Readiness for change and drug use outcomes after treatment

YOUCAN-Stages-of-change-med

This week’s Throwback Sunday is a post about a study on the Transtheoretical Stages of Change (TSOC). It’s relevant due to the ongoing and recent media love for Motivational Interviewing (MI), which is fairly closely tied to the TSOC. (This is disputed, but the motivational interviewing website as 12 pages of search results for “stages of change”.)

Just to be clear, Dawn Farm likes MI. We train staff in MI. We believe it’s a useful tool. However, we also believe it’s often oversold as a treatment for addiction. It may be helpful as a stand-alone intervention for people with low-severity substance use problems. For addiction, it can be very helpful to engage people into other treatments more appropriate for high-severity problems.
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Another study finding that the client’s stage of change is a poor predictor of outcomes:

Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.

There has been high profile criticism that the rush to embrace the stages of change has outpaced the evidence. The question isn’t whether the stages of change have any utility. The question is what are they useful for? Patient/family eduction, counselor education, conceptualizing interventions, matching treatments, etc.

The stages of change have undoubtedly changed the field for the better, but there are a lot of weak points that have not been adequately explained–failure to recognize the instability of motivation; disagreements about how to determine the client’s stage of change; failure to account for stable, unplanned change; failure to explain for stable, initially coerced change. I’ve been especially concerned about practitioners relying on the stages of change for treatment placement and the inevitable post hoc deconstructions of treatment “failures” that blame the client’s motivation and then conclude that we wasted money treating them (and suggest that better assessment would have led to the conclusion that the client wasn’t motivated and a better referral).

Robert West, the editor of Addiction, has offered a new model for understanding change, he has called the PRIME theory.

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