Understanding the Alcoholic's Mind: The Nature of Craving and How to Control It

By Arnold M. Ludwig, M.D.
ISBN 0195059182

Reviewed by Diane J.

I have a confession to make (no, no, not THAT one)--I bought this book strictly because of the subtitle. And it was definitely a good impulse: Understanding the Alcoholic's Mind is a fascinating and elegant little book on craving and relapse, the cognitive distortions that accompany both, and methods used by successfully sober alcoholics to "avoid or resist temptation." The strength of this book is in its vivid presentation of thinking patterns that support drinking and of thought techniques that can be used against these.

Ludwig, a member of the Department of Psychiatry at the University of Kentucky and a prolific researcher and author, begins his book with the flat acknowledgement: "There is no general agreement about the nature, cause, or treatment of alcoholism"--a truism he drives home with a brief discussion of the "paradoxes and contradictions" in current attitudes. Searching for "a common area of overlap" that will allow a clear description of "what individuals need to do to insure sobriety", Ludwig proposes that the answer is "in the mind," and sets out to describe the ways in which alcoholics can change "their thoughts, attitudes, and motivations."

As you may be aware, the alcoholic's mind is an interesting but not exactly low-maintenance piece of work, and Ludwig does it some justice in the chapters that follow. In "The Lure of the Sirens", he traces the ways in which some alcoholics "covertly maneuver to arrange a slip", complete with some disconcertingly plausible examples, and links this to a persistent unconscious belief that one can SOMEDAY, SOMEHOW learn to drink safely again, that "this time will be different." (In a lengthy footnote essay, Ludwig ties this insight into an interesting critique of Marlatt and Gordon's work on the 'abstinence violation effect'.)

The following chapter details nine "drinking scripts" Ludwig identified in the course of his research, patterns of thoughts and attitudes that tend to accompany and intensify craving. Ludwig notes that this kind of thinking is hardly unique to alcoholics, but that it presents special dangers for them given the possible severe consequences of acting on it. He considers the scripts "private self-statements, a type of nonvocal inner speech" that mediates between the intention to drink and the actual act of drinking.

The scripts, which are vividly described and quite recognizable, include "the escape script" (all I want is a little peace....); "the relaxation script"; "the romance script"; the "to-hell-with-it script" (a personal favorite); "the self-control script" (more popularly known as the "I'll just have one--maybe two" script); and, for good measure, the "NO control script": "Just as believing in one's ability to handle alcohol intake is usually a setup for relapse, the attitude of not being able to control cravings virtually insures it."

Having surveyed the distorted thinking that accompanies craving, Ludwig turns his attention to "the mystery of craving" itself, in a chapter that combines anecdotes about craving with an excellent and balanced survey of cognitive-behavioral studies of craving, including research into environmental cues, conditioned responses to emotional states, and the highly individual nature of each alcoholic's personal "Pavlov's bells". (It should be noted that Ludwig makes little attempt to deal with the biology of craving, except to note that it increases markedly if the craver actually drinks.) His ultimate point is that craving is not a mysterious or uncontrollable event, that an individual can learn to predict the likelihood of craving and to resist it, and that it weakens and disappears if the alcoholic abstains for an extended period.

All well and good, but how exactly is this craving, drinking-thinking, planning-for-relapse alcoholic going to be motivated to abstain for long enough to weaken those cravings? And what techniques can she or he possibly bring to bear against powerful cravings triggered by personal cues and the seductive "logic" of the inner drinker whispering from the favorite "drinking script"? I do not think Ludwig has done a particularly persuasive job of answering the first question, but his answers to the second are intriguing and useful.

Ludwig's discussion of the "devloping the proper frame of mind" (adequate motivation) for sobriety is preceded by his survey of the often dismal recovery statistics and review of practically every available treatment modality. The chapter title, "On and Off the Wagon", gives some indication of his tone. While he is generally approving of AA, he does not shrink from the low success rate, notes the existence of other sobriety organizations, and suggests that "the very process of group affiliation" may support abstinence. He then proceeds to discuss "hitting bottom", in what is probably the weakest section of the book, piling up suitably striking anecdotes about various "bottom experiences" and "spiritual conversions to AA" without much analysis. It is clear that he believes that the "spiritual experiences" he portrays have purely psychological explanations, but he escapes by making reference to William James in the text, burying his scientific explanation in a 7-page footnote, and concludes with "If God doesn't intervene, alcoholics will have to find a way of resisting temptations on their own." (Thank you, and about time, too.)

Back on his own cognitive-behavioral ground, Ludwig spends the rest of the book detailing ways of resisting temptations, and they are good ones. He opens by pointing out that some commonly used thought-control techniques are relatively ineffective. Direct counterpoint thinking, "fighting a craving head-on", can fuel it. Resolving NOT to do something can create more difficulties than it solves, as "The picture of NOT doing triggers an image of doing what the individual is resolved not to do...[but] individuals cannot visualize "NOT", so the image of drinking may grow in intensity if you merely oppose it with the idea of "NOT DRINKING." He suggests that you should instead picture a substitute behavior every time the image of the unwanted behavior occurs to you.

Other "mind-control" techniques covered include "distraction", "substitution", "thought-ignoring" and "thought-stopping," "postponement", "playing the thought through" and "immediate negative conditioning". If some of these sound like methods you are already using, they probably are: the advantage of Ludwig's presentation is that he gives a clearly organized description of each one and notes its strengths and weaknesses. He also discusses their similarity to Buddhist meditation techniques for focusing concentration.
The nine "drinking scripts" from the earlier chapters are matched by five "sobriety scripts" drawn from Ludwig's interviews with recovering alcoholics. These are "the negative consequences script," the "benefits of sobriety script", the "rationality script", the "avoid-the-first-drink script", and the "prayer script". Again, you will probably recognize some or many of these, but they are vividly detailed, often in the words of the interview subjects, and you will probably find ideas and phrases that will work for you.

The final chapter, "The Sober Mind", is a brief and rather pedestrian discussion of "living sober." The most interesting portion of it is an extended footnote essay in which Ludwig offers his "personal sobriety formula".(Since this is the third time I have had to refer the reader to the footnotes, let me just urge you to READ the footnotes: there are several full-length essays in there on subjects ranging from Marlatt's Relapse Prevention theory and Gregory Bateson's "The Cybernetics of Self" to drug-induced religious experiences. Ludwig could have used a more adventurous editor.)

All in all, I found this to be an interesting and very useful book. It can be quite valuable to have a "classification system" for those drink-fighting thoughts, and at least one of those drinking scripts is guaranteed to hit a nerve if you are familiar with alcoholism.

Staying Sober: A Guide for Relapse Prevention

By Terence T. Gorski and Merle Miller

Reviewed by Diane J.


Readers interested in Gorski's Relapse Prevention Model (also known as the "CENAPS relapse model", from the name of Gorski's organization) will want Staying Sober, his standard text on the topic. Intended for the relapse-prone individual, and written, according to CENAPS, "at an eighth-grade reading level," Staying Sober goes point by point through Gorski's definitions of addictive disorders, "Post-Acute Withdrawal Syndrome (PAWS)" and its relation to relapse, mistaken beliefs about relapse, and the importance of family involvement and a support group. Gorski's central, and I think valuable, thesis is that relapse is a process that ENDS in the decision to drink or drug rather than an uncomplicated "out of the blue" event.

Offered in addition to the book is

Staying Sober Workbook:
A Serious Solution for the Problems of Relapse

by Terence T. Gorski

The Staying Sober Workbook appeared to me to cover much the same ground in "exercise" fashion, and would probably be very useful for people who are attracted by Gorski's approach and like the idea of working on specific assignments related to it. (I would read Staying Sober first before deciding on this one.)

Restore Your Life: A Living Plan for Sober People

By Anne Geller, M.D. with J. Territo.
ISBN 0-553-07153-X

Reviewed by Diane J.


If you were able to quit drinking or drugging before your addiction seriously damaged your relationships, your work life, and your health, you may find this to be a nicely-written but somewhat obvious volume of commonsense ideas. If you hit the end of your first week sober feeling like a stroke victim confronted with a series of knotted shoelaces and Chinese menus, however, you will find that Restore Your Life is an informative, compassionate, and mercifully secular guidebook for early sobriety.

Anne Geller, who is a physician and recovering alcoholic, notes in her introduction that, while there are many books available on spiritual growth, spirituality "is not the whole of this new life, just as the decision to become sober does not automatically make you a sober person." This is the last time you will hear anything about spirituality in the book until you reach the bibliography (this includes the chapter on attending AA, by the way). Geller focuses throughout on providing information and advice on conducting your daily life sober.

"To begin, you must know where you are," and the first three chapters are one of the best layman's guides to the physiological and emotional disturbances of early sobriety, from a good basic overview of neurochemistry through the damage that alcohol and other drugs can inflict and the symptoms that may appear. This may not be ideal reading for the hypochondriac, but if you are bothered by effects like short-term memory loss or geographic disorientation, it can be oddly comforting to find them listed and described in non-hysterical good English.

The chapters that follow include Geller's suggestions for handling stress and reducing mood swings; rebuilding your relationships with family and friends where possible; joining and using a support group (AA, of course, but Geller's instructions would apply equally well to nonAA groups); working sober and handling the aftermath of working NOT sober; beginning to establish healthy eating and exercise habits, dealing with insomnia, and establishing a health care routine for yourself.

The chapter on relapse prevention is based, as she notes, on the work of G. Alan Marlatt and includes an interesting relapse risk assessment tool. Other welcome features of the book include an unflustered, unshocked, and unhysterical chapter on "Sober Sex" which does NOT presume that the entire audience is heterosexual, male, and married; and "Smoke Free: Giving Up Cigarettes" which addresses the death rate among sober alcoholics from lung disease and argues for a completely addiction-free lifestyle for the sober.

Geller writes clearly and logically. While the book is the standard blend of explanation, exhortation and anecdotes about people with single names and multiple bad habits, she handles these ingredients well. Her anecdotes in particular are much less wooden than the usual recovery book stories, and the cast of characters less stereotyped and much more representative.

In the "Afterword," Geller speaks briefly about her own difficult and relapse-broken path to sobriety, and states "I have written the book I would have liked to read while I was struggling through the first three years of my recovery." I think that a great many people struggling with early sobriety will be grateful that she has.

Passages Through Recovery: An Action Plan for Preventing Relapse

By Terence Gorski

Reviewed by Diane J..

"Passages Through Recovery", on the other hand, is billed as a guide to Gorski's "Developmental Model of Recovery." It was originally a Hazelden publication, and the superior editorial input shows--this is a much smoother text than "Staying Sober". It is also a much more "generic recovery" type book, with sections devoted to working the 12 steps, co-dependency, and family of origin emotional issues (also the Hazelden touch, possibly).
In this work, Gorski divides recovery into six developmental stages: Transition, Stabilization, Early, Middle, and Late Recovery, and Maintenance (outlined first by Stephanie Brown in Treating the Alcoholic: A Developmental Model of Recovery (John Wiley, 1985). The "stage chapters" contain general comments by Gorski on each stage of recovery, exercises, and inspirational thoughts.

There are some useful things here, including an interesting exercise on the "Addictive Voice" (no credit given here either, unfortunately) and some thoughts on the challenges of maintenance. On the whole , though, I think the reviewer for the "Jerusalem Times" who called the book "a melange of trivia" was pretty fair.

Coming Clean: Overcoming Addiction Without Treatment

By Robert Granfield and William Cloud. Foreword by Stanton Peele ISBN: 0-8147-1582-6

Reviewed by Diane Jeanette

In the Winter, 1996 issue of the Journal of Drug Issues, Robert Granfield, a sociologist, and William Cloud, a professor of Social Work, both of the University of Denver, published a 15 page article called "The Elephant that No-one Sees: Natural Recovery Among Middle-Class Addicts." It was a nicely done report on the results of in-depth interviews with 46 survey respondents who had all terminated addictions without formal treatment AND without joining self-help groups.

The authors reported that their subjects had not, for the most part, chosen "addict" or "postaddict" identities, but preferred to view their addictions as "problems they had once had but had now solved." The 46 had avoided treatment and AA/NA because they disagreed with the ideology of "powerlessness," disliked the disease model, found the religious content of the programs offensive, and generally found 12step groups "dependent" and "unhealthy". In addition, most believed in their own abilities to terminate substance use "on their own" and felt strongly that focusing on weaknesses and defects would be counterproductive and shaming.

In the final section of the article, the authors pointed out that their respondents were all employed middle class or stable working class individuals with adequate educations and usually some strong personal relationships. These self-recoverers were almost certainly able to self-recover at least in part because they had external social and economic resources available to them.

This is interesting stuff. If you've ever battled with an addiction or been up against the 12step monolith it's positively fascinating stuff, and you might think there would be a good book in it. Well, Granfield and Cloud decided to spin this material into not one but two books: a scholarly sociological tome and a "popular" guide to various treatment methods.

Unfortunately, they have made bad choices in the presentation of this material almost every step of the way, in both books. Of the two, I would recommend reading Coming Clean, provided you are willing to skim or wade through slabs of the sort of discussion of the literature that is clearly intended to impress, or at least to exhaust, a promotion and tenure committee.

While it is impossible to doubt their sincerity and their interest in helping addicts, it is equally impossible to commend their writing abilities. When you read, in the Preface, that "The title, Coming Clean, denotes two distinct meanings. First, we use it as a way of invoking the popular metaphor for the process of terminating addictions. However, we also use this phrase as a metaphor for lifting the veil of secrecy surrounding the fact that most people overcome their addictions without ever entering formal treatment or participating in 12-step groups such as Alcoholics Anonymous, Narcotics Anonymous, or Cocaine Anonymous...." you are reading their prose at its best.

Coming Clean does, however, quote from and analyze those 46 surveys extensively in Part One, "Perspectives on Natural Recovery," and this material is worth wading through. Expanding on their 1996 article, Granfield and Cloud devote chapters to the process of addiction, the "conversion experience" (sociological definition) that leads to and powers early recovery strategies, and their subjects' attitudes toward the "disease concept" and self-labeling as "alcoholic" or "addict."

The last chapter of this section gives the authors' perspective on the social capital that facilitated their subjects' escapes from addiction: "The experiences of our respondents, who subscribed to an individualistic ideology of recovery, actually attest to the importance of the social relationships that surround and envelop them."

Part Two, "Implications of Natural Recovery," is largely devoted to the argument that this social capital should be considered "recovery capital," and treatment policy implications that might flow from this. Somewhat oddly, while the authors are clearly excited by "natural recovery" and disdain traditional treatment, they fuss repeatedly about their fear that their research will be used by those who want to abolish traditional treatment.

Granfield and Cloud plainly sympathize with their subjects' decisions to "resist disease-based significations of the self" and reject "the pejorative genealogies of the addicted self." They take some predictable and mostly deserved swings at the "hegemonic discourse of disease" and are fashionably skeptical about the necessity of abstinence in recovery. This attitude, however laudable, may have caused them to miss a real chance to ask some interesting questions, however.

Over 92% of their subjects chose permanent abstinence as the solution to their addiction problems. Given that these are subjects who furiously reject the disease model, deny that they are "recovering" or in any danger of relapse, and have no use for AA, how did the overwhelming majority among them come to decide on abstinence, as opposed to controlled use? And how do they construct satisfying identities as permanently abstinent but NOT permanently "recovering"?

Unfortunately, Granfield and Cloud are not interested in the issues surrounding the choice of abstinence as such, and indeed downplay the abstinence choices of their subjects, apparently because in their eyes "disease model" = abstinence only; "scientific model" = variety of outcomes. The 92% who chose abstinence and the 8% who chose moderation are all referred to as "natural recoverers," and no distinctions are discussed.

Nor does it seem to occur to them that people who don't believe addiction is a disease but yet choose to abstain instead of moderate probably try to explain this to themselves somehow. As a result, the book is rather baffling at times, as the authors push for a variety of outcomes model that is in fact unsupported by the data they have gathered.

Coming Clean is far from excellent, but it is worth reading, if only to meet the interview subjects who solved addictions by acting on their beliefs that, as one of them said, "it's your own sense of self and your own power over yourself and what you choose to do that matters."

(Also see my review of "Recovery from Addiction" by these same authors)

Recovery from Addiction: A Practical Guide to Treatment, Self-Help, and Quitting on Your Own

By William Cloud and Robert Granfield ISBN: 0-8147-1608-3

Reviewed by Diane Jeanette


Having buried interesting material in an impenetrable scholarly style in their first book, [Coming Clean] Granfield and Cloud (now Cloud and Granfield) proceeded to dish out pedestrian material in a wooden style in their second book, Recovery from Addiction. Presumably, what they started out to write was a how-to book on natural recovery -- an expansion of the miniature self-help guide they included in Coming Clean as an appendix. Why they, or their editors, decided that two authors with no liking for traditional treatment should combine a discussion of natural recovery with a plodding guide to traditional treatment is anyone's guess.

In addition, the authors were clearly ordered to offend no one in the treatment community (the largest potential market for "recovery books"). The result is Part One of this book, which contains little that is specific enough to be useful, although there is a nice short guide to alternative methods and their websites. You can learn, with some effort at parsing rambling sentences, that most inpatient treatment is 12step, that some people don't like AA because it seems religious to them, and that insurers would rather pay for outpatient treatment because it is cheaper. All of this in a style rather worse than the average email.

Here are Cloud and Granfield on the "group interview" process at a therapeutic community: "The experience can be more of a function of who happens to be a resident at the time of the interview than on [sic] the ability of the applicant to demonstrate a need for and willingness to comply with treatment demands." Here are Cloud and Granfield on estimating addiction severity: "If you or the person your [sic] are attempting to help are regularly injecting drugs, chances are that you or that person has a fairly serious problem or will soon have one if injection continues."

The authors themselves seem to suspect that they have not contributed much to the topic. At the opening of chapter 8, "Selecting an Approach that is Best for You", they actually warn the reader twice on the same page to go back and read the beginning of the book: "Before starting, we want to emphasize the importance of your having familiarized yourself with the other material presented earlier in this book. While you may find the suggestions offered in this chapter helpful without exposure to that content, these recommendations will be of limited value if you have not read chapter 2 through 7....If you are seeking assistance for another person....your friends, relatives and neighbors who might provide this kind of information are generally unaware of the serious kinds of treatment and self-help issues discussed in chapters 2 through 7." This chapter does contain a useful list of 10 questions to ask a treatment provider, but you deserve a medal if you manage to read that far.

Part Two, "Quitting on Your Own," is somewhat better. Much of it is lifted wholesale from the Appendix to Coming Clean, but as few people will persevere to the end of that volume, this makes little difference. Cloud and Granfield are encouraging about self-recovery, and make sensible suggestions concerning such subjects as "health and nutrition" (pay attention to it), "work" (do interesting work if you can get it), "physical exercise" (helps a great deal in early recovery) and "insomnia" (don't lose sleep over it). Granfield and Cloud are especially sensitive to the problem of stigma and the reluctance of people to identify themselves as addicts, and they offer some commonsense advice on disclosure. Their comments on "the Challenge of Moderation" are cautious, and respect their research results. Part Two, taken alone, is certainly not a complete guide to self-recovery, but it is a pretty good introduction.

The authors thank their editor, which makes them either the most courteous or the most oblivious of authors. The book is execrably edited throughout: principle for principal, discrete for discreet, and lack of attention to subject/verb agreement. The founder of Addiction Alternatives, Dr. Marc Kern, is "Marc Fern" in the text and "Mark Kern" on the cover blurb. And the endorsement from Jeffrey Schaler, while enthusiastic, has nothing to do with the actual book, which should have been apparent had he even read the subtitle. There was a very good book in there somewhere. I wish the authors had written it.

(Also see my review of "Coming Clean" by these same authors)