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Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use (1980)

Chapter: Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices

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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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Suggested Citation:"Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices." National Research Council. 1980. Issues in Controlled Substance Use: Papers and Commentary, Conference on Issues in Controlled Substance Use. Washington, DC: The National Academies Press. doi: 10.17226/18827.
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REDEMPTION OF THE OVERUSER: AN APPRAISAL OF PLAUSIBLE GOALS AND METHODS FOR CHANGING SUBSTANCE USE PRACTICES Arlene Fonaroff, John Falk, John Kaplan, and Charles P. O'Brien Language, as an expression of cultural values, influences both individual and social response to substance use. Concepts, theories, and policies related to addiction appear to be rooted in terminology that reflects beliefs and attitudes toward the development, mainte- nance, and control of addiction. There are, for example, varying definitions of use, abuse, addiction, and cure that influence sub- sequent attitudes toward persons labeled as users, abusers, and addicts. The handling of problems of use, abuse, and addiction changes over time, reflecting current popular attitudes and beliefs. We might legitimately question what values about substance use are implied by the choice of such terms and the extent to which this social argot influences goals and methods that attempt to change personal substance use practices. Most societies establish strategies to intervene on behalf of individuals who overuse, i.e., to redeem the overuser, often because society as a whole feels responsible for cur- tailing habitual behaviors that go beyond socially defined norms. While redemption is generally regarded as a moralistic and theological term, we use it in this paper to indicate that a religious or moral perspective of substance use, though out of fashion in most intellec- tual and scientific circles, may be just as effective for communicating about the issue as the more frequently applied medical or economic perspectives. Whether moralistic, medical, or economic terminology is employed in discussing aspects of the natural history of substance use, there is a uniform assumption that remedial plans should be designed to minimize the chance of re-entry into a life-style considered harmful to the individual or society. Yet to be determined, however, are the differ- ential costs and benefits of alternative plans based on goals of abstaining fully from a substance(s), controlling frequency of use of the substance(s), or substituting one substance with another substance (e.g., methadone to replace heroin) or activity (e.g., transcendental meditation to replace heroin). In this paper we will discuss the multicausal roots of overuse and the manner in which ecological perspectives are applied in three alternative models that shape treatment goals and methods to control overuse and excess: the medical model, the holistic model, and the redemption model. We will elaborate on the concept of controlled use 96

97 in formulating redemption goals and methods and describe the process of redemption and its outcomes. Our findings will be reviewed in relation to their implications for public policy and in relation to recommended research on alternative goals and methods for redemption of the overuser. OVERUSE AND THE OVERUSER Inherent in the issue of redemption is the determination of when use becomes overuse and who makes this determination. There is no clear consensus on this issue nor on the relation between what is overuse and who defines it. There is a long-standing tendency to use medical, legal, economic, and moral terminology and criteria to dichot- omize use and abuse. The transition from drug use to drug abuse, for example, is said to occur when the use of a legal drug occurs to such an extent that it interferes with the user's physical or psychological health or adjustment in society, or when any illicit drug is used (Jaffe, l975, p. 284). However, while this definition is used for many drugs, including alcohol, it does not apply to all substances. It is, for example, not generally associated with nicotine. Food overuse is similarly difficult to objectify. The varying definitions applied to identify a person as overweight or obese are based in the United States primarily on the normative relations among height, weight, and body stature. The fact that excess weight is an etiological factor in such major public health problems as heart disease, stroke, and diabetes and the social stigma frequently associated with obesity, generally affect who becomes defined as a food abuser. The difficulties of developing objective ground for defining overuse underlie the many disagreements that users have with standards set by others. Conflicting values are also implicit in this situation. For example, even if a user were to agree that health or social adjust- ment were threatened by overuse, self-perceived benefits attributed to use might outweight benefits associated with good health or social productivity. It is also important to recognize that there is a con- tinuum (rather than a simply dichotomy) between users who do and do not wish to reduce what others consider overuse. For example, an alcohol user may agree that his or her drinking style is inflicting increased liver damage. What this user might most want, however, would not be to abstain from drinking in order to reduce liver damage, but to be able to continue drinking and escape the liver damage. Similarly, if in- cipient alcoholism threatens the loss of a job or a spouse, the willingness to accept a diagnosis of overuse and the motivation for treatment may not relate to the desire to stop excess drinking as much as to the desire to maintain employment or the marriage. Likewise, health effects may not influence a decision to stop what others con- sider heroin overuse as much as may social pressure, either through the threat of jail or through the economic consequences of law enforcement that make heroin too difficult and expensive for use to be maintained. Definitions of overuse are often based on the consequences of use. As noted above, damage to physical or emotional health or to

98 social adjustment is the most frequently employed criterion for de- fining overuse. This definition raises numerous problems in that damage may be relative and evaluated either in terms of short-term or long-term consequences. Short-term consequences of alcohol use, for example, may be limited to the trauma of periodic hangovers. On the other hand, injury from automobile accidents may result in long-term damage, or even death. Long-term consequences of even limited amounts of alcohol use over time may include damage to physical health by destruction of brain cells or by increased susceptibility to various other parts of the body as well as damage to emotional health through stressful social situations. Relatively light or moderate cigarette smoking similarly affects short-term and long-term health outcomes. The staggering amount of $l9 billion in lost earnings can be attributed to cigarette smoking (Luce and Schweitzer, l978, p. 570). Excess eating that produces obesity also affects health and longevity by increasing risks of hypertension, heart disease, and stroke. If the issue is one of the relatively low risk of health damage on either a short-term or long-term scale, a strong case could be made that there is no need to tell an individual that he or she is overusing a substance. It could be argued, even when society defines use as overuse and identifies the imminent health risks, that it is the user's prerogative to determine whether a "better" life is preferred to a longer life. Many would accept the concept of substantiality in defining overuse as use to the point at which physical or emotional health is at a critical threshold for substantial damage. However, this concept requires that someone will have to decide what is and what is not substantial. While it may be very easy to distinguish between no use and any use, and somewhat easy to distinguish use that may damage health or society from use that may not, establishing what is sub- stantial requires the application of an external standard. Who decides on the external standard(s)? Do we regard someone as an overuser based on some societal norm of morbidity or mortality, crime, economic loss, or some combination? Do we regard someone as an overuser when there is substantial damage as defined by an external standard that the user feels is worth the self-perceived benefits attached to use, such as enlightenment, pleasure, or relief from pain? The issue is complex whether society or the user calculates benefits and risks and deter- mines the difference between use and overuse. Despite attempts to standardize criteria to differentiate between use and overuse, doubt often remains as to the relationship between substance use and the impairment of one's physical or emotional health. Interpretations of the effects of overuse on social adjustment also vary depending on how "adjustment" is defined and measured. The issues of substantiality and the calculus as to whether pleasure is worth damaging one's health or disrupting the social order may have different meanings when it is the user who determines his or her status as an overuser rather than society. If the user alone decides what is use and overuse then it is the user alone who deter- mines when help is desirable. If help is sought, the person chosen as the helping agent may be concerned with (a) cutting down overuse so

99 that it no longer does damage; (b) repairing the damage without cutting down overuse; (c) increasing the satisfactions of overuse so that the user becomes willing to regard health or social damage as worthwhile; or (d) working to reduce the concern by redefining overuse as appro- priate use. The choice among these and possibly other outcomes of seeking help is one to be made by the user and the person selected to deal with what the user considers a problem. This is not to say that there are no social issues involved in a self-definition of overuse and what to do about it. There is, for example, the impact of the law. Should the user select an illegal substance, the greatest danger to "health" from overuse may be per- ceived as the danger of being caught and incarcerated. There is also the impact of economic costs, including illness, injury, incarceration, and death. Social response to substance use and abuse also affects costs. The Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) supports research, training, program management, and treatment services at a yearly budget of $800 million (ADAMHA, l978). In dealing with the effects of alcohol abuse, however, there is an additional annual cost to society of $2.6 billion for highway safety, fire protec- tion, criminal justice, welfare, and other related government systems (Luce and Schweitzer, l978). Luce and Schweitzer estimate that smoking and alcohol abuse incur $59.9 billion in economic costs per year to the nation. Direct health care costs are estimated at $20 billion yearly, with appreciable increases due to lost earnings caused by such ill- nesses as heart disease, stroke, and cancer. An accounting of social costs and benefits, however, must also acknowledge the economic advantages of some presumably harmful sub- stances. The tobacco and alcohol industries, for example, expend an estimated $250-500 million each annually for advertising (Beauchamp, l976; Terris, l976). The multiple needs of these industries provide jobs and income for many as well as substantial amounts of tax revenues for the government. Patterns of substance use are also influenced by the kinds of help made available to curtail overuse. Should society provide free psychiatric care, the user may perceive overuse in the context of the medical model and may consequently resist help. Should society provide funds to consult a guru or to attend self-help programs, the user may perceive overuse in other ways. Patterns of use would also undoubtedly change if society designed and implemented programs based on an holistic approach, in which social institutions were subject to change as well as the user. If we operate on the assumption of self-determination and self- care, the individual has the right to determine when, where, and under what conditions to seek help (Levin, l977). It then follows that, so long as the user makes the decision as to whether overuse is occurring, the issues of whether and what harmful consequences accrue may be moot points. The matter then becomes one of negotiation between the user and someone chosen as a helping agent (assuming that one can afford or otherwise gain access to such a person).

l00 When the overuser and society are in agreement about criteria for identifying overuse, there may be significant societal and political consequences. For example, the range of choices for help may be greatly expanded or restricted. Total abstinence from an overused agent is an example of restricted choice. Substitution is an example of expanded choice for redemption. Before the widespread use of metha- done as a substitute agent to reduce heroin overuse, a person who felt that he or she was overusing heroin and wanted to do something about it could not gain legal access to methadone. Examples of restrictions on use are more prevalent. Because heroin is an illicit substance, our current legal system cannot help the person who feels that he or she is overusing heroin and wants to avoid drug impurities by substituting pure heroin. Similarly, the law disallows providing enough heroin for oral use to the intravenous overuser who wants to stop what is known to be a dangerous practice. THE ECOLOGY OF OVERUSE Substance overuse is both produced and maintained by a complex set of interacting factors. Previous research into and treatment of such use emphasized the immediate, direct, and cumulative pharma- cological effects of substances. The phramacological effects were assumed to operate on individuals who varied in their susceptibility to entrapment by drugs. Similarly, obesity was assumed to be acquired by individuals because of variable susceptibility to entrapment by food. The traditional notion of susceptibility locates a readiness for sub- stance overuse in both genetic and social predisposing factors. Susceptibility, then, becomes a quality characterizing an individual. An ecological analysis, on the other hand, reveals the continual involvement of multiple environmental determinants in the development and maintenance of the individual's vulnerability to substance overuse. The invasiveness of a substance for a particular individual or within a social milieu is sustained by a network of environmental factors. A knowledge of those factors that promote behavior falling within the social definition of substance abuse or, for that matter, any other excess behavior is a precondition for their manipulation. And it is the manipulation of the determining variables that allows the allevi- ation of the excesses. It may be advantageous to discuss substance abuse from an epi- demiological perspective, since epidemiology is essentially that part of human ecology concerned with identifying determinants of states of health. In describing the health of populations, the epidemiologist searches for any event, characteristic, or other definable state that changes a health condition for better or worse (Susser, l973). Throughout the life cycle an individual experiences varying levels of health. As in a population, personal health or disease represents a complex set of interactions among the individual (or host), an agent, and an environment. This interactive scheme is applicable in describing the generation and course of development of substance use. Figure l presents a simple diagram of the complex

set (host) substance (agent) setting (environr.ent) Fig 1. The classic epidemiologic interactions between a susceptible host and hazardous agent in a conducive en- vironr.ent are depicted for habitual substance use. The process results through interaction between properties inherent to the agent (e.g. pharmacological/nutritional action of drug/food), the user's personality and attitudes toward use; and the physical and social environments in which use occurs (after Zinherg 5 Robertson, l972). This model also applies to a treatment syster.. The only ad- justrer.t required is redefining the "setting" as the phy- sical ar.d social environment? in which the unlearning of use/or the r_e_learn;ng of new use occurs. l0l

l02 causal elements that are in a continual process of reciprocal interaction. While for convenience we may discuss the host, agent and and environment as discrete entities, in reality it is impossible to under- stand any of the three in isolation. The survival of both host and agent, their interation, and any changes in it depend on and influence the character of the environment. Similarly, environmental change will eventually alter the host-agent relationship. Because of this dynamic interchange, epidemiology employs models of multiple causality to describe health or disease processes (Susser, l973). How can multiple causality be conceived in substance use processes? AGENTS OF OVERUSE Applying the current epidemiological perspective to overuse, an agent can be any substance, object, or activity that engages excessive amounts of behavior. The attention of scientists and the social con- cerns of the general public have been captured by relatively few forms of excessive use. The agents may be roughly classified as drugs, alcohol, tobacco, and food. These all have measurable effects on biological and social systems and, in large amounts per bout of use cumulatively produce known harmful biological, personal, and social consequences. However, these obvious features may distract us from recognizing other agents that are not chemicals, do not have obvious acute physiological and long-term health consequences, and do not cause obvious social or emotional disruptions, but are similar in important ways regarding their likelihood to engage excessive amounts of be- havior. These are activities such as gambling, television viewing, attack behavior, talkativeness, and sexual activity. A person may exhibit a habitual and problematic aggressiveness toward others, particularly relatively defenseless individuals such as one's own children. The availability of statistical data on the in- cidence of child abuse, rape, and assault against the elderly has increased awareness of the extent of attack behavior as a social problem. In some people agents such as television viewing or gambling appear to catalyze a lengthy bout of behavior once they are initiated. Such bouts are difficult to interrupt once begun. One of the marks of such behavior is a certain compulsive component that makes the vari- ations in the quality of the agent appear more or less irrelevant. A habitual gambler, for example, does not require the opulent ambiance of a casino to initiate a gambling bout that the occasional "plunger" might require, nor is a tv addict likely to cease a viewing bout simply because there is a decline in the quality of the programs available in the next time slot. Similarly, a seemingly incessant stream of verbal behavior of a habitual talker requires little more than the presence of another person, irrespective of whom. In its extreme form the sexual activities of a Don Juan may require only minimal pleasing qualities in a compliant agent. Excessive behaviors engaged by "commonly abused substances" on one hand and persistent activities on the other have in common a

l03 compulsive quality, that is, a high-frequence occurrence accompanied by the person's report of inability to resist or control use; persistence in the face of harmful biological, personal, or social consequences; a tendency to override other competing behaviors; and difficulties, including repeated failures in altering the habit even through partici- pation in treatment. Although we lump together an activity like talking with a sub- stance like food, the equivalence is talking and eating, activities that result in listening and responding on the part of an audience and food ingestion. In the case of television viewing, the orienting behaviors toward the tv set, adjustments to improve the picture or sound, and actions to shut out distracting stimuli are all components of viewing, with "ingestion" of the visual and auditory stimuli as the equivalents to eating. The fact that biologically significant conse- quences are not evident in excessive gambling, television viewing, loquacity, or sexual activity makes it even clearer that multiple interactions of the agent, host, and environment triad must be applied to any ecological analysis of use. The following discussion represents an attempt at developing an analytic scheme applicable to a large number of apparently disparate classes of behavior, the excessive use of a broad range of agents. These are initial steps based on data fragments from various sources, not a coherent theory constructed on relatively uniform data in the sense that the data share the same paradigm. As noted, many of the results we would like to have from human behavioral studies are absent. In this sense, we speculate, but invoke the rule of plausibility. It has been difficult for ethical reasons to conduct experiments to analyze the acquisition, maintenance, and cessation of excessive behaviors engaging drugs and the like in human subjects, and an experi- mental analysis of other excessive behaviors in humans has scarcely begun. Therefore, the experimental data base on which to draw direct evidence is small. However, clinical investigations, animal experi- ments, controlled observational studies, and surveys do provide a scientific basis for inferences about organizing principles. Host Characteristics An individual or host possesses a number of behavioral reper- toires. A repertoire is a complex set of behavioral tools that allows an individual to cope with and adjust to an environmental situation. Examples of the most general kind include forms of mobility—walking, running, driving—and forms of communication—talking, reading, writing, etc. A host's repertoires provide a range of adjustive adequacy with respect to the coping required in any environmental situation. Success as a student, for example, requires complex repertoires involving library usage, transcribing oral lectures into comprehensible textual notes, study habits, time allocation strategy during an examination, selection of appropriate courses relative to long-term goals, etc. An individual's social milieu and specific life history determine the range of repertoires and their complexities and flexibilities. An

l04 illiterate, for example, is lost in a strange city despite signs and maps. Repertoires, then, define the habits or operating character- istics of a host: the results of past environmental actions on a person as well as the actions he or she brings to bear on a currently existing situation. For present descriptive purposes, a host may be regarded as being in hazard of developing substance abuse and raaladap- tive habitual behaviors if there is a paucity of repertoires, or if they are poorly articulated or inflexible with regard to situational requirements. In their original contacts with invading Caucasians, for example, Native Americans had no individual knowledge of or social rituals concerning the safe use or consequences of "firewater." The Multidimensional Environment The environment has physical, cultural, social, and emotional dimensions. It provides the opportunities for exercising the host's various behavioral repertoires. Possessing a varied and complex range of repertoires is of limited usefulness to a person if an environment lacks the resource opportunities for these repertoires to be brought into play. An example is the classic wartime situation of the nuclear physicist as footsoldier. On the other hand, a person may possess adequate repertoires and the environment may contain rich resources, but if the rules governing the availability of these resources are onerous or punitive then the host occupies a sparse niche in what superficially appears to be plenty; for example, the sexual opportuni- ties for a person living in an ascetic religious community. The niche may also be considered sparse if the resources necessary for the reper- toire to occur are missing, too costly, or unavailable to the person for social reasons (for example, a desirable job may be beyond someone's aspirations because of lack of sanctioned social connections). There also may be legal barriers and punishments connected with resource availability; for example, heroin to the addict. Even when the re- source may be neither costly nor illegal, its rules of availability may place it beyond anything except fleeting provision for the individual. The acquisition of style, approbation, popularity, a special skill, or differential treatment requires physical and social environmental conditions that not only condone its display but also promote the appropriate repertoire construction by the person, for example, formal or informal opportunities to learn. The environment, then, in numerous ways can impede the exercise of adjustive repertoires possessed by an individual. The Interplay of Host, Agent, and Environment At an initial level of analysis, an agent might be regarded as capable of producing excessive amounts of behavior in the host because the agent is intrinsically "irresistible." While substance abuse is generally regarded as a serious social problem, many persons refrain from any use even when presented with the opportunity, and the majority

l05 of persons exposed to the attractions of any particular agent manage to refrain from undue or excess use (e.g, Abelson et al., l977, Cahalan et al., l974). Just as vulnerability to a disease vector is a function of agent, environmental, and host variables, substance overuse is far from an inevitable consequence of simple exposure. An agent is capable of engaging a strong and persistent stream of behavior only by excluding or displacing other, competing behaviors. This occurs if behavioral repertoires that could compete successfully with substance overuse were never learned, or if repertoires receive little encouragement from the host's environment in terms of social, monetary, or other rewards. Put simply, an agent producing a strong stimulus effect (drugs, food, attack, tv, etc.) may take over the host's behavior with inordinately high probability because nothing else in the host's past training or current environmental opportunities can compete with the agent. The vulnerability of the poor and the unemployable to excessive substance use, tv watching, aggression, etc. is often cited in social policy discussions about controlling behavioral excesses. A simple lack of alternative repertoires or the absence of environmental facilitation for existing repertoires, while they are important factors, are only partially responsible for abuse. When faced with adjustive challenges, the person with a history lacking in versatile coping repertoires is at a disadvantage. This is the theoretical basis for federal job training programs. The person's disadvantage is further increased if the current environment fails to facilitate those adjustive repertoires that can successfully compete with overuse and other forms of excess. Powerful alternative reper- toires leading to tangible values need to be developed that can compete with cocaine successfully in a ghetto environment. However, environ- mental factors other than deficits in acquiring or maintaining conditions for alternative repertoires also need to be considered. This becomes clear in considering what are called adjunctive be- haviors. There is reason to believe that when some commodity or activity of crucial importance to the individual is available in only limited amounts on an intermittent basis that an alternative repertoire (i.e., adjunctive behavior) can become greatly exaggerated and dominate behavior. Adjunctive Behaviors Although scientific evidence for these phenomena is at present limited almost entirely to observations of and experiments on animals, the extension of the analysis to human behavior, especially to cases in which other conditions generating excessive use (see above) appear to be absent, seems to us to be highly plausible. Animal research has helped to describe the conditions that generate adjunctive behaviors (Falk, l969; l97l). If animals are somewhat deprived of food and then allowed to eat only small portions of food in temporally separated episodes, certain other behaviors come into play and become quite exaggerated. It is not the food deprivation itself that produces these adjunctive behaviors, but rather the environmental conditions; when

l06 deprivation is combined with an attenuated rate of access to food, behavioral excesses occur. The specific adjunctive behaviors that occur are a function of what the environment provides. In a number of animal species (rats, mice, monkeys, chimpanzees, pigeons, gerbils, and guinea pigs) a wide range of excessive behaviors have been generated, for example, polydipsia (massive fluid intake), attack behavior, and hyperactivity. The degree of the adjunctive behavior is quite exagger- ated and persists as long as the generating conditions are allowed to remain in effect (Falk, l977). Three points should be noted in considering the applicability of this experimental animal work to human behavioral excesses: (l) The generating conditions are not limited solely to food restriction situ- ations. Various behavioral excesses have been generated by allowing only episodic access to commodities such as water or the opportunity to exercise in a running wheel. Again, limited access alone is insuffi- cient to produce adjunctive behavioral excesses. Episodic access to the limited commodity or activity is crucial to the introduction of persistent and exaggerated behaviors. (2) Substance abuse has been produced by generating adjunctive behavior. Polydipsia was the first substance overuse studied (Falk, l969). Of greater interest is the large intake of various drugs that can be induced. For example, ad- junctive alcohol intake in animals has been kept at a high, continuous level for months, leading to severe physical dependence (Falk and Lamson, l975). (3) Not only have adjunctive behaviors been generated through research on laboratory animals; humans in experimental settings have been shown to exhibit similar behaviors. In these studies, when only intermittent rather than continuous monetary gain or problem solving are allowed, the result is excess drinking, smoking, and hyper- activity (Kachanoff et al., l973; Wallace et al., l975; and Wallace et al., l976). The environment, clearly, is intimately related to the production of excessive and habitual behaviors. It can fail to provide the social and physical supports necessary for the exercise of adjustive reper- toires. It can more actively impede an individual from engaging in adjustive behavioral repertoires by making access to such behaviors costly in time, effort, money, or social sacrifices. Further, our analysis suggests that a situation likely to induce adjunctive be- haviors is in force if the necessities and amenities of living may be available only episodically in spite of continued daily efforts to acquire them. It follows that if alternative, adjustive repertoires are unavailable to the individual and the environment also contains a limited-access condition to a crucial commodity or activity, then the adjuncts generated can result in such socially or medically injurious consequences as alcoholism, aggression, hypertension, etc. (e.g., Falk, et al., l977). Host-agent-environment interaction can be used not only to des- cribe the generation and maintenance of substance overuse and behavioral excess, but also to plan intervention strategies for altering the system that sustains harmful host-agent-environment interactions. Intervention can be addressed to the host (e.g., by decreasing ex- cessive behavior repertoires or by substituting other repertoires), the

l07 agent (e.g., by controlling access to and the quality of a substance or activity), the environment (e.g., by changing social attitudes toward overuse); or by controlling combinations of these elements. However, it is important to remember that change in one part of an ecological system will generate change in some other part of the system. Compre- hensive appraisal of the change process is thus prerequisite to success. APPLICATIONS OF THE ECOLOGICAL APPROACH Models for remedying substance overuse place varying emphases on the ecological approach. We have selected three models from the array of available alternatives to illustrate how emphasis on host, agent, environment, or some combination of interaction among these factors influences goals and methods for working with individuals who are self-motivated or motivated by others to change behavioral repertoires involving substance overuse or other excess behavior. We will discuss the medical model, which is widely employed in public and private programs, the holistic model, which has growing numbers of supporters, and the redemption model, which is less frequently considered. These models illustrate the polar extremes in the continuum of scientific activities to determine and hence to control the development of health and illness. At one end of the continuum the cause(s) is located within the individual at the microbiological level; at the other, outside the individual in multiple environmental settings. The Medical Model This model traditionally places the ultimate origin of illness within the individual and for the last century has been widely applied in the United States and elsewhere to develop, conduct, and evaluate methods to alleviate human suffering. Inherent to the classical medical model are the following assumptions (Hayes-Bautista and Harveston, l977, p. 9): ...the locus of illness is microbiological;...every- one is assumed to be well, and deviance is introduced by a massive invasion of an organism by foreign agents ...beyond the individual's capacity to resist. The responsibility of medical care...is to heal individu- als so that they can return to their normal places in society and fulfill their functions until another bout of illness makes such operation non-functional once again. The sick role...epitomize(s) this process: a sick person is separated from society, made well, then placed back into society as a functioning unit. One outcome of this ideology has been the emergence of a set of specialists who focus on a single organ, tissue, cell, or procedure rather than on the whole individual and the society in which health or

l08 illness is experienced. Another outcome has been the tendency to redefine social problems as medical problems, thereby having them fall within the province of medical care. Alcoholism and drug use are cases in point. Substance use symptoms are translated into clinical concepts and managed by physicians, and appropriate neutralizing agents are developed to "cure" the affliction [e.g., Antabuse, methadone (Hayes- Bautista and Harveston, l977)]. In reality, however, problems relating to excess use of drugs, food, and other agents may be as much social as medical in origin and may require adjustments in both domains. Over the past decade there has been an increased tendency for the medical model to evaluate emotional and social components along with physical aspects of symptomotology and progress in a treatment plan. The ten- dency to involve families or significant others into dealing with a client's adjustive goals is an indication of the broadened medical model approach. The Holistic Model The holistic model shifts the focus of causation from the micro- -biological to the environment. While microbiological elements are not ignored, they are considered in relation to other causal elements whose origins may be political, economic, social, and psychobiological (Hayes-Bautista and Harveston, l977). Thus, while the medical model focuses primarily on altering agent-host variables, with consideration of such key environmental forces as the family, the holistic model more heavily stresses multiple interactions among host-agent-environment and proposes that environmental intervention be a prime target in treatment (Hayes-Bautista and Harveston, l977, pp. 8-9): ...if attention is focused only upon the somatic level, health will never be achieved, although illness might be occasionally and temporarily controlled...making an individual well is ultimately self-defeating if that individual is placed back into the same...situation that caused the illness initially.... The holistic model contends that: (l) individual illness is a reflection of societal ills; (2) multicausal factors determine illness events; (3) multiple types of intervention are required to alter host- agent-environmental stress and hence to affect a "cure"; and (4) active effort is required by the individual and society to maintain a state of health, including the consideration of how to restructure social in- stitutions to minimize hazards and to treat ills. The Redemption Model The medical and holistic models illustrate how ideologies differ- entially influence orientations toward treatment goals and methods. Applying the term redemption to a model for curtailing overuse or

l09 excess behavior implies a moral perspective that may be as effective as a medical or holistic model in altering the ecology of overuse. Moral- istic ideology was prevalent in l9th century American psychiatry, when mental patients were exposed to "benevolently correctional-educational environments...to help them mold their behavior in conformity with the dominant standards and values of the community" (Dolev, l976, p. l00). Many of the mentally ill, then as now, are regarded as "demoralized people" in need of "a new sense of morality and self-responsibility." This can be gained by conforming to normative societal values. Adhering to "conformity" eliminated the uncertainties involved in establishing criteria to assess "improvement," "getting better," or "being cured." Dolev's recommendations for "redeeming" mental patients is transferable to substance overusers, most of whom are involved with psychiatric practitioners in the course of redemption (Dolev, l976, p.l00): Treatment should be converted into (a)...reeducational process geared towards the solution of value conflicts and dilemmas. Restating our goal as education rather than therapeutic rests on the assumption that the ...person...has the potential to develop into a moral being...given the adequate stimulation and push...(and) could assume responsibility and become accountable for his behavior. Redemption, too, employs an ecological approach. It resembles the medical model in viewing the host as a deviant and is unlike the holistic model in placing society above reproach. In redemption, the overuser has behavioral repetoires that include amoral agents that separate "us" from "them." The redemption process aims to re-educate the amoral host in order to avoid social isolation and stigma. Most programs developed by formal institutions (e.g., public service agencies and hospitals) reflect treatment and rehabilitation goals and methods based on the traditional medical model, with a growing number incorporating aspects of the holistic approach. For the most part there is an addict who is regarded as sick. Responsibility for cure (or at best, remission of presenting symptoms) is undertaken by a variety of professional specialists. While language may differ, the redemption model imposes a different cast on our opportunities for changing substance use practices. It emphasizes what must be done by the overuser and hence emphasizes the host as the most viable change agent in substance use. In this sense, the redemption model comes closest to renewed interests in self-care as a major thrust in public health and medicine. The Concept of Controlled Use The medical, holistic, and redemption models each differentially focus on host, agent, and environmental characteristics of overuse. While objectives and methods emerging from the application of these

ll0 models vary, they share a common and basic goal of aiding the indi- vidual in controlling the amount of an overused substance to some socially defined normative limit and to practice use in socially acceptable ways. The limit of use may vary according to host and agent character- istics from zero use to some use (Fig. 2). By far the most prevalent tendency is to attempt to achieve total abstinence from the overused agent. Sometimes this is accomplished by transferring the power of the agent to a deity stronger than one's self, as in Alcoholics Anonymous. In other cases, abstinence may be accomplished by the substitution of another agent for the one overused. In the latter case substitution in and of itself may be formulated as a goal. There is also a growing trend, however, to help the user to learn to control the amount of the overused substance rather than to relinquish the substance at all. As indicated in Figure 2, many overusers learn to engage in occasional use but run the risk of overusing because they may lack skills in assessing limits of use. In recent years, there has been growing controversy over absti- nence, controlled use, and substitution. Can individuals who were once addicted to any agent use it subsequently in a controlled, nonaddictive manner? Can an ex-heroin addict control the use of heroin without becoming re-addicted? Can an ex-obese person eat "normally" without re-engaging in excess caloric intake? Can an ex-alcoholic drink with- out becoming a problem drinker? What common processes in control occur for all substance use behaviors? What constitutes controlled use? What individual differences inhibit or sustain control? In what ways do living environments and social situations encourage recidivism? Who defines acceptable levels of consumption for whom? Abstinence is a widely prevalent ideology: What scientific evidence supports it as a viable goal? What motivations perpetuate it? In what ways does it influence change in behavioral repertoires? Numerous questions also pertain to substitution goals. Substitu- tion implies an underlying need that may be variously satisfied. Formidable methodological questions exist if one attempts to refine this concept, since the rates of many activities are constantly in- creasing and decreasing in the natural behavioral repertoires of any individual. Yet anecdotal observations strongly suggest that some substances and/or activities may be replaced for others on a function- ally equivalent basis in repertoires of individuals displaying excess use. Assessing the validity and generality of this concept is important for both theoretical and practical considerations. THE REDEMPTION PROCESS Ambivalence as a Motivating Force in Overuse When a user weighs benefits and risks of use performances, it is not unlikely that personal ambivalence accompanies some proportion of motivation to reduce or stop overuse as well as motivation to engage in

Addicting Agent (t.g. heroin) Numbers Of Users Controlled or Occasional Use Addicting Agent (t.g. alcohol) Total Abstinence Fig. 2: Coals for liters Achieving the goal of controlled use for such addictive agents as heroin is projected for fewer users in contrast vith an addicting agent such as alcohol where lost users are projected as capable of achieving controlled use. Controlled Dee refers to socially approved practices or rituals surrounding time and amount of use. Occasional or non-ritual use is perhaps the most common outcome of redemption. The many users at the midpoint of this curve who succomb to readdiction, perhaps have access to lack of rituals, or behavioral repertoires that help them to define limits of use. Ill

ll2 recommended methods for changing use. One area for exploration in redemption is the effect of putative ambivalence. Unimpressive "cure rates" for curtailing overuse are common to most attempts to reduce or terminate excess eating, smoking, drinking, or illegal drug use. A number of explanatory hypotheses can be generated in this area, for example, (l) persons entering redemption programs represent the most ambivalent users and therefore are the most difficult candidates for success; and (2) the majority of overusers "cure" themselves without coming to the attention of formal programs. To some extent, ambivalence exists in all overusers throughout the redemption process. Ambivalence must therefore be considered throughout, even for users who appear highly motivated, since the positive or reinforcing aspects of overuse are constantly operating to pull the individual away from redemption. An overuser who is pressured into treatment by legal or family forces may bolt once that pressure is relieved. To mediate ambivalence, redemption must not be aversive but should aim at emphasizing the rewarding aspects of changing use prac- tices. In the case of opiate addicts, for example, redemption can be at least initially aided by the rewarding aspects of methadone. On the other hand, those who appear poorly motivated for redemp- tion may succeed in minimizing or terminating overuse, provided the forces that brought these overusers into the redemption process can be identified and used to maintain motivation. This is particularly important during the crucial initial period of redemption. For example, a drug abuser who is forced into treatment to avoid prison may have ambivalence removed by fear of prison. In that case, the positive aspects of drug use may be outweighed by fear of incarceration. If this overuser can then participate in the redemption process long enough, such positive aspects of abstinence as holding a job, being healthy, and having family stability may provide rewards sufficient to overcome the positive aspects ascribed to drug use. The fear of imprisonment then will no longer be needed to resolve ambivalence. One of the most interesting characteristics of overuse, however, is its persistence in the face of aversive social and physiological forces. For example, once society at large and a significant segment of the individual's own social contacts define overuse as reprehensible, punishing effects are brought into play to offset the intrinsic effects of the overused agent and the social bonds between users serving to strengthen and maintain excessive behavior. One might expect that the censure of society at large would be sufficient to reduce severely the future probability of overuse. Perhaps it does in some, but in others it obviously does not. Such punishing agencies often appear to be only weakly and intermittently effective in attenuating overuse and under- score the persistence of excessive behavior. Furthermore, even when some of the direct intrinsic consequences of overuse produce effects that would normally be punishing (e.g., experiencing the bends of withdrawal), they are ineffective in appreciably decreasing the ex- cessive behavior. This may partially explain why aversive medical and social consequences that often follow overuse or overindulgence do little to decrease future overuse. The insensitivity to the punishing effects of adjunctive behavior described earlier in this paper is

ll3 characteristic of both human and animal research findings. For example, rats that are allowed to eat on an episodic schedule become polydipsic to the extent of drinking half their body weight in water over a 3-4 hour period. Severely dehydrated rats would cease drinking long before such volumes were ingested, presumably because even further fluid intake would produce an increasingly aversive physiological effect that would be punishing to the organism. The relatively weak punishing effect of negative or hazardous social and medical consequences of overuse does not mean that such consequences fail completely to influence behavior. In fact, there is powerful conflict (i.e., ambivalence) between the excessive behavior and its negative consequences. This ambivalence can be used in the redemption process to effect therapeutic change. There are two main ways in which ambivalence can be resolved: (l) Environmental change. If the redemption agency can control change in those environmental factors responsible for generating and maintaining excessive behavior, motivations could be directly allevi- ated. For example, job training and job placement might be provided for the employable or the unemployed. The episodic and onerous factors that limit access to other necessities also must be examined. (2) Behavior change. If only limited attempts can be made to alter the economic and social sources of overuse, then a more accept- able behavior might be substituted for one deemed socially or medically undesirable. It is not uncommon for an intense religiosity or social dedication to be substituted for a former excessive habitual behavior. The Alcoholics Anonymous model applies this principle to aid abstinence. If the ecological configuration of factors that produce undesirable excessive behavior remains in effect, substitution may be one of the best strategies for reducing overuse and excess behavior. Both present and impending punishments for engaging in excessive behavior create ambivalence. It is possible to resolve this ambivalence by substi- tuting another excessive behavior that is not punished. If the substitution produces a desirable personal and social result, then the net gain is a positive one, although the individual may still engage in excessive behavior in response to certain ecological situations. Our society provides individuals and their social groups with a range of intense and excessive behaviors that are rewarded and regarded as unusual yet desirable, for example, creative enterprises, dedicated work. While we have focused on how to influence excess behavior of the ambivalent overuser, at the far end of the continuum are those who are not ambivalent about their wish to persist in overuse. It is likely that few users in this category apply for redemption. The fact is that, except for the trivial example of imprisonment to prevent over- use, we have for the most part no legal means to force people to accept redemption except by threats of punishment. Theoretically, to prevent alcohol abuse we could involuntarily administer implants of Antabuse (disulfiram); to prevent heroin overuse, we could administer large doses of naltrexone. In fact, we do not do this. Rather society attempts to create ambivalence where there previously was none by adding additional threats of undesirable consequences to already

ll4 existing ambivalence; or, in other cases, to reduce ambivalence by providing assumed desirable consequences for reducing or stopping use such as steady employment, marriage counseling, continuing education, etc. In redemption attempts we face numerous problems. Among them is stressing the need for the overuser to appear for redemption (or go through the motions that indicate a desire to decrease use). Some of those who come for treatment are not ambivalent about ceasing use but hope to avoid the consequences of not appearing to want to stop. For example, an obese woman may enter a weight reduction program without wanting to lose weight in order to make others think that she wants to lose weight. However, people cannot be cured involuntarily. While to some extent people can be motivated against their will to seek cure, attaining this goal is another issue. Yet, there is always the possibility that the rewarding consequences of reducing or stopping overuse may become apparent while someone is involuntarily partici- pating in the redemption process. The Redeemer We have been concerned with the overuser as the object of redemp- tion. We now turn attention to the redeemer (i.e., the person who attempts to alter substance use patterns through treatment). Just as the values of the user influence acceptance or rejection of what is overuse, values of the redeemer influence perceptions of use and over- use. The redeemer may or may not be affected by the definitions and attitudes generally accepted in society. For instance, where society defines any use as overuse, a redeemer may disagree with an all-or-none social definition. Redeemers do not always share the full set of social or institutional goals, although they typically are working toward redemption. This further complicates the redemption process because ambivalence exists on the part of both the user and the redeemer. The medical profession may be considered as a formal instrument of social control, not only through the provision of health care services per se, but also through providing such services in compliance with the law. Redeemer values, however, may conflict with normative values in the medical profession. An example is that of the value of loyalty to the patient. A redeemer may feel that maintaining a patient on heroin would be the best solution for redemption. However, the redeemer would be unable to enforce such a treatment plan because heroin maintenance is illegal in the United States. Even if heroin maintenance were legally sanctioned, other societal conditions might prevent the redeemer from choosing this solution for the user. For example, the health value to the patient of a heroin prescription must be weighed against the likelihood of the prescribed heroin being sold on the street. These are not uncommon issues for redeemers and they raise significant questions about the appropriateness of an uncritical acceptance of the medical model.

ll5 Social circumstances and events influence the judgment of re- deemers, users, and others as to when to consider a user an overuser. The lower-class alcoholic is treated differently from the upper-middle- class alcoholic, just as a physician opiate addict's treatment differs from that of a junkie. Similarly, social factors influence public concern about which substances are being overused (by whatever defini- tion is applied). One cannot fail to be struck by the different approaches to the control of cigarettes and alcohol, on one hand, and marijuana, heroin, and LSD, on the other. It is likely that many "legal" drugs do more damage to the individual user and to society as a whole than many illegal drugs. Redemption Goals and Methods Social, political, and professional ideologies guide program goals. Stringent political measures, for example, have eliminated addiction in China and Japan, where the rights of addicts are preempted by the rights of the state. In the United States, response to the addict is intimately tied to the issue of civil liberties, and to one's right to do as one wishes with one's own body. Laws prohibiting drug use are considered by some as attempts to legislate morality (Bourne, l974). In actuality we straddle these two positions, considering both individual and societal needs. It is primarily the overuser who selects a particular way to be redeemed, except in rare cases in which treatment is prescribed and maintained by the legal system. However, entry into the redemption process is frequently prescribed by social institutions: law enforcement, medical, familial. In addition, while redemption goals are actually set by the overuser, they may be in- fluenced by the redeemer and others significant to the overuser's world. It has been most expedient to apply the medical model in arriving at goals for the organization and delivery of redemption programs, although attempts to modify environmental factors through job training and placement, housing relocation, and family counseling indicate a trend toward a more holistic model. The trend toward holism is also evident in issues of social policy that attempt to restructure sub- stance abuse laws and their enforcement. The trend toward self-cure parallels the redemption emphases on personal change. Who determines criteria for selecting redemption goals? As indicated earlier, once the overuser accepts that label and expresses a desire for redemption, he or she sets a personal goal for redemption. This personal goal may or may not correspond to prevailing social attitudes on how to control abuse or addiction. For example, if society sets the goal of no heroin use for a person on methadone main- tenance, and if the user perceives abstinence as an absurd goal, then heroin use would continue on weekends. In most cases, an overuser will identify a desired behavioral outcome before entering the redemption program and will select to enter only that program that affords the opportunity to meet this self-defined goal. For example, an overuser entering some therapeutic communities has eliminated all but abstinence

ll6 or reduced use as a pattern of choice, while the overuser who enters a methadone maintenance program has elected to goal of opiate substitution. Although the goals of redemption are actually set by the over- user, they may be influenced by the redeemer. If we consider a redemption goal to fall within the continuum from total abstinence to some form of controlled use of the overused substance, what should the attitude of the redeemer be toward the various options? For the majority of overusers, significant reduction of use, at least during the redemption process, is a realistic goal. Except in the case of food overusers, total abstinence may be preferable to some use, but this is a more difficult goal than significant reduction. If the goal of total abstinence is required, many overusers will not enter the redemption process. Others who do enter because of external pressures will pay only lip service to this goal. As a redemption goal, controlled use of any addictive agent is very difficult to assess. Lack of consensus on what controlled use is and what it involves increases the difficulty. One aspect is clear: There is no point in having one goal in the mind of the redeemer and a different goal in the mind of the overuser. If the goal selected by an overuser is controlled use, the redeemer should respect the user's wishes and clarify the definition and the process required to achieve this goal. Should it become apparent that attempts to control use repeatedly lead to overuse, the user and the redeemer might agree to modify this goal. Individuals who have already become overusers may be expected to have more difficulty in learning controlled use than those who are just beginning careers as users. The factors that determine an individual's ability to control use are not clearly defined. The majority of people in American society learn to control the use of alcohol and food. We suspect that relatively few people, however, learn to control heroin use. Learning to control use appears to be related to the development of rituals in association with use (Zinberg, l978) and to the presence of controlled users who act as models. There is a good deal of controversy surrounding the achievement and mainte- nance of controlled use. The viability of the concept depends on characteristics of the drug, the user, the society in which use occurs, and the interaction among these variables. Substitution of the overused agent by another agent or activity is a redemption goal that is frequently implemented and increasingly being regarded as a valid way to control overuse. A question remains, however, regarding the usefulness of replacing overuse of one agent with the use of another. Will overuse again be a likely outcome? There is no evidence that redemption increases the overall incidence of a second compulsive behavior (Stimmel, l977), although in many indi- viduals there appears to be a clear association. Smokers may exhibit compulsive eating after they have given up smoking. Alcoholics may become overusers of benzodiazepines or sedatives. The heroin overuser may have periods of alcoholism interspersed with cycles of heroin addiction. The drinking of alcohol is not abandoned while heroin is used, but its use diminishes significantly and increases when heroin use decreases. This was observed on a large scale among United States

ll7 servicemen in Vietnam who decreased alcohol use while heroin was readily available, but resumed alcohol consumption on their return to an environment of relatively low heroin availability (Goodwin et al., l975). One choice model of redemption, therefore, might be the deliber- ate substitution of alternative behaviors deemed less destructive by society as a whole. To some extent this model is applied by self-help organizations such as Synanon or Alcoholics Anonymous, in which heavy involvement in group activities is substituted for drug or alcohol use. Another example of substitution is methadone maintenance. Two or three daily heroin injections are replaced by a daily ingestion of a longer-acting opiate, methadone. As the individual becomes less in- volved with securing a supply of opiates, socially productive behaviors can be substituted for the drug. For success to occur, however, the redemption program must be holistic and attend to environmental change as well as to change in the host and agent. Assistance in job finding and in learning new ways to cope with family or other social problems is necessary. Eventually the individual can further reduce involvement with drugs by substituting methadone with an even longer-acting opiate, levo methadyl (LAMM). Only three doses of LAMM per week are required to satisfy the need for opiates. In this general way, other agents and activities can be substituted for opiate overuse. In establishing the redemption goal and methods to meet it, accurate diagnosis of the overuser's problems is essential. As in all fields of medical services, the development of a rapid and valid diag- nostic profile is the first and perhaps the most important step in redemption. The initial profile focuses on an individual's presenting symptoms in order to design the most effective therapeutic plan. In redemption, the development of such a profile has often been hampered by the traditional medical model and its preconceptions of the addict and addiction. The major diagnostic determinant of overuse, for example, has typically been the primary chemical of abuse rather than the personality and the overall clinical and social characteristics of the overuser. The common result has been a dichotomous classification system (e.g., alcoholic-drug addict), which has often been the sole determinant of treatment assignment (Dudley et al., l974; Liebson et al., l973; Ottenberg and Rosen, l970). The heavy biochemical emphasis generally overshadows equally important symptoms of medical, psycho- logical, and social problems (Pattison, l969; Toomey, l969; Kissin et al., l970). The focus on the primary chemical of abuse has also been carried into the overall treatment process. The therapeutic goal emphasizes chemical abstinance rather than other equally important problem areas. It now seems clear that the addictive process involves a complex ecological system involving psychological, medical, legal, social, and other environmental components. Their character underlies particular redemption needs such as marriage counseling for overusers whose family problems are supporting overuse and individual psychotherapy for over- users who attempt to medicate underlying psychopathology with alcohol or street drugs. Still others require an extensive period of

ll8 therapeutic community living to develop interpersonal, educational, and work skills or to nurture previously underused skills. Despite general recognition of these factors (Porkornoy et al., l968; Toomey, l969; Dolan and Kierman, l976), it has been particularly difficult and time-consuming to develop an individual analysis of the ecological circumstances in each person's addiction syndrome. Often, this inability to assess the nature and severity of a person's particu- lar needs results in inappropriate assessment of goals and assignments to treatment programs and subsequent concentration on aspects of redemption that ultimately have little importance for goal attainment. As part of an ongoing attempt to match particular needs of over- users with specific therapeutic techniques (McLellan et al., l976; McLellan and Alterman, l977), a structured admission interview, the Addiction Severity Index (ASI), has been developed (O'Brien et al., l977). The index represents an attempt to examine the chemical addic- tion syndrome analytically in order to improve treatment efficacy as well as to increase knowledge of the etiologies of addiction. The index was developed to provide the redeemer with a rapid, reliable, and valid diagnostic tool, and at the same time to aid the researcher by providing systematic data collection and a computer-coded system for -reliable data retrieval. The ASI regards addiction as a multifaceted system whose parts may affect redemption. The index examines six potential problem areas that generally encompass the major issues affecting and affected by the addiction syndrome: medical, psychological, pattern of abuse, employ- ment/support, family/social, and legal. The data on the individual's potential problems in treatment, a treatment problem profile, and a cumulative estimate of syndrome severity for each patient provide both objective criteria (e.g., presence or absence of clinically defined disease) and a subjective view of the problem from the overuser's perspective. The analyses of the data yield a cumulative estimate of addiction severity for the individual, a treatment problem profile, and the potential hurdles that may be encountered in altering the addiction syndrome. The ASI is used throughout redemption to measure the extent to which redemption goals and methods are succeeding to control overuse. OUTCOMES OF REDEMPTION Several problems prevent clear understanding of the efficacy of redemption methods, not the least of which is the lack of systematic data on overuse (see Levison and Stunkard in this volume). Typically those who operate successful redemption programs report their observa- tions anecdotally rather than in the context of rigorous research design. Those who are more methodologically pure may be less attracted to or adept at providing redemption services. Attention should be directed toward collaboration between redeemers and researchers in both program development and evaluation activities. More training in re- search methodology for personnel conducting redemption programs might also be useful.

ll9 The problem of evaluating redemption attempts, however, goes well beyond research capabilities of redeemers and others. Chambers (l974) states that such problems are conceptual, methodological, bureaucratic, political, and organizational. How could it be otherwise when the issues of defining overuse (both physical and psychosocial) must pre- cede any attempts to assess the outcomes of redemption? The definition of overuse, overuser, and controlled use are uncertain. Results of program efficacy reported in the literature employ different defini- tions for populations studied, making comparisons unlikely. In order to facilitate attempts to assess redemption outcomes, one must consider physical components of overuse (physical dependence if appropriate to that substance), psychosocial components of overuse, and the natural history of overuse. Does cycling occur naturally? Does substitution occur in the absence of redemption? Which overusers are capable of reverting to controlled use? These merely suggest the order of the complexities of the questions to be addressed. The strategy of selecting reasonably well-defined problem popula- tions and studying them longitudinally and randomly assigning them to various redemption modalities has led to progress in the mental health field. This same strategy might usefully be applied to overuse. The Addiction Severity Index attempts to do this by rating overusers on elements regarded as central to maintaining or changing use. The scale is then applied to assess change over time. The index represents an attempt to measure change that can be applied to various kinds of redemption programs for establishing gradations of success. It is not clear, however, whether overuse or addiction are concepts that lend themselves to quantification along limited dimensions, even though the index attempts to deal holistically with the overuser's problems. Clearly, the dichotomy drug-using and drug-free gives only limited information and may not be relevant to redemption goals established by many overusers and redeemers. There are many advocates of holistic diagnosis to develop and apply valid redemption goals and methods. Such advocates claim that this diagnosis is necessary to select the most appropriate treatment plan. A growing body of evidence demonstrates that it is the assess- ment of characteristics of overusers and their environmental experiences per se, not the mode of treatment, that increases the probability of changing substance use practices. Research on outcome of alcohol programs, for example, indicates that "outcome is best predicted by what the patient brings to treatment, not what happens to him there, and that differential assignment of patients to loosely defined treat- ments is probably premature" (Smart, l978, p. 75). CONCLUSIONS AND IMPLICATIONS FOR RESEARCH In this paper we have developed an ecological view of overuse and described how this perspective is expressed in alternative models that shape goals and methods to control overuse and excess. We have also examined the concept of controlled use as an integral force in redemp- tion. Redemption can be conceived broadly as the series of events that

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l2l influence who gets into treatment, where one goes for it, the rationale for assigning treatment plans and goals, and one's post-treatment experiences. Figure 3 summarizes factors influencing the process of events before, during, and after redemption. Three major findings emerge from our review: l. Alternative Models. Both the medical and redemption models afford limited approaches for formulating goals and methods to minimize the causes and effects of overuse and excess behavior. The former model's focus on the agent of overuse and the latter's focus on host conformity to external environmental standards of use ignore the com- plex, multifaceted environmental system that appears to influence etiology, maintenance, and change in addictive processes. The holistic model, on the other hand, stresses the development of goals and methods that include biomedical, psychosocial, socioeconomic, and political factors. Since treatment modality for any overuser appears to be less salient than knowledge of the overuser and environmental character- istics, refinement of the holistic approach has the greatest potential for redemption. The holistic model implies that the redemption agency can reduce overuse by operating on the host, agent, and environment. The host, for example, may be provided with alternative repertoires through education that provides increased skill in coping with the environment. The environment may be altered by the redeemer so that the more adjustive alternative repertoires are more easily practiced and explicitly rewarded. Overuse could be attenuated in the most direct fashion if the environmental factors that generate adjunctive excess behavior could be located and altered. Agents (either sub- stances or activities) could be altered by changing environmental consequences of abuse that are thought to be partially responsible for sustaining excess behavior. For example, increasing group rituals and sanctions for substance use carry with them implied social punishment for inappropriate overuse. Decreasing some of the ancillary rewards of abuse, such as the glamour of hustling and risk-taking, would also have the effect of decreasing the reinforcing properties of the agent. 2. The Concept of Controlled Use. Just as the medical and redemption models afford limited options for curtailing overuse, so too is total abstinence a limited means of controlling overuse and excess. The controversy over controlled use diminishes (a) when it is conceived as a continuum ranging from abstinence to considerable regular use, and (b) when substitution is incorporated as either a goal for control or a means of goal-attainment. Controlled use appears to succeed with users who learn socially approved practices or rituals that define time, amount, and manner of use. It may be that the threat of recurrent overuse, on the other hand, occurs when former overusers practice occasional use in the absence of social rituals that prescribe limits regarding time, amount, and manner of use. 3. Self-Control or Self-Care. Options and potentials for success in moving from overuser to user status increases when the overuser is regarded as the primary person to determine treatment goals. Congruity between a redeemer's and an overuser's values on use and methods of control also appears to increase potential for success.

l22 Four major areas of multidisciplinary research are recommended to expand our initial findings: l. What are we treating? We have focused on ways in which redemption is influenced by definitions of overuse and those factors that motivate the overuser to seek change in use practices. An under- lying problem is whether overuse is an entity in itself or whether it is a symptom of some underlying condition in the individual, the environment, or both. An example of an underlying problem that may be basic to many forms of overuse is the mental syndrome of depression. Psychic pain involved in depression may lead to compulsive behavior as a form of escape. Indeed the compulsive use of drugs such as opiates or alcohol may provide temporary dulling of pain, or the compulsive behavior itself may have this effect. Although there are few system- atic observations in this area, it has been observed that treatment of underlying depression leads to improvement in drug addicts (Woody et al., l975). To what extent is depression prevalent in obesity, cigarette smoking, and compulsive gambling? To what extent can we determine whether depression causes or is a consequence of these con- ditions? The methodological problem of confusing cause and effect must be addressed. The significance of what we are treating impacts not only on the redemption process but also on the outcomes. If there is some basic mechanism underlying overuse, the possibility exists that those whom we attempt to redeem from one substance may simply adopt another. Can we predict what may cause more problems for the individu- al and society? Underlying factors must be examined across substances. 2. How might we effect change? We have emphasized substitution as a major form of minimizing or eliminating socially defined overuse and excess behaviors. Will redemption inevitably lead to the substitu- tion of equally problematic behavior? What evidence is there that regulated substitution might be a valid goal? Will the substitution process, as suggested in (l) above have more negative than positive impact on the individual or society and can this be predicted? To what extent is this testable? What are the potential harms and benefits of substitution and under what conditions can the benefits of this process be maximized? How do self-prescribed substitutes differ from thera- peutic substitutes? What are the implications for treatment programs? How widely acceptable is substitution as a general principle? 3. How can we measure outcomes? Establishing the outcomes of redemption requires systematic investigation along multiple dimensions. The ability to determine efficacy requires a baseline established at some point from which later measurements are procured. For example, what pre-treatment and treatment variables prevail in the post-treatment environment in relation to user and environment characteristics? How does treatment efficacy per se influence recidivism? What is the role of peer influence in treatment outcome? What are expected outcomes for overusers who do not seek treatment? In assessing outcomes of treat- ment goals, whose goals are to be measured? Since our findings support the advisability of goal definition by overusers, efficacy of redemp- tion should be assessed in terms of the overuser's goals as well as goals regarded as valuable to the redeemer or to society as a whole. Does research support our position that redemption will fail if the

l23 overuser is expected to reach socially imposed goals? How does coer- cion influence goal attainment? Under what conditions might coercion work? If controlled use is the redemption goal, prospective studies of success in attaining controlled use are required. While there is anecdotal evidence from individuals who practice controlled use for specific periods of time or who have succeeded in making the transition from overuse to controlled use, this evidence is quite limited. How does one predict who is capable of controlled use and what can be done to help users to achieve that goal? Systematic data collection that helps to relate controlled use to the population of all users or of all overusers is reuqired to answer such questions. Quantification of the severity of overuse must be measured both in terms of the amount and kind of substance ingested and in terms of the degree to which overuse influences the individual's ability to function adequately in expected life activities. Comparative costs and benefits of various inter- ventions across substances should also be obtained. This implies the need for base rates of use and voluntary termination of use in the general population. 4. How can research findings be applied? While we need to know much more, there is a substantial body of data on overuse and excess that has generated a considerable number of recommendations both for research and policy. What has been the history of reports by advisory commissions and councils? What use have key public decision-makers made of such reports? Who are the key individuals to be reached by such documents and by what process? It is often thought that social science research provides descriptive and analytical data to support a prevailing climate of opinion or to increase the impetus to move in a new direction already defined by policy makers. To what extent does the social scientist have the opportunity to apply accumulated research findings at the initial formulation stages of policy formulation? REFERENCES Abelson, H., P. Fishburne, and I. Cisin (l977) National Survey on Drug Abuse: l977. National Institute on Drug Abuse, DHEW Publication No. (ADM) 78-6l8. Washington, DC: U.S. Government Printing Office. Alcohol, Drug Abuse and Mental Health Administration (n.d.) ADAMHA Obligations, FY l977. Mimeo, Washington, DC. Beauchamp, D. E. (l976) Exploring new ethics for public health: Developing a fair alcohol policy. J. Health Politics, Policy and Law 338-54. Bourne, P. G. (l974) Issues in addiction. In Bourne, P. G., (ed.) Addiction. New York: Academic Press.

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l26 Wallace, M., G. Singer, M. J. Wayner and P. Cook (l975) Adjunctive behavior in humans during game playing. Physiology and Behavior l4:65l-654. Woody, G. E., C. P. O'Brien and K. Rickels (l975) Depression and anxiety in heroin addicts: A placebo controlled study of dexepin in combination with methadone. American Journal of Psychiatry l32:447-49. Zinberg, N. (l978) A study of social regulatory mechanisms in controlled illicit drug users. In Proceedings, Conference on Commonalities in Substance Abuse and Habitual Behavior. Committee on Substance Abuse and Habitual Behavior, National Research Council. Zinberg, N. and J. A. Robertson (l972) Drugs and the Public. New York: Simon and Schuster.

DISCUSSION OF "REDEMPTION OF THE OVERUSER" Norman Zinberg "Redemption of the Overuser" represents a complex effort to approach a very complicated subject. In this discussion, my intention is not to criticize but to point out some crucial omissions and ambigu- ities in the paper. These problems arise, in part, from the difficulty of trying to encompass in one schema (relating etiology, behavior patterns, and treatment) not only drug use but also drinking, smoking, gambling, and other habitual behaviors. The paper attempts to discuss this enormously complicated and mult ifaceted subject virtually in shorthand and requires elaboration on almost a page-by-page level. Language The paper correctly emphasizes the importance of language in discussing issues related to redemption and overuse. When we talk about drugs, we no longer want to accept the legal and medical defini- tions that define any use as abuse. Legally, possession of a single joint of marijuana constitutes abuse, even if it is the first one the individual has ever smoked. Medically, any nonmedical use is abuse by definition, so that the social circumstances of use become important. The concept of substantiality, as explained in the paper, is used to define overuse as use to a point at which physical or emotional health is at a critical threshold of damage, but using substantiality as a criterion for defining overuse is extremely complicated; what is reason- able, harmless use for one group or individual is not for another. The terminology of drug, set, and setting, often used in drug literature, is changed to agent, host, and environment in the paper. The latter is used frequently in epidemiology but is difficult to translate into more familiar concepts about drugs. Although it is used because it enables the authors to incorporate habitual behaviors other than intoxicant use into their scheme, it is at times rather confusing. The Historical Dimension A crucial dimension that is missing from "Redemption of the Overuser," although the authors hint at it, is that the phenomena being 127

l28 discussed (e.g., "redemption" efforts, drug use, social setting of use) are evolving processes. For example, one form of drug treatment— methadone maintenance—is very different in l977-l978 from what it was in l970, particularly in terms of attitudes toward clients. This change came about in part because of the attempt to develop objective treatment evaluation measures. Obviously, nobody would take the word of junkies about how effectively they had been treated, nor would anybody take the word of the people who ran the treatment programs because they might be biased in favor of their own programs. In their attempt to develop objective measures, Dole and Nyswander, the origina- tors of the methadone maintenace method, focused on things like the number of crimes and arrests following treatment. Very quickly what had begun as an evaluative measure became a treatment goal. Once that became a goal of treatment, the very nature of treatment changed con- siderably. In the early years, treatment providers were concerned primarily with working with the clients to help them achieve their own goals. Later, treatment providers began to want from the clients what "society" wanted from them: to get off the streets, stop stealing, and stop causing "us" trouble. Although the clients had the same goals for themselves, once the treatment providers wanted these goals for society, -their attitudes toward the clients changed. Drug use may also be described as an evolving phenomenon. For example, through my contacts with a high school in Arlington, Massachusetts, I have seen marijuana smoking change over the years. I did some work at the high school a few years ago and keep in touch by giving social learning seminars there every month or so. This allows me to communicate at the junior high school and high school levels with kids who are still coming along. Arlington is a nice place to do this because it is mostly lower-middle- and middle-middle-class housing; there is very little upper middle class and almost no working class, so you can take a close look at one segment. The kids still pass mari- juana cigarettes around, and to a certain extent they are still trying to discover how much it takes to get high. The whole concept of "know your limit," whether with marijuana or alcohol, implies testing in order to know what that limit is. This process of testing carries with it a certain amount of anxiety, although the more familiar the process is, the less the anxiety. (Presumably, novices by definition are not personally familiar with the process but have observed or heard about it.) The rigid rituals of passing the joint and the accompanying anxiety that were common at every level l2 years ago are not so common today. People learn to become experienced users fairly quickly and develop different concepts of control. One result of this learning is a lowering of the age of first use. Learning to use drugs in this way is exemplified by becoming an alcohol user, to paraphrase Howard S. Becker's seminal work. When adolescents begin to use alcohol, they often drink too much, get drunk, and sometimes get sick. This experience is not too frightening to them because of the social learning they have undergone while growing up in this culture. Social learning about marijuana use appears to be changing the experience of using marijuana in the same way, so that less anxiety accompanies the initial using experiences.

l29 English pub drinking provides an example of a change in the environment in which a control was developed to serve one function and then came to serve another. After the gin epidemic in the l9th century, pub hours were restricted as a way of reducing the use of alcohol. Today, many people regard the effect of restricted pub hours as changing the quality of drinking, not reducing use. If you have only a short time to drink, you drink more in less time. In Australia, where pub hours are from 4:30 to 6:00 P.M., people who want to do a lot of drinking by 6:00 go into the pubs at 4:30. Similarly, during Prohibi- tion in the United States, people went to speakeasies to do a lot of drinking, not simply to have a beer. The changed environment, then, altered the quality of drinking. Thus, in order to consider issues of treatment for overuse, controlled use, and setting of use, the constant process of social evolution should be taken into account. Knowledge About Drug Use One of the important factors of the environment or social setting in which drug use, or overuse, occurs is the public's knowledge about drugs—which determines, at least in part, knowledge available to the users. The authors do not discuss the acquisition of knowledge by the public or the unconscious inhibition against knowing by the public and informed professionals. A recent study of Harvard Law School professors showed that these people, extremely knowledgeable about every aspect of public affairs, did not "know" the difference between the nature of marijuana and heroin use. On further questioning it was clear that they had been exposed to this information on many occasions. The knowledge had been available to them but they had not learned it. When they were questioned about what stopped them from learning, they were willing to say that they did not want to know. The entire subject was distasteful to them, and one way of expressing that distaste was to restrict their knowledge. Restricted knowledge about drugs can affect drug users in many ways. For example, many heroin users do not know that controlled heroin use as a stable pattern is possible. For marginal users—that is, people who are clearly not stable controlled users and who have had periods of addiction, controlled use, and abstinence—the people with whom they come in contact seem to make a great deal of difference in their careers. Once these marginal users find a stable, occasional user, they are able to learn how one can use successfully in a con- trolled way. Many heroin users have contact only with addicts and junkies or with the abstinence-oriented outside world, and feel that they will inevitably become addicts. Even when knowledge about controlled use is available, people may or may not use this knowledge. For example, in my experience with the "far-gone alcoholic," people know very well what controls are and what happens if they do not use control. We then have to address the more subtle notion of decisions about when they are going to use it and when they are not going to use it. These decisions are very complicated for

l30 people who wish to drink but not be damaged. It is my experience with every alcoholic whom I have seen (and I have spent far too much of my time in recent years with alcoholics) that every one of them really wishes he did not wish to drink. That is, he cannot imagine tolerating further internal struggle with his wish to drink. Therefore, he wants to avoid the struggle and have his wish to drink extinguished. He wishes he did not experience the terrible conflicts, the ambivalence, the mixed feelings, the struggle to deal with himself and his own wishes, and so on. There is little in this paper that reflects this kind of conflict around redemption. Controlled Use vs. Abstinence A discussion of redemption must necessarily deal with the issue of substantiality in the choice between controlled use and abstinence. That is, at what point is the individual's physical or emotional health so damaged that abstinence is the only solution? With the far-gone alcoholic, the choice is easy. Swollen, fatty livers, esophageal varices, and other physiological complications make it perfectly ob- vious that this person should not touch another drop of alcohol as long as he lives. Yet I have seen such people who believe that they can be redeemed to controlled drinking based on their reading of the Rand report on alcoholism, which suggests that somebody who has been drinking too much for a couple of years can return to controlled drinking. Thus, the goal of redemption relies to a great extent on who is being redeemed. With heroin addicts it is even more diffiuclt to decide whether abstinence or controlled use is an appropriate goal and for whom. Is a shift to other drugs, or a shift to meditation, for example, considered redemption? In the Robins sample and a number of other samples that have been collected there is a high percentage of occasional heroin users. Have these people been redeemed? Are they still abusers? Influencing the Drug, Set, and Setting "Redemption of the Overuser" fails to make a sufficient differen- tiation between the capacity to manipulate the three dimensions—drug, set, and setting. The setting can be more readily manipulated than the drug or the individual, particularly if we look at the relationship between formal and informal controls. For example, formal controls on drinking, such as reducing the proof of liquor, represent attempts to influence drinking that are part of a socially evolving process. To the extent that individuals begin to participate in wanting to drink lower proof beverages (wine and beer rather than hard liquor), environ- mental controls have helped to reduce some of the harmful consequences of alcohol consumption. If controls come only from the outside and remain only at the formal level, a prohibition-oriented situation is created, which has very different effects. A move in the direction of formal controls in a prohibitionist way may dissolve the effectiveness

l3l of informal controls. The relationship between formal and informal controls deserves a great deal of further study, but it seems to me that the setting that generates or inhibits informal controls is much more manipulable than the individual or the drug. Substance and individuals can be manipulated in some sense, however. For example, attempts can be made to alter the supply of drugs in the market, or to make drugs "safer" (e.g., vitamins in alcohol). And individuals can be manipulated through treatment, religious conversion, etc. For example, the Black Muslims have had a great deal of success with addiction, and reformed alcoholics often report that they have been moved in a sort of cataclysmic upheaval. But the relationship between formal and informal controls is far more manipulable, particularly by education. Education of the public at large holds great promise for developing changes in informal con- trols. This must be part of the changing concept of redemption that encompasses the relationship between drug, set, and setting and is part of a social historical process.

COMMENTS ON "REDEMPTION OF THE OVERUSER" Irma H. Strantz First I would like to express my appreciation for the opportunity to participate in this conference and present what I hope are some helpful comments on this paper. As you may be aware, this paper is highly relevant to the type of work in which I am involved (that is, the planning, implementation, and evaluation of drug abuse programs in a large metropolitan county). Concept papers and deliberations of groups such as this can be extremely helpful to program planners, not only in terms of advancement of knowl- edge and skills in dealing with substance abusers, but also in terms of supportive and interpretative communications to legislators and funding agencies. Overall, I found this paper to be thoughtful and stimulating. I have the following comments and observations. In the section that addresses overuse the concept of substantiality needs to be expanded. We need to have a better understanding of substantiality as a threshold separating use from overuse. For most abusers, the decision to cross this threshold is made unwittingly, albeit in harmony with cultural and social norms. Let me give an example of a step-wise progression that is often used in the field of alcohol treatment. At the first level of use is the experimental or occasional drinker. The second level includes the social drinker, who uses alcohol only in social settings, in which there are informal controls as to amount consumed and kinds of behavior accepted. Passage to the third level occurs when alcohol use becomes valued as a reward or is used to relax and unwind after stressful situations on a more or less regular basis. At the fourth level, alcohol has become a crutch, a special aid to get through anxious situations, which may be periodic or episodic in the life of the in- dividual. The fifth level is characterized by the compulsive use of alcohol; in this situation the individual has become dependent upon it for daily functioning, and the effects of its use are injurious to family and occupational and social norms of behavior. In this progression, the third level is considered to be the threshold where the criteria of substantiality are met. Negative behavioral effects may be noted at this level of use, but they are usually tolerated by the individual and society because there is the general expectation that these effects are intermittent. Family and l32

l33 friends may be loath to comment at this level, or even at the next. However, the farther along the individual progresses in this heirarchy of use, the more difficult it is to communicate the fact that sub- stantiality has been reached with the use of confrontation and crisis terminology. The paper goes on to discuss various treatment models in an ecosystem framework. I question whether the ecological structure, as presented, is in fact useful in differentiatiing between current treat- ment models. For example, the medical model is too narrowly perceived and anachronistic. To my knowledge, there are very few substance abuse treatment programs that focus on the origin of illness within the host. Even in methadone maintenance programs, the physician is seen as only part of the team, and the emphasis is placed on assisting the client (not patient) to develop competence in dealing with his environment or finding new and more supportive environments. How would the ecosystem framework be applied to the preponderance of current treatment efforts, which include: social model detoxi- fication, Alcoholics Anonymous, Narcotics Anonymous, therapeutic communities, encounter groups, reality therapy, and "competence development" activities? There is a wide variety of treatment alter- natives that have been developed to meet the range of social and cultural differences among substance-abusing individuals. For example, the traditional therapeutic community has been modified in California for the Mexican-American male so that emphasis is on action rather than confrontation and analysis of interpersonal and family relationships and problems. By providing role modeling and demands for work and other responsible behavior, the Chicano male is helped to develop competence and self-esteem in terms of his personal perceptions of valued cultural norms. The holistic model broadens the ecosystem focus to encompass the environment, to include those programs that aim to accomplish change there as well. Examples of current efforts in this model are more difficult to find. Synanon addresses the environment, but deals with it by requiring that the Synanon member withdraw himself or herself totally rather than attempt to change the environment or find a more compatible niche. We find, therefore, that many substance abuse programs have incorporated Synanon encounter group methods within their treatment systems, but few have chosen to deal with the environment by rejecting it. Aided by recent federal disability legislation and job development programs (such as CETA), they apply some effort to the confrontation of businesses and industry for the purpose of assisting the substance abuser to re-enter the work environment. Current prevention efforts are more typical of the holistic model. The school, the family, and the community are the primary foci for intervention. In a growing number of schools, greater emphasis is being given to affective education techniques and the provision of a more supportive environment for student development and decision making. In a number of communities, family environments are targets of change through parent-effectiveness training and similar programs that are supportive of better communications and mutual respect in primary groups. Finally, in recreational and parks programs, alternative

l34 activities are being offered that serve to enhance interpersonal skills and feelings of competence in our youth. The redemption model is defined as the re-education of the "amoral host in order to avoid social isolation and stigma." The discussion of this model is rather confusing. First, it is presented as a separate model; then, as an attitude or screen through which the medical and holistic models are again discussed; and finally, it becomes the model or structure for organizing the series of events determining who gets into treatment, in which program, with which treatment plan, and with which prognosis for success. I'm unclear as to the implications of the redemption model, as presented. Are we asking for a national perspective on substance abuse—a unifying and moral ideology that will provide the rationale for all intervention efforts? If so, more discussion is needed. If there is any national consciousness in the United States about sub- stance abuse, it relates to costs to society in terms of crime and accident rates. Salvaging or redemption of wasted lives is a somewhat lower priority. Economic factors that exacerbate the substance abuse problem, such as rising unemployment rates, inflation, inadequate housing, and inadequate education, are deplored and attacked piecemeal instead of in a coordinated system that gives the primary value to the need of each citizen to feel competent and capable of achieving a decent quality of life. In passing, there are several groups involved in drug abuse treatment who employ a redemption model philosophy: Ten Challenge, Hasidic Judaism, Seventh Day Adventists, Mormons, etc. Religious values and activities are offered as alternatives to drug abuse. The paper goes on to discuss the value of an addiction severity index. There are a variety of these available to drug abuse treatment programs, and they have been found to be helpful in assessing the client's status at intake: i.e., level of sustance abuse, motivation for treatment, social and personal support system, etc. They also provide the framework in which objectives can be set. The majority of programs in California are aware that each client must have a treatment plan, developed with client input and with measurable objectives. Client progress should be assessed and documented throughout the course of treatment and at discharge as well. Discharge statistics in Los Angeles County in l977 indicated that slightly over one-third of clients in all drug abuse programs (residen- tial, maintenance, and drug-free outpatient programs) were discharged "treatment completed." However, client discharge data also indicated that at least 40 percent left the programs without completing treatment. Program evaluators queried whether these clients left because they felt that they had received maximum benefits from the programs (even though program staff felt they hadn't) or whether they had received only short-term benefits and in fact had returned to substance abuse. To answer this and other questions, an outcome study was per- formed in Los Angeles County. We found that while "discharged, treatment completed" was not necessarily a predictor of success (i.e., drug-free, arrest-free, and employed one year later), the longer an

l35 individual participted in a treatment program, the better his chance of being adjudged a treatment success one year past discharge. With outcome studies, there are many problems. One of these, relating to the tracking of clients, was mentioned at this conference. In order to comply with all of the confidentiality requirements that apply to this target group, one can expect to pay at least £300 per completed interview and to rely entirely on the accuracy and complete- ness of treatment program records. I feel strongly that this is one area that needs to be addressed by researchers and evaluators of substance abuse programs. Federal and state confidentiality require- ments are such that we are unable to use rap sheets or social security numbers or even driver's licenses for tracking. Also, when we want to validate the respondent's self-report of being arrest free, even with that individual's signed consent, we cannot obtain access to state Bureau of Criminal Statistics rap sheets in other than aggregate form. Therefore, in our recent outcome study, the arrest and conviction data were very difficult to analyze statistically in terms of before and after correlates of criminal activity or inactivity. We have found, therefore, that when legislators, policy makers, and funding agencies ask us to document the impact of treatment programs, outcome measures must be confined primarily to client self-report, without independent validation. One small comment I'd like to make about one of the outcome measures used for drug treatment programs that are federally funded. The desired client status at discharge and upon follow-up is "drug- free," that is, using no drugs. In reality, most program personnel working with heroin or polydrug addicts believe that they have been successful if the individual has ceased heroin or other narcotic abuse, but continues to use marijuana or alcohol on a semiregular basis. While the federal reporting system (CODAP) policy is tolerant of occasional alcohol use at discharge, there is no such acceptance of occasional marijuana use. Agencies must, therefore, choose between claiming successful treatment according to their perception of reality in the target community, or appearing generally unsuccessful according to federal policy definitions. With reference to treatment outcome studies, there is a great need for a matched control group in the community that is not exposed to treatment or incarceration during the same time period. Such a study would be costly, but not impossible. In Los Angeles, we attempted to match a jail population of heroin addicts with a group exposed to treatment during the same time period. The assumption was that the courts diverted addicts to drug abuse treatment programs primarily when they were supportive of the principle of rehabilitation. We found that it was impossible to identify two matched cohorts. The jail population of heroin addicts were felons first, with many more arrests and convictions for crimes not related to addiction. The treatment group were addicts primarily, whose criminal activity tended to be entirely related to supporting an expensive habit. An interesting question is raised at the end of the paper: What use is there for applied and pure research studies in substance abuse? I am convinced that there are many uses. Besides the obvious ones that

l36 lead to the planning and provision of more effective and efficient services, there are other potential spinoffs. In California for several years we have had an inadequate level of state support for drug abuse treatment and prevention programming. Existing programs have been underfunded and many priorities, including prevention, have not been met. As a result, program planners and providers across the state mounted an aggressive campaign to convince state legislators of the needs. For two years in a row, the legislature added funds to the drug abuse budget, only to have these blue-pencilled by the governor in the final budget. The message received over and over again from the governor, the Department of Finance, and certain local and state legis- lators was that of little confidence in the efficacy of drug treatment. We were asked why additional support should be provided without any data being submitted that justify expansion. As a result, a tremendous interest and activity was generated across the state in drug abuse cost-effectiveness and cost-benefit studies. Some people in the drug abuse treatment community resented the use of any drug abuse funding for this activity, pointing out that alcohol and mental health programs did not have to expend the same amount of effort to justify their existence. We agree that the drug abuse treatment system is in the vanguard of evaluative research, probably because drug abuse is a frequent source of political controversy (i.e., the deployment of resources for supply reduction versus that for demand reduction). Also, measures of success are easier to identify, such as before and after measure of drug abuse and addiction, criminal justice involve- ment, and employment. As a result of better documentation of need and the various outcome and cost-benefit studies that could be reported to the legis- lature and governor this year, the drug abuse planning and treatment community are finally assured of an augmentation in the state drug abuse budget for fiscal l978-l979. This augmentation represents a 30-percent increase and will total $5 million, if it is matched by the counties on a 90/l0 ratio. Whether it will serve in state and local budgets in the event that Proposition l3 carries next week remains to be seen.

COMMENT ON "REDEMPTION OF THE OVERUSER" Thomas C. Schelling The general direction taken by the authors of "Redemption of the Overuser" is a salutary one. It does not go very far, however, in dis- entangling itself from traditional beliefs and attitudes. Even the term redemption is loaded with connotations of guilt and morality. The paper deals with a deadly serious subject, the kind of overuse that can in the extreme case lead to death or, in the dramatic terminology that I think these authors hoped to get away from, a fate as bad as, if not worse than, death. My suggestion for escaping some of the traditional attitudes and even the traditional language of addiction would be to start at the opposite end of the scale: To look at some of the least harmful or least addictive substances or those that generate the least social con- cern, even look at some practices that involve no substance at all. To begin with the kinds of overuse, or even use, or (when no substance is involved) the kinds of habits that mainly annoy or hurt or embarrass the person who has the habit or somewhat endanger the person or reduce his or her productivity or are an offense and a bother to family and associates but are below the threshold of social concern. And then work up toward the substances that invite sympathy rather than condemnation—and probably not to even take on yet the inherently controversial subject of illicit drugs. Several reasons may be given for this approach. In terms of policy, of costs and benefits, it may be important to identify those habits and substances for which the degree of harm to the patient or victim or subject is not measured by the degree of addiction, so that we can work on the easy cases rather than the hard ones, doing as much good by helping the easy cases as we might do by helping the hard ones. If some people are more addicted to cigarettes than others but smoke the same quantity and suffer the same risks to their health, it may be unnecessary to take on the challenge of redeeming the unredeem- able when there are plenty of other people who might be more success- fully helped. Some people conjecture that the quantity of coffee or the number of cigarettes is proportionate to the addiction, and that saving the easy cases doesn't save much, only those who neither smoke enough cigarettes nor drink enough coffee to do themselves much harm. That does not seem to be a demonstrated relationship, but usually is put forth as something that stands to reason and that fits a model l37

l38 that exists in the mind of the theorist. If a great many people drink too much coffee or eat too much salt or smoke too many cigarettes who could reduce or eliminate the substance without much pain, there may be more good to be done by concentrating efforts where success is likely than to invest futilely where the challenge is greatest. It may also be helpful to break out the framework in which there is necessarily a substance. In their book, Habit Control in a Day, Nathan Azrin and Gregory Nunn estimate that about 40 million people in America bite or otherwise abuse fingernails during some part of their lives, and another 8 million abuse hair and whiskers. Nobody has ever proposed making it illegal as far as I know. In some ways, these habits are more intractable than, say, alcohol, because one cannot go on any kind of journey and leave one's fingernails behind. Nobody has ever proposed that a little bit of fingernail biting is good for you, and only too much is abuse. It has been proposed that if a person gives up a nervous habit like fingernails there remains a pressure or motivation that needs to get out and that it will show up as some other bad habit. That again seems to be based on metaphor rather than theory, and too quickly one assumes that these habits are somehow functional. To get away even from theories that nail biting meets some inner need, I would propose looking at behaviors like the scratching of hives. Most people, when they itch, try not to scratch. The satisfac- tion is momentary and most people expect that, with a time horizon of more than five minutes, scratching is not satisfying. Especially, in- advertent scratching that stimulates the itching, as when people awake in the night to find themselves scratching and it is too late not to get started, is something that most people try to guard against. Then there are habits like bad posture, careless speech, and procrastination that people try to guard against or break. And there are good habits, like persistence in practicing a language or a sport or a musical instrument or the cultivation of rapid reading that people hope and try to reinforce. Whether or not fingernail abuse is as bad as alcohol abuse—and I suspect for some people it is—there may be a lot to be learned by studying it. First, we can get away from moral and legal constraints in our study. Second, we do not have to engage in controversy with all-or-none crusaders. Third, we needn't bother too much with how to define abuse or overuse or to ask who gets to determine the criteria of abuse and overuse; it is easy to identify the person who cares, or a very small number of people who care, and invariably it is the person who has the habit whose concern is central. Finally, there may be some suggestive experience in coping with these kinds of habits or in failing to cope with them that will illuminate other habits, even the habits involving the more deplorable substances. And I particuarly have in mind the ways that people try to protect themselves from their own habits. I incline to the view that in most discussions of addictive and habitual behavior not much credit is given to the possible conscious exercise of control over their own behavior that people may be capable of. Among the different models or perspectives or attitudes I would

l39 make a division between those that treat the patient as essentially incapable of contributing much to the management of his own problem, and those that substantially depend on and try to help and reinforce the conscious efforts of the patients to manage their own behavior. And it may be important when discussing the ambivalence of patients about their own behavior to recognize that there are moments or periods when the one motivation is dominant, moments and periods when the op- posite motivation is dominant, and periods when the two may be mixed together. People can try wearing mittens to bed to avoid scratching in their sleep or gloves in the daytime to avoid biting their fingernails, and people who know that they can control their drinking but not their smoking when they drink, may lay off alcohol while they are trying to quit smoking, just as people may give their car keys to their host upon arrival with the request not to return them if the guest appears drunk when it is time to go home. It is somewhat difficult to know just how much better knowledge and better training it contributes to the ability of people to reduce or eliminate their smoking or their alcohol, but two considerations suggest there may be quite some scope for effective help. One is simply that most people know very little, and don't know where to go to learn more, and have never had any training, with respect to the con- trol of habits, whether innocuous or serious habits. Some people have discovered only by accident that changing their hair style is enormously helpful in avoiding a hair pulling habit, or that professional manicures can be enormously helpful in nail control, or that certain tools and implements can double their reading speed, or that changing the time of day for exercise will help them stay on a regime. How to stop smoking, or how to cut down effectively, is not necessarily something that people already know or can easily find out. So this may be an under- developed area of habit control. Second, even the people who doubt the ability of patients to help themselves much and who vividly describe the overpowering of patients by cues and associations and so forth offer a number of hints that could help a person help himself. If home is where you learned to use heroin, the advice seems to be, don't go home. It usually isn't given as advice; it is given as an observation that when the person returns home he will return to his habit, or that the person needs to be kept from returning home to keep him from returning to his habit. But it may be equally important as advice to the person who, ambivalent about heroin because he both wants it and wants to kick the habit, is at least momentarily clear about his desire to kick the habit at the time that he happens to be deciding whether to go home. And so forth. To sum up, I propose that we pay more attention to the "lesser" bad habits, like salt and coffee and fingernails or daydreaming or losing one's temper or reading too slowly or slumping or getting hooked on late night television movies. First, because they matter, too. Second, because we may see things that we are blind to when we look at the familiar and dramatic addictions. And especially we may better discover the extent to which the patient's own self-management can be helped to be more effective, possibly in a manner that generalizes even to the harder kinds of addiction.

REDEMPTION OF THE OVERUSER: GENERAL CONFERENCE DISCUSSION Deborah Maloff The general discussion following Kaplan's presentation began with the issue of cost-benefit analyses of treatment programs. Stunkard stated that the cost of treating obesity has been fairly accurately calculated; investigators have determined how much money must be ex- pended for an obese individual to loose each pound, depending on what type of treatment is used. Benefits are more difficult to calculate when we consider subjective aspects such as improved quality of life. Cost-benefit analyses of various substance use treatment programs are complicated by the many variables that must be measured. For example, the comparative benefits of different programs depend on the time scale the investigator is using to evaluate effectiveness. Carried to an extreme, to take complete account of costs and benefits, one must look at the birth-to-grave experience. Johnson commented that some have contended that treating alco- holism (or other forms of substance abuse) is disadvantageous from a cost-benefit standpoint. The alcoholic who dies as a result of alcohol consumption at age 50 is relatively more productive than the non- alcoholic who lives to age 85 and must be supported by society for 20 years. This then becomes a moral or ethical issue. Many are shocked by the attempt to view human lives in terms of maximum years of produc- tivity. Kaplan argued, however, that individuals choose to use sub- stances and therefore choose to die young. What obligation does society have to alter individual choice? Terris stated that individuals are not necessarily free agents in their decisions to use substances. He pointed out that, for example, the tobacco industry encourages people to choose to smoke. Further, the tobacco lobby has prevented public health campaigns from adequately warning or educating the public about the danger of smoking. Kaplan felt that industry advertising is not as effective in molding people's choices as one might think. For example, despite the absence of advertising of marijuana and heroin, their use increases. Zinberg commented that there is much validity to the idea of social pregnancy—that is, when people are ready to accept the messages of advertising campaigns or antidrug abuse commercials, these ads be- come effective. The social situation is an important variable here. For example, the antismoking advertisements began to be meaningful to individuals who were beginning to think about the hazards of smoking. 140

l4l Conversely, formal antidrug ads in the late l960s were rarely effective, since there was great sentiment in favor of drugs among many young people. De Rios stated that regardless of the social situation, media messages can impact usage. She gave the example of the sharp decline in use of LSD related to the media's treatment of the drug as damaging to chromosomes. Thus it is possible to scare people away from using things they would otherwise be positively inclined to use.

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