- Email: [email protected]
Recovering from addiction: Guided steps through the healing process
326
of arrest or being hurt, the dealers are nonetheless wellinformed about the chances they take, and in what proportions, They are, in the authors’ words, making an “informed” choice of supplemental occupation. This is all the more disconcerting, since an overwhelming percentage of those interviewed held drug dealers in the lowest regard. Comparing RAND’s data to those of a recent Urban Institute study on older adolescents, one finds that the percentages of dealing, and the prevalence of using among dealers, have advanced dramatically in just a few years’ time. In other words, the adolescents shying away from drug use (at least, so they report) shift quickly to adult drug abusers as they slide into their age majority. Like most RAND studies, this one is carried out with intelligent forethought, and executed thoroughly. The techniques and the data for the analyses are described in sufficient detail that specialists probably can retest them, form new hypotheses, or argue about their validity. On the other hand, Money from Crime really belongs to a very narrow readership. While it is true that Peter Reuter and colleagues picked a “hot” topic, and that some popular media are quite likely to pick up and publicize the results, the text is very closely written. I suspect that few will read it cover to cover, and fewer still understand the monograph. In fact, RAND publications generally are intended for a narrow, scholarly audience, making few, if any concessions to the general student of the field. Such is surely the case here. I looked in vain for policy recommendations of any depth. There are very few of them here, and the authors’ view is clearly that research proceeds by modest increments, and broad generalization is not warranted. I did think that the notion that there may be a critical period in late adolescence (for Black males in Washington, DC, at any rate) when educational or other interventions might be most effective is intriguing. More than that, it seemed quite clear that the authors are extremely skeptical of “workfare” programs for drug abusers, since the risks of dealing are high, but the gains potentially an order of magnitude greater than that available through legitimate employment among the poor. I was struck by the spectacular inattention on the part of the authors to the possible interactions of drug treatment programs with the economics of drug use and dealing. In vain did I search the entire text for a singular reference on the subject, much less a reasonable discussion, even for purposes of dismissing the idea. Years ago, when Jerome Jaffe was the first White House drug “czar”, he was said to have remarked that the cops and the dots met only in his office to talk about policy, that the twain had no contact at any other level. Is this still the case? Disconcerting and sad, if true.
Journal of Substance Abuse Treatment Marc Hertzman, MD Department of Psychiatry and Behavioral Sciences The George Washington University Medical Center Washington, DC
Recovering from Addiction: the Healing Process
Guided Steps Through
James R. Baugh, Ph.D. New York: Plenum Press, 1990, $22.95, 298 pages. At one time, the term “addiction” was used primarily to refer to the state of physical dependence on a chemical substance. Removal of the substance resulted in physical withdrawal symptoms. In recent years, the term addiction has been used to describe a myriad of behaviors such as compulsive overeating, substance abuse, sexual impulsivity, compulsive gambling, and excessive need for affection. It is in this vein that Recovering from Addiction deals with maladaptive behavior. Following a brief introduction in which this general definition of addiction is explained, the book goes on to describe the various psychological processes which characterize addictive behavior and the individuals afflicted with such problems. Chapter 1 describes the profile of “victims,” noting that addicts are often characterized by themselves or others as victims. The person recovering from addiction must, as a victim, confront his or her fears of loss, repetitive crises, feelings of powerlessness over addiction, and discover different means of escape from crises, other than addictive behavior. Chapter 2 focuses on the ways in which one can go about making a change in personal circumstances by first acknowledging that one is powerless to avoid or escape losses and defeat in life, and that grief and mourning are important parts of any recovery process. Chapter 3 is a fairly complex outline (for a self-help guide) of levels of functioning. Dr. Baugh describes how one must first understand what motivates his or her behavior before one can ever hope to exert any control in life. This third chapter provides a number of diagrams and tables for helping the reader to code and clarify their motivational style and level of psychological maturity. Chapter 4 addresses conflict in a variety of life experiences. Explicitly discussed are conflicts pertaining to loss, relationships, and victim responses to loss and conflict. Chapter 5 discusses the way in which addicts can regain a healthier and more adaptive sense of self through a greater understanding of one’s own values and through examining one’s self-worth. Chapter 6 addresses issues involved in finding and developing a relationship with a personal caretaker (e.g., trust in others, assuming personal responsibility, etc.), while Chapter 7 explores the process of maturation and the role of spirituality in recovery. The final chapter provides a series of case
Book
Reviews
327
examples of individuals who have struggled with various forms of addiction. In keeping with the focus of this book, the cases reflect many different types of addictions, including alcohol and -drug abuse, compulsive sexual behavior, “relationship addiction,” anorexia/ bulimia, and compulsive dishonesty. Finally, a number of appendixes are provided, including an outline of AA’s twelve step program, various personal and group exercises which can be used to apply principles from each chapter, and a directory of self-help resources from around the world. Overall, the major strength and attraction this book offers is that it works with a broad definition of addiction, it is styled as a self-help guide, and thus the insights offered among the pages can potentially be of use to a wide variety of individuals. However, the absence of a clear organizational flow and the disjointed manner in which the sections of this book are presented make for a lack of continuity and cohesiveness between various sections of the book. For one, though this book is said to provide guided steps through the twelve step process, it is never made explicitly clear to the reader as to which step of the recovery process particular chapters or sections apply. In addition, several of the tables and graphs are somewhat cumbersome for a lay audience and are likely to turn away many of the readers for whom this volume was written, namely those people recovering from addition. Although Recovering from Addiction is written and packaged as a self-help guide through the well-recognized, twelve step recovery program, it is apt to leave many lay readers frustrated with having to pull out relevant material. Instead, the book may serve as a reference for counselors and clinicians, particularly those who lead educational or didactic groups. Some of the material and exercises might be adapted for use in portions of structured treatment programs. Sections of the book may also provide useful handouts for patients and clients as well. On the whole, however, this book falls short as a self-help guide that could be prescribed for recovering addicts. Joseph T. McCann, Psy.D. Erie County Medical Center School of Medicine and Biomedical Sciences State University of New York at Buffalo
Preventing Relapse in the Addictions: psychosociai Approach
A Bio-
Emil J. Chiauzzi Elmsford, New York: Pergamon Press, 1991. 160 pages. This is a thoughtful and refreshingly pragmatic manual on a topic which has been largely, and to this reviewer, regrettably, overlooked in the addictions literature.
This text seems destined to become a standard reference manual on the subject. Chiauzzi articulates the biopsychosocial model of relapse prevention, while neatly sidestepping the controversy related to whether or not addictive behavior should be considered a disease. He contends that while most models of relapse incorporate biological, psychological, and social components to some degree, actively assessing patients’ risk factors in each domain increases clinician effectiveness. Furthermore, Chiauzzi shows that patients are highly variable in their vulnerability to risk factors, as some may be biologically predisposed to an addiction, while others may be more sensitive to psychological or social factors. He also maintains that the three domains are interactive, rather than separate and discrete factors (e.g., expectations and perceptions often affect drinking related behaviors). The strength of this work is in Chapters 4, 5, and 6, titled Biopsychosocial Factors in Relapse, Assessment of Relapse Potential, and Relapse Prevention Techniques, respectively. In the section on biopsychosocial risk factors (Chapter 4), he meticulously reviews addictions literature, including research studies that inform a thorough understanding of biological, psychological, and social risk factors. The biological perspective includes family history and severity, neurological and neuropsychological impairments, cue reactivity, and biochemical deficiencies. The section on psychological risks examines expectancies, coping skills, and psychopathology, while social risk factors involve life events, socioeconomic status, and family, employment, and residential stability. Chapter 5 (Assessment of Relapse Potential) recommends taking a detailed family, personal, treatment, and relapse history in order to carefully review the risk factors listed above. The author offers strategies and methods to assist clinicians in examining their client’s cognitive processes, behavior, and social skills as they relate to relapse risk. Although this section is comprehensive and thorough, with lists and tables of cues or triggers, sample questions, and diagnostic indicators, I found his reliance on formal testing instruments to be distracting. Many of these scales and inventories are surely useful, but I think only a few practitioners would have the resources to rely on more than the clinical interview as their primary assessment technique. Chiauzzi’s presentation of Relapse Prevention Techniques neatly follows the previous chapters. He advises clinicians to repeat interventions, and to speak concretely and specifically, rather than offering abstract and general suggestions. This is especially important for clients who may experience some cognitive impairment in early stages of recovery. He reviews some problem solving techniques and applies them as coping skills to be taught for use in high risk situations. He offers specific responses for a multitude of problems and behaviors that are familiar to almost any
of arrest or being hurt, the dealers are nonetheless wellinformed about the chances they take, and in what proportions, They are, in the authors’ words, making an “informed” choice of supplemental occupation. This is all the more disconcerting, since an overwhelming percentage of those interviewed held drug dealers in the lowest regard. Comparing RAND’s data to those of a recent Urban Institute study on older adolescents, one finds that the percentages of dealing, and the prevalence of using among dealers, have advanced dramatically in just a few years’ time. In other words, the adolescents shying away from drug use (at least, so they report) shift quickly to adult drug abusers as they slide into their age majority. Like most RAND studies, this one is carried out with intelligent forethought, and executed thoroughly. The techniques and the data for the analyses are described in sufficient detail that specialists probably can retest them, form new hypotheses, or argue about their validity. On the other hand, Money from Crime really belongs to a very narrow readership. While it is true that Peter Reuter and colleagues picked a “hot” topic, and that some popular media are quite likely to pick up and publicize the results, the text is very closely written. I suspect that few will read it cover to cover, and fewer still understand the monograph. In fact, RAND publications generally are intended for a narrow, scholarly audience, making few, if any concessions to the general student of the field. Such is surely the case here. I looked in vain for policy recommendations of any depth. There are very few of them here, and the authors’ view is clearly that research proceeds by modest increments, and broad generalization is not warranted. I did think that the notion that there may be a critical period in late adolescence (for Black males in Washington, DC, at any rate) when educational or other interventions might be most effective is intriguing. More than that, it seemed quite clear that the authors are extremely skeptical of “workfare” programs for drug abusers, since the risks of dealing are high, but the gains potentially an order of magnitude greater than that available through legitimate employment among the poor. I was struck by the spectacular inattention on the part of the authors to the possible interactions of drug treatment programs with the economics of drug use and dealing. In vain did I search the entire text for a singular reference on the subject, much less a reasonable discussion, even for purposes of dismissing the idea. Years ago, when Jerome Jaffe was the first White House drug “czar”, he was said to have remarked that the cops and the dots met only in his office to talk about policy, that the twain had no contact at any other level. Is this still the case? Disconcerting and sad, if true.
Journal of Substance Abuse Treatment Marc Hertzman, MD Department of Psychiatry and Behavioral Sciences The George Washington University Medical Center Washington, DC
Recovering from Addiction: the Healing Process
Guided Steps Through
James R. Baugh, Ph.D. New York: Plenum Press, 1990, $22.95, 298 pages. At one time, the term “addiction” was used primarily to refer to the state of physical dependence on a chemical substance. Removal of the substance resulted in physical withdrawal symptoms. In recent years, the term addiction has been used to describe a myriad of behaviors such as compulsive overeating, substance abuse, sexual impulsivity, compulsive gambling, and excessive need for affection. It is in this vein that Recovering from Addiction deals with maladaptive behavior. Following a brief introduction in which this general definition of addiction is explained, the book goes on to describe the various psychological processes which characterize addictive behavior and the individuals afflicted with such problems. Chapter 1 describes the profile of “victims,” noting that addicts are often characterized by themselves or others as victims. The person recovering from addiction must, as a victim, confront his or her fears of loss, repetitive crises, feelings of powerlessness over addiction, and discover different means of escape from crises, other than addictive behavior. Chapter 2 focuses on the ways in which one can go about making a change in personal circumstances by first acknowledging that one is powerless to avoid or escape losses and defeat in life, and that grief and mourning are important parts of any recovery process. Chapter 3 is a fairly complex outline (for a self-help guide) of levels of functioning. Dr. Baugh describes how one must first understand what motivates his or her behavior before one can ever hope to exert any control in life. This third chapter provides a number of diagrams and tables for helping the reader to code and clarify their motivational style and level of psychological maturity. Chapter 4 addresses conflict in a variety of life experiences. Explicitly discussed are conflicts pertaining to loss, relationships, and victim responses to loss and conflict. Chapter 5 discusses the way in which addicts can regain a healthier and more adaptive sense of self through a greater understanding of one’s own values and through examining one’s self-worth. Chapter 6 addresses issues involved in finding and developing a relationship with a personal caretaker (e.g., trust in others, assuming personal responsibility, etc.), while Chapter 7 explores the process of maturation and the role of spirituality in recovery. The final chapter provides a series of case
Book
Reviews
327
examples of individuals who have struggled with various forms of addiction. In keeping with the focus of this book, the cases reflect many different types of addictions, including alcohol and -drug abuse, compulsive sexual behavior, “relationship addiction,” anorexia/ bulimia, and compulsive dishonesty. Finally, a number of appendixes are provided, including an outline of AA’s twelve step program, various personal and group exercises which can be used to apply principles from each chapter, and a directory of self-help resources from around the world. Overall, the major strength and attraction this book offers is that it works with a broad definition of addiction, it is styled as a self-help guide, and thus the insights offered among the pages can potentially be of use to a wide variety of individuals. However, the absence of a clear organizational flow and the disjointed manner in which the sections of this book are presented make for a lack of continuity and cohesiveness between various sections of the book. For one, though this book is said to provide guided steps through the twelve step process, it is never made explicitly clear to the reader as to which step of the recovery process particular chapters or sections apply. In addition, several of the tables and graphs are somewhat cumbersome for a lay audience and are likely to turn away many of the readers for whom this volume was written, namely those people recovering from addition. Although Recovering from Addiction is written and packaged as a self-help guide through the well-recognized, twelve step recovery program, it is apt to leave many lay readers frustrated with having to pull out relevant material. Instead, the book may serve as a reference for counselors and clinicians, particularly those who lead educational or didactic groups. Some of the material and exercises might be adapted for use in portions of structured treatment programs. Sections of the book may also provide useful handouts for patients and clients as well. On the whole, however, this book falls short as a self-help guide that could be prescribed for recovering addicts. Joseph T. McCann, Psy.D. Erie County Medical Center School of Medicine and Biomedical Sciences State University of New York at Buffalo
Preventing Relapse in the Addictions: psychosociai Approach
A Bio-
Emil J. Chiauzzi Elmsford, New York: Pergamon Press, 1991. 160 pages. This is a thoughtful and refreshingly pragmatic manual on a topic which has been largely, and to this reviewer, regrettably, overlooked in the addictions literature.
This text seems destined to become a standard reference manual on the subject. Chiauzzi articulates the biopsychosocial model of relapse prevention, while neatly sidestepping the controversy related to whether or not addictive behavior should be considered a disease. He contends that while most models of relapse incorporate biological, psychological, and social components to some degree, actively assessing patients’ risk factors in each domain increases clinician effectiveness. Furthermore, Chiauzzi shows that patients are highly variable in their vulnerability to risk factors, as some may be biologically predisposed to an addiction, while others may be more sensitive to psychological or social factors. He also maintains that the three domains are interactive, rather than separate and discrete factors (e.g., expectations and perceptions often affect drinking related behaviors). The strength of this work is in Chapters 4, 5, and 6, titled Biopsychosocial Factors in Relapse, Assessment of Relapse Potential, and Relapse Prevention Techniques, respectively. In the section on biopsychosocial risk factors (Chapter 4), he meticulously reviews addictions literature, including research studies that inform a thorough understanding of biological, psychological, and social risk factors. The biological perspective includes family history and severity, neurological and neuropsychological impairments, cue reactivity, and biochemical deficiencies. The section on psychological risks examines expectancies, coping skills, and psychopathology, while social risk factors involve life events, socioeconomic status, and family, employment, and residential stability. Chapter 5 (Assessment of Relapse Potential) recommends taking a detailed family, personal, treatment, and relapse history in order to carefully review the risk factors listed above. The author offers strategies and methods to assist clinicians in examining their client’s cognitive processes, behavior, and social skills as they relate to relapse risk. Although this section is comprehensive and thorough, with lists and tables of cues or triggers, sample questions, and diagnostic indicators, I found his reliance on formal testing instruments to be distracting. Many of these scales and inventories are surely useful, but I think only a few practitioners would have the resources to rely on more than the clinical interview as their primary assessment technique. Chiauzzi’s presentation of Relapse Prevention Techniques neatly follows the previous chapters. He advises clinicians to repeat interventions, and to speak concretely and specifically, rather than offering abstract and general suggestions. This is especially important for clients who may experience some cognitive impairment in early stages of recovery. He reviews some problem solving techniques and applies them as coping skills to be taught for use in high risk situations. He offers specific responses for a multitude of problems and behaviors that are familiar to almost any