Substance abuse treatment and the stages of change, by Gerard J. Connors, Carlo C. DiClemente, Mary Marden Velasquez, & Dennis M. Donovan

I will declare an interest. I have been a “critical friend” of the Stages of Change model for almost 30 years. It has been integral to both my clinical work and teaching.

This book was first published over a decade ago, allegedly as a practical guide to the treatment of alcohol and drug misuse disorders. In particular, it set out to describe and rationalize the optimum treatment intervention for the particular motivational stage of the presenting individual client. The Stages of Change model was said in the preface to the first edition to be an “excellent” heuristic to organize the “vast” array of information available to clinicians on the treatment of substance misuse. In addition, the second edition was said to focus more on the processes of change as well as introducing relevant literature published on the Stages of Change over the past decade. The four authors have had a longstanding commitment to the model and, as would be expected, are effusive in their praise of its ability to integrate therapeutic interventions, processes of change and motivational intent. Some of the newer material has been around recent conceptualizations of motivational intervention.

This is an interesting and well-written text. However, I have a number of reservations about giving it a wholehearted recommendation. Firstly, it is beginning to look dated. Despite the putative intent to update the literature, most of the treatments, assessment methods, psychometric instruments, stages, processes and epidemiological considerations are squarely located in the past century. Secondly, I am not clear if it is a critical academic text or a clinician's handbook. It was meant to be a practical guide for a range of clinicians but in reality is basically a text for academic psychologists. However, despite this appearance, it does not offer a proper review of recent literature and, in particular, it does not present a robust appraisal of recent critiques of the model, for example, by West (2005) or Davidson (1998). These are mentioned but only in passing. Thirdly, the elephant in the room is that there is actually very little convincing evidence that there is an interaction between stage of change and type of treatment in terms of long-term outcomes. This is central to the thesis of the book but is given only one page in over 300 pages of text. Fourthly, it is quite “American” in style and context. The epidemiology on alcohol and drug use is almost entirely USA data. This may limit its appeal to European readers.

The book is based around the rather elegant but simple matching thesis, which has long concerned drug clinicians; notably matching stage and process, the latter being essentially a proxy for broad treatment modality. In 300 pages, there is inevitably much repetition often using different words to make the same point. I was left wishing that authors of this calibre had produced a handbook for a range of clinicians from different backgrounds. I also found myself wishing they had given us a straightforward sat nav to chart the complex journey of treatment and assessment choice. I would also have liked practical guidance on an optimum evaluation of physical, social, emotional and most importantly, behavioural outcomes. That all being said this book is an important linking text in the Stages of Change literature.

Robin Davidson

Consultant Clinical Psychologist

Belfast, Northern Ireland, UK

E-mail: [email protected]