Cultural and sociological aspects of alcoholism and substance abuse

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research in the area of relapse prevention and the next few chapters share their expertise with us. We are given 35 very clear relapse warning signs to be on the alert for in the recovering person. One of the most important elements pointed out is that, “if you are not in the process of recovery, you are in the process of relapse.” “Recovery is like going up a down escalator. There is no such thing as standing still. As soon as you stop going up, you begin moving backwards.” The one area of caution regarding the relapse chapter is where it states, “most people do not make it after the first attempt at sobriety.” It is important to check how these results were obtained. If they were obtained through treatment facilities, then it is important to realize that people in treatment centers are there because they are having difficulty with sobriety. If the statistics were obtained after people had been through a recovery process, the results would be far different. The relapse prevention plan should automatically be included in each individual recovery plan and discharge summary. Following the presentation of these signs, the authors offer a specific relapse prevention plan to “intervene” in relapse before it occurs. These appear to be very helpful suggestions and may work in some cases, but actual outcome from research and observation would yet be required before suggesting this plan to all. In summarizing this very factual and well written book, the authors have presented all the support systems available to the recovering person. They have also included the best basic introduction to A.A. we have seen in a long time, and they emphasize the importance of A.A. involvement in order to maintain sobriety. It is imperative that what is pointed out in the support resources chapter about there being a bond and a sense of trust between the helping person and the recovering alcoholic be followed. This can be one of the most important elements in relapse prevention and maintaining sobriety. Overall, “Learning to Live Again” is an exceptional reference book for both the professional and lay reader. It also tends to remove some of the stigma and uniqueness of the disease from other disease by the authors’ frequent comparison of alcoholism to other illnesses and the need to face life no matter what. This book has truly accomplished its goals and will help many who are “Learning to Live Again.”

James S. Cusack Executive Director Veritas Villa Kerhonkson, N. Y. 12446

Cultural and Sociological Aspects of Alcoholism and Substance Abuse Barry Stimmel New York: Haworth Press, 1984, $19.95 This monograph, which was published as Advances in Aicohol and Substance Abuse (Volume 4, Number 1, Fall 1984) contains five articles, one editorial, and a “Selective Guide to Current Reference Sources on Topics Discussed in This Issue.” In its journal form, the eighty-four page content and the limited scope of selections on the broad topic of sociocultural aspects of chemical abuse would be quite acceptable. However, this writer has a fundamental problem with turning a monograph into a hardcover book and offering it for sale at $19.95. The book’s major weakness, therefore, is failure to deliver the substantial content which the title implies. The five articles are presentations of research material and do not specify treatment modalities. In fact, several of the studies do not offer suggestions for treatment. The book is not geared toward specific treatment providers, but the data supplied does have applicability to most disciplines. The introductory editorial “The Role of Ethnography in Alcoholism and Substance Abuse: The Nature versus Nurture Controversy” by Barry Stimmel, M.D., examines the acceptance of many stereotypes and biases concerning race and drug use. Research findings have challenged many of these causative theories, and Stimmel suggests that a profile of family dynamics and gender may foster more understanding than concentration on race and social class. Unfortunately Stimmel then goes on to weave an introduction to several of the articles and the end product becomes fragmented and difficult to follow. In his summary he states that the nature versus nurture controversy in identifying causal factors in alcoholism is not resolved and that, indeed, it should not be because an eclectic approach is needed by caregivers. My controversy with the editorial remains. What is significant when real controversies and biases are exposed (along with Stimmel’s interpretations) but are allowed to sit there since the small number of articles in the book cannot adequately address the issues? In “The Role of Ethnicity of Substance Abuse,” Joseph Westermeyer, MD, PhD, begins by providing definitions of the concepts of ethnicity, nationality, religion, language, race, minority groups and culture in the context of working with substance abusers. No matter what the ethnic background of the substance abuser, previously held values are replaced as the abuser increases involvement with the substance. The author believes that some substance abusers who have become increasingly detached from family and friends will seek a subculture of similarly chemically

Book Reviews

dependent people. These groups have many similar characteristics of other groups in society, but are usually more brittle. Westermayer emphasizes, however, that not all previously held ethnic values and attitudes are renounced, and provides interesting examples of alcoholics who profess to disregard ethnic affiliation yet hang on to symbols of these cultures. When the chemicals are eliminated, the addict must also relinguish chemically dependent values and behaviors. Westermayer contends that these losses cause “post-treatment anomie” in which the individual no longer has a sense of what is worthwhile or valuable. Many eventually revert to prior values or seek a new identity. The author then discusses minority-run and staffed treatment programs which do not necessarily produce better treatment outcomes but do attract more minority clients. While Westermayer is adept at describing the complex transition phase which recovering people experience, he neglects to mention the resource of A.A. as a role-model for regaining a value system. Discussion of this would lead to much needed literature addressing the negative perceptions minority groups have of A.A. “Causal Attribution of Drinking Antecedents in American Indian and Caucasian Social Drinkers” by Deborah J. Jones-Saumty, MS, Ralph L. Dru, MD, and Arthur R. Zeiner, PhD compares the testing results of 65 American Indian and 100 Caucasian college students. The sample students were identified as having had no previous alcohol-related problems and were matched for age, education, and drinking history. They were tested with Linda Beckman’s rating scale for beliefs about the causes of alcohol-related problems Beckman’s study (limited to women) concluded that non-alcoholic women favored internal causation (that is, the alcoholic is responsible for the drinking) over external factors. The aim of this study was to replicate Beckman’s work and extend it by adding American Indian college students as the Indian populations is at higher risk for developing alcoholism than the Caucasian. The students were asked to prioritize the importance of seven causal factors: other people, distressing event, environment, heredity, self, illness/disease, and fate. In order to replicate Beckman’s work, two of the experimental groups were female Indians and female Caucasians. Results showed that both Indian and Caucasian subjects accounted for problem drinking as being related to the individual more than external events, which reinforced Beckman’s study. The Indian social drinker sample rated alcoholism as an illness/disease more frequently than the Caucasian. The remainder of the discussion portion of the study addresses the similarities, differences and implications of the study, but an evaluation of the weaknesses of the research is missing. The next research, “Influence of Family and

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Religion on Long-term Outcomes Among Opioid Addicts” by John J. Hater, PhD, B. Krisna Singh, PhD, and D. Dwayne Simpson, PhD, used a large sample (1,174 opioid addicts) who had received treatment 6 years earlier. Family support and cohesion and adherence to religious values are seen as being related to absent or decreased use of illicit drugs. The researchers believe that these researchers are not frequently addressed in outcome studies. Family resource variables were marriage, positive psychological support by the family, family contact, and free time spent with the family. Disturbance variables were high family conflict and broken homes. Religion variables were attendance at religious services during childhood, membership in organized religion, frequent attendance at religious events as adults, and self-reported religious commitment. This paper provides a significant and concise description of the sample prior to admission to treatment and details the type of treatment received. The follow-up interview focused on employment, drug-use and criminality and included background information on family and religion. These behaviors were recorded retrospectively on a month-by-month basis from the time of termination of formal treatment to the follow-up. While the original hypothesis tended to be supported, the authors, in the discussion section of this research, provided a thorough and admirable critique of their work and offer suggestions for further study. Attention to reliability and validity testing, adequate sample size, and evaluation of data makes this a more thoroughly prepared research report than the JonesSaumty paper. Two topics of current research attention are addressed in “Women, Alcohol, and Sexuality” by Stephanie S. Covington, PhD and Janet Kohen, PhD. The authors suggest that increased use of alcohol and frequency of sexual activity “often bring respect for the man but distain for the woman.” (p. 42) While both increased drinking and increased sexual activity societal disapproval for women than men, the two behaviors are interrelated. Intoxicated women are frequently viewed as “promiscuous.” While studies have reported women’s subjective belief of increased sexual enjoyment when drinking, the physiological research refutes this. If drinking and sex are associated, there may be an expectation of heightened response when drinking that the woman interprets as enjoyable even though there has been difficulty in attaining orgasm. There is also a relationship between abuse and sexual difficulties. This study paired 35 alcoholic women with 35 nonalcoholic women counterparts by age, education, marital status, and religious background. Profiles of the “typical” sample women are provided. All respondents were asked whether they had engaged in

132 any of seven different sexual activities. This study showed that the alcoholic women reported a greater variety of sexual activities but they did not report higher frequency of sex with a partner. The women were then questioned about sexual dysfunction and these reports were markedly higher in the alcoholic women. Any instances of abuse during the women’s lifetime were reported and described as either physical or sexual. Data concerning age of occurrence, relationship of the perpetrator, frequency and duration of the abusive relationship were obtained. More alcoholic than nonalcoholic women reported abuse, but this was significantly different for sexual abuse, not physical abuse. The-authors acknowledge that their sample size is small, but do suggest implications for treatment settings. Their interesting writing style and this writer’s bias make it easy to overlook insufficient evaluation and treatment provider criticisms rather than suggestions. While the criticisms of ineffective treatment of alcoholic women’s sexual and abuse issues are undoubtedly valid, it would have been helpful to include guidelines for gathering data, incorporating information into treatment programs, and providing therapy. As the authors acknowledge, more research is needed. The final article, “Sex-Role Values and Bias in Alcohol Treatment Personnel” by Marsha Varmicelli, PhD and Gayle Hamilton, PhD, may not give generalizable information but, for any clinician, it is thought-provoking. The authors conducted a two day workshop with 45 staff members from various treatment agencies in Nebraska. It should be noted that 36 members of this group were female. Some of the group members, through role-playing, became surrogate clients. The authors believed that the staff members’sex-role stereotypes of “manliness” and “womanliness” would be transmitted to clients. This posed significant problems for the female alcoholic with a “man’s” disease. The four phases of clinical practice which could be affected by sex-role bias were identified as: 1) client comfort 2) therapist’s perception of the importance of the client’s problems in view of sex, presenting problems, and “sex-appropriate” nature of the problems, 3) reflection of this information in the treatment plan and 4) the therapist’s prognosis for the client. Following testing concerning values, the staff member group was subdivided and grouping was determined by shared important values. Each individual and then each group made up lists of “typical” male and female problems found in alcoholic clients. The top three male problems were job, legal, and family pressure while the top three female problems were child care, financial, and no family support. The surrogate clients were then assigned either “sex-appropriate” or non “sex-appropriate” problems. The groups became “treatment teams” and made clinical assessments and treatment

Book Reviews plans. In the discussion section of this article, the authors suggest that clients will be more comfortable in a treatment program that they perceive to hold similar values to their own. Clinicians, particularly female, tended to give the female alcoholic a poorer prognosis and rated sex-appropriate problems as more important than non sex-appropriate. The stereotypes of male and female expected behavior therefore influence the clinician’s view of the client. Perhaps most significant of all the data gathered was the absence of “job” as an important problem for women, even though the majority of this study group was made up of working women. Since the data gathered by the authors uses a small, disproportionate sample yet raises uncomfortable issues by being directed at clinicians, it would be extremely valuable to seek replication of this work in a more experimentally controlled group. Pages 69 through 84 of this book contain a reference list for the articles. Again, in a journal this is perfectly acceptable, but, in hardcover form, it is simply padding. While the book clearly states that it has also been published as a journal, I can’t help but feel deceived. The articles are readable and provide interesting data for all clinicians working with substance abusers, but the price is disproportionate for the amount of information offered. Jane Henderickson R.N. H. Ed. C. A. C Administrator and Clinical Director Ripley Alcohol Rehabilitaton Center Brattleboro, Vermont

Handbook of Overdose and Detoxification Emergencies A. James Giannini, M.D., Andrew E. Slaby, M.D., Matthew C. Giannini, M.D. Medical Examination Publishing Company New Hyde Park, New York $16.95, 170 pp. The “Handbook of Overdose and Detoxification Emergencies” is another in a long line of “handbooks” that proport to be unique, helpful or geared to a particular problem. In general, “handbooks” are neither comprehensive, accurate or truly written with the professional in mind. There are exceptions to this, such as “The Hand, Examination and Diagnosis” which is produced by the American Society for Surgery of the Hand. Unfortunately, “Handbook of Overdose and Detoxification Emergencies” is not an exception and is, in my view, potentially a source of inaccurate and incomplete information. In their preface, the authors state that the emphasis is on “medical intervention” and that the book should “be of use to all professionals involved with drug abuse: aids, counselors, corpsmen, nurses, psycho-