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The Treatment of Drinking Problems: A Guide to the Helping Professions

Mary Morreale, MD

Wayne State University, Detroit, MI, USA

By E. Jane Marshall, Keith Humphreys, and David M. Ball. Cambridge, United Kingdom: Cambridge University Press; 2010; ISBN 978-0-521-13237-4; pp 276; $70 (paperback).

As a “helping professional” it is imperative to be well versed in the diagnosis and treatment of alcohol use disorders. This small textbook gives us a refreshing perspective of this subject beyond the DSM system, complete with a charming use of British language (“He may just be trying to put the frighteners under me. But if he’s really saying I’m going to die of cirrhosis, I’ll go out on the crest of the all-time greatest booze-up”).

The book begins with a definition of drinking problems, from sensible drinking to dependence. Although the bulk of the remaining chapters focus on abusive and dependent drinking, it is important other forms of drinking are mentioned because these often are harbingers to more severe drinking and are amenable to intervention. Chapter 2 focuses on the “science” of alcohol, including alcohol’s interaction on various neurotransmitter systems. Chapter 3 goes on to discuss causes of drinking problems, including the easy availability of alcohol, value systems, economic factors, and genetic contributions. Environmental factors also are considered. Chapter 4 addresses the social implications of disordered drinking, particularly the impact of alcohol on relationships and family structures.

Chapter 5 thoroughly describes the physical manifestations of excessive drinking and includes 2 tables, which concisely summarize the impact of problematic drinking on health-related measures. Chapter 6 describes psychiatric comorbidities associated with alcohol use and chapter 7 addresses alcohol and other drug problems.

The tone of chapter 8 changes, with descriptions of several clinical presentations. These include the young drinker; the violent patient; a presentation on a general hospital ward; the pregnant drinker; a patient who abuses both alcohol and drugs; the patient with cognitive impairment; the patient from a cultural background other than the therapist’s; the family member as an intermediary; the “very important patient”; and a child at risk. Case abstracts are interwoven throughout the text, and the material is presented in an interesting and engaging manner, with practical suggestions for intervention.

The second section focuses on treatment. Chapter 9 discusses “treatment trajectories,” which often are quite “messy,” highlighting the complicated nature of substance recovery. Chapter 10 introduces nonspecialist treatment settings, for example, the criminal justice system, schools, workplaces, primary care practices, emergency rooms, and general psychiatry clinics. Laboratory tests are discussed, as are screening questionnaires and brief motivational interviewing. Within this chapter, the authors devote a section addressing how to determine when a case should be handled in a nonspecialist setting.

Chapter 11 includes a detailed explanation of the evaluation process. The authors laboriously describe the appropriate intake for patients who misuse alcohol. To highlight the level of detail included, the authors include assessment of the evolution of the patient’s drinking, an account of a typical recent heavy drinking day, and an explanation of the salience of drinking to the patient. Again, a table is included which nicely summarizes the history-taking scheme. An equally detailed interview template is included for family members. The chapter concludes with keys to the case formulation.

Chapter 12 defines alcohol withdrawal, pharmacologic management, and treatment setting. Chapter 13, titled “The basic work of treatment,” begins with a description of the therapeutic relationship and moves on to discuss motivation and readiness to change, utilizing clinical vignettes. This chapter discusses “dealing positively” with relapse, information regarding working with the family, and ends with recommendations on appointment spacing and treatment duration.

Chapter 14 delves more deeply into specialist treatment, exploring cognitive-behavioral therapy, and other psychosocial treatments. Two large trials involving psychosocial treatments—Project MATCH and the United Kingdom Alcohol Treatment Trial—are described. The authors discuss approved pharmacotherapies for alcohol dependence, including disulfiram, naltrexone, and acamprosate, and mention those with potential utility, such as ondansetron, baclofen, and topiramate. The chapter ends with a table ranking the efficacy of treatment based on a review of 381 studies. Rightfully, the authors stress there is “there is no one single pathway to recovery, rather a number of different individual paths” (p 212).

Chapter 15 highlights the utility of Alcoholics Anonymous (AA), describing the typical AA meeting, the 12-step process, and the basic tenets of the organization. Chapter 16 is titled “Spiritual and religious issues in treatment.” My opinion is the scope of this chapter extends beyond this small text and the key points could have easily been incorporated into the previous chapter.

Chapter 17 is targeted toward treating patients who want to drink “normally.” It begins with a table delineating factors that are favorable and unfavorable to a controlled drinking goal. Simple strategies are discussed to provide techniques for self-control. The text ends with a chapter titled “When things go wrong and putting them right.” Again, case scenarios are interestingly interwoven throughout to illustrate problems one may encounter while treating individuals with substance use disorders.

Overall, this is an engaging and easy-to-read book. The clinical vignettes bring clinical relevance to the material, and the many well-designed tables summarize information effectively. This book would be beneficial for social workers, nurses, psychologists, and any physician who assesses and treats patients with substance use disorders. As an academic psychiatrist, I intend to utilize this book, particularly the concise tables, as I prepare lectures for medical students on substance abuse.