Vaillant's (1983) summary of the treatment literature indicated that the same kinds of environmental, social, and life changes accompany and encourage remission from alcoholism due to treatment. For example, Orford and Edwards (1977) discovered improved working and marital conditions were most responsible for positive outcomes in alcoholism treatment. The work of Moos and Finney (1983) has in recent years signaled a whole now focus on the life context of alcoholics in treatment. Vaillant noted several surveys have found "that the most important single prognostic variable associated with remission among alcoholics who attended alcohol clinics is having something to lose if they continue to abuse alcohol" (p. 191). This is another way of saying that treated alcoholics do best when they have other involvements which are important to them and which are inconsistent with continued addiction.

Relapse Avoidance as Moral Certitude

Relapse prevention model is currently a major focus of cognitive and behavioral therapies (Marlatt and Gordon, 1985; Brownell et al., 1986). Rather than concentrating on quitting an addiction (drinking, smoking, overeating, drug-taking), this model focuses on the internal and environmental forces that lead the individual to resume the addiction after having quit. The process of managing the urge to return to the addiction, particularly after the person has had an individual smoke, drink, or fattening dessert, is a special target for analysis and intervention. In Part I of Marlatt and Gordon (1985), Marlatt recommended balancing feelings of responsibility for and being able to control the addiction with avoiding guilt when the addict fails to do so and has a slip. The client can be wrecked either by overreacting with too much guilt or by denying the possibility of being able to control an urge to continue after having had a drink, smoke, etc.

Marlatt's sinuous and complex analysis - involving literally hundreds of pages - makes one pessimistic that any human being can safely steer a passage between the alternate shoals of assuming too much responsibility and guilt and not enough responsibility for his or her behavior. When some clients need to be brought into therapy, in Marlatt's view, to have another smoke but to be guided through feelings of powerlessness and guilt and reminded of how much they wanted to quit in the first place, we also may wonder what are the survival chances of their remission in the dangerous world out there. Are people ever able to get this straightened out on their own or are they forever obligated to belong to an AA, Weight Watchers, Smokenders group or else to return to their cognitive-behavioral therapist for lessons on relapse prevention? One wonders about the 25 million or so Americans who have managed this difficult passage on their own in the case of smoking alone.

While Shiffman (1985) and others have studied coping strategies of those who have quit smoking successfully on their own, these studies typically involve short-term follow-ups. In a larger time frame, reformed addicts may relinquish their original preoccupation first with withdrawal and then with relapse in order to become more concerned with broader issues like lifestyle and establishing and maintaining social networks. Wille (1983) found this post-withdrawal process was retarded for those in treatment, who were more preoccupied with and more dependent on therapy to keep them abstinent. Are these treated addicts manifesting differences they showed on entering treatment, or did treatment itself provoke such continued dependence? Interestingly, Waldorf (1983) found few differences between untreated and treated addicts in remission but for a tendency for untreated addicts not to believe abstinence was obligatory and to use heroin again without relapsing.

This difference suggests that therapy often serves the function of convincing addicts that a slip will cause them to relapse. Orford and Keddie (1986) and Elal-Lawrence et al. (1986) in England found that involvement with standard treatment programs and being convinced that controlled drinking was impossible were the main hindrances to resuming moderated drinking patterns. This may also explain why, in Vaillant's (personal communication, June 4, 1985) data, membership in AA was associated with greater relapse than quitting by oneself, since nearly all alcoholics drank again and those in AA were persuaded this meant they would resume alcoholic drinking. While clinicians in Marlatt and Gordon (1985) were at pains to encourage their patients' self-efficacy, these psychologists and others likewise indicate to patients that a great deal of therapeutic work needs to be performed to prevent the patients from relapsing.

The formerly obese subjects in Harris and Snow (1984) who averaged long-term weight loss of 40 pounds and who were not susceptible to eating binges show there is a further stage in addiction remission, one in which the person gets beyond devoting their major emotional energy to avoiding relapse. These reformed overeaters seem to have developed a new, stable image of themselves as nonobese people. Indeed, the mark of the cure of their addictive behavior is that they no longer need to rely on external supports to maintain their new behavior. Perhaps this is a goal to shoot for in therapy, since it guarantees such stable recovery outcomes. The essential cure in this case is the development of a confident, natural approach to avoiding relapse - a kind of moral certitude about the opposing issues of guilt and responsibility. Is this state obtainable through current therapy practices, or is the individual obligated to develop such a secure moral sense of self on his or her own?

Both natural and treated remission express people's values about themselves, their worlds, and the choices available to them. Marsh (1984), based on a survey of 2700 British smokers, found quitting smoking required that smokers "lose faith in what they used to think smoking did for them" while creating "a powerful new set of beliefs that non-smoking is, of itself, a desirable and rewarding state" (p. 20). While people may in some sense inadvertently become addicts, to continue life as an addict is an ultimate statement about oneself that many people are unwilling to make. The way they extricate themselves from addiction expresses additional values - about preferred styles of coping with problems ("For me to have to ask someone else to help with a self-made problem, I'd rather drink myself to death; Tuchfeld, 1981:631), how well they endure pain (such as withdrawal pain), or how they see themselves (after a difficult bout in defeating alcoholism, one of Tuchfeld's subjects declared: "I'm the champ; I'm the greatest," p. 630).

Conclusion

We have disarmed ourselves in combating the precipitous growth of addictions by discounting the role of values in creating and preventing addiction and by systematically overlooking the immorality of addictive misbehavior. In this way, scientists and treatment personnel contribute to the loss of standards that underlies our surge in addiction and criminal behavior by addicts. The steps we take - as in fighting the importation of drugs and introducing routine drug-testing - are exactly the opposite of the steps we need to take of creating more positive values among our drug-using young and holding people responsible for their drug use and other behavior. After the death of basketball star Len Bias, University of Maryland officials promised greater vigilance against drugs - even though they already had a model drug-testing program in place. Meanwhile, the University revealed Bias had failed all of his courses the previous semester.