Alcohol & Alcoholism Vol. 39, No. 1, pp. 71-72, 2004
© Medical Council on Alcohol 2004; all rights reserved
BOOK REVIEW
Shame, Guilt and Alcoholism — Treatment Issues in Clinical Practice, 2nd edn
Shame, Guilt and Alcoholism — Treatment Issues in Clinical Practice, 2nd edn. By Ronald Potter-Efron. The Haworth Press, New York. 237 pp., $24.95. ISBN 0-7890-1517-X.The first edition of this book appeared in 1989 and this new edition incorporates developments in the psychology of guilt and shame. The author is an experienced counsellor in mental health and addictions. Those reared on the importance of defining terms in a way that is categorical and susceptible to reproduction may worry about the elusive nature of the concepts involved here. He describes shame as ‘a painful sense of one's basic defectiveness as a human being’ and guilt as an ‘uncomfortable self conscious affect related to the fear of harming others’. One interesting consequence of this view is that shame typically prompts an individual to withdraw while guilt provokes reparative action. He then links both of these ‘self conscious emotions’ to alcohol misuse as viewed from a variety of psychological models of addiction such as the disease model, affect theory, family systems theory and functional theory (i.e. shame has served a purpose).
Excessive drinking can be a means of dealing with shame and guilt, and of course it can inevitably provoke and worsen these emotions. He discusses the well-known downward spiral of addiction and shame and the defences adopted to maintain self respect. In two helpful chapters he outlines his ‘guidelines for the treatment of shame’. The first tenet is one of the most important: ‘never shame a person feeling shame; shame only begins to heal when it is exposed within a safe environment’. He then moves on to a thoughtful consideration of the ways in which counselling can unravel the complex links between shame and addiction. The shift from self judgement to self acceptance is ably discussed.
That guilt and consequent reparation can be a positive emotion is well recognised in the eighth and ninth stages of AA. However, guilt can be maladaptive and the author acknowledges the need to help clients separate guilt which is rational and that which is irrational, excessive or misplaced. Fear of rejection or ostracism is prominent in maladaptive guilt. ‘Whereas shamed persons fear not being allowed to join the community, guilty individuals dread being thrown out of the group.’ These processes are particularly meaningful in group therapy. The emphasis in this book is on individual counselling but the applicability to group therapy is evident. There is a concluding chapter by Patricia Potter-Efron on creative approaches to shame and guilt in working with the adult children of alcoholics.
Any psychologist reading the book will wonder about clinical depression and the distorted prominence assigned to guilt and shame in this condition. The author does briefly acknowledge the importance of screening ‘clients with shame concerns for past and current depression’. A little more consideration would have been welcome. It is also surprising that there is virtually no consideration of religious beliefs and conversion experiences which commonly appear in accounts of recovery processes.
This book is very readable and well set out and clearly draws from extensive experience of teaching and practice. It is inevitably embedded in office practice from the US and some parts will travel better than others. It should prove valuable for practitioners and trainees in counselling alcoholics.
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