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Medicine and Books

Why do some people drink the way they do? What is it that accounts for the "glue" that holds the drug taker fast to a repeated pattern of harmful use? Does treatment, whether complex or simple, actually affect the relation between a drug taker and his or her drug? Does a preoccupation with the issues of diagnosis and treatment divert attention from the more important issue of prevention? It may be a reflection of the miserly amounts of research money and effort directed at unravelling such questions that they remain so perplexing to this day. It may of course be that they are actually more complex questions than they appear. Whatever the reason, the present foundations on which programmes of alcohol treatment rest are conceptually extremely fragile. This collection of essays, emerging from a number of research workers who style themselves New Directions in the Study ofAlcohol Group, confronts each of these questions in turn and does so in a refreshingly lively way by including contributions from established experts on the topic who are known to hold contrary views. As a result the argument over whether the concept of the alcohol dependence syndrome is useful or not, which has been known to empty conference halls and fill conference bars, regains some of the vitality that it had in the sixties, when it first began to flourish. So, for example, there is a fairly damning review of the evidence for a true alcohol dependence syndrome from sociologist Stan Shaw, supported by a more opaque and somewhat self indulgent piece from Douglas Cameron. Shaw's argument is that the concept is superfluous, offers nothing useful for those interested in helping problem drinkers and actually gets in the way by emphasising a biological model of alcohol abuse when a much more psychosocial approach would make better sense. In contrast, Jonathan Chick, Anthony Thorley, Ray Hodgson, and Tim Stockwell, psychiatrists and psychologists who have been in the forefront of efforts to put alcohol problems and their treatment higher up on the professional and public agenda, argue for the retention of the syndrome on the practical grounds that it provides a clinically useful way of comprehending some alcohol problems in some people. The evidence marshalled in the section on treatment seems to support the clinicians. A survey, rather small it is true, of psychiatrists actively concerned in the detection and treatment of alcohol problems did not show that they restricted their approach to a biological one. In fact, actual treatment consisted of giving advice, providing an explanation, exchanging information, pointing out the role of lifestyles and environmental factors that lead to or aggravate harmful drinking, and providing detoxification and withdrawal facilities when necessary. Success or failure was not seen purely in terms of whether or not the allegedly dependent drinkers abstained, which one might predict from a too slavish adherence to a narrow disease model, but in terms of the extent to which the patients made adjustments in their social and personal lives and reduced their drinking to non-harmful patterns and levels. Much of the argument about models reflects a profound unease as to the efficacy of treatment. Bill Saunders, in a blunt, honest review, concedes that quite why alcohol abusers start, continue, and stop is a mysterious process. The best evidence favours the impact of the increasing toll of drinking that eventually impinges on the drinker who makes a commitment to change. As problem drinkers get worse so they sow the seeds of their own recovery. This raises the uncomfortable possibility that some treatment might actually retard recovery by shielding drinkers from the consequences of their own behaviour, an echo here of Alcoholics Anonymous' insistence that some alcohol abusers have to hit "rock bottom" before they accept that they have a problem, and do something about it. As Saunders himself, and Alan Cartwright in a much more optimistic piece, point out, however, treatment may influence the extent to which problem drinkers recognise that they do indeed have a problem. Doctors, particularly those in general practice and general medicine, appear well placed to contribute. The final section on prevention covers familiar ground concerning the economic aspects of alcohol, media portrayal of drink and drinking, and the case for limiting alcohol consumption. There is a particularly salty contribution from Anthony Thorley documenting the difficulties and the achievements of the mass media campaign undertaken in the north east of England under the auspices of the Health Education Council that makes it plain that the conceptual difficulties in alcohol studies do not disappear at the door of the clinic. In summary, this is a very readable book. A real plus is that the editors have resisted the temptation to ensure that all the contributions fitted neatly and uncontroversially together. They don't, but that reflects the present state of play in alcohol research and treatment. As we say to our clients and patients, better to face reality than inhabit a fantasy land where all is sweetness and light. Sometimes, though, one has to confess, the arguments over the disease model are enough to drive one to drink.