Book Reviews
Compiled by Susan Savva & Griffith Edwards
LEAD REVIEW
Critical Incidents: Ethical Issues in the Prevention and
Treatment of Addiction (2nd edn)
WILLIAM L. WHITE & RENEE M. POPOVITS
Bloomington, IL, Lighthouse Institute, 2001, 310 pp,
US$17.95, ISBN 0938475 10 X
This book is designed to improve ethical decision-making
for counselors, nurses, outreach workers, case managers
and clinical support staff who work in addiction treat-
ment and related fields. With its exercises, work sheets
and checklists, it is written in the form of a training
manual to be used as part of a course or a workshop, but
it can also be read like a book. Either way, it is interesting,
enjoyable, practical and very well done.
The primary goal of the book is to show the reader
how to recognize ethical dilemmas and how to use a
structured model of ethical problem-solving to respond
to these situations. Another laudable purpose is to
describe a process through which standards of ethical
conduct can be developed as a component of a service-
orientated organizational culture. The book is written
from the practical perspective of a clinician and organi-
zational consultant, rather than from theoretical per-
spective of the ethicist.
As noted in the brief historical introduction, addiction
treatment flourished and then declined in the United
States and other countries during the late 19th and
early 20th centuries. One factor in its demise in the
United States was the damage to the field’s credibility that
resulted from ethical breaches in its clinical and business
practices. It is argued that today the field of addiction
treatment is experiencing a similar crisis in values, which
is exacerbated by the fact that its practitioners and orga-
nizational entities do not have a framework of ethical
standards and ethical decision-making that can consis-
tently protect its service consumers, its workers and the
public. As the addiction field has grown and matured, the
authors maintain that there is now a critical need to go
beyond the traditional concern with clinical ethics.
Addiction treatment professionals regularly face difficult
ethical and legal issues related to business practices,
public safety and peer relationships without either the
technical training to conduct such an assessment or a
© 2002 Society for the Study of Addiction to Alcohol and Other Drugs
decision-making model through which such judgements
can be made.
According to the authors, the addictions field lacks a
clear moral compass, in part because of its heterogeneity
and diversity in terms of age, race, culture, religion, sex,
sexual orientation, education and professional training.
Workers in the field are likely to encounter a range of
complex ethical issues that few are prepared by their
training or life experience to address. Even when ethical
issues are considered professionally, they are more likely
to be addressed in an abstract or prescriptive prescriptive
way (‘Thou Shalt Not . . . ’) rather than as part of an
ethical problem-solving processes.
Following its very informative introduction, the
book’s second chapter provides an extremely useful step-
by-step guide to those interested in developing a code of
professional practice for use in any organization engaged
in addiction treatment or prevention. A code of profes-
sional practice (CPP) is an explicit set of beliefs, values
and standards that guide organizational members in the
conduct of their professional activities. The code articu-
lates values and defines the boundaries of appropriate
and inappropriate conduct.
The next seven chapters of the book present over 200
‘critical incidents’ that raise important ethical and pro-
fessional practice questions. These ethical case studies are
presented in the form of short vignettes that describe a
situation or problem, followed by an analysis of the ethi-
cal principles involved and the appropriate course of
action to be taken by the addiction worker. The critical
incidents are organized according to the following chapter
topics: (1) conduct related to the practice of business in
addiction service organizations (e.g. fundraising, market-
ing, financial management); (2) personal conduct outside
the work environment (e.g. use of alcohol and drugs); (3)
adherence to professional values (e.g. representation of
credentials, use of agency resources); (4) relationships
with clients and families (e.g. confidentiality, informed
consent, self-disclosure, sexual relationships) (5) profes-
sional peer relationships (e.g. nepotism, sexual harass-
ment, professional misconduct); (6) conduct in situations
that pose a risk to public safety (e.g. reporting child abuse,
HIV/AIDS and sexual abuse); and (7) performance of spe-
cialty roles within the substance abuse field (e.g. social
activism, research with human subjects).
Addiction, 97, 761–766
762 Book Reviews
The cases are analyzed with sensitivity, logic and
reason. There is no moralizing or sense of ethical
superiority. The analyses provide guides to action rather
than definitive decisions by deriving conclusions about
the most appropriate course of action from sound (and
for the most part universal) ethical principles, such as
autonomy, beneficence, justice, honesty, conscientious
refusal, stewardship and non-maleficence. Legal annota-
tions have been added to this new edition to show the
connection between ethical and legal issues.
To the extent that the ethical principles discussed
in this book are universal, they would apply to most
countries, professional groups, and clinical situations.
Nevertheless, the book is written for an American audi-
ence. The case studies are derived from the kinds of
ethical dilemmas, professional issues, organizational sit-
uations and legal problems that are distinctly American,
reflecting that country’s relatively large investment of
resources in addiction treatment services and other kinds
of substance abuse programs. The book would there-
fore not be very useful as an ethical training manual
for addiction professionals outside the United States.
Nevertheless, it may be relevant to those in other coun-
tries interested in the application of a very practical
approach to their own ethical dilemmas. Here its value
would be primarily to illustrate how ethical decisions can
be made, with the legal discussions being far less relevant.
But to the extent that this book is unique in its content
and approach, it has a great deal to offer to anyone inter-
ested in the improvement of ethical decision-making
in the addictions field; and for the legions of addiction
workers in the United States, it may well take its place
next to the Holy Bible as a moral compass to guide them
through the ethical minefields they often encounter in
their everyday work.
TOM BABOR
University of Connecticut
Farmington
CT, USA
FURTHER REVIEWS
A Community Reinforcement Approach to Addiction
Treatment
ROBERT J. MEYERS & WILLIAM R. MILLER, eds
Cambridge University Press, 2001, 188 pp, £49.95,
US$74.95, ISBN 0521 77107 2
It is very rarely that I read a scientific book of about 200
pages in a rather short period of time, that such a book
is not only scientifically sound and well written, but in
some parts even exciting in such a way that you do not
want to stop reading it. Part of the secret for such an
© 2002 Society for the Study of Addiction to Alcohol and Other Drugs
unusual combination of characteristics is the fact that
the book starts with a chapter on the historic develop-
ment of the community reinforcement approach (CRA)
in the 1970s and the 1980s. This reminded me of my first
treatment studies between 1970 and 1985, and the
fights we had with the scientific community as well as
with practitioners to implement some principals of CRA
in our treatment trials for drug and alcohol addicts.
However, beyond this personal involvement, I think that
it is extremely valuable of the authors to describe the
roots and the developments of CRA in the United States
and the strong opposition to that approach on the back-
ground of traditional treatment concepts for addictions
around that time. The history helps to understand the
present state, strength and weaknesses of CRA.
Apart from the (first) chapter on the history of CRA
and a summary, the book covers three major areas: (1)
the early 1973, 1976 and 1982 Azrin CRA studies and
a modern replication by the editors with an extended
design and statistical analysis; (2) a description of CRA
components; and (3) some studies on the application
of CRA for specific target groups: homeless, cocaine
and opiate dependents and finally families of substance
abusers. A must for young researchers is the list of pos-
sible errors and mistakes in the design and handling of
clinical studies (p. 101).
What are the central characteristics of CRA? The first
chapters define CRA by a functional analysis and a
slightly arbitrary list of techniques with a social ‘touch’,
such as communications skills training or social rein-
forcement of abstinent behavior. You have to reach p.
167 for a discussion of the theoretical basis. I agree with
the editors that CRA in the first place . . . ‘is good behav-
ior therapy’ (p. 168). That means: (1) classic functional
analysis of problem behaviors, of the social environment,
of resources and targets of the client; and (2) allocation
of treatment components according to individual condi-
tions. But within this broad spectrum, CRA emphasizes
the role of positive social reinforcement, e.g. the reverse
side of the medal. This bias is strength as well as weak-
ness or CRA: strength, as cognitive-behavior therapy, the
actual dominant concept, forgets the social contingencies
of substance related disorders. Weakness, as the CRA
stress on social reinforcement neglects ‘inner’ problem-
related conditions; e.g. how to deal with Marlatt’s inter-
nal relapse stimuli? Therefore, I personally like to add to
CRA a pinch of Pavlow and Beck.
The authors finally ask the question why CRA has
not been used more broadly and give some hypothetical
answers. I have two additional hypotheses: The ‘selling’
of CRA, together with the concept of controlled or mod-
erate drinking, which is theoretically understandable
but not necessary, made CRA even more suspicious of
clinical practitioners. Secondly, CRA needs much more
Addiction, 97, 761–766

therapist engagement, creativity, competence and work
outside their work-place than the classic in-patient group
sessions, based on clients’ experiences and insight inter-
pretations. Nevertheless, the majority of German thera-
pists would definitely not undertake ‘home visits’ or build
up a ‘buddy system’. Reinforcement of therapists is a pre-
requisite of a wider CRA utilization.
Altogether the book is a well-written and needed plea
for a broader use of CRA, but with good critical distance
to the concept and the outcome of that approach (e.g. see
p. 99). However, the problem could be that not enough
people will read the book: the scientific community has
a precise and relatively short overview of the research
on CRA and about future research needs, but many col-
leagues will claim to know already the described studies.
Many practitioners should read the book, but I fear that
it will be too research-dominated in their eyes. I would
wish the book to be also read by supervisors, trainers
and those responsible for service provisions. Obviously,
students will like the book for the sake of time-saving.
GERHARD BÜHRINGER
Institut für Therapieforschung
Munich, Germany
Quantum Change: Bridging the Schism Between
Science and Spirituality, Ordinary People Tell Their
Stories of Extraordinary Change: When Epiphanies and
Sudden Insight Transform Ordinary Lives
WILLIAM MILLER & JANET C’DE BACA
New York, Guilford Press, 2001, 2005 pp, $US15.95,
ISBN 1 57230 505 3 (paperback)
Just occasionally one is asked to review a book, accep-
tance of which is not dictated by academic obligation but
by a real sense of excitement. This is one such book. It
is a book which one would have wished to have written.
Its subtitle marks it out as different. Except that its
authors are esteemed behavioural psychologists, whose
copious scientific publications attest to their serious
purpose, it could signify a religious tome or one of those
innumerable guides to self-improvement. In fact it is
neither. It is a serious attempt to understand one of psy-
chology’s more mystifying phenomena—the transforma-
tion of lives apparently without therapeutic intervention.
Basing themselves on a number of volunteered
accounts of such changes the authors attempt to under-
stand what might have prompted them, the process by
which they were wrought and their permanence. In
the course of their analysis, Miller & C’de Baca discern
some remarkable consistencies. The changes were often
unsought, they broke in upon ordinary unsuspecting
lives, were almost always experienced as benevolent,
occasioned a great sense of connectedness, peace and
emotional outpouring and were permanent. They
© 2002 Society for the Study of Addiction to Alcohol and Other Drugs
Book Reviews 763
effected notable change in the way those who experi-
enced them viewed their world. In plain language, those
affected became ‘new people’.
As the authors acknowledge, there is much in the
reports of their respondents which is resonant of the
writings of the mystics and much which can be trans-
lated into religious terms. What is novel about their
approach is their attempt to apply a modern psychologi-
cal understanding to these events. Even so, they do not
pretend to have understood these phenomena; indeed,
they leave us with some intriguing observations: for
example, that such events undeserved and ineffable may
represent ‘periodic reminders to human kind of what we
have already known and yet have failed to take seriously’.
What recommends this book is that the authors have
taken such ‘reminders’ seriously and in doing so have
opened us up to a line of therapeutic enquiry which had
previously hidden behind that inadequate phrase ‘spon-
taneous recovery’. If only all books offered for review
were such a joy to read.
DAVID HAWKS
Emeritus Professor of Addiction Studies
National Drug Research Institute
Curtin University of Technology, Western Australia
Women and Alcohol in Social Context: Mother’s Ruin
Revisited
JAN WATERSON
Basingstoke, Hants and New York, Houndmills, Palgrave,
2000, 240 pp, £16.99, ISBN 0333 66589 9
Women and Alcohol in Social Context: Mother’s Ruin Revis-
ited by Jan Waterson considers women’s drinking prac-
tices more holistically than many other studies, placing
them within the context of their work and family circum-
stances. In particular, she attempts to go beyond the myth
of ‘mother’s ruin’, the enduring image of the negligent,
drunken mother, to uncover the reality of women’s expe-
riences with alcohol. Influences and consequences, both
positive and negative, are seen as shaping their drinking
careers. Waterson explores the drinking experiences of 60
new British mothers to develop a portrait of their drinking
careers. By organizing the women according to social
class (professional versus non-professional) and alcohol
consumption (heavy versus light), she is able to examine
the influences upon their drinking habits of employment
status and type of job, partner’s job and family history.
Several major themes emerge from her analysis, in partic-
ular the strong linkages between drinking practices and
social class, psychiatric co-morbidity and gender role
expectations.
A considerable focus of the book is on the relationship
between drinking practices and social class. Like many
Addiction, 97, 761–766
764 Book Reviews
authors, Waterson finds that more affluent women drink
more frequently and more heavily than less affluent ones,
due to factors such as more financial access, more leisure
time and greater social acceptance of female drinking.
She argues that working class women’s drinking is less
likely to occur at home, and is usually tied more closely
to a pub culture than that of middle-class women. When
opportunities for socializing outside the home diminish
with the birth of a child, there is a concomitant reduc-
tion in drinking among non-professionals. Working-class
women who did drink heavily experienced more prob-
lems as a result of their drinking. Few of the middle-class
women, even those regularly consuming considerable
amounts of alcohol, mentioned alcohol-related prob-
lems. Waterson attributes this difference to alcohol’s
exacerbation of existing problems, the primary cause of
which is social injustice. It should be noted that the
pattern Waterson documents may not generalize beyond
her narrowly defined study sample. In many other coun-
tries, there is both less of the pub culture she describes
and also fewer social strictures on working-class women
not to drink at home. Additionally, what may be lost on
those less familiar with the subtleties of the British class
system are the many cultural and socio-economic factors
which shape the drinking mores of the study groups.
The book does not give the same attention to other
problems the women may have, such as psychiatric
symptoms or drug use. The author views their problems
more as discrete ‘difficulties’ rather than co-morbid con-
ditions, and frames the relationship between them and
the women’s drinking practices in terms of ‘drinking to
cope.’ Although it is difficult to think that drug use is not
an important factor related to their drinking, she does not
address it at all. While she attributes most of the women’s
difficulties, including mental health problems, to social
injustices, she does acknowledge that their psychiatric
problems may be independent from their socio-economic
status. It would have been instructive to explore further
questions such as whether, in fact, some of the mental
health issues were the result of such heavy alcohol
consumption.
Several limitations detract from the larger importance
of the book. Although she describes clearly the sample’s
lack of generalizability, she does not address what may
be universal about these women and their drinking.
The research she uses is, on the whole, confined to the
European literature. Much, although not all, of the other
work on women and drinking, including that by Linda
Beckman, Genevieve Ames and Sharon Wilsnack, is con-
firmed by her study and would have helped in under-
standing its relevance for a broader group of women.
Little attention is paid to how the study’s conservative
definition of problematic consumption might also impact
the generalizabity of findings.
© 2002 Society for the Study of Addiction to Alcohol and Other Drugs
Waterson puts forth several commonsense recom-
mendations for addressing the issue of potentially
harmful drinking among women. Citing the myriad
missed opportunities for ‘teachable moments’, she sug-
gests implementing screening, education and possible
brief interventions in a variety of the health and social
service settings which women commonly frequent. She
also cites the dearth of treatment options for women in
Britain, and calls for a significant increase in access to
treatment options. Her suggestion that ‘positive’ drinking
opportunities for economically disadvantaged women
should also be increased, and that doing so would result
in decreased negative drinking practices, is certain to be
more controversial.
A final note: the book contains numerous typo-
graphical, grammatical and spelling errors, which dis-
tract the reader from the substance of the material. It
is hoped that these errors can be corrected in future
editions.
STACY STERLING
Kaiser Permanente
Northern California Division of Research
Oakland, CA
USA
CONSTANCE WEISNER
Department of Psychiatry
University of California
San Francisco, CA
USA
Substance Abuse Intervention, Prevention,
Rehabilitation, and Systems Change Strategies. Helping
Individuals, Families, and Groups to Empower
Themselves
EDITH M. FREEMAN
New York, Columbia University Press, 2001, 487 pp,
$42.50, £28.50 ISBN 0231 10236 4
Edith M. Freeman has written an ambitious book on
personal, social and environmental ways to deal with
substance abuse problems. The first part of her book
delineates the conceptual, theoretical and research foun-
dations of empowerment principles and practice in sub-
stance abuse services. The second part tackles funding
and power issues in this service system. The third part
describes ways in which this system could be improved
by expanding the client-centred continuum of care, and
the last part describes four community programmes
for special populations. The epilogue pulls together
the lessons learned from empowerment practices and
research.
Freeman defines her basic concept, empowerment, as
‘a lifelong, dynamic process that involves certain power-
Addiction, 97, 761–766

sharing qualities of systems, practice, or research strate-
gies, beliefs and values, and outcomes that provide oppor-
tunities for individual or collective control over personal,
interpersonal or political aspects of life situation’
(p. 11). This definition aims at a comprehensive view
of the question, but it risks remaining vague and overly
inclusive. What is actually meant by ‘power-sharing
qualities of systems, practice, research strategies, beliefs,
values, and outcomes’? How do they enhance individual
or collective control over various aspects of life situation?
The following chapters with their multi-level tables
provide some answers to these questions. Documenting
empowerment-related individual experiences also sheds
more light on the issue; yet the conceptual problems
remain, because the subjects seem to interpret empower-
ment in so many different ways. A clearer definition
of empowerment and its essential components would
have given this integrated approach a more plausible
basis. Comparing it to related concepts, such as self-
efficacy, that have been studied extensively by addiction
researchers would have clarified the picture further.
However, I do sympathize with the basic intentions of
the author and find her book otherwise valuable and
gallant. The aim to break out from the client-limited
approach of dealing with substance abuse problems and
the attempt to involve families, communities and cultural
groups in this work is a welcome extension of the clini-
cal paradigm. The role of administrative structures and
socio-political systems is also analysed. Empowering
programmes for multi-cultural adolescents, perinatal
women and children, dual-diagnosis patients and
African American adults are described in more detail.
These descriptions are enriched with client voices on
empowering and disempowering experiences. An intrigu-
ing aspect of these accounts is that even disempowering
experiences sometimes seem to contribute to recovery.
More research is therefore needed on the meaning of
empowerment and the ways it works in dealing with sub-
stance abuse. Quantitative data on the effectiveness of
empowering programmes would also make the argument
more compelling.
All in all, Freeman’s book provides a comprehensive
view of the ways in which substance abuse prevention,
treatment and rehabilitation could be improved by
power-sharing practices. The book is best suited for social
workers, but it is also useful for other professionals in the
field. Much could already be learned from Freeman’s (p.
450) quote of Lao Tsu’s from 700 B C . It urges us to go
to the people, listen to them, respect them, and start
from what they know. What is then added to it will
have greater chances to initiate constructive change and
increase the sense of agency in the people involved. This
simple truth is often unduly forgotten by addiction
specialists.
© 2002 Society for the Study of Addiction to Alcohol and Other Drugs
Book Reviews 765
ANJA KOSKI-JÄNNES
University of Kuopio
Finland
Insights: Injecting Risk Behaviour and Qualitative
Research in the time of AIDS
TIM RHODES, MARINA BARNARD, JANE FOUNTAIN,
FABIENNE HARIGA, NURIA ROMO AVILÉS, JULIAN
VICENTE & URBAN WEBER
EMCDDA, Lisbon, 2001, 125 pp, €21,
ISBN 92 9168110 5
This is a very concise and useful overview of the state
of the art of qualitative research into injecting drug
use. It is the product of a working group at EMCDDA
(the European Union drug monitoring group based in
Lisbon) and was led by Tim Rhodes. This research
represents the products of the very strong network of
qualitative drug researchers working in Europe since
the mid-1980s and provides a compendium of the
studies commissioned by EMCDDA as well as the
products of other national research programmes. In
addition it provides a series of comparative tables
showing the rates of injection-related AIDS over the
period of the epidemic in Europe. The book also ties in
the studies of overdose (i.v. use is the main route associ-
ated with overdoses) and sexual risks—which, while not
directly related to injecting per se, is so often confounded
easily with injecting in studies of HIV transmission. The
qualitative studies make clear that the two are almost
inseparable.
While its focus is on injecting in the ‘time of AIDS’,
when injecting first came to be understood as the ‘main
cause of health damage related to illegal drug use’, this
brief book (125 pages) covers the historical context of
such work—starting with De Quincy. But while opiates
are ancient, their injection is relatively recent—injecting
itself is mainly a 20th-century innovation. The hypoder-
mic syringe was not widely available until the early
20th century, and cheap disposable syringes only after
1960.
The book includes an overview of all the modern
research into injecting and its now well-understood bio-
logical link to transmission of infectious diseases and key
role in the establishment of the global HIV and hepatitis
C epidemics. It identifies the broader social context of
drug use and the genesis of certain customs related to
sharing of injecting—the take-home message is that we
need to be very specific in our work, and keep it up to date.
Such behaviors are very specific to each subculture of
drug use and these are subject to change with circum-
stances, for example as the price and purity of drugs vary
in any locale.
Addiction, 97, 761–766
766 Book Reviews

In addition to its review of the significance, methods injecting is no easy task’ and we must understand ‘why
and findings of qualitative research around injecting, the and how people decide to engage in such dangerous
book also explains the important relationship of such behaviour’. This accessible volume makes it easy to see
qualitative work to interpreting the findings of quan- the wisdom of this view.
titative research, whose practitioners (especially medical
infectious disease epidemiologists) often scorn such data ERNEST DRUCKER
because it they not framed positivistically. But the ratio- Albert Einstein College of Medicine
nale for its significance is made clear in the foreword by Bronx, New York, USA
EMCDDA Director, George Estevienart: ‘Studying drug

© 2002 Society for the Study of Addiction to Alcohol and Other Drugs Addiction, 97, 761–766