CMR OVERVIEW
George De Leon, Ph.D. and Gerald Melnick, Ph.D.
Center for Therapeutic Community Research at NDRI
Overview: The CMR is an 18-item self-administered instrument designed to measure motivation and readiness for treatment and to predict retention in treatment among abusers of illicit drugs. The instrument is based on recovery theory (De Leon, 1995, 1997, 2000) which stresses the impact of both external and internal motivation on the readiness for treatment. Items were developed on the basis of interviews with drug abusers who asked to identify the influences that contributed to their entering and remaining in treatment. Many of their self-reported expressions are used verbatim in the items to create a sense of familiarity and perceived relevance. The CMR can be used as an intake device, clinical treatment planning tool, and research instrument.
The instrument consists of four factor derived scales, Circumstances 1 (external influences to enter or remain in treatment), Circumstances 2 (external influences to leave treatment), Motivation (internal recognition of the need to change), and Readiness for treatment. Confirmatory factor analysis in samples drawn from outpatient, methadone maintenance, and short- and long-term residential treatment have demonstrated the generality of the factors among the four treatment modalities.
Test Administration and Scoring: The CMR is a self-administered instrument consisting of 18 Likert type items. The respondent uses a 5-point scale to rate each statement from strongly disagree to strongly agree. Items may also be scored as Not Applicable.
Reading level and Perceived Relevance: The items were drawn from interviews with recovering drug abusers and capture the tone and vernacular of the respondents. Statements were selected that were easy to read and would be perceived as familiar and relevant to abusers of drugs.
Credentials and Training: There are no special credentials necessary for the administration of the CMR. The major functions of test administrator is to answer any questions concerning the purpose of the testing, explain the instructions and check the completed instrument to determine that there is no missing data and that items marked Not Applicable were understood by the respondent. In the event that respondents are non literate, the instrument can be read to the respondent.
Completion Time: Most clients complete the CMR in less than 10 minutes.
Scoring Procedures for the CMR: Circumstances 1 consists of questions 1-3, Circumstances 2 consists of questions 4-6, Motivation consists of questions 7-11, and Readiness consists of questions 12-18. Scoring involves reversing the score values for questions 4, 5, 6 and 12—scores of 5=1, 4=2, 3=3, 2=4 and 1=5. The individual score values of each scale are then summed to derive the scale values. The scale values are then summed to derive the Total Score. Not Applicable responses are recoded to the client's mean score for the scale in which the response falls. This recoding is limited to one item on each of the C scales, one item on the M scale and two items on the R scale. Examination of the CMR data base of some 11,000 cases indicates that nearly all clients will fall within this criteria.
CMR and Retention: Identification of client risk for early drop-out is based on a dividing respondents into four score categories consisting of Low scorers (1 Standard Deviation or more below the mean), Moderately Low scorers (between the mean and - 1 Standard Deviation), Moderately High scorers (between the mean and + 1 Standard Deviation) and High scorers (1 Standard Deviation or more above the mean). These score categories are calculated for each of the scales and for the Total Score.
Scoring Time: Approximately 5 minutes to sum the scores and compare scores to reference scores for the agency.
Reliability: Cronbach's alpha for the Total score is in the .70s and .80s across 30 separate studies involving a wide variety of client populations and treatment settings. Individual scale score reliability varies with C1 evidencing low reliability in outpatient samples. Reliability for C2 is mainly in the .50s and reliability for M and R are in .60 to .80 range.
Validity: Validity for the CMR is measured by two criteria, the ability of the instrument to differentiate between groups and the prediction of retention.
Differentiation Between Groups: The 18-item CMR was derived from the longer 42-item CMRS. The correlation of .92 between the instruments indicates that they are virtually equivalent. Prior studies with the CMRS have found that the instrument differentiates between a street sample, entrants into a detoxification program and respondents of a waiting list to enter a residential therapeutic community (Lipton, Morales & Goldsmith, 1991). Another study found that the instrument differentiated between drug abusing homeless women who refused treatment and those entering a treatment program (Erikson, et al 1995).
Prediction of Retention: The major retention studies have involved long-term residential treatment (De Leon, et al. 1994). In three cohorts of 300, 330 and 795 adult admissions there was a linear relationship between score category and 30-day retention with retention on each of the scales and the Total Score. Furthermore, 30-day retention for the High scorers on Total Score exceeded Low scorers by as much as 87 to 42 percent, or better than 2 to 1. At one year, retention among high scorers exceeded Low scorers by as much as 47 to 16 percent, or approximately 3 to 1. Additional studies with adolescents show that the CMRS predicts retention in treatment across age groups (Melnick, et al. 1997). These findings have subsequently been replicated with the CMR (Melnick, 1999). Studies of prison-based TCs have found that the CMR predicts entry into aftercare (De Leon, et al. 2000).
Normative Data: A secondary analysis of 30 studies involving over 11,000 clients (Melnick, 1999) provides comparative data for a wide variety of treatment populations and modalities including women's programs, MICA programs, prison based TCs, methadone maintenance programs, drug free outpatient, detox, and adolescent TCs.
Gender, Race/Ethnicity, Age, and Primary Drug Considerations: Reliability for the CMR is similar across gender, race/ethnic, age and primary drug groups. Additional analyses and published papers have demonstrated the validity of the original CMR scales across gender, race/ethnic, age and primary drug, including cocaine/crack cocaine, opiates and marijuana.
Inquiries: Write to either George De Leon, Ph.D., or Gerald Melnick, Ph.D., at the Center for Therapeutic Community Research at National Development and Research Institutes, 71 West 23rd Street, 8th Floor, New York, NY 10010, or call (212) 845-4400.
References:
De Leon, G. (1995). Therapeutic communities for addictions: A theoretical framework. The International Journal of the Addictions, 30(12), 1603-1645.
De Leon, G. (1997). Community As Method: Therapeutic Communities for Special Populations and Special Settings. Westport, CT: Greenwood Publishing Group, Inc., pp. 3-18.
De Leon, G. (2000). The Therapeutic Community: Theory, Model and Method. New York, NY: Springer Publishing Co.
De Leon, G., Melnick, G., Thomas, G., Kressel, D., & Wexler, H. K. (2000). Motivation for treatment in a prison-based therapeutic community. American Journal of Drug and Alcohol Abuse, 26(1), 33-46.
De Leon, G. Melnick, G., Kressel, D., & Jainchill, N. (1994). Circumstance, motivation, readiness, and suitability (The CMRS Scales): Predicting retention in therapeutic community treatment. American Journal of Drug and Alcohol Abuse, 20(4), 495-515.
Erickson, J.R., Stevens, S., McKnight, P., & Figueredo, A. J. (1995). Willingness for treatment as a predictor of retention and outcomes. Journal of Addictive Diseases, 14, 135-150.
Lipton, D.S., Morales, E., & Goldsmith, D. S. (1991). Pathways into Treatment: A study of the drug treatment entry process. Final Project Report. Rockville, MD: National Institute on Drug Abuse.
Melnick, G. (1999). Assessing Treatment Readiness in Special Populations: Final Report of Project Activities, NIDA Grant Number 2 R01 DA07377-03. Rockville, MD: National Institute on Drug Abuse.
Melnick, G., De Leon, G., Hawke, J., Jainchill, N., & Kressel, D. (1997) Motivation and readiness for therapeutic community treatment among adolescents and adult substance abusers. American Journal of Drug and Alcohol Abuse, 23(4), 485-507.