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Treating alcohol problems—Marital and family interventions
Book Reviews
965
T. M. SKOVHOLT and M. H. RONNESTAD: The Evolving Professional Self--Stages and Themes in Therapist and Counsellor Development. Wiley, Chichester (1995). xii + 221 pp. £16.95. Scholarly and well researched, this book, according to the authors, was at least five years in the making. It is a very good example in stating the case for qualitative research and the authors are fully aware of the limitations imposed by the methodology in practice. They know that one of the criticisms levelled against them could be that they chose to generalise from a cross-sectional study when a longitudinal approach would have been more appropriate. Broadly explanatory theories of development and a historical life-span orientation, as well as more specific theories of counsellor/therapist development, are reviewed in the first chapter. Chapters 2-9 develop the eight stages which the authors postulate as developmental stages of transition that all successful counsellors and therapists undergo in their professional life. Not negotiating the transitions successfully can lead to stagnation or pseudo-development, and a possible exit through premature closure from the therapist/counsellor role, at any of these crisis points. The authors, in their extensive research which forms the background to this book, identified 20 themes grouped under the headings: 1. Primary characteristics, 2. Process descriptors, 3. Sources of influence, and 4. Secondary characteristics. Evidence for these themes are provided through marginal comments over edited interviews with three Senior Informants presented in Appendix B. Empirical, laboratory research is unlikely to yield concepts like "'an older wiser person" (p. 91), simply because they cannot be operationalised. What this book shows quite emphatically is that counselling and therapy are intensely personal pursuits almost unique to the individual practising these ~arts'. The present day successful practitioner is no different from the archetypical shaman or the 'wise old man/woman'. At the Integrity Stage, the final stage according to the authors, the individuated therapist/counsellor draws little from "empirical studies in the behavioural sciences". Instead, he/she "'readily talks about understanding human behaviour through anthropology, literature, novels, poetry, religion, and similar fields" (p. 90). This is not science in the generally accepted sense of the term. Convservely, those therapists/counsellors who are likely to fall by the wayside report '~a lack of positive client response to the therapist/counsellor's use of a major theoretical approach that the therapist/counsellor had worked hard to m a s t e r . . . " (p. 118). Symptom removal, therefore, may not be enough. Clients seek an encounter with an authentic individual who has made sense of his or her own life and expect a range of services from "such diverse areas as reducing anxiety" to "struggling with meaning and purpose in one's life" (p. 1). It would be interesting to see if and how this book is likely to influence the selection, training and development of new entrants to the profession of therapist/counsellor or, equally likely, whether it would be ignored as irrelevant to the scientific study of a vaguely understood and still mysterious area of human activity. MIGEL JAYASINGHE
MICHAEL J. SCOTT, STEPHEN G. STRADLING and W. DRYDEN: Developing Cognitive-Behavioural Counselling. Sage Publications, London (1995). ix + 141 pp. £9.95 paperback; £19.95 hardback. This book is part of a series entitled "Developing Counselling" published by Sage and edited by Windy Dryden. The series provides counsellors and counselling trainees with short, practical guides on the problems they come across in the counselling process. In this volume the authors take the principles of the cognitive-behavioural therapy originally developed by Beck and Ellis to develop a useful approach in the counselling of clients with depression and anxiety. By looking at the limitations of the standard brief cognitive-behavioural counselling of many common problems, the authors suggest that an effective therapeutic intervention should consider early maladaptive interpretations (EMIs) and the presence of personality disorders. A guideline for assessment and treatment of major disorders is given with case examples to illustrate the appplication of cognitive-behavioural counselling in the therapeutic context. The limitation of this book is that, with so many topics to cover, some disorders such as social phobia and the avoidant personality are only briefly discussed and insufficient information about counselling of these problems is provided. Besides, management of personality disordered patients is well detailed in depression but not in the anxiety disorders. That said, the book does achieve its aims with respect to helping counsellors to think how their work can be refined with a cognitive-behavioural approach. It is a useful guide to clinical psychologists in training and other mental health professionals. L1GIA M. ITO
M. B. SOBELL and L. C. SOBELL: Problem-Drinkers--Guided Self-Change Treatment. Guilford Press, New York (1993). 206 pp. $24.25. T. J. O'FARRELL (Ed.): Treating Alcohol Problems--Marital and Family Interventions. Guilford Press, New York (1993). 446 pp. $36.95. After first reading these books I drafted a review, but before sending my comments to the editor, I began having second thoughts about what 1 had written. I was nagged by the feeling that I had neglected to mention something important.
966
Book Reviews
First, I will summarize my initial impressions. These are extremely practical and incisive works, addressing treatment issues that are among the most common and important in the field. The Sobells focus on assisting problem drinkers--people who tend to have fewer problems and greater resources than the more numerous population of dependent drinkers. The intervention that they describe is a marvel of economy, involving two sessions of motivational enhancement coupled with aspects of familiar behaviour therapy. Both the content and process of this approach are abundantly described. Moreover, the text is extremely user friendly. Assessment materials, readings for clients, and homework exercises, are all presented and are reproducible for use in clinical practice. For his part, O'Farrell has taken the most demonstrably effective family interventions and presents them in a tightly integrated volume. Chapters representing various theoretical perspectives are divided into sections corresponding to the major stages of treatment: initiation of change (e.g. confrontation); stabilization of drinking; and maintenance of change. The chapters are brief, yet rich in strategies, interpretations, and research relevant to clinical practice. These volumes represent the state of the art in their respective areas of practice, and for clinicians working with alcohol problems and family therapy, they are essential reading. However, as noted above, 1 was struck by a greater significance to these works, which became apparent to me against the backdrop of developments in the alcohol field. Empirical advances in the treatment of substance use disorders have been very hard won. Research findings have often been challenged in a way that goes beyond healthy scholarly debate. Vested theoretical interests and economic concerns have had a conspicuous influence on the emergence of treatment models. Explaining these events calls more on the philosophy of science than the science of psychology. Even those who aspire to remain above the fray have had a portion of their energies diverted by less productive conflicts. Few people are in a position to appreciate this more than the Sobells. Yet in reading their book, and O'Farrell's edited volume, it was gratifying to note that the empirical foundation of these works speaks for itself, with persuasive significance for practice. These are important books. In their style, content, and tone, they signal the emergence of a mature, scientifically informed approach to the treatment of alcohol problems. It remains to be seen whether we have arrived at a point where beliefs will yield to research in the alcohol field. However, these books illustrate what we have to gain by doing so. J. SOMERS
I. PARKER, E. GEORGACA, D. HARPER, T. McLAUGHLIN and M. STOWELL-SMITH: Deconstructing Psychopathology. Sage Publications, London (1995). viii + 167 pp. £11.95. Although there has been a good deal of critical writing on various aspects of 'psychopathology' in the last few years, this is the first textbook which, as the title implies, attempts a general deconstruction of the area. The authors therefore faced a formidable task not only in setting out the complex theoretical frameworks necessary for this task, but also in covering a wide enough area to show their general applicability and relevance. Perhaps surprisingly, then, the book is quite short--136 pages of text--but into this the authors have put a prodigious amount of information and ideas. The book draws extensively on the ideas of Michel Foucault and Jacques Derrida in order to establish the centrality of language and meaning to the theoretical and clinical practices of psychopathology (a term used to refer to the subject matter of both clinical psychology and psychiatry). The main premises are that, far from discovering and cataloguing mental disorders which exist "out there'--'carving nature at the joints'--psychologists and psychiatrists construct psychopathology using a language surrounded by assumptions and values which are rarely made explicit or subjected to critical scrutiny. Challenging this language is not simply a matter of semantics: the authors show that the language is central to the maintenance, and seeming reasonableness, of clinical, professional and social practices whose benefit to patients and clients is highly questionable. The book does not adopt a conspiracy theory of psychological and psychiatric practice but argues that psychiatric institutions operate as power structures regardless of the individual intentions of their 'members'. These themes are developed in eight chapters which provide some basic theoretical ideas and post-structuralist histories of'abnormality'; a critical evaluation of alternatives to traditional, medical accounts of abnormality (e.g. Laing; Szasz; family therapy; cognitive therapy); discussion of the challenge to diagnostic categories of the issues of gender, race and class; discussion of the interaction of lay and professional representations of madness; a deconstruction of the concept of psychopathy; and analysis of "thought disorder'; a description and evaluation of some radical responses to psychiatric practice; and, finally an attempt to anticipate and answer some of the criticisms which the authors think might be made about the book. This is not a list of chapter headings and does not really do justice to the contents. For example, the chapters on psychopathy and thought disorder use these areas as exemplars in order to illustrate larger themes on the crucial role of language in constructing psychiatric categories and identities. Throughout the book, the authors emphasise the interdependence of language, knowledge and power, and the importance of focusing on the professionals themselves as well as on those who are the usual subjects of our theories and practices. Given the scope of the task and the relative brevity of the book, the authors succeed very well indeed in conveying both the scale of the problem they are 'addressing and the importance of an analysis in which langauge is central. One of the strengths of this book is the wealth of material and analysis contained in each chapter. The fact that it is highly compressed might make it less accessible to readers who are not familiar with post-structuralist ideas, but it is extensivly referenced and is the sort of book which repays more than one reading. For those with an interest in behaviour therapy, the book may appear to have little to offer; indeed, the authors give short shrift to behaviourism, which is described as h a v i n g . . . "'a view of distress which treats individuals and which operates on a strict dinstinction between what is normal and abnormal, between what is appropriate behaviour and what i s . . . ~maladaptive behaviour' "" (p. 27). Behavioural therapies are described as having been crude, mechanistic, and sometimes punitive (p. 33). The authors here seem to conflate the study of individuals, fostered by behaviourism, with individualism, to which Skinner at least was implacably opposed. In spite of this, and the book's apparent dismissal of behavioural
965
T. M. SKOVHOLT and M. H. RONNESTAD: The Evolving Professional Self--Stages and Themes in Therapist and Counsellor Development. Wiley, Chichester (1995). xii + 221 pp. £16.95. Scholarly and well researched, this book, according to the authors, was at least five years in the making. It is a very good example in stating the case for qualitative research and the authors are fully aware of the limitations imposed by the methodology in practice. They know that one of the criticisms levelled against them could be that they chose to generalise from a cross-sectional study when a longitudinal approach would have been more appropriate. Broadly explanatory theories of development and a historical life-span orientation, as well as more specific theories of counsellor/therapist development, are reviewed in the first chapter. Chapters 2-9 develop the eight stages which the authors postulate as developmental stages of transition that all successful counsellors and therapists undergo in their professional life. Not negotiating the transitions successfully can lead to stagnation or pseudo-development, and a possible exit through premature closure from the therapist/counsellor role, at any of these crisis points. The authors, in their extensive research which forms the background to this book, identified 20 themes grouped under the headings: 1. Primary characteristics, 2. Process descriptors, 3. Sources of influence, and 4. Secondary characteristics. Evidence for these themes are provided through marginal comments over edited interviews with three Senior Informants presented in Appendix B. Empirical, laboratory research is unlikely to yield concepts like "'an older wiser person" (p. 91), simply because they cannot be operationalised. What this book shows quite emphatically is that counselling and therapy are intensely personal pursuits almost unique to the individual practising these ~arts'. The present day successful practitioner is no different from the archetypical shaman or the 'wise old man/woman'. At the Integrity Stage, the final stage according to the authors, the individuated therapist/counsellor draws little from "empirical studies in the behavioural sciences". Instead, he/she "'readily talks about understanding human behaviour through anthropology, literature, novels, poetry, religion, and similar fields" (p. 90). This is not science in the generally accepted sense of the term. Convservely, those therapists/counsellors who are likely to fall by the wayside report '~a lack of positive client response to the therapist/counsellor's use of a major theoretical approach that the therapist/counsellor had worked hard to m a s t e r . . . " (p. 118). Symptom removal, therefore, may not be enough. Clients seek an encounter with an authentic individual who has made sense of his or her own life and expect a range of services from "such diverse areas as reducing anxiety" to "struggling with meaning and purpose in one's life" (p. 1). It would be interesting to see if and how this book is likely to influence the selection, training and development of new entrants to the profession of therapist/counsellor or, equally likely, whether it would be ignored as irrelevant to the scientific study of a vaguely understood and still mysterious area of human activity. MIGEL JAYASINGHE
MICHAEL J. SCOTT, STEPHEN G. STRADLING and W. DRYDEN: Developing Cognitive-Behavioural Counselling. Sage Publications, London (1995). ix + 141 pp. £9.95 paperback; £19.95 hardback. This book is part of a series entitled "Developing Counselling" published by Sage and edited by Windy Dryden. The series provides counsellors and counselling trainees with short, practical guides on the problems they come across in the counselling process. In this volume the authors take the principles of the cognitive-behavioural therapy originally developed by Beck and Ellis to develop a useful approach in the counselling of clients with depression and anxiety. By looking at the limitations of the standard brief cognitive-behavioural counselling of many common problems, the authors suggest that an effective therapeutic intervention should consider early maladaptive interpretations (EMIs) and the presence of personality disorders. A guideline for assessment and treatment of major disorders is given with case examples to illustrate the appplication of cognitive-behavioural counselling in the therapeutic context. The limitation of this book is that, with so many topics to cover, some disorders such as social phobia and the avoidant personality are only briefly discussed and insufficient information about counselling of these problems is provided. Besides, management of personality disordered patients is well detailed in depression but not in the anxiety disorders. That said, the book does achieve its aims with respect to helping counsellors to think how their work can be refined with a cognitive-behavioural approach. It is a useful guide to clinical psychologists in training and other mental health professionals. L1GIA M. ITO
M. B. SOBELL and L. C. SOBELL: Problem-Drinkers--Guided Self-Change Treatment. Guilford Press, New York (1993). 206 pp. $24.25. T. J. O'FARRELL (Ed.): Treating Alcohol Problems--Marital and Family Interventions. Guilford Press, New York (1993). 446 pp. $36.95. After first reading these books I drafted a review, but before sending my comments to the editor, I began having second thoughts about what 1 had written. I was nagged by the feeling that I had neglected to mention something important.
966
Book Reviews
First, I will summarize my initial impressions. These are extremely practical and incisive works, addressing treatment issues that are among the most common and important in the field. The Sobells focus on assisting problem drinkers--people who tend to have fewer problems and greater resources than the more numerous population of dependent drinkers. The intervention that they describe is a marvel of economy, involving two sessions of motivational enhancement coupled with aspects of familiar behaviour therapy. Both the content and process of this approach are abundantly described. Moreover, the text is extremely user friendly. Assessment materials, readings for clients, and homework exercises, are all presented and are reproducible for use in clinical practice. For his part, O'Farrell has taken the most demonstrably effective family interventions and presents them in a tightly integrated volume. Chapters representing various theoretical perspectives are divided into sections corresponding to the major stages of treatment: initiation of change (e.g. confrontation); stabilization of drinking; and maintenance of change. The chapters are brief, yet rich in strategies, interpretations, and research relevant to clinical practice. These volumes represent the state of the art in their respective areas of practice, and for clinicians working with alcohol problems and family therapy, they are essential reading. However, as noted above, 1 was struck by a greater significance to these works, which became apparent to me against the backdrop of developments in the alcohol field. Empirical advances in the treatment of substance use disorders have been very hard won. Research findings have often been challenged in a way that goes beyond healthy scholarly debate. Vested theoretical interests and economic concerns have had a conspicuous influence on the emergence of treatment models. Explaining these events calls more on the philosophy of science than the science of psychology. Even those who aspire to remain above the fray have had a portion of their energies diverted by less productive conflicts. Few people are in a position to appreciate this more than the Sobells. Yet in reading their book, and O'Farrell's edited volume, it was gratifying to note that the empirical foundation of these works speaks for itself, with persuasive significance for practice. These are important books. In their style, content, and tone, they signal the emergence of a mature, scientifically informed approach to the treatment of alcohol problems. It remains to be seen whether we have arrived at a point where beliefs will yield to research in the alcohol field. However, these books illustrate what we have to gain by doing so. J. SOMERS
I. PARKER, E. GEORGACA, D. HARPER, T. McLAUGHLIN and M. STOWELL-SMITH: Deconstructing Psychopathology. Sage Publications, London (1995). viii + 167 pp. £11.95. Although there has been a good deal of critical writing on various aspects of 'psychopathology' in the last few years, this is the first textbook which, as the title implies, attempts a general deconstruction of the area. The authors therefore faced a formidable task not only in setting out the complex theoretical frameworks necessary for this task, but also in covering a wide enough area to show their general applicability and relevance. Perhaps surprisingly, then, the book is quite short--136 pages of text--but into this the authors have put a prodigious amount of information and ideas. The book draws extensively on the ideas of Michel Foucault and Jacques Derrida in order to establish the centrality of language and meaning to the theoretical and clinical practices of psychopathology (a term used to refer to the subject matter of both clinical psychology and psychiatry). The main premises are that, far from discovering and cataloguing mental disorders which exist "out there'--'carving nature at the joints'--psychologists and psychiatrists construct psychopathology using a language surrounded by assumptions and values which are rarely made explicit or subjected to critical scrutiny. Challenging this language is not simply a matter of semantics: the authors show that the language is central to the maintenance, and seeming reasonableness, of clinical, professional and social practices whose benefit to patients and clients is highly questionable. The book does not adopt a conspiracy theory of psychological and psychiatric practice but argues that psychiatric institutions operate as power structures regardless of the individual intentions of their 'members'. These themes are developed in eight chapters which provide some basic theoretical ideas and post-structuralist histories of'abnormality'; a critical evaluation of alternatives to traditional, medical accounts of abnormality (e.g. Laing; Szasz; family therapy; cognitive therapy); discussion of the challenge to diagnostic categories of the issues of gender, race and class; discussion of the interaction of lay and professional representations of madness; a deconstruction of the concept of psychopathy; and analysis of "thought disorder'; a description and evaluation of some radical responses to psychiatric practice; and, finally an attempt to anticipate and answer some of the criticisms which the authors think might be made about the book. This is not a list of chapter headings and does not really do justice to the contents. For example, the chapters on psychopathy and thought disorder use these areas as exemplars in order to illustrate larger themes on the crucial role of language in constructing psychiatric categories and identities. Throughout the book, the authors emphasise the interdependence of language, knowledge and power, and the importance of focusing on the professionals themselves as well as on those who are the usual subjects of our theories and practices. Given the scope of the task and the relative brevity of the book, the authors succeed very well indeed in conveying both the scale of the problem they are 'addressing and the importance of an analysis in which langauge is central. One of the strengths of this book is the wealth of material and analysis contained in each chapter. The fact that it is highly compressed might make it less accessible to readers who are not familiar with post-structuralist ideas, but it is extensivly referenced and is the sort of book which repays more than one reading. For those with an interest in behaviour therapy, the book may appear to have little to offer; indeed, the authors give short shrift to behaviourism, which is described as h a v i n g . . . "'a view of distress which treats individuals and which operates on a strict dinstinction between what is normal and abnormal, between what is appropriate behaviour and what i s . . . ~maladaptive behaviour' "" (p. 27). Behavioural therapies are described as having been crude, mechanistic, and sometimes punitive (p. 33). The authors here seem to conflate the study of individuals, fostered by behaviourism, with individualism, to which Skinner at least was implacably opposed. In spite of this, and the book's apparent dismissal of behavioural