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Addiction Treatment: A Strengths Perspective

Article in Alcohol and Alcoholism · January 2004

DOI: 10.1093/alcalc/agh008 · Source: OAI

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Alcohol & Alcoholism Vol. 39, No. 1, pp. 70–73, 2004
available online at www.alcalc.oupjournals.org
BOOK REVIEWS
doi:10.1093/alcalc/agh007
Treatment Matching in Alcoholism. Edited by T. F. Babor and
F. K. Del Boca. International Research Monographs in the Addictions
(IRMA), Cambridge University Press, 2003, 275 pp., indexed, £55.
ISBN 0-521-65112-3. Hardback.
The sheer size of this US government-funded project is a well-known
fact. The book is dedicated to the 1726 research subjects, 159 research
personnel, 81 therapists, and the many others who were involved. It
is also widely recognized that Project Match set new standards
of methodology for alcoholism treatment research. The National Institute
on Alcohol Abuse and Alcoholism (NIAAA) made available protocols
for the three treatments, which are now being used around the world.
Despite the Project’s fame, for some in the alcoholism treatment
world its results are a mystery, misunderstood or myth-reported:
‘Project Match cost millions of dollars ($28 m according to this
book) but showed nothing — for example, it was too complex/subjects
were so over-selected that they all got better anyhow/the research
assessments were so lengthy they obliterated all between-group
differences’.
The 26 scientists in the research group elegantly set the record
straight in this monograph, bringing together data published in papers
in several journals over the past 7 years, as well as some previously
unpublished analyses.
The chief aim of MATCH was to discover which of three out-patient
treatments (individual not group-based) best helped prevent relapse in
which types of alcoholic patients: Motivational Enhancement Therapy
(MET), Cognitive Behavioural Therapy (CBT) and Twelve Step
Facilitation (TSF). TSF helped the client to link with Alcoholics
Anonymous and start attending meetings regularly, assisting the patient
to understand the principles of AA. Clients were randomly allocated to
one of the three treatments. Each therapist working on the project only
conducted his or her usual form of therapy.
Some subjects entered the study on discharge from in-patient treatment
(‘Aftercare’), the others as outpatients. More of those who entered at the
end of residential treatment sustained complete abstinence for the first 15
months than those entering the study in the outpatient arm (26.7 vs
13.8%). In both arms there was also a decrease in heavy drinking sessions,
as shown by average drinks per drinking day. In the Outpatient arm this
diminished from 15 to 3 drinks per drinking day.
Three out of the four ‘matching’ effects that emerged were in the
Outpatient arm.
1. The benefit of TSF compared to MET was strongest for those clients
who had little support in their community or family to help sustain
abstinence.
2. For clients who were ‘angry’ at the initial assessment, MET was
associated with better outcomes than either TSF or CBT (conversely,
it was less effective than either for clients who were low on anger).
3. At least in the first 9 months, TSF was superior to CBT for clients
who did not have concomitant psychiatric impairment.
4. Among Aftercare subjects, CBT was more effective than TSF for
clients with relatively low dependence, whereas TSF was more
effective in sustaining abstinence than CBT for clients having high
dependence.
AA attendance was associated, in all treatment groups, with more
abstinence.
Other chapters deal with precious MATCH byproducts. On the inter-
relation between outcome measures, we see that drinks per drinking
day better predicted absence of problems than per cent days abstinent.
However, the authors do not give a rate for those who managed to drink
occasionally and completely avoid adverse consequences of drinking
throughout the follow-up — the holy grail of ‘return to unproblematic
drinking’.
Another chapter deals with motivation, ‘the process of intentional
behaviour change’ and therapist variables. The authors speculate on why,
70
Alcohol & Alcoholism Vol. 39, No. 1 © Medical Council on Alcohol 2004; all rights reserved
even in this large study, more specific effects of these different treatments
did not emerge. Although some improvement could be explained by the
natural course of alcoholism, where periods of sobriety intervene
between periods of problematic drinking, the MATCH data suggest that
the quality of the relationship with the therapist, perhaps as much as the
therapy method, can also be important. As in some recent
cognitive therapy research, the client’s assessment of the working
alliance (not the therapist’s assessment!) predicted outcome: Project
Match found that certain ‘outlier’ therapists, more often than by chance,
had clients who did poorly. Although MATCH has given succour to
many that ‘treatment works’, it is important to be reminded that
treatment, wrongly conducted, could sometimes cause harm.
JONATHAN CHICK
doi:10.1093/alcalc/agh008
Addiction Treatment: A Strengths Perspective. By Katherine van
Vormer and Diane Rae Davis. Thomson Brooks/Cole, Pacific Grove,
CA, USA. 2003, 436 pp., £25.99. ISBN 0-534-59670-3.
This book is written by two US professors of social work and is aimed
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primarily at social workers who take a special interest in problems of
addiction among their clients.
When reviewing US textbooks in the addictions field, it never ceases
to surprise how far behind that great country is, in both practical and
conceptual terms, compared with the way addiction is understood in the
UK and some other European countries. For example, in the first
sentence of the Preface, we learn that: ‘The moderation versus
abstinence controversy is easily the most hotly contested issue in sub-
stance abuse treatment today.’ In the UK, although pockets of
misunderstanding may still be found, this issue was largely resolved in
practice about 15 years ago. Similarly, the disease concept of addiction
is said to be increasingly subjected to public and professional scrutiny
in the USA — the kind of scrutiny apparently that occurred in the UK
in the 1970s. ‘Harm reduction’ is strangely defined here as ‘an
umbrella term for a set of practical strategies based on motivational
interviewing’ but the European origins of the harm reduction
movement are at least recognized by the authors. Needless to say, the
US contains within its borders many of the scientists and scholars who
have helped transform our understanding of addiction over the past 40
years but this ‘paradigm shift’ has had far less influence at the grass
roots level there than it has had in the UK and elsewhere.
The key characteristic of this book is eclecticism. Indeed, in the
‘bio-psycho-social-spiritual’ model presented by the authors, it is
difficult to think of any school of thought, any reasonable approach to
treatment or prevention or any well-known point of view on addictions
that has not been included. If there is any unifying theme to be found,
it is the ‘strengths perspective’. This is defined by six elements said to
be crucial to recovery: identity as a competent human being; the need
for personal control or choice; the need for hope; the need for purpose;
the need for sense of achievement; and the presence of at least one key
person. Disregarding the possible vagueness of these prescriptions,
there is little to disagree with there.
The book consists of four parts. The introductory Part 1 discusses the
nature of addiction and various historical perspectives on it before
presenting the elements of strengths-based helping strategies. Part 2
describes knowledge on the biology of addiction, including
interventions related to these biological foundations. In Part 3 we find
the psychology of addiction applied across the life-span, to various sorts
of behavioural addictions and to comorbid disorders. Last, in Part 4, the
social aspects of addiction are described under headings of family risks
and resiliencies, racial, ethnic and cultural issues, gender and sexual
orientation differences, mutual-help groups and public policy.
One should not appear too sniffy about this book. It is well written,
contains a great deal of sound common sense and obviously derives
from a warm and genuine concern for the plight of addicted persons.
 BOOK REVIEWS
Nevertheless, I cannot recommend it for anyone wishing to further a
scientific understanding of addiction; there are many other books far
more suited to this aim. I am sure the book would be useful to social
workers wanting to increase their knowledge of how to respond to
addictions in their clients, if only because of the professional
orientation of its authors. Finally, the book would be a useful read for
anyone intending to visit the US and who wishes to get a feel for what
goes on in the addictions field there, particularly for what is considered
new and radical in US treatment circles.
NICK HEATHER
doi:10.1093/alcalc/agh009
Under the Weather: Coping with Alcohol Abuse and Alcoholism.
By John G. Cooney. Newleaf, Dublin, 2002, 176 pp., £9.99.
ISBN 0-7171-3424-5.
This is a new edition of a book first published in 1991. If that means
the original sold well enough to persuade the publishers that it was
worth updating, one can see why. Dr Cooney’s style is very readable
and he seems to be aiming as much at the numerous long-suffering
members of alcoholics’ families as at the treatment industry or at
alcoholics themselves, though both groups would also benefit from his
‘broad church’ approach.
The 12 chapters, with titles such as ‘signs, symptoms and cross
addiction’, ‘physical and psychiatric complications’, ‘a family illness’
and ‘mental mechanisms and medication’ are a mixture of debate,
71
to illustrate the way in which the field of addictions has evolved in
recent decades. Each section is provided with a brief summarizing
commentary by notable experts in that area.
What do we mean by the ‘field’ of addiction? It covers the full range
of addictive substances: alcohol; licit and illicit drugs; tobacco, but no
gambling or sex. Contributions include those from scientists, prac-
titioners, activists and policy makers. Evidently the field draws on
expertise in a wide range of disciplines including public health,
education, pathology, psychiatry, psychology, politics and a range of
neurosciences. In the UK and elsewhere there are an increasing number
of departments of addiction studies in universities, although there are
still only a handful of centres for research. The ‘field’ still has a long
way to develop, yet at the same time it needs to avoid the risk of
isolation from other disciplines, services and social policies. Most of the
contributors to this book illustrate in their life histories the way in which
their interest in addictions grew out of other life experiences, which they
then brought to illuminate different aspects of addictive behaviours.
Readers with a particular interest in alcohol-related problems will be
able to renew their acquaintance with old friends and learn new things
about them. They will also learn the views of eminent workers in
addiction — selected for inclusion by the Editor of Addiction and
expertly questioned by an interviewer chosen to bring out features of
their character, background and contribution. It is hard to pick out
individual interviews, but a sample may encourage potential readers to
dip into the book. Le Clair Bissell tells about her early work in setting
up a residential rehabilitation unit for alcoholics in New York in 1974 —
she makes a simple statement that must ring true for many practitioners:
‘I don’t think there is anything more gratifying than having an individual

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didactic information and answers to ‘frequently asked questions’.
patient get well’. There is a wonderful interview with Fred Glaser which
Unusually, but for me gratifyingly, the section on ‘medication’ gives
brings to life his animated and endlessly questioning approach to
pride of place to Antabuse, rather than to acamprosate or naltrexone, and
treatment research and service organizations. Typically, he concludes on
he stresses the need for third-party supervision, often involving family
treatment: ‘Nothing works for everyone, but everyone can benefit from
members as with Marc Galanter’s ‘network therapy’. He also believes,
something’. The Addiction Research Foundation of Ontario is described
as I do, that patients who refuse Antabuse but continue drinking, usually
as ‘the jewel in the crown’ and is well represented by Martha Sanchez-
refuse it because they are not serious about engaging with treatment.
Craig and Reg Smart. Australia, which has produced so many
Accordingly, I can forgive the repeated misspelling of acetaldehyde as
outstanding addiction scientists, is the only country that also has a Prime
‘acid aldehyde’. Alcohol, he says, is ‘a devious and powerful enemy and
Minister as interviewee. Robert Hawke’s commitment to establishing
all legitimate means should be employed to combat it’.
centres for research, training and treatment is well known, as was his
His ‘broad church’ approach doesn’t quite run to controlled drinking as
courageous promotion of harm reduction as opposed to the zero
a treatment option and though he recognizes the importance of the debate,
tolerance strategies beloved by so many politicians. David Hawks
it isn’t mentioned in the comprehensive index. However, he does agree that
conducted this interview and is himself interviewed by Griffith
‘recovery, rather than mere abstinence’ is the important thing. The
Edwards. David, as a psychologist, is someone who moved from a focus
updating includes ‘Project Match’ whose results — like most of us — he
on the individual towards a more global and political interest in
regards as ‘disappointing’. He also makes an important point which should
prevention and the development of treatment systems. He sums up this
be made more often and which the drinks industry is also inclined to deny:
journey: ‘It matters that the individual person gets better, these things
‘Ethyl alcohol is an addictive drug — a fact not generally accepted even
hurt, but that individual person will be replaced by another and another
by those drinkers who will vociferously denounce ‘drug abuse’.’
and another until somehow or another we can reduce the flow from the
The complications and manifestations of alcoholism, from liver
tap, and I guess I have always wanted to get my hands on the tap…’.
palms, through fits and gastritis to Korsakov’s syndrome and
From Europe, the interplay of research and policy is well illustrated
hallucinosis, are described in terms understandable to the non-medical
by Klaus Makela and Gabriel Romanus. It is personally cheering to
reader. At times, the style is a bit too populist or simplistic. Detoxi-
read an interview with my old friend Wilhelm Feuerlein from Munich,
fication is not really about ‘ridding the body of the poisons which have
who did so much to re-establish the now flourishing field of alcohol
accumulated because of abnormal drinking’. It’s about neuroadaptation
research in Germany. There are many others: Raj Rathod and Thomas
following withdrawal of alcohol but he is correct in noting that ‘on
Bewley are amongst a list of UK drug researchers.
average … this process takes three to four days’ and that it can often be
I could continue listing contributors and the insights they provide,
done on an out-patient basis.
but I hope this is enough to encourage you the reader to look into this
Finally — and this is not a criticism — this is an Irish book and intending
book. Of course the regular reader of Addiction will have read these
purchasers should be prepared for a few Irishisms. They include the idiom
interviews already but there is merit in having them collected together
‘he had drink taken’ and the advice that ‘certification of an alcoholic is a
in one volume.
serious step and … should be employed … only as a last resort’. No
UK doctor has had this option since the 1959 Mental Health Act yielded
BRUCE RITSON
to its 1983 successor. Even so, I would confidently recommend the book
to my patients, their families and to some of their GPs.
doi:10.1093/alcalc/agh012
COLIN BREWER
Shame, Guilt and Alcoholism — Treatment Issues in Clinical
Practice, 2nd edn. By Ronald Potter-Efron. The Haworth Press,
doi:10.1093/alcalc/agh011 New York. 237 pp., $24.95. ISBN 0-7890-1517-X.
Addiction — evolution of a specialist field. Edited by Griffith
Edwards. Blackwell Science, Oxford, 2002, 400pp. £27.50. The first edition of this book appeared in 1989 and this new edition
ISBN 0-632-05976-1. incorporates developments in the psychology of guilt and shame. The
author is an experienced counsellor in mental health and addictions.
This book is a selection of annotated interviews originally published in Those reared on the importance of defining terms in a way that is
the journal Addiction between 1990 and 2001. They have been chosen categorical and susceptible to reproduction may worry about the

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