by G. Alan Marlatt and Katie Witkiewitz (Editors)
American Psychological Association, 2008
Review by Nancy Nyquist Potter, Ph.D. on Sep 8th 2009
This hefty anthology of twenty-six chapters on research and insights into struggles with substance abuse and addiction would make a good textbook for students of social work, public health, and clinical psychology. The combined chapters make clear, if readers did not already know firsthand, that substance abuse and addiction ravage the mental health of users and their loved ones and wreak havoc on finances, work, and home life as well as on psyches. This is a public health issue that continues to need attention from clinicians, health care reform, and policymakers.
All chapters have been published since 1997, giving the material a fairly relevant quality. The book includes a discussion of ecstasy, a street drug that is popular among young men and women but much less often considered by clinicians and researchers. Also included are attention to the differing effects of youth and age, of gender, and of ethnicity on prevalence and treatment options. Readers will be exposed to changes in screening and assessment due to technological advances, advances that likely have continued to develop and change the face of clinical research since many of the articles were written.
Addiction is understood as a brain disease, drawing primarily on the disease model of medicine--although note that neither 'addiction' nor 'disease model' is defined. Given that researchers from the clinical and philosophical literature have struggled for decades to define just what makes behavior an 'addiction,' it is unfortunate that the editors do not take up this difficult and intractable problem (cf. the forthcoming anthology from MIT press on addiction and responsibility edited by Jeffrey Poland and George Graham for a philosophically oriented yet multi-disciplinary analysis of the 'addiction' construct). I have selected just a few chapters from the book under review to give readers a sense of the quality and content of the anthology.
Following the prevailing disease model, readers will find that abstinence is still by far the more prevalent aim for treatment of addictions, but harm reduction is also gaining respect. The article 'Toward a psychology of harm reduction' (Robert MacCoun), sets out reasons why harm reduction rather than abstinence is a worthy and possible goal for those with addictive behaviors. This model also aims to reduce users by discouraging the initiation into drug usage of current non-users. The author notes that Americans, in particular, are resistant to this model and MacCoun discusses this problem with respect to the American reasoning that anything short of abstinence 'sends the wrong message.' MacCoun identifies what he calls 'deeply rooted and strongly felt symbolic factors' that explain the recalcitrance toward harm reduction but that are independent of actual evidence about what does and does not work. He concludes with a list of five ways in which harm reduction may be beneficial.
In a later chapter, Katie Witkiewitz and G. Alan Marlatt examine models of relapse prevention, noting that some people who receive treatment and then decide to use again 'may be vulnerable to the "abstinence violation effect," which is the self-blame and loss of perceived control that individuals often experience after the violation of self-imposed rules.' Considering these two chapters and others like them, readers might find themselves disappointed and frustrated that this book contains no section on philosophical issues in the conceptualization of substance abuse as disorder or what, exactly, is meant by the construct 'addiction'? One wishes that issues of responsibility and agency had been addressed, along with justification for viewing certain behaviors as addictive, where questions of the will and choice plague the field. Yet otherwise, these chapters contribute to the research field.
A useful and clear article is by Rudolf Moos on principles and puzzles of addictive disorders. Also good is a chapter by Elizabeth Kawkins, Lillian Cummins, and G. Alan Marlatt that offers a brief overview of prevention concepts, examines bicultural competence interventions, and introduces the gateway theory of substance use.(I do find it perplexing, though, that the editors placed this chapter in the last third of the anthology; it might have been more helpful earlier on.) It is at this point that the anthology begins to address what seem to be culturally-inflected differences in substance use and its effects. Relatively little research has been conducted on substance use by American Indians, especially research that resists the prevailing stereotypes of American Indians as hopeless drunks, so it is with a sigh of relief that we reach this section of the book. Other chapters follow that take into consideration cultural differences and, although this is only a smattering, a classroom would certainly benefit from discussion and examination of this salient issue in drug prevention and harm reduction. A central finding, in my view, is the genetic differences that different gene pools show when it comes to metabolizing alcohol: some groups, such as Asians, have an enzyme that aids in protection from drug dependence (and others lack that enzyme).
Lynam et al present research that suggests that school intervention programs to prevent or reduce drug usage are ineffective, yet those programs remain popular. This discord might be a fruitful direction for researchers to investigate. Thomas Dishion and Lee Owen present a longitudinal study that focuses on deviant friendships and their role in shaping adolescents' inclination to use drugs. For example, they found that 'deviant talk' violated conventional norms for dialogue and that, by paying attention to that and other norm violations, researchers can get a sense of a developmental pathway of rule-breaking that can include under-age use of drugs and use of illegal drugs--while not relying on 'just say no' campaigns for youth.
Causal factors such as genetics, personality types (temperament that is novelty-seeking, for example) are discussed; consider, for example, the messiness of co-morbid diagnoses found in adolescents: 'co-occurrence among alcohol dependence, drug dependence, conduct disorder, adolescent antisocial behavior, and a disinhibitory personality style assessed in late adolescence can be traced to a highly heritable externalizing factor' (Krueger et al, 76). A chapter by Qing Zhou, Kevin King, and Laurie Chassin examines the influence of family alcoholism and of family harmony. They posited that family disharmony serves as mediator of family alcoholism; their study is the first prospective test that examines this mediation in terms of young adults. Thomas Ashby Wills, James Sand, Alison Yaeger, and Ori Shinar report findings on the role that temperament plays as moderator of family risk factors. They looked into the possibility that a temperament that is resistant to external control leaves a person less skilled at planning for the future that involves anticipating the positive and negative effects of various choices.
On the downside, the title of the book (Addictive behaviors: New readings on etiology, prevention, and treatment) is misleading if the reader wants to get a sense of the scope and variety of problems that people face when it comes to addictive behaviors: although fairly thorough in discussing alcoholism and other substances that are abused (including cigarette smoking), the editors did not include any material on such behaviors as compulsive shop-lifting, sexual addiction, self-injury addiction, food addiction, Internet addiction, or workaholism. This partial list arises from a prevalent cultural investment in understanding behaviors that exceed norms for moderation: when is posting on Facebook, for example, 'excessive' and what would make that excess a symptom of pathological behavior? It would have added a lot to the book had the editors defended their choice of omissions, as it would have required them to define more precisely what a 'genuine addiction' really is and which social factors are likely to contribute to the rise or [fall] of particular behaviors. If this book is to be used as a textbook, it should be accompanied by at least one other book that addresses a broader domain of addictive behavior and one that focuses on the deep and difficult philosophical questions of what an addiction is, when something is an addiction, what makes an addiction undesirable, and how to think about the will, agency, and responsibility of the person who seems to be exhibiting addictive behavior.
© 2009 Nancy Nyquist Potter
Nancy Nyquist Potter, (Department of Philosophy, University of Louisville, Kentucky) is author of several books, most recently, Mapping the Edges and the In-between: A critical analysis of Borderline Personality Disorder (Oxford University Press, 2009).