Velleman, Richard. (2001 2nd Ed.). Counselling for Alcohol Problems.

London: Sage Publications, Inc. [ISBN 0-7619-6579-3 paperback, pp.202].

The title of this book may mislead readers to assume that this book is about counselling techniques--the nuts and bolts of helping "alcoholics." In fact, it is much more than that. It recasts the problem of "alcoholism" into alcohol problems. Velleman does not like the term "alcoholic" or the slightly modified one by the World Health Organization in 1977, "alcohol dependence syndrome" and prefers "people with alcohol problems." This epistemological preference reveals the shift in thinking about alcohol problems. Indeed, it challenges the long-entrenched paradigm, which assumes that "alcoholics" resist any change and relapse because of their "chemical dependency." This dominant paradigm, as Velleman points out sets up both counselors and clients for failure: counselors convey that their clients are unmotivated and in denial; clients justify failures and relapses on being "chemically dependent."

The central thesis of the author is to challenge the single-cause theory of alcohol problems and promote a multiple-factor theory based on internal, vulnerability or predisposing factors (biology, genetics, personality, and socialization) and external factors (culture, politics, economics, media and advertising). Such a paradigm change in etiology has refreshing implications for the counselling process and techniques.

This book is divided into three parts. In the first part, Velleman outlines the theoretical and therapeutic approaches with new insights and research into causation and developments in drugs to help with withdrawal symptoms. His definition of the alcohol problem clearly indicated his approach:

   If someone's drinking causes problems with his or her health,
   finances, the law, work, friends, or relationships, then that
   drinking is problematic; if it causes problems for husbands,
   wives, children, parents, bosses, or subordinates, then that
   drinking is problematic (p.3).

By defining the alcohol problem in holistic way and without incorporating addiction, quantity of drinking at fixed timing, Velleman rejects alcoholism as 'disease' view promoted by Jellinek (1960) in his book The Disease Concept of Alcoholism. The disease model shift responsibility away from the people with alcohol problems on to the medical profession. The fear of being labeled 'alcoholic' discourages people from getting help. Velleman suggests to looking at normal drinking based on daily consumption rather than weekly: for men 3 to 4 units and not more than 2-3 units for women. (A unit is nearly 3 ounces of wine with an alcohol content of 12 percent. Thus, the daily among that constitutes normal drinking equal about one-and a half ounces of alcohol--which is the approximate alcohol content for a four-ounce glass of wine, a 12-ounce can of beer, and a cocktail with one ounce of hard liquor). In addition to the internal factors within the individuals cited earlier Velleman examines the external or precipitating and perpetuating factors such as stress, social context, and availability. For instance, the author identifies that the alcohol use patterns in many European countries are affected by high availability, few restrictions, and acceptability throughout the day. This has led to high consumption compared to a country like Saudi Arabia. Based on such understanding, it logically follows that the entire counseling process is designed to deal with the basic question.

   What factors made this man or woman to drink so much, and
   therefore what can I do to help him or her to deal with these
   particular factors in the future? (p.17).

With this framework, in part two, Velleman adopts a more eclectic practice that allows the counselor to focus on predisposing, precipitating and perpetuating factors. The basic principle is that counselling clients with alcohol problems is similar to counselling clients with any other problem. The only difference is that alcohol, being an addictive drug, can cause withdrawal, dependency, craving, and strong ambivalence about whether to give up. The author advocates the evidence-based, empirically supported effective modalities based on the work of Miller and his colleagues (1998) and Project MATCH. He endorses Cognitive-Behavior Therapy, Motivational Enhancement Therapy and 12-step Facilitation. This is clear departure from the medical/AA model to counselling focused on the individual.

For Velleman, counselling is an empowering process involving six stages, which he describes in detail illustrating with a specific case. They are:

1. Developing trust;

2. Exploring problem areas;

3. Helping set goals;

4. Empowering into action

5. Helping to maintain change; and

6. Agreeing to end (p.33).

He also strongly endorses the 'cycle of change' model, which was pioneered by Prochaska and DiClemente (1983) based on their work with smokers. This also involves a variety of stages:

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

Lapse/Relapse and

Back to contemplation...

Finally to life without alcohol problems (p.53).

The "cycle of change" model recognizes the fact that people make several attempts and that is not a self-defeating behavior. Often smokers say: "I am so determined to stop smoking that I tried it several times." In fact, such comments should be positively reinforced by emphasizing that relapse is common, motivation is not static, and change is not a linear process. The author recognizes that change is a process the client goes through all the time. Another issue concerning alcohol is that client's fear of being judged that can affect motivation. He highly recommends the motivational interviewing techniques developed by Miller in 1983. This helps the counsellors to be non-judgmental and non confrontational which is key to establishing a positive relationship.

Velleman devotes an entire chapter to dealing with relapse based on research by Marlatt and Gordon (1985). It begins with the idea of giving permission to relapse so that it is not interpreted as lack of resolve, which can undermine the commitment of the client. The key is to find out why relapses occur and develop strategies to prevent them. He highlights and encourages counselors to share a critical research finding with clients:

   The reason people relapse after one drink is not because they
   have an uncontrollable urge: it is because they expect they will
   relapse (pp.99-100).

Such a message helps clients not to view as a failure but as an opportunity to learn new skills. The obvious skills are to recognize the early warning signs, monitor high-risk situations, and develop coping strategies and, most notably, problem-solving skills to deal with relapse successfully. Velleman recommends groups to only those who are likely to benefit. He considers group work as a highly skilled activity better performed with training and a co-facilitator and with regular supervision.

Part three deals with very vital issues such as dealing with difficult situations (aggression, violence, drunk clients, relatives, confidentiality, use of volunteers), people with more than one problem, myths and facts about problem drinkers and treating relatives of problem drinkers. All these chapters contain useful information and therapeutic strategies. Some of the common myths that the author highlighted should help people recognize and avoid a judgmental attitude and blaming. This alone can help counsellors in relating to people with alcohol problems better. Some of the myths are: alcoholics are liars or deniers; one can't work with clients unless they have admitted to be an alcoholic; abstinence is the only solution; treatment success is a rarity; and only those who have had alcohol problems can help problem drinkers. As Velleman states:

   Counselling is about facilitating clients, about empowering
   them so they can go on to take control over their own lives. A
   good counsellor does not force clients into admitting anything
   (pp.157).

All the chapters end with reference and further reading materials. This book will be valuable not only for new and the experienced counsellors but also to those who deal with alcoholic in any capacity. This would be a good text for introductory courses on treatment of addictive disorders at the undergraduate and graduate levels. It is the key book recommended by the National Alcohol Training Strategy for training counsellors in the U.K. It certainly deserves to be.