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Clinical guide to alcohol treatment: The Community reinforcement approach
Journal of Substance Abuse Treatment, Vol. 13, No. 3, pp. 275-279, 1996 Copyright © 1996 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/96 $15.00 + .00 ELSEVIER
B O O K REVIEWS
rents, and consequences in as positive a manner as possible. Years ago Skinner showed that positive and negative reinforcement are approximately equal in effectiveness. But for human beings in social settings, positive reinforcement is much more likely to induce clients, and their families, to engage in and adhere to treatment regimens. Then, too, CRA operates from a disarmingly straightforward approach, which is probably more immediately accessible to clients than many forms of psychotherapy. In fact, CRA intends to enlist clients and their spouses from the outset in a psychoeducational search-and-succeed mission [my words, not the authors']. CRA has created a series of instruments, questionnaires, and guides from which to take history and evaluate, as well as to form the basis of assessing progress. They are in clear, standard English, and invite the clientele to participate in, and construct, their own treatment plans. These are "take home" documents, which lend themselves to "homework," and ready reminders to carry around in everyday life, not only metaphorically, but even actually. Much of the text of Clinical Guide is couched as dialogues between clients and a therapist. Initially I approached this warily, as my experience is that such exchanges often (a) are excerpts from recordings, which are dull, hard to follow, and often somewhat off the point or (b) may be filler for lack of substance. Nothing could be further from the truth for this book. The dialogues are pithy, illustrative, and pleasantly pointed. They have the hallmarks that the authors have accurately digested typical therapist-patient exchanges, and reconstructed them most helpfully to illustrate the kind of reframing and coaching that the CRA therapist must constantly employ. After presenting the common and usual, they also do not shrink from the more difficult: the client who is there under duress, and not forthcoming; the repeat sinner; and so forth. CRA also does not hesitate to incorporate techniques that have been proven useful in other schools of therapy (e.g., the use of paradox for disarming power struggles, and cognitive techniques for marital therapy or relapse prevention). Clinical Guide passes the acid test for how-to therapy guides: as I was reading it, I could immediately think of a number of ideas that I could incorporate into everyday practice, whether or not I should ever adopt CRA wholecloth. For example, if money is what motivates some drug addicts, why not incorporate money into their behavioral reinforcement programs? Why not pay people to get more clean, since society is clearly the winner?
PII S0740-5472(96)00047-5 Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach Robert J. Meyers and Jane Ellen Smith Guilford Press, New York & London: Guilford, 1995, $26.95,211 pages. It has become fashionable in the social sciences to speak of "paradigm shifts." By this we usually mean that a creative idea arises, or a new way of framing old ideas. This novel concept is so powerful, suggesting such more potent ways of understanding previous quandaries or solutions to old problems, that it quickly comes to overshadow the concurrent, consensual wisdom on the subject. Now, I am not quite ready to call the "Community Reinforcement Approach" (CRA) a paradigm shift. However, it is an idea whose time has clearly come. This book lays out clearly and concisely the operational meaning of CRA, and how to put it into practice. I first heard of the notion of a more global, community-based approach to alcoholism treatment at least two decades ago, at a conference on behavioral therapies for treating drug addiction. The principal creator of the idea was Nathan Azrin. At that time he and his coworkers were working with some of the most intractable, longstanding cases of alcoholism, in chronic care settings, where "success" in treatment was a sham. Starting with the behavioral therapies more limited in scope most commonly used in office practice, even today, Azrin and colleagues demonstrated that the same principles of reinforcement could be generalized to the rewards (and deterrents) that people identified in their everyday lives. Building these into the (individualized client) program dramatically improved the results, at least on a small scale. As I gather from the introductory chapters in this book, only a surprisingly modest amount of follow-on work to Azrin's was conducted for some years, after that group dissolved. There are presently several groups who are more formally treating people using CRA, and researching the approaches and results. This book is the product of Azrin's disciples who migrated to the University of New Mexico. One of the many qualities to recommend Clinical Guide to the broad audience of clinicians it deserves is the fact that it is so upbeat. Meyers and Smith portray CRA as constantly searching to frame rewards, deter275
276
Book Reviews
Clinical Guide to Alcohol Treatment is well written, and superiorly presented and edited. Its extensive appendices are lucid and cogent documentation of the instruments CRA employs. Even the price is fight for the quality of the work. Run right out and buy it. You will be up tonight reading through it. Marc Hertzman, MD 1600 Crain Highway, No. 410 Glen Burnie, MD
PII S0740-5472(96)00050-5 Escaping the Journey to Nowhere: The Psychology of Alcohol and Other Drug Abuse Glenn D. Waiters, PhD Bristol, PA: Taylor & Francis, 1994, $45.00 (cloth), $29.50 (paper), 230 pages. One of the most valuable contributions a book can make is to offer new concepts and ideas that, in turn, can inspire exploration in thought leading to different and expanded approaches to treatment. This is the essence of what Dr. Glenn D. Waiters has presented in his work entitled, Escaping the Journey to Nowhere, the psychology of alcohol and other drug abuse. The foundation of this writing is based on lifestyle theory, defined by the author as an alternative view of drug-seeking behavior. He is optimistic that it may be used to supplement or even replace the current traditional and unquestioned perspectives on substance abuse. We are alerted early on, in the Preface, that uncomfortable emotions may be experienced due to the introduction and inclusion of new material and views that stray from the norm within the field. The author also indicates, at this point, that the information offered finds its origins in his earlier work with criminal offenders and may not be applicable to all populations, but that further study and consideration of this possibility are clearly warranted. An analogy of pebbles, ponds, and ripples is used to delineate the way in which lifestyle theory differs from a more traditional view of drug use behavior. Within this context, pebbles symbolize a set of conditions leading to drug use. These are the elements that are most frequently focused upon, with the belief that a true understanding of these influences will offer insight into an individual's development and thus aid the treatment of his/her drug-abusing pattern. Lifestyle theory sees the ripples, or interactions, created by the tossed pebble as the arena for intervention and treatment. Significant consequences exist within the ripples housed by the pond of one's life linked to adjacent and adjoining ponds, representing the lives of others. Although not considered irrelevant, the study of
pebbles plays a smaller role in the investigation of a drug-using lifestyle. This analogy may appear somewhat confusing, but succeeds in distinguishing a major contrast from the more well-known theories and treatments of drug and alcohol abuse. The term "lifestyle" helps us explore drug and alcohol in a comprehensive manner. The lifestyle approach operates along two tracks. The first is the structural, or content, track, which focuses on conditions, choices, and cognitions. Once identified it is suggested that these three factors interact to form the structural make-up of the drug-using lifestyle. The other track is referred to as functional. This outlines the process of development and change. An individual's reaction to existential fear is the focus and points to a poor decision-making strategy where shortterm repetitive solutions are chosen; that is, drug use, rather than more adaptive, long-term plans to address ongoing problems. Thirteen chapters are divided among three sections, or parts: "Origins," "Development," and "Treatment." Biological, psychological, and sociological factors are discussed in the first of these parts. Dr. Waiters cites research from genetic studies, which attempt to substantiate a biological connection to substance abuse. He then offers alternative findings based on these studies. Biological components are viewed as significant when seen as one piece of the puzzle, with environmental elements playing an equal if not more substantive role. The author writes, "while it is possible that an inborn underresponsiveness to the inebriating effects of alcohol may place a person at risk for substance abuse, psychological, sociological, and situational factors can either exacerbate this risk or reduce it through a combined interactive effect." In its simplest terms, this view can be useful to patients struggling with substance abuse problems. It allows for the possibility of change within their own lives and hopefulness for the lives of their children. Consider how frequently we see a patient empowered by the recognition of his/her own ability to create shifts in destructive behavioral patterns rather than to surrender to a learned helplessness stemming from the belief that biological factors dictate the future, exclusively. Psychological factors are considered within a framework made up of three major learning paradigms: operant studies, classical conditioning, and observational learning. The Minnesota Multiphasic Personality Inventory (MMPI) and the MMPI-2 are cited in a discussion of objective personality research on substance abuse. Within the section depicting sociological factors we find several key elements seen as precursors to the development of a drug- and alcohol-using lifestyle. For example, it is suggested that a polarization of attitudes may develop in the presence of cultural prohibitions against drinking. The overall rate of abuse is proportionately low when compared to a larger population sample, whereas the interpersonal level of conflict due to use, is high.
B O O K REVIEWS
rents, and consequences in as positive a manner as possible. Years ago Skinner showed that positive and negative reinforcement are approximately equal in effectiveness. But for human beings in social settings, positive reinforcement is much more likely to induce clients, and their families, to engage in and adhere to treatment regimens. Then, too, CRA operates from a disarmingly straightforward approach, which is probably more immediately accessible to clients than many forms of psychotherapy. In fact, CRA intends to enlist clients and their spouses from the outset in a psychoeducational search-and-succeed mission [my words, not the authors']. CRA has created a series of instruments, questionnaires, and guides from which to take history and evaluate, as well as to form the basis of assessing progress. They are in clear, standard English, and invite the clientele to participate in, and construct, their own treatment plans. These are "take home" documents, which lend themselves to "homework," and ready reminders to carry around in everyday life, not only metaphorically, but even actually. Much of the text of Clinical Guide is couched as dialogues between clients and a therapist. Initially I approached this warily, as my experience is that such exchanges often (a) are excerpts from recordings, which are dull, hard to follow, and often somewhat off the point or (b) may be filler for lack of substance. Nothing could be further from the truth for this book. The dialogues are pithy, illustrative, and pleasantly pointed. They have the hallmarks that the authors have accurately digested typical therapist-patient exchanges, and reconstructed them most helpfully to illustrate the kind of reframing and coaching that the CRA therapist must constantly employ. After presenting the common and usual, they also do not shrink from the more difficult: the client who is there under duress, and not forthcoming; the repeat sinner; and so forth. CRA also does not hesitate to incorporate techniques that have been proven useful in other schools of therapy (e.g., the use of paradox for disarming power struggles, and cognitive techniques for marital therapy or relapse prevention). Clinical Guide passes the acid test for how-to therapy guides: as I was reading it, I could immediately think of a number of ideas that I could incorporate into everyday practice, whether or not I should ever adopt CRA wholecloth. For example, if money is what motivates some drug addicts, why not incorporate money into their behavioral reinforcement programs? Why not pay people to get more clean, since society is clearly the winner?
PII S0740-5472(96)00047-5 Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach Robert J. Meyers and Jane Ellen Smith Guilford Press, New York & London: Guilford, 1995, $26.95,211 pages. It has become fashionable in the social sciences to speak of "paradigm shifts." By this we usually mean that a creative idea arises, or a new way of framing old ideas. This novel concept is so powerful, suggesting such more potent ways of understanding previous quandaries or solutions to old problems, that it quickly comes to overshadow the concurrent, consensual wisdom on the subject. Now, I am not quite ready to call the "Community Reinforcement Approach" (CRA) a paradigm shift. However, it is an idea whose time has clearly come. This book lays out clearly and concisely the operational meaning of CRA, and how to put it into practice. I first heard of the notion of a more global, community-based approach to alcoholism treatment at least two decades ago, at a conference on behavioral therapies for treating drug addiction. The principal creator of the idea was Nathan Azrin. At that time he and his coworkers were working with some of the most intractable, longstanding cases of alcoholism, in chronic care settings, where "success" in treatment was a sham. Starting with the behavioral therapies more limited in scope most commonly used in office practice, even today, Azrin and colleagues demonstrated that the same principles of reinforcement could be generalized to the rewards (and deterrents) that people identified in their everyday lives. Building these into the (individualized client) program dramatically improved the results, at least on a small scale. As I gather from the introductory chapters in this book, only a surprisingly modest amount of follow-on work to Azrin's was conducted for some years, after that group dissolved. There are presently several groups who are more formally treating people using CRA, and researching the approaches and results. This book is the product of Azrin's disciples who migrated to the University of New Mexico. One of the many qualities to recommend Clinical Guide to the broad audience of clinicians it deserves is the fact that it is so upbeat. Meyers and Smith portray CRA as constantly searching to frame rewards, deter275
276
Book Reviews
Clinical Guide to Alcohol Treatment is well written, and superiorly presented and edited. Its extensive appendices are lucid and cogent documentation of the instruments CRA employs. Even the price is fight for the quality of the work. Run right out and buy it. You will be up tonight reading through it. Marc Hertzman, MD 1600 Crain Highway, No. 410 Glen Burnie, MD
PII S0740-5472(96)00050-5 Escaping the Journey to Nowhere: The Psychology of Alcohol and Other Drug Abuse Glenn D. Waiters, PhD Bristol, PA: Taylor & Francis, 1994, $45.00 (cloth), $29.50 (paper), 230 pages. One of the most valuable contributions a book can make is to offer new concepts and ideas that, in turn, can inspire exploration in thought leading to different and expanded approaches to treatment. This is the essence of what Dr. Glenn D. Waiters has presented in his work entitled, Escaping the Journey to Nowhere, the psychology of alcohol and other drug abuse. The foundation of this writing is based on lifestyle theory, defined by the author as an alternative view of drug-seeking behavior. He is optimistic that it may be used to supplement or even replace the current traditional and unquestioned perspectives on substance abuse. We are alerted early on, in the Preface, that uncomfortable emotions may be experienced due to the introduction and inclusion of new material and views that stray from the norm within the field. The author also indicates, at this point, that the information offered finds its origins in his earlier work with criminal offenders and may not be applicable to all populations, but that further study and consideration of this possibility are clearly warranted. An analogy of pebbles, ponds, and ripples is used to delineate the way in which lifestyle theory differs from a more traditional view of drug use behavior. Within this context, pebbles symbolize a set of conditions leading to drug use. These are the elements that are most frequently focused upon, with the belief that a true understanding of these influences will offer insight into an individual's development and thus aid the treatment of his/her drug-abusing pattern. Lifestyle theory sees the ripples, or interactions, created by the tossed pebble as the arena for intervention and treatment. Significant consequences exist within the ripples housed by the pond of one's life linked to adjacent and adjoining ponds, representing the lives of others. Although not considered irrelevant, the study of
pebbles plays a smaller role in the investigation of a drug-using lifestyle. This analogy may appear somewhat confusing, but succeeds in distinguishing a major contrast from the more well-known theories and treatments of drug and alcohol abuse. The term "lifestyle" helps us explore drug and alcohol in a comprehensive manner. The lifestyle approach operates along two tracks. The first is the structural, or content, track, which focuses on conditions, choices, and cognitions. Once identified it is suggested that these three factors interact to form the structural make-up of the drug-using lifestyle. The other track is referred to as functional. This outlines the process of development and change. An individual's reaction to existential fear is the focus and points to a poor decision-making strategy where shortterm repetitive solutions are chosen; that is, drug use, rather than more adaptive, long-term plans to address ongoing problems. Thirteen chapters are divided among three sections, or parts: "Origins," "Development," and "Treatment." Biological, psychological, and sociological factors are discussed in the first of these parts. Dr. Waiters cites research from genetic studies, which attempt to substantiate a biological connection to substance abuse. He then offers alternative findings based on these studies. Biological components are viewed as significant when seen as one piece of the puzzle, with environmental elements playing an equal if not more substantive role. The author writes, "while it is possible that an inborn underresponsiveness to the inebriating effects of alcohol may place a person at risk for substance abuse, psychological, sociological, and situational factors can either exacerbate this risk or reduce it through a combined interactive effect." In its simplest terms, this view can be useful to patients struggling with substance abuse problems. It allows for the possibility of change within their own lives and hopefulness for the lives of their children. Consider how frequently we see a patient empowered by the recognition of his/her own ability to create shifts in destructive behavioral patterns rather than to surrender to a learned helplessness stemming from the belief that biological factors dictate the future, exclusively. Psychological factors are considered within a framework made up of three major learning paradigms: operant studies, classical conditioning, and observational learning. The Minnesota Multiphasic Personality Inventory (MMPI) and the MMPI-2 are cited in a discussion of objective personality research on substance abuse. Within the section depicting sociological factors we find several key elements seen as precursors to the development of a drug- and alcohol-using lifestyle. For example, it is suggested that a polarization of attitudes may develop in the presence of cultural prohibitions against drinking. The overall rate of abuse is proportionately low when compared to a larger population sample, whereas the interpersonal level of conflict due to use, is high.