The Impact of Treatments Offered to Addicts in Quebec

Over the past 10 years, many studies have been conducted in Quebec to assess the impact of treatments offered to substance abusers. In January 2001, most of the researchers who conducted those studies attended a seminar at which they presented the findings of their work and the ensuing discussions helped to expand on the meaning and scope of their research. Those findings were presented in a book published by the Laval University Press in November of this year under the title, "Impact of Alcoholism and Substance Abuse Treatment: Quebec Studies". Some 20 researchers contributed to the nine chapters it contains.

Here we first present the work of a number of researchers from the team at RISQ (Recherche et intervention sur les substances psychoactives – Québec) who have taken a particular interest in treatments offered at public rehabilitation centres in Quebec. This part provides an overview of the methods and instruments used in many impact studies conducted in Quebec. Second, we provide a summary of all the research presented in the book.

1. Summary of three studies conducted at two public rehabilitation centres in Quebec

Research over the past 30 years on the etiology of substance abuse has highlighted the complex nature of the phenomenon: a set of biological, psychological and sociological factors are likely to contribute to the development of dependence on psychoactive substances (Landry, Lamarche, Boislard and Nadeau, 1994; Nadeau and Biron, 1998). Heredity, the way in which those substances are managed in a given culture, parental negligence, peer influence and psychological distress are all factors which may gradually, and more or less quickly, lead an individual to become dependent on alcohol and other drugs. In addition, the relative importance of each of these factors and the manner in which they interact in the development of substance abuse may vary considerably from one individual to the next. Lastly, the study of risk factors associated with substance abuse development has emphasized how difficult it is to determine what is antecedent, concomitant or consequence in the development of this phenomenon.

In addition, the use and abuse of psychoactive substances (PAS) may in themselves be the source of a set of other social and health problems or develop in close association with them. For this reason, there has been increasing interest in the interaction between substance abuse and a set of other problems such as mental disorders, crime, suicide, family violence, parental negligence, transience, infectious diseases and pathological gambling. This examination has led to the increasingly inevitable conclusion that substance abuse has an impact on all other social and health problems and that the phenomenon cannot be addressed in isolation without considering a set of other individual and social aspects.

This revelation of the importance and complexity of the problems associated with the abuse of PAS has underscored the need for a holistic approach (Brochu and Mercier, 1992) and fostered development of multimodal treatment programs and matching strategies to improve the effectiveness of treatments by offering substance abusers interventions adapted to their specific needs (Annis, 1988; McLellan, 1981; Miller, 1989; Pattison, 1982). It is now recognized that addiction treatment must address not only inappropriate drinking and drug use, but also the entire set of problems associated therewith. In the late 1970s, Quebec resolutely adopted a psychosocial approach in the field of substance abuse intervention (Brisson, 2000). This orientation resulted in the creation of a system of public addiction rehabilitation centres, which gradually replaced hospitals in that capacity. The services offered are diversified and help first to address the multiple aspects of PAS dependence and all the problems that may accompany it: disintoxication, ambulatory and residential services, education, psychotherapy and social reintegration.

Studies on the impact of treatment offered to substance abusers must therefore take all these aspects into consideration. The Addiction Severity Index (McLellan et al., 1980) is an instrument that was developed to assess most of these factors. Its seven scales are used to evaluate changes in substance abuse (alcohol and drugs) and the severity of bio-physical-social problems associated with addiction: medical status, psychological status, family and social relations, employment and legal status. The instrument has been translated and validated in Quebec as the Indice de gravité d’une toxicomanie (IGT) (Bergeron, Landry, Brochu and Guyon, 1998, Bergeron et al. 1992) and is used for both clinical intervention purposes and research to assess its impact.

In addition, a large number of studies conducted to assess the effectiveness of addiction treatment have focused on the amount and duration of treatment received by substance abusers as improvement factors. A number of studies suggest that the effectiveness of a substance abuse program is linked to the perseverance of clients while under treatment (Baekeland and Lundwall, 1975; DeLeon, 1985; Sells and Simpson, 1980; Simpson et al., 1997). A recent review of the literature by Simpson (1997) identifies duration of treatment as one of the most powerful factors in predicting positive treatment outcomes in drug users. Two significant studies on the effectiveness of intervention in a rehabilitation context suggest that a minimum number of meetings is necessary for treatment to be effective. The Rand project findings (Armor, Polich and Stanbul, 1978; Polich, Armor and Braiker, 1981) indicate that 20 days of in-patient treatment and 15 out-patient meetings constitute a critical effectiveness threshold for alcoholics. The DARP project (Simpson, 1979; Simpson and Sells, 1982) mentions thresholds of 90 days, with increased effectiveness at 180 and 300 days for drug users. A recent study (Gossop, Mardsen, Stewart and Rolfe, 1999) identify critical durations of 28 and 90 days, depending on the type of treatment offered, for residential treatments.

However, the data on this point differ. In 1997, Edwards et al. found that a simple "two hours' notice" given to alcoholics in the presence of their spouses was as effective as a complete treatment. More recently, MATCH project researchers (Project MATCH Research Group, 1997) found that interventions of 12 meetings spread over 12 weeks were effective and that a program of four meetings over 12 weeks was as effective as longer programs. However, it is possible that, through their inclusion and exclusion criteria, the controlled effectiveness studies eliminated the most difficult subjects and that their findings are not very comparable to those of studies conducted in the field involving the random clientele that enters treatment centres. That is why certain authors (Drummond, 1997; Landry, 1995) feel that no one should prematurely conclude from these studies that all substance abusers may benefit from brief interventions.

The data presented here are taken from three of the studies conducted between 1991 and 2000. Although evaluating impact of the treatment was not the only objective of a number of these studies, it was nevertheless an important aspect.

The purpose of this section is to compare the data of three assessment studies conducted in two public addiction rehabilitation centres in Quebec, with a particular focus on the nature of changes during and after the intervention.

The three studies from which the data presented are drawn concern four different groups.

Although the objectives and methodologies of these studies differ in a number of respects, they also have a number of common characteristics.

All three are pre-post-type studies with at least two post-measurements. The subjects were thus assessed at the time they entered treatment (pre) and the same assessment was conducted at least twice thereafter (post) to measure interim changes. The intervals between measurements varied from five to eight months. Changes in the subjects of the studies were measured in seven areas of life concerning not only the consumption of alcohol and other psychoactive substances, but also problems generally associated with substance abuse. This way of assessing change is consistent with the biopsychosocial approach adopted by the addiction rehabilitation centres under study.

The instrument used to assess change in the subjects was the Indice de gravité d’une toxicomanie (IGT) (Bergeron, Landry, Brochu et Guyon, 1998), a validated adaptation of the Addiction Severity Index (McLellan et al., 1980). The IGT scales concern the following fields: alcohol, drugs, physical health, employment and resources, psychological status, family and social status and legal status.

All were so-called "naturalist" studies. The intervention programs were assessed as given by the centres' workers to the users who commonly entered the centres for treatment. The procedure did not provide for control groups or random assignment to two or more forms of treatment.

The variable used to assess the impact of the intervention programs offered to each of these four groups is the amount of exposure to treatment. For the purposes of these studies, exposure to treatment was measured in two ways: number of days in treatment and number of hours of activities taken. Number of hours of activities was established through a review of the user files in which all significant interventions made were reported.

The approach used thus makes it possible to address the impact of interventions from two angles:

Is there a link between observed changes and amount of treatment received? Researchers looked at potential interaction between change and exposure to treatment as an indicator of its impact.

In what areas of life do the changes occur? The perspective adopted in this instance is thus more qualitative: is the impact of the intervention programs related to the biopsychosocial approach adopted in the addiction rehabilitation centres?

The subjects of the four groups under study were on average 35 years old, with the exception of the inmate addicts in Trois-Rivières, who were younger (32). There was the usual male-female distribution of 70% to 30% for the general program, but 87% male to 13% female in the inmate groups. Approximately half of the subjects had at least completed high school.

Researchers first observed that the average number of days in treatment of the study subjects was relatively high (five to eight months) and reached thresholds associated in other studies with increased effectiveness (Simpson and Sells, 1982; Simpson et al., 1997). Furthermore, the average number of hours of exposure to treatment was relatively low among three of the four groups (between 10 and 12 hours). Note, however, that these figures are comparable to those generally observed in mental health and addiction services (see the review by Stark, 1992, in this regard).

The intensity of treatment taken by the subjects in these three groups, as indicated by the ratio of number of hours of exposure to treatment to number of days in treatment is thus very low: users had approximately one hour of treatment every two weeks. There was one noteworthy exception: the number of hours of treatment taken by subjects of the general program was two to nearly four times greater than those of the other groups. How to explain this significant discrepancy? It does not appear that the way of compiling hours of treatment is in question since the method used (user file review and use of a standardized input grid) was the same across the board. Instead, the explanation appears to lie in the intervention programme offered at the rehabilitation centre at the time. A larger percentage of users were admitted for residential program intervention, most often at the start of their treatment. The intensity of treatment in this program was greater than in the outpatient program. In addition, a session of eight groups spread over four weeks had to be taken by all users registered on an outpatient basis.

In conclusion, a relatively long length of exposure to treatment with low intensity is observed in three of the four groups. The subjects in the first group present an appreciably larger number of hours of exposure to treatment, undoubtedly because of the specific terms and conditions of the intervention program offered to them.

First of all, there is a major similarity between the change curves of the subjects of the four groups on the alcohol, drugs, psychological and family/social status scales. Figures 1 to 4 illustrate these change curves.

CHANGES OF THE FOUR GROUPS IN AGGREGATE SCORES ON THE ASI PSYCHOLOGICAL SCALE

CHANGES OF THE FOUR GROUPS IN AGGREGATE SCORES ON THE ASI FAMILY/SOCIAL SCALE

A similar pattern is observed in all cases: the subjects improved significantly in time 2 and that improvement was maintained in times 3 and 4. This positive change is, of course, expected, particularly on the alcohol and drug scales, and is directly related to the missions of the addiction rehabilitation centres and to the requests for help by users of those centres. This positive change appears to be equally systematic in the subjects' mental health and relations with members of their immediate circle.

The case of the legal status scale is more complex. In view of the structure of the rehabilitation programs offered at the Montreal centre where the study was conducted, users directed to the adult program must, by definition, have no legal problems. They therefore cannot improve this area. Two of the three other groups (general program and Trois-Rivières inmate) improved significantly and maintained that improvement, as may be seen in Figure 5, whereas the improvement of the third group (inmate addict program in Montreal) almost reached the significance level (.06).

CHANGES OF FOUR GROUPS IN AGGREGATE SCORES ON THE ASI PHYSICAL HEALTH SCALE

CHANGES OF THE FOUR GROUPS IN AGGREGATE SCORES
ON THE ASI EMPLOYMENT/RESOURCES SCALE

CHANGES OF THE FOUR GROUPS IN AGGREGATE SCORES ON THE ASI LEGAL STATUS SCALE

The statistical analyses for studying the relationship between subjects' changes and their exposure to treatment reveal an interaction between subjects' improvement and exposure to treatment in two of the four groups and only on the alcohol and drug scales. In the general program in Montreal, there is an interaction between these two variables as regards the number of hours of exposure to treatment, whereas, in the case of a sub-sample of the Montreal inmate addict group (Lefebvre, 2000), there is an interaction, for the men, between the improvement and number of days in treatment.

No other link can be found between exposure to treatment and positive changes observed on the alcohol and drug scales of the other two groups or on the psychological status and family/social status scales or in other changes observed on the other ASI scales.

One initial observation seems obvious from consideration of the findings of the three studies: the four user groups which began rehabilitation in programs in Montreal and Trois-Rivières improved, and that improvement was maintained over the 12- to 15-month period during which they were followed in a research context. This result must be considered as reassuring and positive, regardless of the causes of the changes in the subjects.

It may also be observed that the improvements are clearly concentrated in the areas of substance abuse, psychological status and family relations. Legal status also improved in the majority of cases in which subjects initially had legal problems, whereas employment and physical health status improved little or not at all.

It is interesting to note that the first two areas of improvement (alcohol and drugs) are directly related to the missions of the rehabilitation centres where these subjects were monitored. However, the subjects improved unevenly relative to the biopsychosocial spectrum which is the focus of the approach adopted by these centres. Although the psychological and relational spheres improved constantly, the social and biological areas were much less affected.

The picture these findings paint calls into question the biopsychosocial approach used in these programs. Is it simply a reflection of a tendency by clinical researchers to favour intervention focused on the individual and intra-psychic dimension of the problems rather than their environmental aspects? This question has been raised many times in recent years, and these results would indicate that efforts made to give addiction intervention a more social orientation have not yet produced results. That conclusion should be qualified, however, based on other factors which might explain the results observed here. One must first consider the objective possibilities for improvement in the employment area for the subjects of these studies, in light of the economic context of Quebec society at the time they were conducted and the particular handicap which addiction represents in looking for a job. In addition, the physical health scale of the ASI is very short and its ability to reflect subjects' changes in this area limited. Lastly, note that the attention focused on the psychological status of users requesting assistance at addiction rehabilitation centres is entirely consistent with their expectations, as could be seen in one of our studies of inmates in Montreal and Trois-Rivières (Landry, Brochu, Bergeron, 1999).

The lack of interaction in most cases between exposure to treatment and observed changes naturally raises questions about the specific impact and effectiveness of the intervention programs taken by users at the centres studied. The fact that those who have received little or no treatment change as much as those who have taken a great deal leads us to consider the influence of factors other than treatment received at a rehabilitation centre.

In the case of some subjects, we could be seeing what is commonly called a "natural remission" phenomenon, as documented by a number of researchers (Klingeman, 1992; Sobell, Sobell and Toneatto, 1992; Vaillant, 1983). The effect of the initial motivation to request assistance could also be more decisive in some subjects than the treatment itself, such that merely becoming aware of an addiction problem and deciding to take steps to deal with it was enough to cause positive change. Lastly, it is possible that the observed change merely reflects an attenuation of an acute crisis which, as is very often the case with addiction, triggers the request for help (see Guyon and Landry, 1996). Based on our data, we cannot determine the respective influence of each of these factors, but we are inclined to conclude that a number of change factors other than treatment may have contributed to the positive change in the subjects and interacted in a complex way in that result.

The follow-up rates for research subjects are also another factor to be considered in interpreting the observed results. Relative to the total number of subjects recruited in time 1, the number of subjects for whom we have two other measurement times is distributed as follows: general program, 32%; adult program, 44%; inmate addicts in Trois-Rivières, 60% and inmate addicts in Montreal, 72%. These follow-up rates are insufficient in three of the four groups. These data limit the scope of the results, while shedding additional light on the lack of any relationship between results and exposure to treatment. Even though the subjects who continued in the study do not differ from those who dropped out on a large number of socio-demographic and clinical variables, it is possible that the drop-outs improved less than those who were followed up at the three times. They may have been harder to reach precisely because they had relapsed and were thus more disorganized and less inclined to talk to a research officer about their situation. The risk of this kind of bias is obviously greater in the case of studies where follow-up rates are lower. It should be pointed out, however, that, in the case of the general program, another analytical strategy with only measurement times (pre-post), making it possible to obtain a higher follow-up rate (66%), resulted in change curves identical to those presented here.

Furthermore, it may be observed in two of the groups studied (the inmate addict group in Montreal and the adult group) that exposure to treatment was appreciably and significantly less in those who dropped out of the research projects. These were also the groups in which we found no interaction between observed changes and exposure to treatment. This could also help explain the absence of any relationship between exposure to treatment and the subjects' changes. If the drop-outs were more those who had had less treatment and showed less change, it may be considered that their presence in the cohort helped reinforce the interaction between treatment and observed change.

A number of questions remain unanswered following these studies and suggest avenues for future research. Qualitative research appears to be a particularly promising way to achieve a better understanding of the process of change at work in the users of addiction rehabilitation centres. In this way, it would be possible to explore the various factors influencing the process by contrasting the histories of users who have or have not improved, with or without treatment. Particular attention should be given to the role of motivation and change factors other than treatment, such as significant life events, use of other resources and so on.

A deeper exploration of interventions designed to improve socio-professional reintegration is another important research orientation. A number of aspects should be considered. First, in the field of substance abuse, we have very few studies enabling us to assess the most effective methods in the field, in particular because there is very little intervention in that field, contrary to what may be observed in the area of mental health, for example. It would therefore be appropriate to consider the parallel development of intervention and study programs to assess their implementation and results. It is also important to gain a better understanding of the motivations (or lack thereof) of clinical workers and users themselves in this area of change. It is not clear that the latters' interest lies in this direction. Moreover, there is every reason to believe that clinical workers are generally more interested in the psychological aspects of intervention. Is this in response to client expectations? Is it related to the training they have received? A better understanding of the role of each of these factors would help in more clearly identifying the change targets in order to stimulate greater investment in this "social" field of intervention.

As regards methodology, the difficulty experienced in achieving higher follow-up rates for participants in research projects is a concern. The limits this places on the scope of conclusions that may be drawn from our studies are an inducement to explore more effective ways of staying in touch with participants and maintaining their interest in continuing their participation. It must also be recognized that these studies focus on subjects who are particularly unstable socially and have difficulty functioning personally. In addition, major efforts have been made in this area based on common methods in the field. It is difficult to see how one could go further without breaking the ethical barriers regarding free consent and confidentiality.

The studies presented address the question of impact of treatment from a number of standpoints:

· Of course, all the studies raise the question of changes in the addicts under treatment: Do they change and do they change for the better?

· A number focus on the impact of treatment on specific clienteles: those in trouble with the law (Brochu and Schneeberger, 2001), those with mental health problems (Nadeau, 2001) and heroin addicts (Perreault, Lauzon, Mercier, Rousseau et Gagnon, 2001).

· The influence of treatment variables is also addressed: is the impact of treatment linked to the duration/amount of treatment received (Landry, 2001) or to its degree of intensity (Redko, Legault, Brown et Dongier, 2001)?

· In combining the effect of client characteristics with that of treatments offered, one comes to the question of matching (Brown and Seraganian, 2001; Brochu and Schneeberger, 2001): do certain forms of treatment have different impact depending on the characteristics of the persons treated?

· The very nature of changes that occur is also examined: in addition to substance abuse problems, what areas are touched upon across the biopsychosocial spectrum of the person (Landry, 2001; Perreault et coll., 2001)?

· More specifically, the role of social reintegration in rehabilitation and the impact of intervention specifically designed to promote it are addressed by Boivin (2001).

The only inventory of these ways of addressing the question of the impact of addiction treatment provides an eloquent overview of the issue's complexity. Examination of the data from the studies presented assists in delving more deeply into that complexity and identifying clear and grey areas. Certain constants may also be observed, but, what is more, an exploration of the links that may be made based on all the studies presented in this book sheds additional light on the scope of each.

As a whole, the findings presented tend to show that persons who take steps to rehabilitate through the services provided in Quebec improve their situation. According to a number of those findings (Landry, 2001; Perreault et coll., 2001; Redko et coll., 2001; Wood, Vargas, Schwartz and Dongier, 2001), that improvement is maintained over the period of six months to one year following treatment. This is a positive and reassuring result. The same is true of a very large number of other research projects conducted mainly over the past 20 years (see Nadeau and Biron, 1998, O’Brien and McLellan, 1996; Roberts and Ogborne, 1999). Clinical workers who deal on a daily basis with substance abusers and managers of addiction rehabilitation centres have reason to rejoice at the fact that these persons, on the whole, change for the better.

Furthermore, this positive change appears to occur in all treatment centre users regardless of the severity of their substance abuse profile or of the problems associated with that profile when they enter the centres. This is the case of inmate addicts, those who have a substance abuse - mental health comorbidity and heroin addicts. In the chapter by Landry (2001), the change curves show that initial severity of the problems may vary with the program to which these persons have been directed (for example, the severity of the aggregate score on legal problems of users of the inmate addict program is initially higher than those of the other groups), but the change curve remains as favourable for these persons as for those in the other groups. Some Quebec studies (Guyon et Landry, 1996; Nadeau, Landry et Racine, 1999) shed light on the seriousness of substance abuse problems and other psychosocial problems of users of Quebec rehabilitation centres: multiple substance abuse, personality disorders, legal problems, psychological distress. As a result, the profiles of the Quebec samples are more serious than those in the U.S. studies, based on the same measurement instruments. According to a number of studies (Hser, 1995; McLellan et coll., 1983; Rounsaville et coll., 1987) the prognosis for these individuals is quite poor and the chances for successful treatment diminished. What emerges from the data here presented is a more encouraging vision of their ability to benefit from the services offered to them. However, these findings must be characterized in a number of ways.

In most of the studies presented, the available data applies to groups: it is the group average that improves. This does not prevent certain individuals within those groups from failing to improve or others from deteriorating. The fate of these individuals must be studied further. In the field, clinical workers are much more concerned by these persons than by those who are doing well. The study by Michel Perreault et al. (2001), which monitors a number of subjects individually, is very interesting in this regard. It provides an examination of the change profile of each of the subjects, shows that certain areas improve more quickly, others more slowly, and that the situation may deteriorate in some areas and improve in others. For clinical workers, who treat individuals, not groups, these profiles are definitely of assistance in orienting clinical intervention and adapting it to changes in rehabilitation paths.

In addition, according to the data as a whole, the main area of improvement is substance abuse. This is a satisfactory and expected result in view of the missions of the centres evaluated in the studies. An attenuation of psychological problems is also observed in most of the studies (Boivin, 2001; Brochu et Schneeberger, 2001; Landry, 2001; Nadeau, 2001; Perreault et coll., 2001). In addition, a number have revealed an improvement in the subjects' family status (Landry, 2001; Redko et coll., 2001; Perreault et coll., 2001, for men only) and, for the majority of the groups in trouble with the law, an attenuation of those problems.

Changes appear to be much more difficult in the area of social reintegration and, more specifically, employment (Landry, 2001; Perreault et coll., 2001). In one of the CRAN groups studied (Perreault et coll., 2001), an improvement was observed among the men but not among the women. Even in an intervention program specially designed to promote professional reintegration (Boivin, 2001), subjects improved their situation with respect to psychological distress and substance abuse, but not employment. Perreault et coll. (2001) observed that a longer period of time is needed, and in other areas, for an improvement to occur. These are good reasons for reviewing not only our intervention priorities, but also our conception of the change process in this area so as to adjust our expectations and intervention strategies.

Instead of relying to a procedure for randomly assigning subjects to an untreated control group and an experimental group (to assess whether observed changes are actually attributable to the treatment itself), a number of Quebec studies have observed the relationship between the duration and amount of treatment received and improvement in subjects. The hypothesis is advanced that, if observed changes are linked to treatment, they will be a function of the duration of exposure to treatment.

Most of the authors in this book who have considered this question find no relationship between exposure to treatment and observed changes (Landry, 2001; Nadeau, 2001). Simply put, in these three studies, the subjects improved as a group, whether they had received little or no treatment or a lot of treatment. Various factors may explain these findings: insufficient follow-up rates for research subjects, effect of initial motivation to request assistance, natural attenuation of crisis situation at start of treatment. These factors are discussed in detail by Landry (2001) and Nadeau (2001). This could also be a phenomenon analogous to that of the natural remission corrupting our impact findings. The chapter by Wood et coll. (2001) sheds helpful light on this point.

There may exist a phenomenon of natural remission among persons requesting assistance

The so-called "natural remission" phenomenon is now well documented (Vaillant, 1983; Klingeman, 1992; Sobell, Sobell and Toneatto, 1992). A large percentage of individuals who have developed dependence on psychoactive substances manage to break that dependence without resorting to formal treatment. Of course, the natural remission studies show that other factors and treatment may have been at work in the remission: illness, risk of job loss and new romantic relationships are some of the best documented examples.

In reinterpreting two previously published double-blind clinical studies, Wood et coll. (2001) examined the natural healing process as a factor of improvement in their subjects. In both trials, alcoholics recruited through the newspapers were randomly distributed between treatment involving active medication and treatment with a placebo. The data show that a large number were already abstinent at the time they began treatment. The authors suggest that the decision to request help and to enter treatment was as important an improvement factor as drugs and that, as a result of this factor alone, many were already "cured". Other pre-treatment factors may have influenced those subjects' motivation and led them to decide to stop drinking, and treatment was more a confirmation of that decision. While emphasizing the biases introduced in the trials by the recruitment method and the criteria for including and excluding subjects, the authors suggest consideration should be given to other variables than treatment itself, particularly motivation, in explaining the changes in the individuals who took it.

The concept of motivation is raising increasing interest in the area of addiction intervention. In the late 1970s, Rossi and Filstead (1976) overturned the conventional wisdom which held that motivation was a prerequisite to treatment and that all those who lacked it should be excluded. In proposing a dynamic model for explaining change, Prochaska and DiClemente (1982) provided a conceptual framework for eliminating the notion of motivation as a static attribute of persons who enter treatment and introducing the idea that motivation is an evolving phenomenon that can be influenced. Miller (1989) advanced an intervention method for acting on motivation and promoting its development so as to make it an active ingredient of change. Caseworkers are no longer more or less powerless spectators confined to determining whether or not a person is motivated and are becoming important actors in promoting motivation to change in addicts.

The studies reported by Bergeron et al. (2000 and 2001) focus on the role of motivation as a treatment perseverance and improvement factor in persons who have it. Perseverance in treatment is important to the extent that, as noted above, a number of studies have observed a link between exposure to treatment and treatment impact. The work of Bergeron et al. refers not only to the Prochaska and DiClemente model, but also to two other conceptual models (Fishbein and Azjen, 1975; Deci and Ryan, 1991) in their study on the role of motivation. The findings presented establish a link between subjects' motivation and their perseverance in treatment. In the second study, these two conceptual models predict impact in a paradoxical manner. The studies focus on two aspects of motivation: motivation to take treatment and motivation to change in relation to problems. Whereas motivation to change, assessed in the perspective of the Prochaska and Di Clemente model, predicts perseverance in treatment, intentions to change and continue treatment, evaluated under the Fishbein and Azjen model, prove to be linked to effectiveness of treatment more than to perseverance in treatment. Predictions obtained using these models thus lack precision and suggest that further work on this question is necessary.

In addition, the study by Simoneau (2001) in this area sheds particularly helpful light by showing not only that motivation evolves significantly over a relatively brief period (six weeks), but also by identifying the factors responsible for that evolution.

The matching approach (or should we say strategy or philosophy?) has been the cause of much hope and disappointment over the past 20 years. The underlying assumption of this approach is that what must be sought is not an effective form of treatment for everyone, but the most effective treatment for a particular individual based on his or her characteristics and specific needs. Matching exercised an attraction at the time the complex nature of the substance abuse phenomenon was discovered, highlighted by the explosion in etiological studies in the field starting in the 1950s. However, scientific confirmation of the approach, which still makes clinical sense, has yet to occur, and the results of the studies conducted on the subject are ambiguous to say the least. The MATCH project data (Project MATCH Research Group, 1997) did much to raise scepticism about matching, doubtless because of the means used and the study's methodological rigour.

However, as may be seen from the literature survey on the question by Brown and Seraganian (2001), the jury is still out and studies must continue. The data from their study supports the matching hypothesis. When subjects are randomly assigned to two intervention programs, certain variables (sex, psychological distress and psychoactive substance abuse profile) make it possible to predict a differential impact from those programs. Those directed to their preferred program did better than those whose random assignment did not correspond to their preference.

On the other hand, Brochu et Schneeberger (2001) find no difference between the effectiveness of a specialized program for inmates and that of a general program offered to the same clientele: both groups improved and those of the general program improved more at the outset. The data thus suggests there is a basis for matching, but if used in accordance with a carefully thought out strategy. Matching, a powerful tool for therapists, could, in some instances, turn against them if they provoke reactions of opposition from patients grouped in this manner, as was the case for the inmate clientele.

These observations suggest further thought on matching strategies is required. This is a very complex question since, by definition, it brings a large number of variables into play with regard to both treatments provided and the persons who take them. In addition, the specific effect of matching could be masked by the fact that, in all the studies presented, the subjects changed in a positive direction, regardless of the treatment taken. This means the method represents value added to a common effect already present and, as a result, more difficult to detect. The data from Brown and Seraganian (2001) nevertheless confirm the interest in pursuing matching studies. They also show that observations do not always tend in the expected direction and that it is better for clinical intuition to be tested by assessment studies. Lastly, they emphasize the importance of the choice of the person himself in implementing a matching strategy.

Many studies on the impact of treatment given to addicts appear to have persuaded some that treatment is the only possible rehabilitation method. Persons in authority thus attempt to convince addicts to take treatment. Large businesses and the courts are thus faced with the difficulty of referring a person who is more or less aware of his condition to treatment services. Too often the solution consists in threatening or compelling an individual to enter treatment.

As a result, a significant increase in the number of addicts forcibly referred to treatment has been observed over the past two decades. This is a care decision made in large part by union and legal authorities with the tacit consent of the person involved. Addicts are thus asked to obey requests to take therapy or else be deprived of their jobs or, even worse, their freedom. In so doing, authorities have little consideration for the law or the limits of intervention in such circumstances. Compelling individuals to take therapy is becoming a preferred instrument of standardization. Authorities are attempting to help individuals despite themselves. Our impact studies must not divert our attention from the ethical dangers of abusive use of treatment that would be "too" effective.

Conversely, one might be tempted to offer "too little" treatment, relying on the fact that individuals who take treatment at an addiction rehabilitation centre improve in any case, regardless of the amount or duration of treatment. On the one hand, based on the data presented in this book, we cannot tell who actually needs long-term intervention and who remains in treatment without deriving any benefit. What is more, the offer of service in addiction rehabilitation centres, which are public in nature, cannot adhere solely to rules of effectiveness. Their mission is also humanitarian in scope and very often involves very disadvantaged people who need to be helped, understood and treated in a humane and compassionate manner, even if that assistance does not necessarily result in change that can be observed using our instruments of measurement.

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Armor, D.J., Polich, J.M., Stambul, H.B. (1978). Alcoholism and Treatment, New York, NY : Wiley.

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[1] Director, Professional and Research Services, Centre Dollard-Cormier, Co-Director, Recherche et intervention sur les substances psycho-actives-Québec (RISQ) and Collectif en intervention et recherche sur les aspects socio-sanitaires de la toxicomanie (CIRASST)