Book Review
Substance Abuse
Substance Abuse Treatment and the Stages of Change:
Selecting and Planning Interventions. Gerard J Connors, Dennis
M Donovan, Carlo C DiClemente. New York: Guilford Press; 2001. 274
p. US$35.00.
Reviewer
rating*: Excellent
Review by Maurice Dongier, MD, FRCPC
Montreal, Quebec
Interventions for substance abusers have to be tailored to clients
with varying levels of readiness to change. The Prochaska and DiClemente
construct, developed over the past 20 years, posits 5 stages: precontemplation,
contemplation, preparation, action, and maintenance (1). It covers
a cycle of attitudes from denial to secure, solidly established
commitment to change. The stages-of-change model is particularly
influential in the field of addictions. More often than not, individuals
regress to earlier stages of change before permanently reaching
the maintenance stage—as is illustrated by Mark Twain’s
observation: “Quitting smoking is easy, I have done it many
times.”
This book provides lively case examples to illustrate the stages,
together with useful tables of common characteristics. For instance,
the action stage is “the stage in which individuals modify
their behavior, experiences or environment in order to overcome
their problems . . . with firm and clear commitment to change”
(p 25).
The maintenance stage (that is, the stage of avoiding relapse)
“is not static but instead an active and vital endeavour”
(p 29). Most relapses occur during the 6-month period following
the action stage. Managing relapses is, of course, part of the maintenance
stage.
A chapter is dedicated to the detailed measurement of alcohol and
other drug use. This is a major ingredient of success, valid both
for research and clinical use, because reliable assessment is an
essential part of intervention. Indeed, assessment itself has been
shown to be a highly effective “minimal intervention”
technique.
The stage of change can be measured with different instruments,
such as the University of Rhode Island Change Assessment (URICA),
the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES),
and the Readiness to Change Questionnaire (RCQ). A staging algorithm
provides strong evidence that the stage of change can predict treatment
outcomes.
All the available assessment instruments are well described, and
the need to individualize treatment goals is emphasized. Table 4.2
(p 88) is a checklist of the qualities of well-formed treatment
goals. It will be valuable to any therapist engaged in the (usually
long-term) treatment of individuals with addictions. For therapists,
reassessing treatment objectives and current status (occasionally
with the client) is a worthwhile and unfortunately often-neglected
exercise. The authors’ proposed treatment goals deserve a full
quotation. Treatment should be as follows:
1. salient and meaningful to the client
2. incremental and thus more manageable
3. concrete, specific and behavior focused
4. focused on increasing desired behaviors
5. include progressive steps for achieving goals
6. realistic and achievable
7. perceived as requiring work and effort
8. appropriate for the projected treatment period.
This book is by 3 of the best American experts in the field. It
may be seen as a useful complement to Miller and Rollnick’s
1991 volume on motivational interviewing (MI), a classic in the
field of addiction treatment (2). In this book, the authors had
identified the factors underlying the development of motivation,
which they summarized in the acronym “FRAMES” (“feedback”
of information from assessment, emphasis on personal “responsibility”
for change, “advice” to change, providing a “menu”
of strategies for change, therapist “empathy,” and facilitation
of clients “self-efficacy”). These ingredients are in
fact common to many psychotherapies and counselling techniques,
and there is a growing consensus that similar mechanisms of change
may underlie all treatments, despite superficial differences.
Subsequent research has shown that MI may be either used in isolation
or as a preparation for treatment (for example, residential treatment)
and that it may double the alcohol-abstinence rate.
Training practitioners to change their behaviour from the traditional
confrontational style to the techniques clearly articulated here
deserves considerable attention. As an example, relying on therapist
authority is inconsistent with the theory of these books. Close
supervision of counsellors often shows that the points at which
they most need help are those they do not perceive and, thus, cannot
describe in their self-report.
This book is very much worth its price. It will be an excellent
resource for all professionals and counsellors involved in addiction
treatment.
References
1. Prochaska JO, DiClemente CC. The transtheoretical
approach: Crossing the traditional boundaries of therapy. In: Malabar
FL: Krieger; 1984.
2. Miller WR, Rollnick S. Motivational interviewing:Preparing
people to change addictive behaviour. New York: Guildford Press;
1991.
*Reviewer Rating Scale/ Échelle d’évaluation du réviseur
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Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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