Mei-Yu Yeh
261, Wen- Hwa 1st Road, Kwei-Shan,
Tao-Yuan, 333, Taiwan, R.O.C.
E-mail: yehdiana@mail.cgit.edu.tw
TEL: +886-3-2118999 EXT: 5540
Fax: +886-3-2118866
Dear Editor(s),
Thank you very much for revising request on my manuscript “An ongoing process: A
qualitative study of how the alcohol-dependent free themselves of addiction through
progressive abstinence”.
All the review comments from your reviewer have been incorporated and addressed in
my revised edition and are listed below for your easy reference.
Reviewer’s comments:
1. In the authors’ revisions (pp. 20 – 21), they stated,
“By contrast, the other participants who cannot reach the Ongoing Process are reluctant to
admit that they are drunkards, and cannot accept the religious rituals arranged by self-help
groups due to Eastern and Western cultural differences. Based on interview data, a few
participants believe that they have not yet reached the point of inability to control alcohol
abuse, and find it hard to recognize themselves as drunkards. To be called a drunkard means
to be despised, and to be thought to have no sense of dignity. In traditional Chinese culture
men are treated with more respect than women, men have a relatively higher status in family.
When they join AA, alcohol-dependent individuals must admit they are drunkards through an
AA ritual. This creates a sense of being belittled and despised. Furthermore, the predominant
religions in Taiwan are Buddhism, Taoism and folk beliefs. To join AA, it is necessary to
accept western religious beliefs. Some participants said it is relatively difficult to accept
faiths you are unused to or which go against individual or the household religious tradition.
They cannot accept AA values and withdraw from the program after initial participation.”
My comments:
I think the addition of this portion by these authors added much value to their manuscript. I
also think these authors can perhaps provide some brief and tentative suggestions regarding
how to adapt Western AA to better fit the context of Chinese culture and local customs. For
example, perhaps the concept of “Higher Power” or spirituality, instead of a specific religion
(Christianity or other religions), can be emphasized. The third of AA’s 12 steps—make a
decision to turn our will and our lives over to the care of God as we understood Him—can
also be emphasized.
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Response:
We added some sentences to emphasize the differences of religion in the 7th to 13th lines
on page 21 (in blue highlight). In Western countries the term “God” is used, but we are use
“Buddha” in Taiwan or China. We think your comments are very important for the
self-help groups in handling the 12-steps about alcoholism.
2. In the authors’ revisions (p. 21), they stated,
“In Chinese culture, drinking alcohol is an obligatory social behaviour. In a culture where it
is impossible to avoid consumption of alcohol, alcoholics and their family members believe
that full prevention of drinking is hard to achieve, but if the goal is reducing the amount of
alcoholic consumed, this should be relatively easy to accept and achieve. This is also a
reason underlying self-rationalization by hospital inpatients. However, the results of our
studies show that those that wish to give up alcohol must abstain completely. They cannot
take a single glass. Harm reduction is not easily effective in achieving successful
abstinence.”
My comments:
I think it might be clearer if these authors modify their statements as follows: Although, in
general, alcohol consumption or alcohol drinking behavior is more prevalent in Western
countries than in Taiwan, for certain groups or sub-cultures in Taiwan or at certain special
events, drinking alcohol might be an obligatory social behaviour.
Response:
According your advice and a new reference (Yang MJ: The Chinese drinking problem:
a review of the literature and its implication in a cross-culture study. Kaohsiung J Med Sci
2002, 18(11): 543-549.), we modified the paragraph to describe the cultural difference in
drinking between westerners and Chinese in the last line on page 21 to the 10th line on
page 22 (in blue highlight).
3. I am not sure what the authors meant by “an obligatory social behaviour.” Traditionally,
among certain groups or at certain occasions, it may be perceived as somewhat disrespectful
or “bu gai main tze” (giving no face to others) if an individual refuses to drink when another
at the same table, or in the same room, invites him to drink. I think it might be helpful if
these authors can present some demographic data of the participants such as their ethnic
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backgrounds, education, and occupation or socio-economic status (SES). The aboriginals
may be more likely to drink or abuse alcohol than others in Taiwan; the working class may
be more likely than the middle class to abuse alcohol, whereas businessmen of middle or
higher SES may be more likely than their counterparts who are not businessmen to drink or
abuse alcohol, as drinking might facilitate getting a business deal done successfully. More
studies are needed to understand these issues in Taiwan and China.
I also suggest to take out or modify the statement “In a culture where it is impossible to avoid
consumption of alcohol,” as it may be misconstrued by some readers. Compared to the
western society, drinking alcohol is less of a part of daily life in Chinese society (tea is
probably more so). Rather, many Chinese drink mainly, or only, at special occasions such as
weddings, celebrations, or festivals.
Response:
Please refer to the last line on page 21 and ten lines on page 22 (in blue highlight). We
added the demographic data in the 2nd to 4th lines on page 6 and 10th to 12th lines in stage 2
section on the same page (in blue highlight). We stated the social relations in Chinese culture,
and said that if participants (AA) have a stable job they could refuse alcohol and have deep
faith that they can succeed in abstinence. According to the demographic data, AA
participants were anonymous, so that we had all the detail of drinking and abstinence
histories, ethnic background, education level, and whether or not they were working. This is
also the same as alcohol-dependent inpatients’ demographic data. In Taiwan, those of
aboriginal ethnic background are more likely to drink than Han, and have more drinking
problems. Our study participants were all Han, so that we could not compare with different
ethnic backgrounds.
4. Finally, these authors stated that “However, the results of our studies show that those that
wish to give up alcohol must abstain completely. They cannot take a single glass. Harm
reduction is not easily effective in achieving successful abstinence.” I agree with these
authors that for individuals with severe alcohol problems or alcohol dependence disorder,
even one drink can be too much and may lead to uncontrollable use. However, harm
reduction in this context can also be considered as a process aiming for the goal of total
abstinence. The “total abstinence” requirement might work for some individuals; however,
for others, it might be more effective to engage them for treatment initially by using harm
reduction strategies such as motivational interviewing.
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Response:
Please see the 3rd to 7th lines in the second section on page 22, and the 13th line in
limitations of the study on page 23 (in blue highlight). According your advice and a new
reference (Marlatt GA, Blume AW, Parks GA: Integrating harm reduction therapy and
traditional substance abuse treatment. J Psychoactive Drugs 2001, 33(1): 13-21.), we added
the explanation of harm reduction. It is based on AA participants’ viewpoint that abstinence
must mean total abstinence, but harm reduction may be suitable for inpatient alcoholics.
Hopefully, the aforementioned statements are helpful guides. Should you have any questions
please contact me at your earliest convenience.
Best Regards,
Mei-Yu Yeh
27 Oct 2009
E-mail: yehdiana@mail.cgit.edu.tw
Tel: +886-3-2118999, Ext 5540
Fax: +886-3-2118866
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