Source: Journal of Drug Issues, Vol. 17(2) (1987): 187-215.
How People's Values Determine Whether They Become and Remain Addicts
Contemporary theories of addiction of all stripes rule out faulty values as a cause of addiction. Yet evidence from cross-cultural, ethnic, and social-class research, a laboratory study of addictive behavior, and natural history and field investigations of addiction indicate the importance of value orientations in the development and expression of addictive behaviors, including drug and alcohol addiction, smoking, and compulsive eating. Furthermore, the rejection of moral considerations, in addition, deprives us of our most powerful weapons against addiction and contributes to our current addiction binge. The disease myth of addiction in particular attacks the assumption of essential moral responsibility for people's drug use and related behavior, an assumption that we instead ought to be encouraging.
[John] Phillips is not altogether realistic about himself. He recalls that when he was a postman, he threw mail away because his mailbags were too heavy; as a graveyard plot salesman, he received down payments, pocketed the money and never recorded the transactions. Still, on page 297 of a 444-page book, in reporting how he skipped out on a $2,000 hotel bill, he writes, "My values were beginning to corrode under the prolonged influence of hard drugs." (Finkle, 1986:33)
Thomas (Hollywood) Henderson, the former Dallas Cowboy linebacker, who has been jailed in California since 1984 on sex charges involving two teenage girls, will be released this week and has already been scheduled for a paid speaking tour to talk against drug and alcohol abuse. Henderson was an admitted drug user. (New York Times, October 14, 1986:30)
Introduction
The scientific study of addiction has strongly opposed value considerations in addiction, regarding these as remnants of an outdated, religious-moral model. Behavior therapists, experimental psychologists, and sociologists hold this view in common with disease theorists who have championed the idea that a moral perspective oppresses the addict and impedes progress toward a solution for alcoholism and addiction. Many social scientists and others, however, believe the disease approach actually is just another form of the moral model, and that "the acceptance of the 'disease' concept ... [has] covertly intensified rigid moralizing" (Fingarette, 1985:60). It has accomplished this by embodying the evil of addiction in the use of the substance - in any use of such drugs as cocaine and in any kind of drinking by those with alcohol problems - and by urging abstinence as if it represented a modern scientific and therapeutic invention.
Nonetheless, the aim of "demoralizing" addiction retains a strong appeal for liberal observers and for social and behavioral scientists. In fact, social researchers frequently bemoan the strong tendencies for both general populations and treatment personnel to continue to see addiction in moral terms even as most people ostensibly endorse the fashionable model view of addiction as a disease (Orcutt et al., 1980; Tournier, 1985). In other words, as scientists, they wish to stamp out entirely people's continuing tendency to regard addiction as a reflection of the addict's moral qualities and to hold people responsible for addictive behavior. The view of the present paper, on the other hand, is that appetitive behavior of all types is crucially influenced by people's pre-existing values, and that the best way to combat addiction both for the individual and the society is to inculcate values that are incompatible with addiction and with drug- and alcohol-induced misbehavior.
I sat with an older woman watching a program in which a woman who directed a prominent treatment program described how, as an alcoholic in denial, she drank alcoholically throughout her years as a parent, thus raising six children who all either became substance abusers or required therapy as children of an alcoholic. The woman's argument was that she had inadvertently inherited her alcoholism from her two alcoholic grandfathers (a model of genetic transmission of alcoholism, incidentally, which no one has actually proposed). The woman I was sitting with clucked about how insidious the disease was that it could make a mother treat her children this way. I turned to her and asked: "Do you really think you could ever have gotten drunk and ignored your children, no matter how delightful you found drinking or how it relieved your tension or however you reacted to alcohol genetically?" Neither she nor I could imagine it, given her values as a parent.
Scientists have ignored successful, value-based personal and social strategies against addiction because of their uneasiness about making distinctions among value systems. Their reluctance is counterproductive and, put simply, wrong on the evidence. The evidence that a person's or group's values are essential elements in combating addiction include the following areas of research: (1) the large group differences in the successful socialization of moderate consumption of every kind of substance; (2) the strong intentional aspects of addictive behavior; (3) the tendency for some people to abuse a range of unrelated substances and to display other antisocial and self-destructive behaviors; (4) developmental studies that repeatedly discover value orientations to play a large role in styles of drug use in adolescence and beyond; (5) the relationship of therapeutic and natural remission to personal value resolutions by addicts and to life changes they make that evoke values which compete with addiction.
How Do Some Groups Encourage Almost Universal Moderation and Self-Control?
The power of the group to inspire moderation of consumption is perhaps the most consistent finding in the study of addictive behavior. Even the most ardent supporters of the disease theory of alcoholism, including Jellinek himself, clearly indicated that cultural patterns are the major determinants of drinking behavior. Vaillant (1983), while defending the disease theory, claimed alcoholism had both a cultural and a genetic source. He noted that Irish-Americans in his core-city sample were seven times as likely to be alcoholic as were those of Mediterranean descent (Italians and Greeks, with some Jews). Clinical outcomes in this study, such as return to moderate drinking, were more closely tied to ethnic group than they were to numbers of alcoholic relatives, which Vaillant used as a measure of genetic determination of drinking.
Vaillant, like Jellinek, explained these data in terms of cultural differences in visions of alcohol's power and in the socialization of drinking practices. Yet this kind of explanation of group differences does not fit well with Vaillant's professed belief in inbred sources of individual drinking problems. Vaillant's ambivalence is indicated by his explanation for the large social-class differences in alcoholism he found: this core-city group had an alcoholism rate more than three times as great as that for his Harvard-educated sample. Vaillant suggested this discrepancy was due to the tendency for alcoholics to slide down the social ladder, in which case inherited alcoholism would be more prevalent in lower social classes. Among other problems with his explanation is its failure to take into account the ethnic differences in the composition of his two samples (almost entirely recent ethnic immigrants in the core-city group, predominantly upper-middle-class WASPs in the pre-World War II Harvard sample).
Vaillant's uneasiness about group differences in alcoholism rates is common among clinicians and other representatives of the dominant alcoholism movement in the United States, although it is certainly not limited to these groups. For example, a number of years ago the NIAAA published a popular poster entitled "The typical alcoholic American" that depicted a range of people from different ethnic, racial, and social groups, of different ages, and of both sexes. The point of the poster, obviously, was that anyone from any background could be alcoholic, a point often made in contemporary media presentations about alcoholism. Strictly speaking, this is true; at the same time, the poster ignores fundamental and major differences in alcoholism rates that appear with regard to almost every demographic category it depicted. Without an awareness of those differences, it is hard to imagine how a researcher or clinician could understand or deal with alcoholism.
One mark of the disbelief in social differences in alcoholism has been the tendency to hunt for hidden alcoholics in groups that ostensibly display few drinking problems. We are told regularly, for instance, that so many more men than women are in alcoholism treatment because the stigma attached to women's drinking problems prevents women from seeking treatment. In fact, indications are that women with drinking problems are more likely than men to seek therapy for alcoholism, as they are for all kinds of psychological and medical problems (Woodruff et al., 1973). Epidemiological investigations find that women have far fewer drinking problems than men by every kind of measure (Ferrence, 1980). Even researchers with biological and disease orientations find powerful sex differences in alcoholism. Goodwin et al. (1977), for example, found 4% of women with alcoholic biologic parents were alcoholic or had a serious drinking problem; the authors suggested that since from .1 to 1% of women in Denmark (where the study was conducted) were alcoholic, the findings hinted at a genetic component to female alcoholism, although the small number of female alcoholics discovered in the study forbade definitive conclusions.
Another group popularly singled out for denying their alcohol problems is the Jews. All surveys find Jews underrepresented among problem drinkers and alcoholics (Cahalan and Room, 1974; Greeley et al., 1980). Glassner and Berg (1980) conducted a survey of a Jewish community in an upstate New York city with the hypothesis "that low alcohol abuse rates among Jews resulted more from the ability to hide excessive drinking [and research methodology flaws] ... than from actual drinking patterns of Jews" (p. 651). Among 88 respondents, including both observant and nonpracticing Jews, Glassner and Berg discovered no problem drinkers. Even by accepting at face value all reports of Jewish alcoholics by zealous community alcoholism representatives, the researchers calculated an alcoholism rate far below that for Americans at large (less than 1%, probably closer to 1 in 1,000). Such research in no way discourages frequent claims that Jewish alcoholism is on the increase and may be rampant, and that Jews have an urgent need to deal with the denial brought on by the stigma they attach to alcoholism.
One particularly interesting cultural difference in alcoholism rates concerns Asian and Native American populations. That is, the large-scale alcohol problems often described among Indian and Eskimo groups have been attributed to the way these racial groups metabolize alcohol. Native Americans often show a quick onset of intoxication and a visible reddening from ingesting small amounts of alcohol. Unfortunately, while reliable racial differences in processing alcohol have been measured, these do not correlate with alcohol abuse (Peele, 1986). In particular, Chinese and Japanese Americans, who have the same reactions to alcohol as do Native Americans, display according to some measures (such as alcohol-related crime and violence) the very least alcohol abuse among American ethnic and racial groups, measures by which Indians show the highest such rates.
What Accounts for Cultural Differences in Alcoholism?
The effort to explain Native American alcoholism by way of racial differences is, of course, another version of the denial of the importance of social learning in addiction. A related suggestion is that natural selection has weeded out those susceptible to alcoholism in groups that have a long history of drinking, and that this elimination of alcoholics in some races accounts for their lower alcoholism rates. Besides displaying a Lysenko-like optimism about the speed of genetic adaptation, this hypothesis neglects important elements in the history of drinking. Aboriginal Indian groups did drink beverage alcohol and therefore were available for a similar racial elimination of alcoholism; moreover, different Indian groups in Latin and North America have had very different experiences with problem intoxication, depending usually upon their relation to Caucasians (MacAndrew and Edgerton, 1969).
Jews, on the other hand, have been known as moderate drinkers since Biblical times - that is, from their first identification as a group distinct from the racially related Semitic populations that surrounded them (Keller, 1970). This analysis strongly suggests that their belief system from the beginning distinguished the Jews from their neighbors. Some theorists have speculated that Jewish moderation stems from the group's perpetual minority status and the premium this has placed on self-control and intellectual awareness (Glazer, 1952). Similar kinds of cultural explanations have been used to account for the notable drinking patterns of other groups. For example, Bales (1946) analyzed frequent problem drinking among the Irish as a reflection of a world view that is at once flamboyant and tragic. Room (1985) points out that Indian groups lack a value for self-control that would inhibit excessive drinking or drunken misbehavior.
Maloff et al. (1979) summarized the results of decades of social-scientific observations of cultural drinking styles and other consumption practices in detailing cultural recipes for moderation. One rather remarkable element in cultural recipes for moderate consumption is illustrated by the cases of Jewish and Chinese-American drinking. As described by Glassner and Berg (1984:16), "Reform and nonpracticing Jews define alcoholism in terms of psychological dependency and view suspected alcoholics with condemnation and blame." In other words, Jews guarantee almost universal moderation by explicitly rejecting the major contentions of the disease theory of alcoholism, including a belief in biological causation and the need for a nonpunitive attitude toward habitual drunkenness. Jews instead strongly disapprove of drunken misbehavior and ostracize those who do not conform to this standard of conduct.
The Cantonese Chinese in New York City, as described by Barnett (1955), employed a similar approach in disapproving of and applying powerful group sanctions to those who do not control their drinking. These people simply refused to tolerate loss-of-control drinking. As a part of his study, Barnett examined police blotters in the Chinatown district of New York. He found that, among 17,515 arrests recorded between 1933 and 1949, not one reported drunkenness in the charge. Are these Chinese suppressing alcoholism or simply its overt manifestations? Actually, since drunken arrest is a criterion for alcohol dependence in DSM III, its elimination automatically eliminates a central element of alcoholism. All this is academic, however. Even if all these Chinese accomplished was to eradicate drunken misbehavior and violence in a crowded urban area for 17 years, their model is one America as a whole could emulate with great benefit. 1
This Chinese case study stands in stark contrast to that of an Ojibwa Indian community in northwest Ontario studied by Shkilnyk (1984). In this community, violent assault and suicide are so prevalent that only one in four die of natural causes or by accident. In one year one-third of the children between five and fourteen were taken from their parents because the parents were unable to care for the children when almost continuously drunk. This village was marked by a "cycle of forced migration, economic dependence, loss of cultural identity, and breakdown in social networks" (Chance, 1985, p. 65) that underlay its self-destruction through alcohol. At the same time, the people of this tribe had an absolute belief that alcoholism was a disease they could not control. The title of this work, "A poison stronger than love," comes from a village resident who declared "The only thing I know is that alcohol is a stronger power than the love of children."
Can somebody seriously recommend converting Chinese or Jewish populations to the conception of alcoholism as an uncontrollable disease - one that is not indigenous to their cultures? What might we expect from such a conversion? MacAndrew and Edgerton (1969) surveyed cultural differences in attitudes toward alcohol in relation to drinking patterns. Their primary finding was that drunken comportment took a specific form in each society, a form that often varied dramatically from one cultural setting to another. Societies accepted that drunkenness led to certain behaviors and, not surprisingly, had a high incidence of such behaviors - including violence and alcoholic crime. In other words, societies have varying notions of both the degree and the results of loss of control caused by drinking, differences with major consequences for behavior. Similar differences in the belief that alcohol causes misbehavior have also been found to hold for individuals within American culture (Critchlow, 1983).
The Causes and Consequences of the Denial of Social Forces in Addiction
The measurement of social variation in the addictive and appetitive behaviors often achieves an order of magnitude comparable to that Vaillant found between Irish- and Italian-American drinking styles. For example, in the case of obesity, Stunkard et al. (1972) found low-socioeconomic-status (SES) girls were nine times as likely to be fat by age 6 as high-SES girls. Is there a cultural bias against such social-scientific findings compared with results that are seen to indicate genetic or biological causality? If some biological indicator were found to distinguish two populations as well as ethnicity does in the case of alcoholism or SES does in the case of childhood obesity for women, the discovery would surely merit a Nobel Prize. Instead, in our society, we ignore, minimize, and deny socially based findings.
In other words, rather than Jews denying their alcoholism, the alcoholism movement is practicing massive denial of social factors in alcoholism. We commonly read reviews of the literature which declare that research findings with regard to social differences run exactly counter to standard wisdom in the field. Thus, "The stereotype of the typical 'hidden' female alcoholic as a middle-aged suburban housewife does not bear scrutiny. The highest rates of problem drinking are found among younger, lower-class women ... who are single, divorced, or separated" (Lex, 1985:96-97). Unemployed and unmarried women are far more likely to be alcoholics or heavy drinkers (Ferrence, 1980). Why are such findings regularly denied? In part, middle-class women (like Betty Ford) are eagerly sought as alcoholism patients because of their ability to pay for therapy and because their prognosis is so much better than that for lower-SES or derelict women.
Perhaps also in America this denial comes from a pervasive ideology that minimizes class distinctions. It is seen as an additional and unwarranted burden to the oppressed to announce that low-SES women are far more likely to be obese (Goldblatt et al., 1965), that low-SES men are far more likely to have a drinking problem (Cahalan and Room, 1974), and that the greater likelihood for lower-SES people to smoke has become increasingly pronounced as more middle-class smokers quit (Marsh, 1984). In general, social class is correlated with people's ability and/or willingness to accept and act upon healthful recommendations. The health belief model finds that health behaviors depend on the person's sense of self-efficacy, the value the person places on health, and the person's belief that particular behaviors really make a difference to health outcomes (Lau et al., 1986).
The alternative to discussing such issues in terms of values is usually to ascribe addiction, alcoholism, and obesity to biological heritage. But what are the consequences of believing, as Vaillant (1983) claimed (with so little evidence), that low-SES people are more often alcoholic because their parents' alcoholism has propelled them downward economically and socially, and that they harbor a biological inheritance likely to perpetuate this trend? What should we make of the high incidence of alcoholism, drug addiction, cigarette smoking, and obesity among black Americans? Should we believe they have inherited these tendencies, either separately or as one global addiction factor? This thinking offers little chance for improving the lot of those who suffer the worst consequences of addiction.
In addition to less secure values toward health, lower socioeconomic status seems to be associated with the failure to develop effective strategies for managing consumption. The best illustration of this is the presence of high abstinence and abuse levels in the very same groups. For example, in the United States, the higher a person's SES, the more likely a person is both to drink at all and to drink without problems (Cahalan and Room, 1974). Low SES and minority racial status make people both more likely to abstain and more likely to require treatment for alcoholism (Amor et al., 1978). It is as though, in the absence of a confident way of drinking, people strive to avoid alcohol problems by not drinking at all. This strategy is highly unstable, however, because it depends mainly an the person's ability to remain outside drinking or drug-using groups throughout his or her lifetime.
It seems often that the secrets of healthful behavior are limited to those who already possess them. Many middle- and upper-middle-class people appear to gain this knowledge as a birthright, even when they endorse disease theories of alcoholism. Despite Vaillant's (1983) emphasis on the uncontrollable nature of alcohol abuse, an illustration accompanying the Time magazine piece on Vaillant's book showed the Valliant family taking wine with a meal. The caption read: "Wine is part of the meal an special occasions for the Vaillants and Anne, 16, and Henry, 17. 'We should teach children to make intelligent drinking decisions'" ("New Insights into Alcoholism," 1983:64). In his book, Vaillant (1983:106) advised that "individuals with many alcoholic relatives should be ... doubly careful to learn safe drinking habits," although he nowhere discussed how this is to be done.
When I observe public health officials, academicians, and the largely managerial class of people I know, I find almost none smokes, most dedicate themselves to physical fitness and exercise, and hardly any have time for drinking or taking drugs in a way that leads to unconsciousness. I haven't attended a party in years where I have seen anyone get drunk. I am perplexed when these same people make public health recommendations or analyze addictions in a way that removes the locus of control for addictive behavior from the individual and places it in the substance - as when they concentrate on preventing people ever from taking drugs, treat alcoholism and comparable behaviors as diseases, and explain overweight as an inherited trait - all exactly opposite to the approach that works in their own lives. This anomaly marks the triumph of the very values and beliefs that have regularly been shown to lead to addiction; it is a stunning case of bad values chasing out good.
The explanation for this perverse triumph starts with the success of a majority of people with the worst substance abuse problems in converting the majority population to their point of view. For example, Vaillant (1983) explained how several alcoholics educated him about alcoholism, thereby reversing the point of view he previously held (Vaillant, 1977) and placing him in conflict with most of his own data. This triumph of bad values is due also to the dominance of the medical model in treatment for psychological problems in the U.S. - and especially the economic benefits of this model of treatment, residual superstitions about drugs and the tendency to convert these superstitions into scientific models of addiction (Peele, 1985), and a pervasive sense of loss of control that has developed in this country about halting drug abuse.
Do Human Beings Regulate Their Eating Behavior and Weight?
The idea that people regulate their consumption in line with personal and social values is perhaps most disputed in both popular and scientific circles in the case of obesity. People we know all the time strive but fail to achieve a desired weight. Strong evidence has been presented and widely publicized that weight and obesity are genetically determined. If this is the case, then the attempt to restrain eating to achieve a healthy, but biologically inappropriate, weight is doomed and is likely to lead to eating disorders like bulimia and anorexia that are rampant among young women. This view of the futility of conscious restraint of eating has been most emphatically presented by Polivy and Herman (1983).
Yet there are also strong commonsensical indications that weight is closely associated with social-class, group, and individual values: after all, the beautiful people one watches in movies, television, and performing music seem very much thinner (and better looking) than average. In this section, I examine the idea that weight and eating behavior are under cultural and individual control by tracing the work of three prominent researchers and their followers: (1) psychiatrist Albert Stunkard, who established that weight is greatly influenced by social group and yet who has sought to prove that weight is a biological inheritance; (2) social psychologist Stanley Schachter (and several of his students), who have striven to show through experimental research that eating behavior is irrational and biologically determined; and (3) physical anthropologist Stanley Garn, who depicts human weight levels as largely malleable and adaptable to social standards.
Albert Stunkard and the Inheritance of Overweight
Stunkard conducted some of his most important research on obesity as an epidemiologist with the Midtown Manhattan study, where he found low-SES women were six times more likely to be obese than were high-SES women (Goldblatt et al., 1965; cf. Stunkard et al., 1972). Differences in obesity rates were also apparent among ethnic groups in the Manhattan study; for example, obesity was three times as prevalent among Italian as English women. What emerged from these data, however, was the flexibility of weight level, since members of the same ethnic groups showed considerable movement toward the American mean the longer they remained in America and the higher their socioeconomic status became. In other words, people (especially women) zeroed in on the American ideal of thinness to the extent they became integrated into the mainstream of the American middle class.
Stunkard (1976), however, expressed little faith in conventional psychological accounts of obesity and looked more toward a biological basis for overweight, even as he stressed behavior modification techniques for losing weight. Recently, Stunkard et al., (1986) elicited a tremendous media reaction when they found, in a study of Danish adoptees, that biological inheritance swamped any environmental effects in determining weight levels. Despite this discovery, Stunkard remained committed to a program of weight loss for high-risk populations who can be targeted for weight-control programs at an early age based on their parents' obesity ("Why Kids Get Fat," 1986).
Stanley Schachter and His Students and the Social Psychology of Obesity
Stanley Schachter (1968), a pioneering social psychologist, extended his work on the cognitive determination of emotions to the idea that fat people labeled their hunger based on external cues, rather than on the actual state of their stomachs. That is, instead of deciding whether they were hungry based on how full they were, they heeded such cues as the time of day or presence of inviting food to make decisions about eating. While the "externality" model of overeating initially showed promising results in a series of ingenious experiments, it later came under fire and was rejected by prominent students of Schachter's who had collaborated on much of the externality model research in the 1960s and 70s (cf. Peele, 1983). For example, Rodin (1981) repudiated the externality model of obesity primarily because there are externally oriented eaters at all weight levels.
Nisbett (1972) proposed that people's weight levels themselves (as oppose to external eating styles) are set at birth or in early childhood, so that when weight descends below this level the hypothalamus stimulates eating until the natural weight level is regained. This is one version of the so-called set-point model, which has enjoyed tremendous popularity. Rodin (1981) rejected the set-point model based on research that shows women who have lost weight do not show greater responsiveness to food cues, as set-point predicts. Rodin herself, however, emphasized physiological factors in overweight and held out the possibility that "arousal-related overeating" can be explained "without relying on psychodynamic factors" (p. 368). She also noted the self-maintaining nature of overweight, a kind of inertial adaptation by the body that might be called a model of "relative set-point" - people tend to stay at the weight level they are at.
Despite the strong emphasis on inbred and physiologic causes of overweight that characterizes the writing and research of Schachter and such Schachter students as Rodin, Nisbett, and Herman, subjects in their research often appear spontaneously to achieve self-directed weight loss and desired weight levels. For example, Rodin and Slochower (1976) found that girls who reacted strongly to external cues gained more weight than others at a food-rich camp, but that these girls frequently managed to lose much of this weight before returning home, as though they were learning how to respond to their new environment in order to maintain their preferred weight. Schachter (1982) himself discovered long-term weight loss was a relatively common event. Sixty-two percent of his ever-obese subjects in two communities who had tried to lose weight had succeeded and were no longer obese, having taken off an average of 34.7 pounds and kept the weight off for an average of 11.2 years. This result strongly contradicted previous statements by Schachter, Nisbett, and Rodin, to wit, "Almost any overweight person can lose weight; few can keep it off" (Rodin, 1981:361).
Although the dominant view of obesity - even including this group of prominent social psychologists - has insisted on the biological determination of weight level and has strongly resisted the idea of social and cognitive regulation of weight, a body of social-psychological literature supports the impact of parental socialization on eating and obesity. For example, Wooley (1972) found that both obese and normal-weight subjects did not regulate their eating based on the actual caloric content of the food subjects ate, but that they did respond to the amount of calories they thought this food contained. Milich (1975) and Singh (1973) discussed findings that indicate subjects may respond very differently in natural settings - where other matters are important to them - than they do in the typical laboratory settings where set-point and externality research have been conducted. Woody and Costanzo (1981) explored how learned eating habits (such as the types of food young boys eat) in combination with social pressures lead to obesity or its avoidance.
Stanley Garn and the Social Relativity of Eating Behavior
When leading social-psychological researchers espouse biogenic theories of obesity, we aren't likely to find much space given to models of overweight and of eating behavior based on parental and cultural socialization and value-oriented or other goal-directed behavior (cf Stunkard, 1980). The most comprehensive body of data opposed to reductionist models of obesity like set-point has been presented by an anthropologist, Stanley Garn. The primary point of departure for Garn (1985) is evaluating whether "fatness" changes or remains constant throughout the individual's lifetime, based on Garn's own and several other large-scale longitudinal investigations. Indeed, it is remarkable that both proponents of set-point and later revisions of the idea that obesity is intractable (such as Schachter, 1982) make no reference to epidemiological studies that directly test this question of constancy of weight levels and fatness.
These data contradict the set-point hypothesis in the most direct way possible. "Taking all of our data into consideration, and the more relevant data from the literature, it is clear that fatness level is scarcely fixed, even in adults. Some 40 percent of obese women and 60 percent of obese men are no longer obese one decade and two decades later. The percent of obese who become less than obese increases in succession for adolescents, for children, and finally for preschool children. Three quarters of our obese preschoolers were no longer obese when they were young adults. To the extent that fatness level is not fixed for long we may have to reconsider some of the more popular explanations for obesity" (Garn, 1985:41). The finding that the earlier the age of initial assessment the less continuity there is with adult fatness particularly contradicts assertions like those by Polivy and Herman (1983) that those who do lose weight, such as Schachter's (1982) subjects, do not have genuine set-point obesity as measured by childhood fatness.
Garn (1985) also evaluated the question of inheritance of obesity and came to conclusions diametrically opposed to those announced by Stunkard et al. (1986), although Garn's work seems somehow to invite less media attention than the Stunkard group's. In general, Garn et al. (1984) also found continuities in parental-child fatness. However, this correlation peaked at age 18 and declined thereafter, as children left home. The correlation Garn found between adopted children and biological relatives decreased the earlier the age of adoption. Data like these have prompted Garn to propose the "cohabitation effect," based on the idea that "family-line resemblances in fatness, however striking, may be less the product of genes held in common than of the living-together effect" (Garn, 1985:20-21).
Resolving the Irresolvable - What Does Weight Have to Do with Values?
How do we account for the nearly opposite conclusions reached by Garn (1985) and Stunkard et al. (1986)? Perhaps these are due to different measurements - in Stunkard et al. the measure is body mass, which varies with height (and leg length) while in much of Garn's work (and Stunkard's Midtown Manhattan research) the measures were of actual fatness (such as triceps skin-fold thicknesses). Interestingly, in Stunkard et al.'s (1986) but not in Garn's (1985) data, childhood weight correlated far more with mother's than father's weight - a difference which would seem more the result of feeding habits than genetic inheritance. Nonetheless, despite their opposite points of departure, Garn and Stunkard have issued almost identical statements about the relevance of their findings: for Garn et al. (1984:33), "The largely learned family-line nature of fatness and obesity becomes important in the early diagnosis of obesity, the prevention of obesity, and in ... fatness reduction."
Stunkard "suggests that the children of overweight parents could be targeted for intensive weight-control measures, particularly vigorous exercise programs.... Such notions are the backbone of ... [Stunkard et al.'s] new weight loss program for black teenage girls" ("Why Kids Get Fat," 1986:61) - or, in other words, exactly the same group Stunkard et al. (1972) found to suffer obesity from a socioeconomic source. This popular news magazine story was accompanied by a photograph of a slender Stunkard and another thin researcher with an obese black woman, her husky husband, and their overweight daughter. Apparently, whatever the source of obesity, it infects underprivileged groups more readily and it becomes less likely when people are aware of the dangers of obesity and have the resources with which to combat it.
The most emphatic rejection of the idea that people successfully achieve desired weight levels through planned eating strategies was presented by Polivy and Herman (1983:52), who argued "for the forseeable future, we must resign ourselves to the fact that we have no reliable way to change the natural weight that an individual is blessed or cursed with." Instead, the effort to go below this preordained body weight by restraining eating is doomed to failure, a failure often marked by compulsive dieting, episodic binge eating and subsequent guilt and self-induced vomiting that characterize bulimia (Polivy and Herman, 1985). Polivy and Herman's model is a complex one that emphasizes the role of cognitive factors in binge eating and that it is not weight loss per se, but dieting as a method of weight loss that leads to eating disorders.
There are certainly strong grounds to say that the marketing of unrealistically thin images of beauty leads to bulimia, because people (usually young women) strive for a weight goal unobtainable through their ordinary eating habits. There is nothing that requires, however, that biological inheritance creates "natural" body weight or prevents people from being as thin as they like. Polivy and Herman's work has regularly found that all people restrain their eating - after all, most people don't eat banana splits for breakfast, no matter how delicious an idea this is in the abstract. Bulimia could as easily be described as the failure of some people's habitual eating habits to bring about desired weight and hence their need to rely on unsuccessful dieting techniques. On the other hand, people generally conform to cultural norms of weight and thinness, change their weight as they change social groups, and frequently (though not inevitably) bring their weight (and eating) in line with a desired self-image.
Harris and Snow (1984) found that people who maintained considerable weight loss (an average of 40 pounds) displayed little binge eating, in contrast to unsuccessful dieters who had lost less weight and regained it. Apparently, there are better and worse ways to go about losing weight. We all know such stable examples of weight loss because they frequently appear on our television and movie screens, in the forms of entertainers and actors like Cheryl Tiegs, James Coco, Judith Light, Lynn Redgrave, Dolly Parton, Joan Rivers, professional weight watchers like Jean Nidetch and Richard Simmons, and athletes like Joe Torre, Billie Jean King, John McEnroe, and Chris Evert Lloyd. Perhaps no group of people has greater motivation and opportunity to become biologically new people than those who go before the public, and they regularly take up this opportunity. Polivy and Herman's pessimism and recommendation that people accept whatever weight they find themselves at lest they do themselves more harm than good represents more a world view than a proven empirical position (Peele, 1983).
Addiction as Intentional, or Value-Driven, Activity
My argument is that in a real sense, people select their weight and obesity levels in line with who they are. In particular, the continuous excessive eating or periodic binge eating that most correspond to addiction cannot be understood biologically. Yet a crucial image of addictive behavior is that it is uncontrollable. Otherwise, people would simply cease doing whatever it was (overeating, overdrinking) that caused them problems or brought about undesired results. Levine (1978) argued that the idea of loss-of-control drinking inaugurated the modern conception of addiction and was first used at the turn of the eighteenth century to explain excessive drinking. In recent years, loss of control à la the addiction model has become increasingly popular as an explanation for all sorts of self-defeating and self-destructive behavior (Room, 1985). Still, the concept of loss of control is nowhere more insistently marketed today in the definition of alcoholism, most notably by Alcoholics Anonymous.
To challenge the notion of loss of control, as Marlatt and Gordon (1985) and others have done, is to reorient our thinking about addiction in a manner whose impact has not yet been fully explored. To begin with, that addicts often do things they regret and wish they could change does not distinguish their behavior from much ordinary behavior; nor does their desire to reorient the larger pattern of their life and their inability to do so. In the words of philosopher Herbert Fingarette (1985:63): the "difficulty in changing the large pattern [of alcoholism] is not an 'impairment' of self-control; it is a normal feature of anyone's way of life.... This is no mystery or puzzle, no rarity, no pathology or disease needing a special explanation." From this perspective, addiction is a medicalized version of an essential element in all areas of human conduct, an element that has been noted throughout history but which has for the most part been explained by concepts of habit and will or the lack of it.
Neither laboratory nor epidemiological experimentation provides support for the idea that alcoholics lose control of their drinking whenever they consume alcohol. That is, drinking alcohol does not inevitably, or even typically, lead to excessive drinking by the alcoholic. Moreover, experiments with alcoholics demonstrate that they drink to achieve a specific state of intoxication or blood alcohol level: that they are often self-conscious about this state, what it does for them, and why they desire it; and that even when they become intoxicated, they respond to important dimensions of their environments which cause them to drink less or more. In other words, although alcoholics often regret the effects of their drinking, they do regulate their drinking in line with a variety of goals to which they attach more or less value (cf Peele, 1986).
The failure of loss of control to provide an explanation for chronic overdrinking is now so well established that genetic theorists posit instead that alcoholics inherit special temperaments for which alcohol provides welcome amelioration (Tarter and Edwards, this issue). In this and related views, alcoholics are extremely anxious, overactive, or depressed, and they drink to relieve these states. Here the difference between genetic and social- learning viewpoints is solely in whether a mood state is seen to be inbred or environmentally induced, and to what extent the theorist believes drinking is reinforcing because learning plays a part in interpreting the pharmacological effects of alcohol. But either perspective leaves a great deal of room for the intervention of personal choices, values, and, intentions. Just because someone finds drinking relieves tension - even if this person is very tense - does not mean he or she will become an alcoholic.
The life study of alcoholism provides good support for the idea of alcoholism as an accumulation of choices. That is, problem drinkers do not become alcoholics instantaneously but instead drink with increasing problems over periods of years and decades (Vaillant. 1983). The development of clinical alcoholism is especially noteworthy because most problem drinkers reverse their drinking problems before reaching this point (Cahalan and Room, 1974). Why do some drinkers fail to reorient their behavior as over the years it eventually culminates in alcoholism? As Mulford (1984:38) noted from his natural processes perspective, "early acquired definitions of self as one who meets his responsibilities, who does not land in jail, and other self definitions that are incompatible with heavy drinking will tend to retard progress in the alcoholic process and accelerate the rehabilitation process." Mulford indicated here by "self definition" the values by which one defines oneself.
Why Do the Same People Do So Many Things Wrong?
Modern models of addiction have consistently overestimated the amount of variance in addiction accounted for by the chemical properties of specific substances (Peele, 1985). Although popular prejudice continues to uphold this view, no data of any sort support the idea that addiction is a characteristic of some mood-altering substances and not of others. For example, among the many fundamental re-evaluations caused by examining narcotics use among Vietnam veterans was the finding that heroin "did not lead rapidly to daily or compulsive use, no more so than did use of amphetamines or marijuana" (Robins et al., 1980:217-218). A related finding was:
Heroin does not seem to supplant the use of other drugs. Instead, the typical pattern of the heroin user seems to be to use a wide variety of drugs plus alcohol. The stereotype of the heroin addict as someone with a monomaniacal craving for a single drug seems hardly to exist in this sample. Heroin addicts use many other drugs, and not only casually or in desperation. Drug researchers have for a number of years divided drug users into heroin addicts versus polydrug users. Our data suggest that such a distinction is meaningless. (Robins et al., 1980:219-220)
Cocaine use is now described as presenting the same kind of lurid monomania that pharmacologists once claimed only heroin could produce; again, the explanation presented is in the "powerful reinforcing properties of cocaine" which "demand constant replenishment of supplies" (Cohen, 1985:151). Indeed, "if we were to design deliberately a chemical that would lock people into perpetual usage, it would probably resemble the neurophysiological properties of cocaine" (Cohen, 1985:153). These properties demand that those who become dependent on the drug "continue using [it] until they are exhausted or the cocaine is depleted. They will exhibit behaviors markedly different from their precocaine lifestyle. Cocaine-driven humans will relegate all other drives and pleasures to a minor role in their lives" (Cohen, 1985:152).
Seventeen percent of 1985 college students used cocaine in the previous year, 0.1% of 1985 students used it daily in the previous month (Johnston et al., 1986). Former college students who used the drug for a decade typically remained controlled users, and even those who abused the drug showed intermittent excesses rather than the kind of insanity Cohen described (Siegel, 1984). Perhaps the key to these subjects' ability to control cocaine use is provided by research by Johanson and Uhlenhuth (1981), who found that members of a college community who enjoyed and welcomed the effects of amphetamines decreased their usage as it began to interfere with other activities in their lives. Clayton (1985) pointed out the best predictors of degree of cocaine use among high school students were marijuana use, truancy, and smoking, and that even the very few people in treatment reporting cocaine as their primary drug of choice (3.7%) regularly used other drugs and alcohol as well.
These data indicate that we need to explore the user - particularly the compulsive user - for the key to addiction. Robins et al. (1980) constructed a Youthful Liability Scale for abuse from demographic factors (race, living in the inner city, youth at induction) and problem behaviors (truancy, school dropout or expulsion, fighting, arrests, early drunkenness, and use of many types of illicit drugs) that preceded drug users' military service, and that predicted use of all types of street drugs. Genetic-susceptibility models based on individual reactions to given drugs are unable to account for simultaneous misuse by the same individuals of substances as pharmacologically diverse as narcotics, amphetamines, barbiturates, and marijuana in the Robins et al. (1980) study or cocaine, marijuana, cigarettes, and alcohol in the Clayton (1985) analysis. Istvan and Matarazzo (1984) summarized the generally positive correlations among use of the legal substances caffeine, tobacco, and alcohol. These relationships are particularly strong at the highest levels of usage: for example, five out of six studies Istvan and Matarazzo cited have found 90% or more of alcoholics to smoke.
The relationships among negative health behaviors and addiction are not limited to correlation among drug habits. Mechanic (1979) found smokers were less likely to wear seat belts, while Kalant and Kalant (1976) found users of both prescription and illicit amphetamines suffered more accidents, injuries, and untimely deaths. Smokers have 40% higher accident rates than nonsmokers (McGuire, 1972). From the standpoint of these data addiction is part of a panoply of self-destructive behaviors some people regularly engage in. Drunk drivers turn out to have more accidents and worse driving records than others even when they drive sober (Walker, 1986), suggesting that drunk driving is not an alcohol problem but one of drunk drivers' generally reckless and antisocial behavior. The disease model and behavioral theories both have missed the extent to which excessive and harmful substance use fits larger patterns in people's lives.
Drug Abuse as the Failure of Children to Develop Prosocial Values
The use of a combination of early-life factors to predict both heroin use and addiction to other drugs reinforces the results of a large (and growing) number of studies of adolescent drug use. Jessor and Jessor's (1977) pioneering work emphasized a kind of nonconfomity dimension in predicting both drug and sexual experimentation. This factor seems rather too global, in that it confuses personal adventurousness with antisocial alienation (not to dismiss the possibility that adolescents can confuse these things). Pandina and Scheul (1983) constructed a more refined psychosocial index on which drug and alcohol-abusing adolescents showed high scores, but on which "a large proportion of student moderate users did not display problematic or dysfunctional profiles" (p. 970). Further explorations in this area of research have indicated at least three interesting and potentially related dimensions associated with drug and alcohol abuse:
- alienation. Adolescents who abuse a range of substances are more isolated from social networks of all kinds. At the same time (perhaps as a result), they associate with groups of heavy drug users that reject mainstream institutions and other involvements connected with career success and accomplishment (Kandel, 1984; Oetting and Beauvais, this issue). Individual orientations in part precede the selection of group association, although group involvement then exacerbates individual inclinations in this direction.
- rejection of achievement values. Jessor and Jessor found that absence of achievement values strongly predicted drug use. In the Monitoring the Future study of the class of 1980, Clayton (1985) pointed out, second to marijuana use in predicting extent of cocaine involvement was truancy. Clayton speculated it was unlikely that cocaine involvement preceded truancy in these data, and thus the absence of a commitment to school attendance was a condition for drug abuse. Lang (1983) provided a summary of data indicating an inverse relationship between achievement values and substance abuse.
- antisocial aggressiveness and acting out. A relationship between antisocial impulsiveness or aggressiveness and alcoholism has been repeatedly noted. MacAndrew (1981) reported 16 studies showing a higher (in some cases much higher) than eighty percent detection rate for clinical alcoholics through the MAC scale of the MMPI. The highest factor loading for the scale was "boldness," interpreted as "an assertive, aggressive, pleasure-seeking character," an example of "factor loadings that make alcoholics resemble criminals and delinquents" (MacAndrew, 1981:617). MacAndrew (1981) in addition noted five studies of clinical drug abusers that showed similarly high detection rates according to the MAC scale. MacAndrew (1986) has found a similar kind of antisocial thrill-seeking to characterize women alcoholics.
The MAC scale and similar measures are not measuring the consequences of alcohol and drug abuse. Hoffman et al. (l974) found the MAC scores for treated alcoholics were not significantly different from those the same subjects showed on entering college. Loper et al. (1973) also detected higher Pd and Ma scores on MMPI responses (indicators of sociopathy, defiance of authority, et al.) in college students who later became alcoholic. This finding is reinforced by similar results Jones (1968) obtained with young respondents through use of Q sorts.
These findings are so well established that the battle is to claim them for different domains of explanation. Genetic models of alcoholism now regularly incorporate the idea of the inheritance of impulsive, delinquent, and criminal tendencies. Tarter and Edwards (this volume), for example, postulated that impulsivity is the central element in inheritance of alcoholism. I have elsewhere summarized grounds for caution about such genetic models (Peele, 1986b). The crucial issue is the relationship between addiction as antisocial misbehavior and socialization processes and social values. Cahalan and Room (1974) found alcohol abuse was strongly related to antisocial acting out, but their data clearly identify this as a social phenomenon found among particular groups. The question I pose in this article is whether we see it as within our cultural control to minimize through social learning the expression of uninhibited aggression, sensation-seeking, and disregard for social consequences that characterize addiction.
The Commonplaceness of Natural Remission in Addiction
A crucial element in the disease myth of addiction, one used to justify expensive, long-term - and increasingly coercive and involuntary - treatment is the progressive and irreversible nature of addiction. According to one television advertisement, overcoming alcoholism on one's own is like operating on yourself. All data dispute this. Epidemiological research finds that people typically outgrow drinking problems, so that alcohol abuse decreases with age (Cahalan and Room, 1974). The data on drug abuse are identical, and less than one-third of men who have ever used heroin continue to do so throughout their twenties (O'Donnell et al., 1976). We have reviewed data such as Schachter's (1982) and Garn's (1985) which indicate that long-term weight loss is a common event. Yet perhaps the single greatest area of self-cure of addiction is smoking - approximately 30 million people have quit smoking, with ninety-five percent quitting on their own (USPHS, 1979).
Conventional wisdom about addiction denies this commonplace reality to such an extent that addiction and alcoholism experts often seem embarked on campaigns to attack their own data. For example, Vaillant (1983:284-285) combined data showing that a majority of alcohol abusers in his sample were in remission, hardly any due to treatment, and that his own hospital patients' outcomes after two and eight years "were no better than the natural history of the disorder" with an insistence that alcoholism be treated medically (Vaillant, 1983:20). Although he found the large majority of his natural-history population recovered from alcoholism without the assistance of AA (including even those who abstained), all of Vaillant's lengthy case studies indicated that this is impossible. (In further data from his study Vaillant has sent me, those who quit drinking by attending AA had higher relapse rates than those who quit on their own.)
Gross (1977: 121) described the difficulties confronting the alcohol dependence model:
The foundation is set for the progression of the alcohol dependence syndrome by virtue of its biologically intensifying itself. One would think that, once caught up in the process, the individual could not be extricated. However, and for reasons poorly understood, the reality is otherwise. Many, perhaps most, do free themselves.
Here an originator of the alcohol dependence syndrome, which emphasizes the self-perpetuating nature of the biological effects of alcoholism, is bewildered when it fails to explain the majority of the outcomes of alcoholism. Most nonexperts would explain the predominance of alcoholic remission by resorting to concepts like "sowing one's oats" and "growing up." Fortunately, this folk wisdom persists in some remote areas of addiction theory, like Mulford's (1984:38) natural process model:
Time is moving the developing alcoholic out of the status of the "young man sowing wild oats." He is now expected to be a responsible husband, father, employee, and useful community member. It is no longer excused as "boys will be boys."
The medicalization and biologization of ordinary human development is a dangerous misunderstanding of the nature of human behavior. For example, Merrell Dow Pharmaceuticals has been placing full-page ads in major magazines indicating the basis of smoking is a "physical dependence on nicotine.... Because these effects can defeat even a strong willpower, your chances of quitting successfully are greater with a program that provides an alternative source of nicotine to help alleviate tobacco withdrawal," that is, chemical detoxification under medical supervision. Schachter (1982), for one, found smokers who tried to quit on their own were two to three times more successful than those who sought professional help. In a review of the methods Schachter's subjects used to quit, Gerin (1982) reported:
The techniques of the 38 heavy smokers who quit smoking for nearly seven years were less varied. Roughly two-thirds reported their only technique was deciding to stop. "I took the cigarettes out of my pocket," one said, "threw them away, and that was it."
How well would we expect the same smokers to do under a medically supervised withdrawal maintenance program extending over months in which the doctor and nicotine-weaning drug were seen as the agents of control?
It is not enough to say merely that self-cure in addiction has been discredited by professionals. Self-curers are now being penalized. When many baseball players revealed during a federal trial that they had used cocaine but had quit (reasons given were "I was getting older and had too much to lose" and that one player felt "cocaine played some part" in his slipping performance), baseball commissioner Peter Ueberroth ordered severe fines and other penalties. Yet players who admit they are "chemically dependent" and who submit to treatment are not penalized according to the policies of professional baseball and other sports. In this scheme, those who claim to be addicted or whose drug use becomes uncontrolled are better off than those who control their substance use or who quit on their own.
How Do So Many Quit Addictions Without Our Help?
When we consider the elaborate and expensive treatments that have been created to eliminate addiction, we may marvel at the naive techniques self-curers employ. In the Schachter (1982) study
it seems that these people lost weight when they made up their minds to do so, and managed to drop substantial poundage by eating smaller portions and less fattening food. People made comments like: "I just cut down, just stopped eating so much." To keep the weight off, they stuck to their regimens of eating less (Gerin, 1982:32).
Recall that these subjects had lost an average of 34.7 pounds and maintained this weight loss for an average of 11.2 years. Again, Schachter found those who did not undergo formal weight-loss programs stood a better chance of achieving remission, although weight loss was just as common for the superobese (thirty percent or more overweight) as it was for less overweight subjects.
In considering the banality and at the same time the idiosyncratic or personalized nature of people's methods for losing weight, it might seem that the best techniques are the ones people devise for themselves in line with their own life circumstances. Thus, every time a well-known personality loses weight, magazines rush to report the star's reduction secrets to others, although the methods may have worked primarily because they were developed by the person who relied on them in the first place. Similarly, founders of weight-reducing movements like Richard Simmons and Jean Nidetch point to themselves as examples of why everyone should follow their methods, when in fact they might as well instruct people to find the methods that make the most sense for them.
Possibly, larger processes of change may be the same for people whether or not they enter therapy (Waldorf, 1983) or whatever the area of addictive behavior they seek to modify. On the other hand, in a study of comparisons between treated and untreated smokers who quit, those who were treated relied more on behavioral-type methods for avoiding a return to smoking, while self-curers used more cognitive coping techniques (Shiffman, 1985). Those who were treated appeared to be rehearsing learned strategies, while self-curers seemed to look to themselves for a method - usually involving thinking about themselves and their situations - that worked. It could well be that different types of people resort to treatment or do it on their own. Wille (1983) found those who relied on treatment to quit narcotic addiction feared that they could not manage withdrawal by themselves.
Several accounts of the self-descriptions of alcoholics (Ludwig, 1985; Tuchfeld, 1981) and heroin addicts (Waldorf, 1981; Wille, 1983) who quit on their own have emphasized powerful and at the same time subtle existential shifts in attitudes about themselves and their addictions. That is, while the episode that prompted a change in their lives could be undramatic (unlike the hitting-bottom phenomenon usually described at AA), some such unexceptional event often triggered a powerful psychological reaction in the addict. These reactions were connected with other areas of their lives that addicts valued - for example, alcoholics who quit or cut back frequently mentioned the effect their drinking had on their families (Tuchfeld, 1981). The former addicts usually made changes in their work lives and personal associations that supported their new drug-free or non- addict identities, just as such life shifts often added to their urge to quit.
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.
Here a University made moralistic proclamations while indicating it didn't have the guts to insist that a student basketball player get an education. Universities also now regularly undermine their moral and intellectual integrity by sponsoring profitable programs on chemical dependence and other behavioral diseases, programs in which minimum standards of analytical thinking and academic freedom are disregarded (Peele, 1986a). At universities and elsewhere we have elevated the self-deception of the disease theory (Fingarette, 1985) to a place of scientific and academic honor. We mainly communicate with young people about drug use through irrational, anti-intellectual speeches, arguments, and programs (of the type typified by Dave Toma). This type of communication is most readily accepted by those with the most unsure values who are most likely to become addicted in the first place and to remain addicted despite such programs (Goodstadt, 1984).
Moral Outrages
On December 26, 1985, the ABC program 20/20 ran a segment on third-party responsibility for drunk- driving accidents. After drinking at a restaurant bar where he regularly got drunk, an alcoholic man ran head-on into another car and seriously injured its driver. Now "recovered," he claimed he wasn't accountable for his behavior after drinking, and that the proprietor of the restaurant was to blame for the accident. The restaurant proprietor, the alcoholic, and the victim - who has been incapacitated since the accident - met to discuss the case before 20/20's cameras. Although she had previously indicated she held the drunk driver responsible for her pain and suffering, in an actual face-to-face confrontation with the two men, the victim blamed the restaurant owner. The frustrated proprietor could only repeat that he had no way of telling who was drunk at a crowded bar and who was not.
As a second part of this segment, the 20/20 producers arranged for a number of drinkers to be served by mock-bartenders at a Rutgers Center of Alcohol Studies laboratory that simulates a bar setting. The point of the exercise was to show, a la research by Langenbucher and Nathan (1983), that for the most part people are not good judges of whether other people are intoxicated. Here the issue of whether a man should be held accountable for his actions in maiming another person was reduced to a techno-scientific matter of the accuracy of judgments of the effects of alcohol on others. It seems that, like the victim herself, we cannot confront the essential moral issues involved and instead trivialize them by burying them beneath elaborate but irrelevant scientific methodology.
An article entitled "I still see him everywhere" (Morsilli and Coudert, 1985) has been reprinted regularly in Reader's Digest ads as "The magazine article most highly acclaimed by Americans in 1984." The article is by a father whose popular, outgoing 13-year-old son, a ranked tennis player in his age-group, was run down and killed by a hit-and-run driver. The driver, a 17-year-old girl, spent the day "drinking beer at a friend's house starting at ten in the morning, and later they switched to vodka." After killing the boy, she drove her car into a tree and was apprehended. "She didn't go to jail. Her three-year sentence was suspended. Her probation terms included regular psychological counseling, work at a halfway house and no drinking."
This case is an example of a trend in American jurisprudence to replace jail sentences for crimes committed by alcoholics (and other addiction-related crime) with treatment. The crimes are not only drunk driving, but felonies up to and including murder (Weisner and Room, 1984). The girl in this case may, as part of her work in a halfway house, serve as an educator, role model, and counselor for other young substance abusers. She may also (as have several young people who have killed people in drunk driving accidents) lecture ordinary school children and their parents about the dangers of drugs and alcohol. Drug and alcohol education programs regularly feature presentations by young reformed addicts and alcoholics. In this way, the emotionally crippled and morally infirm in our society are elected to positions of respect and moral leadership, based on the cultural self-delusion that addiction is a disease that may strike anyone (Fingarette, 1985), like the girl who spent her day drinking, got in her car, killed somebody, and then drove off.
Just Say No
In a nationally televised speech on September 14, 1986, Nancy and Ronald Reagan inaugurated a campaign against drug abuse in America. That campaign - like this article - emphasized positive values for young people but, unfortunately, it did so in a simplistic and a moralistic way that undermined from the start any chance it had to succeed. A keynote to the Reagan campaign (as promoted by the First Lady) has been the "Just Say No" program, whose aim is to have teenagers simply reject drugs whenever drugs are available. Of course, the idea that young people (and others) should not take drugs has been the staple of mainstream moral judgments for the last fifty years. Nonetheless, beginning in the late sixties, college and then high school students became regular consumers of drugs.
Indeed, the most notable aspect of the prohibitionist approach to drugs in this century has been its utter and abject failure first in preventing addiction, and then (in the latter half of the century) in eliminating widespread drug experimentation (Peele, 1987). It seems an impossible dream to recall that for most of human history, even under conditions of ready access to the most potent of drugs, people and societies have regulated their drug use without requiring massive education, legal, and interdiction campaigns (cf. Mulford, 1984). The exceptions to successful self-regulation have come for the most part (as in the Chinese Opium Wars and in the drinking of Native American groups) as a result of cultural denigration brought on by outside military and social domination.
Now, in a powerful, world-dominating country, we have completely lost faith in the ability of our society and its members to avoid addiction on their own. Just Say No and other government programs (along with much private advertising by treatment programs and research experts) incessantly convey the idea that people cannot be expected to control their drug use. It is remarkable under these circumstances that the vast majority of young drug users in fact do take drugs occasionally or intermittently without interfering with their ordinary functioning. Our official cultural attitude seems to be that this reality should be ignored and discouraged, with what results we can only guess. Meanwhile, the adoption of routine drug testing - coupled with increasingly compulsory treatment referrals - further infantilizes the drug-using population.
Nancy Reagan and her adherents have suggested that the Just Say No program could also be effective in discouraging teen pregnancy, which may actually be the social crisis of the 1980s. Teen-age child-bearing cost the nation $16.6 billion last year, a figure that grows with each cohort of pregnant teens. The problem is monumental among black teens and guarantees large-scale social failure for this group through the coming decades (which will provide a constant supply of drug addicts and alcoholics). Even considering only white Americans, the United States leads industrialized nations in teen births and abortions. Exaggerated teen pregnancy occurs in this country despite the fact that U.S. teens are not more sexually active than those in other Western nations. "Overall ... the lowest rates of teen-age pregnancy were in countries that had liberal attitudes toward sex [and] had easily accessible contraceptive services for young people, with contraceptives being offered free or at low cost and without parental notification" (Brozan, 1985:1).
These are not the policies endorsed by Nancy Reagan. Rather, the Just Say No program in the case of sex seems intent on reversing the worldwide trend toward earlier sexual intercourse. It seems safe to say that no official policy in this country will soon be built on accepting that the majority of teenage girls will be sexually active. But moralizing against sexual activity has important negative consequences. A leading psychological investigator of contraceptive use by women noted that "unmarried women with negative attitudes toward sex tend to use less reliable methods of birth control - if they use them at all.... Women with such negative attitudes seem to have trouble processing information about sex and contraception and often rely on their partner to make decisions about contraception" (Turkington, 1986:11). In other words, just like problem drug users, they are unprepared to accept moral responsibility for their actions.
The Reagan logic is that all teen pregnancy is an unintended consequence of illicit sexual activity, just as addiction is thought to be an unintended consequence of drug use. However, many adolescents (particularly those in deprived settings) report seeking specific satisfactions from the pregnant role and motherhood, although these expectations are soon disappointed and replaced by the harsh reality of raising a child with inadequate resources. The solution to the problem of premature parenthood, like that of drug use, is to provide these adolescents with more substantial and enduring sources of satisfaction that will replace their search for a sense of personal value and accomplishment through self-defeating means. We need also have enough respect for people to acknowledge they have a right to certain life choices while insisting that they accept their responsibilities as potential parents, as members of our society, and as self-directed human beings who will live with the consequences of their actions.
By implacably (but unsuccessfully) opposing personal behaviors that offend us like sexual activity and drug use, we avoid the essential task of teaching young people the values and skills they need to achieve adulthood. The issue is not only to get through to the large numbers of the young who seem not to be hearing us, but to establish bedrock moral principles for our society. As it is, we seem to be falling further behind in creating a moral environment in which we want to live, and in giving children a set of values that are adequate for such a world. Some of the values we need more of, as outlined in this paper, are values toward health, moderation, and self-control; achievement, work, and constructive activity; larger purposes and goals in life; social consciousness, concern for the community, respect for other people, and mutuality in human relationships; intellectual and self-awareness; and acceptance of personal responsibility for our actions. These are the value choices that confront all of us, and not just drug users.
Notes
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Eventually, you will want to share these experiences with your partner; guide them around those parts of your body that aroused you when you stimulated them - let him find other ways to arouse you too. Let your partner stimulate your clitoris - over time, when you find yourself on the brink of orgasm after your partner has touched and caressed your clitoris, move straight on to intercourse, with you or your partner continuing to stimulate your clitoris. If at any time you find you're worried about not reaching orgasm, or you suspect there might be a physical reason preventing you, consult your medical practitioner.
To deal with loss and grief issues is not an easy matter. There are, however, two major things to remember about the grieving process. The first is to allow yourself to feel. To do this you may need supportive counseling, good friends, or you may want to consider joining a support group. Some other suggestions are shown below. The second and perhaps most important is to come to accept and let go. As Elizabeth Kubler Ross suggests, one must first go through the stages of loss in order to come to the place of acceptance. These stages revolve around the primary emotions of denial, anger, bargaining, depression, and finally acceptance.
