301
whose composite Readiness score was, at the time this study was
initiated, its best predictor (Project MATCH Research Group,
1997), and not as an assessment of stage membership or pattern of
stage endorsement, as in previous studies. This being the case, we
did not explicitly test the TTM but rather the reliability and
validity of the URICA.
Thus, the goals of the current study were (a) to evaluate the
psychometric properties of the URICA, among individuals with
concurrent alcohol and cocaine problems, and (b) to evaluate the
concurrent and predictive validity of both the URICA original
subscales (Precontemplation, Contemplation, Action, Mainte-
nance, and the Readiness composite), as well as the new CA
composite within this sample.
Method
Participants
Participants were 106 individuals who met current Diagnostic and
Statistical Manual of Mental Disorders (3rd ed., rev.; DSM–III–R; Amer-
ican Psychiatric Association, 1987) criteria for cocaine dependence and
current criteria for alcohol dependence or abuse who participated in a
randomized controlled clinical trial investigating the efficacy of a pharma-
cotherapy (disulfiram) and behavioral treatments for comorbid cocaine and
alcohol dependence (Carroll et al., 1998; Carroll et al., 2001; Carroll et al,
2000). Because the study methods and results have been reported in detail
elsewhere, they are summarized only briefly here.
Participants were randomized to 12 weeks of either disulfiram or no
medication, plus one of three manual-guided psychotherapies: cognitive–
behavioral therapy; 12-step facilitation; or clinical management, a control
psychotherapy that provided nonspecific factors commonly found in a
therapeutic relationship, medication management, and a persuasive thera-
peutic rationale (see Carroll et al., 1998). Individuals were excluded who
(a) were currently physically dependent on opiates or barbiturates, or
whose principal drug of dependence was not cocaine; (b) met lifetime
DSM–III–R criteria for a psychotic or bipolar disorder, or expressed sig-
nificant suicidal or homicidal ideation; (c) had a current medical condition
that would contraindicate use of disulfiram; (d) had been treated for
substance use during the previous 2 months or who were currently involved
in psychotherapy or pharmacotherapy for any other psychiatric disorder; or
(e) had conditions of probation or parole requiring reports of drug use to
officers of the court (which would undercut the validity of self-reports of
substance use).
Of the 117 individuals who initiated treatment, 106 completed URICAs.
The 11 who did not complete URICAs either dropped out within the first
3 weeks of the trial or missed the administration of the scale because of
clerical errors or logistical problems. Of the remaining 106, 78 (74%) were
male; 44 (42%) were White, 57 (53%) were African American, and 4 (4%)
were Hispanic; 89 (84%) were single, 39 (75%) had completed high school
or the equivalent; 81 (77%) smoked crack; and 30 (47%) had antisocial
personality disorder, 50 (52%) had another personality disorder, and 74
(77%) had an Axis I psychiatric disorder (other than alcohol or drug
dependence). The mean age of the sample was 30.7 (SD ⫽ 5.6), and the
mean number of years of alcohol and cocaine abuse was 11.8 (SD ⫽ 6.8)
and 7.4 (SD ⫽ 4.4), respectively. No statistically significant differences
were noted between participants in the disulfiram versus no-medication
conditions or among the three psychotherapy conditions, based on: (a) the
baseline characteristics reported above; (b) the severity of medical, em-
ployment, alcohol, cocaine, legal, family, or psychiatric problems, as
measured by the Addiction Severity Index (ASI; McLellan et al., 1992); or
(c) the severity of depression in the past 30 days prior to treatment entry,
as measured by the Beck Depression Inventory (BDI; Beck, Ward, Men-
delson, Mock, & Erbaugh, 1961). In addition, there were no differences on
302 PANTALON, NICH, FRANKFORTER, AND CARROLL
the demographic or clinical variables between this sample (n ⫽ 106) and
those who, because of dropout or clerical errors, did not complete the
URICA (n ⫽ 11).
To briefly summarize the trial’s major findings, disulfiram treatment was
associated with significantly better treatment retention and longer duration
of abstinence from alcohol and cocaine compared with participants as-
signed to no medication. Also, participants treated with cognitive–
behavioral therapy or twelve-step facilitation demonstrated significantly
greater reductions in cocaine use than those in the clinical management
condition (Carroll et al., 1998; Carroll et al., 2001).
Measures
All participants were administered the URICA (DiClemente & Hughes,
1990). There are eight, Likert-type items per stage or subscale, each
ranging from 1 to 5, with higher scores indicating greater endorsement of
particular attitudes or behaviors. The scale provides four discrete stage
scores as well as the two composite scores as described above (i.e.,
Readiness and CA). Total discrete stage scores range from 8 to 40, whereas
Readiness scores range from –16 to 112. For the novel composite devel-
oped for this study, CA scores range from –32 to 32. Participants com-
pleted the URICA based on their motivation to change their use of both
alcohol and cocaine.
We used the 4- versus 5-stage version of the URICA, the former of
which excludes the preparation stage, because it is the version used in
virtually all of the studies on the psychometric properties of the scale. In
addition, the URICA’s instruction set does not specify the nature of the
“problem” about which the participant is asked to respond. Instead, he or
she fills in the blank next to where it says “the problem.” In this trial, the
research associate administering the scale specifically instructed the par-
ticipants to respond to the URICA items while considering both their
cocaine and alcohol problems. We used the URICA instead of the staging
algorithm because the staging algorithm questions, which measure
“planned time to action” (Sutton, 2001, p. 176), would not have been
applicable to our treatment-seeking sample, most of whom came to the
intake appointment saying that they were ready to quit right away.
To evaluate concurrent validity, we used baseline ASI composite scores,
including those measuring alcohol and cocaine use severity. To evaluate
predictive validity, we used (a) participant self-reports of the percentage of
days abstinent from both alcohol and cocaine during the 12-week treatment
and (b) number of study weeks completed.
Data Analysis
CFA, using AMOS, Version 3.6 (Arbuckle, 1997), was used to evaluate
the factor structure of the URICA. CFA allows for the fitting of an a priori
factor structure (such as the four-factor solution for the URICA found by
several studies) when all latent variables are considered separately or
together. In the latter case, an a priori factor structure can be fit to any
number of different correlation (or covariance) matrices or models. Al-
though CFAs and exploratory factor analysis may reveal the same under-
lying structures, CFAs have the unique advantage of allowing a test of a
prior latent structures (Bartko, Carpenter, & McGlashan, 1988) and avoid
problems associated with exploratory factor analysis, namely, factor selec-
tion and rotation decisions (McDonald, 1985). Given these advantages of
CFA, and its fit with one of the primary the goals of the present study,
which was to confirm an a priori factor structure, CFA is the preferred
method of analysis. Specifically, in this report, the URICA scale was
hypothesized to have four a priori defined factors, whose validity was
evaluated separately and when considered together. Given that there are a
number of different correlation matrices/models within which to test the
validity of the four-factor structure when all latent variables are considered
together, as well as the fact that only one published report on the use of
CFA with the URICA exists, we conducted a series of models. These
models included fitting the four-factor structure with (a) no correlations
among the latent variables (factors); (b) correlations among the latent
variables Contemplation, Action, and Maintenance, but not Precontempla-
tion; (c) correlations among all of the latent variables, as in Belding et al.
(1996); and (d) an overall latent variable of “motivation.”
We used Cronbach’s alphas to derive estimates of the internal consis-
tency of the URICA’s subscales. To evaluate the utility of a dichotomiza-
tion of motivational level, which, as described earlier, could potentially be
more clinically useful than a continuous measure of motivation, we cate-
gorized participants as having high or low Readiness, as well as high or low
CA, based on a median split of the continuous scores. We used chi-square
tests to evaluate comparability of treatment groups and both Readiness
(low and high) and CA (low and high) groups on baseline characteristics
that are categorical in nature (e.g., gender), whereas we used analysis of
variance (ANOVA) for baseline characteristics that are continuous (e.g.,
years of alcohol use). We also used ANOVA and independent t tests to
evaluate differences in baseline ASI scores between the dichotomized
motivation levels (as described above; i.e., high vs. low Readiness and high
vs. low CA).
We used simple correlations between pretreatment ASI composite scores
and URICA subscale and composite scores to evaluate the concurrent
validity of the URICA. To evaluate the predictive validity of the URICA,
we calculated simple correlations between URICA stage and composite
scores, and the percentage of days abstinent from both alcohol and cocaine
during the 12-week treatment and treatment retention (study weeks com-
pleted). We also used ANOVA to evaluate differences in drug use and
retention between the dichotomized motivation levels, as well as to eval-
uate possible Motivation ⫻ Treatment interactions.
We hypothesized that the URICA would demonstrate concurrent valid-
ity if high baseline Precontemplation or Contemplation scores were asso-
ciated with higher concurrent severity of alcohol and drug use as well as
drug-related problems at baseline. On the other hand, high Action, Main-
tenance, Readiness, and CA scores should show the opposite relationship,
because higher motivation should be associated with fewer drug problems.
Similarly, to evaluate predictive validity, we hypothesized that high Pre-
contemplation or Contemplation scores would be associated with poor
retention and more frequent alcohol and drug use during the study. Higher
Action, Maintenance, Readiness, and CA scores should show the opposite
relationship, in that they should be associated with low levels of alcohol
and drug use during, and high retention in, the study.
Results
Factor Structure of the URICA
Table 1 presents the results of the CFA, using a model in which
each of the four factors were evaluated independently. These
results replicated the original four-factor structure of the URICA
and suggest an acceptable fit based on several standard indices. In
addition, none of the other models described above, including the
model tested by Belding et al. (1996), yielded an acceptable fit. In
CFA, a nonsignificant chi-square value is indicative of a well-
fitting model. However, as some authors have suggested that these
criteria may not frequently occur (Bentler & Bonett, 1980; Marsh,
Balla, & McDonald, 1988), we used additional indices of fit. The
goodness-of-fit index (GFI) and the incremental fit index (IFI) for
each of the four factors (stages), which are recommended alterna-
tives (Yadama & Pandey, 1995), suggested adequate to good fit, as
they exceed or closely approached both Bentler’s (1992) cutoff of
.90 and, in one case (i.e., Maintenance), exceeded Hu and
Bentler’s (1999) more conservative cutoff of .95 as a well-fitting
model. However, the root-mean-square error of approximation
(RMSEA) values only approximated the criteria for a reasonable
 MOTIVATION TO CHANGE 303

Table 1
University of Rhode Island Change Assessment (URICA) Confirmatory Factor Analysis Results

URICA subscale ␹2 df p GFI IFI RMSEA ␹2–df ratio

Precontemplation 35.17 20 .02 .91 .90 .10 1.76

Contemplation 39.86 20 .01 .89 .89 .11 1.99
Action 38.31 20 .01 .90 .92 .11 1.92
Maintenancea 19.75 14 .14 .94 .96 .07 1.41

Note. N ⫽ 83, based on URICAs with no missing data. GFI ⫽ goodness-of-fit index; IFI ⫽ incremental fit
index; RMSEA ⫽ root-mean-square error of approximation.
a
Results for the Maintenance subscale are presented with Item 9 (“I have been successful in working on my
problem, but I’m not sure I can keep up the effort on my own”) omitted because its low correlation with other
Maintenance items. The maximum-likelihood solution with Item 9 included yielded a chi-square of 45.82 (df ⫽
20, p ⬍ .01), a GFI of .90, an IFI of .84, an RMSEA of .13, and a ␹2–df ratio of 2.29. However, as seen above
in the results for the Maintenance subscale, these fit statistics were improved when this item was removed.

fit, which is less than or equal to .08 (Browne & Cudeck, 1993).
Adequate fit is also indicated by a ␹2–df ratio of less than 2. This
criterion was met by all four of the subscales.
Additional analyses suggested that Item 9 on the Maintenance
subscale (“I have been successful in working on my problem, but
I’m not sure I can keep up the effort on my own”) had very low
correlations with other Maintenance items. The maximum-
likelihood solution with Item 9 yielded a chi-square of 45.82 (df ⫽
20, p ⬍ .01), a GFI of .90, an IFI of .84, an RMSEA of .13, and
a ␹ 2–df ratio of 2.29. However, these fit statistics were improved
when this item was removed, ␹2(14, N ⫽ 83) ⫽ 19.75, p ⫽ .14,
GFI ⫽ .94, IFI ⫽ .96, RMSEA ⫽ .07, ␹2/df ⫽ 1.41). Therefore,
all of the analyses from this point forward were conducted with
Item 9 omitted.
Internal Consistency
Cronbach’s alphas are reported in Table 2. These range from .75
(Precontemplation) to .87 (CA), indicating an acceptable level of
internal consistency of the URICA subscales and composite scores
within this sample.
Descriptive Analyses
As shown in Table 2, descriptive analyses indicated that there
was an overrepresentation of low Precontemplation scores. In fact,
the modal score was 8, which is the lowest score one can attain on
this subscale. Precontemplation scores were also markedly lower
than scores on the other three subscales. Thus, as would be
expected for this treatment-seeking subsample, Precontemplation
and Maintenance scores were quite low; most of the variability in
scores would be associated with the Contemplation and Action
scores.
Readiness scores were not significantly correlated, suggesting that
these subscales measure independent constructs.
Concurrent Validity
The correlations between the URICA subscales and baseline
ASI alcohol and cocaine severity composite scores presented in
Table 4 suggest a significant negative association between Precon-
templation scores and alcohol use severity but a significant posi-
tive relationship between Contemplation scores and alcohol use
severity. These results suggest that lower Precontemplation and
higher Contemplation scores (both of which are believed to indi-
cate higher motivation to change) were significantly correlated
with greater baseline severity of alcohol problems. None of the
correlations between the URICA stage scores and pretreatment
cocaine severity were statistically significant.
For the two URICA composite scales, as indicated in Table 4,
both the Readiness and CA composites showed some evidence of
concurrent validity. Results suggested that higher baseline Readi-
ness scores were significantly associated with greater baseline
severity of alcohol problems, whereas higher CA scores were
significantly associated with lower baseline severity of alcohol
problems.
When participants were categorized as having low versus high
Readiness, and low versus high CA (through median splits of the
Readiness and CA composite scores, where low Readiness ⬍86;
Table 2
Means, Standard Deviations, and Cronbach’s Alpha Coefficients
Among Subscales of the University of Rhode Island Change
Assessment (URICA)
URICA subscale M SD Mode ␣

Precontemplation 13.62 4.61 8 .75

Intercorrelations Among URICA Subscales Contemplation 35.95 3.40 40 .79
Action 33.46 3.83 32 .83
The results presented in Table 3 indicate, as expected, that Maintenance 30.68 5.30 32 .78
Precontemplation scores were negatively correlated with the other Readiness compositea 86.47 12.92 82 .79
three subscales, as well as the Readiness composite, and that CA Committed Action compositeb ⫺2.46 3.38 0 .87
scores were negatively correlated with Contemplation scores but Note. N ⫽ 106.
positively correlated with action scores. CA scores were unexpect- a
Readiness composite ⫽ (Contemplation ⫹ Action ⫹ Maintenance) ⫺
edly positively correlated with Precontemplation scores. CA and Precontemplation. bCommitted Action ⫽ Action ⫺ Contemplation.
304 PANTALON, NICH, FRANKFORTER, AND CARROLL

Table 3
Correlations Between University of Rhode Island Change Assessment Stage
and Composite Scores

Variable 1 2 3 4 5 6

1. Precontemplation — ⫺.482** ⫺.243* ⫺.263* ⫺.648** .209*

2. Contemplation — .567* .561** .815** ⫺.364**
3. Action — .585** .768** .561**
4. Maintenance — .814** .131
5. Readiness Composite — .050
6. Committed Action Composite —

Note. N ⫽ 106.
* p ⬍ .05. ** p ⬍ .01.

high Readiness ⬎86, low CA ⬍–2, and high CA ⬎2), results
suggested that those with high Readiness had significantly higher
cocaine (.62), but not alcohol, ASI composite scores than those
with low Readiness (.54), t(104) ⫽ –2.24, p ⬍ .05. No such
differences were found when participants were classified by high
and low CA.
The data in Table 4 also indicate that correlations between
URICA subscale and composite scores and baseline ASI compos-
ite scores were quite low and rarely reached statistical significance.
The one exception was the statistically significant correlation
between the ASI Employment composite and Precontemplation,
Contemplation, Readiness, and CA scores. When considering the
original subscales and composite, it appeared that higher motiva-
tion was associated with greater severity of employment problems,
whereas with the CA score the reverse was found.
Predictive Validity
As shown in Table 5, none of the five original subscale scores
demonstrated predictive validity, as assessed by percentage of days
abstinent from both alcohol and cocaine or number of treatment
weeks completed. However, the results did indicate that higher CA
scores were significantly associated with a greater proportion of
days abstinent from alcohol and cocaine. Similarly, data presented
in Table 6 indicate that only the CA composite had a statistically
significant relationship with outcome, as participants with high CA
reported a significantly greater percentage of days abstinent from
both alcohol and cocaine (85.6% vs. 72.7%, respectively). It
should be noted that BDI score was used as a covariate in the
analyses pertaining to CA given that participants with low CA had
significantly higher BDI pretreatment scores (M ⫽ 14, SD ⫽ 5.7)
than those in the high-CA group (M ⫽ 10, SD ⫽ 6.2), t(104) ⫽
2.80, p ⬍ .01, indicating a higher level of depression for low-CA
participants. No other statistically significant differences were
found between low and high Readiness or CA groups.
Finally, a significant Treatment (disulfiram medication vs. no
medication) ⫻ CA interaction emerged, suggesting that low-CA
participants had better outcomes with disulfiram than without,
whereas high-CA participants fared equally well with or without
medication. No significant Psychotherapy ⫻ Composite Score
interactions were found. None of the composites was associated
with treatment retention.
Discussion
We evaluated the psychometric properties of the URICA with
participants taking part in a clinical trial of treatments for concur-
rent cocaine and alcohol problems. The results suggest that, on the
whole, the URICA’s psychometric properties are acceptable, in
that its factor structure was replicated and its internal consistency
was acceptable. There was some evidence for concurrent validity
in this sample, as several of the URICA subscales were signifi-
cantly correlated with pretreatment indicators of alcohol severity
in the expected directions. None of the original subscales demon-
strated predictive validity, a finding similar to those of previous
studies (Carey et al., 1999). Although the CA composite score did

Table 4
Correlations Between University of Rhode Island Change Assessment (URICA) Stage and
Pretreatment Addiction Severity Index (ASI) Composite Scores

ASI composite

URICA stage Cocaine Alcohol Employment Family Psychiatric Legal Medical

Precontemplation ⫺.170 ⫺.204* .344** ⫺.128 .013 .109 ⫺.030

Contemplation .150 .252** ⫺.336** .157 .086 .026 ⫺.012
Action .056 .015 ⫺.123 .031 ⫺.027 .081 .016
Maintenance .112 .166 ⫺.063 .165 .060 .122 .048
Readiness .156 .192* ⫺.273** .164 .034 .042 .032
Committed Action ⫺.087 ⫺.236* .195* ⫺.123 ⫺.117 .067 .030

Note. N ⫽ 105 (1 participant was missing an ASI composite score).

* p ⬍ .05. ** p ⬍ .001.
 MOTIVATION TO CHANGE 305

Table 5 Precontemplation, Contemplation, and Readiness scores. One pos-

Correlations Between University of Rhode Island Change
Assessment (URICA) Stage and Composite Scores and
Percentage of Days Abstinent From Both Alcohol and Cocaine
(PCTDAAC) During Treatment and Number of Study Weeks
Completed
URICA stage PCTDAAC Study weeks completed
Precontemplation .139 ⫺.132
Contemplation ⫺.070 .118
Action .101 .072
Maintenance .115 .073
Readiness .015 .120
Committed Action .223* ⫺.039
Note. N ⫽ 106, except for PCTDAAC, which is 96 because of missing
data points. Correlation between PCTDAAC and study weeks completed ⫽
.062 (p ⬎ .05).
* p ⬍ .05.
show evidence of concurrent, as well as predictive validity, the
variance accounted for was low (i.e., 5.8% for predictive validity).
Concurrent validity was supported by the Precontemplation and
Contemplation subscales as well as the Readiness composite score.
These findings, as did those on the dichotomized Readiness score
(high vs. low), suggest that participants with higher motivation had
more severe cocaine problems at baseline than did those with
lower motivation and are consistent with those of Velasquez et al.
(1999), who demonstrated that higher levels of motivation were
related to greater severity of pretreatment alcohol use. Neverthe-
less, the proportion of variance accounted for by the Readiness
score in the current study was quite small (M ⫽ 4.8%). The CA
composite score also suggested concurrent validity but, in contrast
to the above findings, there was a significant negative relationship
between baseline alcohol problem severity (r ⫽ –.24, p ⬍ .05) and
the CA composite, where lower severity was associated with
higher CA scores. Similarly, CA scores were negatively associated
with baseline employment problems, whereas the reverse was
found for the relationship between employment problems and
sible explanation for these findings is that perhaps greater prob-
lems confer greater readiness to change, but reductions in alcohol
use or employment problems (or both) just prior to treatment may
lead to increased commitment to take active steps toward change.
Although the finding that CA scores are positively correlated
with Precontemplation scores is perplexing from a TTM perspec-
tive, it is not necessarily problematic when considering the URICA
as a scale that measures four aspects or domains of general
motivation to change versus stages of change. In fact, Sutton
(2001) argued that such “positive correlations between adjacent or
nonadjacent stages are actually evidence against the idea that the
stages measured by the URICA are discrete or qualitatively dis-
tinct” (p. 177). Despite this, it remains difficult to interpret this
correlation from a theoretical perspective, as strong endorsement
of Precontemplation items, such as “I don’t think I have any
problem that needs changing,” should not go hand in hand with CA
scores, which are calculated by subtracting Contemplation from
Action scores and thus reflect strong endorsement of items such as
“I am actively taking steps to change my problem.”
None of the original subscales or the Readiness composite score
were strongly associated with treatment outcome. However, par-
ticipants categorized as having high CA had a significantly greater
percentage of days abstinent from both alcohol and cocaine than
those categorized as having low CA (85.6% vs. 72.7%, respec-
tively; p ⬍ .01), suggesting that those with higher commitment to
taking active steps toward changing their substance use problems
had better outcomes. Furthermore, a significant Treatment (disul-
firam vs. no medication) ⫻ CA interaction emerged, suggesting
that low-CA participants had better outcomes with disulfiram than
without, whereas high-CA participants fared equally well with or
without medication. This may speak to the motivational effect of
taking medication, in that medication may have been particularly
helpful to participants who were not committed to change on their
own, whereas those who were highly committed to change may
have taken greater steps to change their behavior and were thus
less likely to require disulfiram to benefit from treatment. No
significant Psychotherapy ⫻ CA interactions were found. Finally,

Table 6
Percentage of Days Abstinent From Alcohol and Cocaine by Readiness and Committed Action
Level and Treatment Condition (Disulfiram Versus No Medication)

Low High

Disulfiram No medication Total Disulfiram No medication Total

M SD n M SD n M SD n M SD n M SD n M SD n
a
Readiness level

83.6 15.5 13 66.4 39.5 35 75 25.1 48 81.8 21.6 18 79.7 21.5 27 80.9 21.3 45
b
Committed action level

80.4 19.3 16 60.6 34.5 25 72.7 27.6 41 84.4 17.6 15 88.5 17.1 37 85.6 17.4 52
a
Readiness main effect, F(1, 93) ⫽ 1.25, p ⫽ .267; Readiness ⫻ Treatment Condition interaction, F(1, 93) ⫽
2.16, p ⫽ .145. b Committed Action main effect, F(1, 93) ⫽ 10.61, p ⬍ .01; Committed Action ⫻ Treatment
Condition interaction, F(1, 93) ⫽ 6.09, p ⬍ .01; pretreatment Beck Depression Inventory score covariate
(Committed Action analyses only), F(1, 93) ⫽ .068, p ⫽ .795.
306 PANTALON, NICH, FRANKFORTER, AND CARROLL
none of the URICA subscales, including CA, significantly pre-
dicted treatment retention, suggesting that motivation for treatment
and motivation for change may not be interchangeable concepts.
One reason why the CA, but not the Readiness, composite score
demonstrated predictive validity may be because it relied exclu-
sively on the subscales that were most relevant to treatment seek-
ers (i.e., where most of the variability was likely to be seen),
namely, the Contemplation and Action subscales, whereas the
Readiness score considered all of four subscales. Therefore, the
CA composite may prove a worthwhile measure with which to
further evaluate the relationship between motivation and treatment
outcome, particularly for the treatment-seeking population evalu-
ated for this article.
Overall, the findings of this study do support the common notion
that the higher the motivation, the better the outcomes of drug and
alcohol abuse treatment. However, the fairly weak relationship
between the URICA scores and outcome suggests that researchers
who wish to identify a clear and robust relationship between
motivation to change and treatment retention and outcome still
have a long way to go.
Limitations
There are several limitations of this study. First, the sample size
was small and may have reduced statistical power needed to find
other significant differences. Second, participants completed the
URICA based on their motivation to change both their alcohol and
cocaine problems combined. The results may have been different
had we assessed motivation to change with regard to each of these
problems separately. Third, the median split used in comprising
the CA groups is sample dependent and may provide no evidence
of how the current cutoffs might work with other samples. Addi-
tional research is needed on the applicability of these cutoffs to
other samples and to different types of substance abusers. Fourth,
this study was conducted with individuals participating in a ran-
domized controlled trial of several manual-guided treatments of
alcohol and cocaine dependence and for which outcomes were
quite good overall. This may have substantially reduced the vari-
ability of the outcome data, which potentially reduced the likeli-
hood of significant findings with regard to the relationship be-
tween motivation and outcome. Finally, the CA accounted for only
5.8% of the variance in predicting posttreatment substance use.
Conclusions
This report suggests that the URICA scale has acceptable psy-
chometric properties in a sample of outpatient treatment-seeking
individuals with combined cocaine and alcohol problems and that
a newly defined composite score, Committed Action (Action mi-
nus Contemplation), demonstrated improved concurrent and pre-
dictive validity compared with the four original URICA subscales
and one composite score (i.e., Readiness). The CA score may
prove more useful in the identification of pretreatment level of
motivation, which is relevant to researchers (e.g., for balanced
randomization) and clinicians (e.g., targeting low motivation early
in treatment) alike and in the further study of the relationship
between motivation and treatment outcome.
As researchers continue to broaden the evaluation of existing
measures of motivation in more diverse groups of participants,
such as drug users or substance users with comorbid psychiatric
disorders, the landscape of this relationship becomes increasingly
complicated. Carey et al. (1999) concluded that it might be best to
consider motivation to change as a multidimensional construct that
varies in a complex manner with behavior, cognition, and envi-
ronmental context. Therefore, in future studies investigators might
make clearer the distinctions among patient groups (e.g., treatment
seekers vs. nontreatment seekers vs. patients mandated to treat-
ment), as well as other patient differences that may mediate the
relationship between motivation and treatment outcome, such as
those related to patient expectations of treatment, self-efficacy,
treatment goals (abstinence vs. use reduction), co-occurring psy-
chiatric and substance use disorders, or treatment setting (e.g.,
methadone maintenance program vs. self-help groups).
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Received April 17, 2001
Revision received November 15, 2001
Accepted November 15, 2001 䡲