Expanding Addiction: Critical Essays [1 ed.] 0415843286, 9780415843287

Table of contents :
Cover
Title
Copyright
CONTENTS
Preface
Acknowledgments
INTRODUCTION
1 Addiction Is Not Just a Brain Disease: Critical Studies of Addiction
PART I: HISTORICIZING ADDICTION
2 Discovering Addiction: Enduring Conceptions of Habitual Drunkenness in America
3 The Cultural Framing of Addiction
4 Deviant Drinking as Disease: Alcoholism as a Social Accomplishment
5 The NIDA Brain Disease Paradigm: History, Resistance, and Spinoffs
PART II: LOCATING ADDICTION
6 What Neurobiology Cannot Tell Us about Addiction
7 Praxis, Interaction, and the Loss of Self-Control
8 Framing Nicotine Addiction as a “Disease of the Brain”: Social and Ethical Consequences
9 The Roots of Addiction in Free Market Society
10 The Extraordinary Science of Addictive Junk Food
PART III: TREATING ADDICTION
11 Financing and Ideology in Alcohol Treatment
12 Ideological Implications of Addiction Theories and Treatment
13 Disciplining Addictions: The Bio-Politics of Methadone and Heroin in the U.S.
14 Drug Courts and the Logic of Coerced Treatment
15 Social Capital and Natural Recovery: Overcoming Addiction Without Treatment
PART IV: EXPANDING ADDICTION
16 A Disease of One’s Own: Life Stories, Identity, and the Emergence of Co-Dependency
17 Regulated Passions: The Invention of Inhibited Sexual Desire and Sex Addiction
18 Gambling and the Contradictions of Consumption: A Genealogy of the “Pathological” Subject
19 Governing (through) the Internet: Pathological Computer Use as Mobilized Knowledge
20 Constraint Theory: A Cognitive, Motivational Theory of Dependence
21 The More the Merrier: A Multi-Sourced Model of Addiction
Credit Lines
Contributor Biographies
Index

Citation preview

Expanding Addiction Critical Essays The study of addiction is dominated by a narrow disease ideology that leads to biological reductionism. In this short volume, editors Granfield and Reinarman make clear the importance of a more balanced contextual approach to addiction by bringing to light critical perspectives that expose the historical and cultural interstices in which the disease concept of addiction is constructed and deployed. The readings selected for this anthology include both classic foundational pieces and cutting-edge contemporary works that constitute critical addiction studies. This book is a welcome addition to drugs or addiction courses in sociology, criminal justice, mental health, clinical psychology, social work, and counseling. Robert Granfield is Professor of Sociology and Vice Provost for Faculty Affairs at the State University of New York at Buffalo (UB). He is also an associate research scientist at the Research Institute on the Addictions at UB. Dr. Granfield is the author of Making Elite Lawyers: Visions of Law at Harvard and Beyond and co-author of Coming Clean: Overcoming Addiction without Treatment, Recovery from Addiction: A Practical Guide to Treatment Self-Help and Quitting on your Own, and Private Lawyers in the Public Interest: The Evolving Role of Pro Bono in the Legal Profession. He has also published numerous articles on law, drug use, and addiction. Craig Reinarman is Professor of Sociology and Legal Studies at the University of California, Santa Cruz. He has been a Postdoctoral Fellow at the Alcohol Research Group at UC Berkeley, a Visiting Scholar at the Center for Drug Research at the University of Amsterdam, and a principal investigator on research grants from the National Institute of Drug Abuse. He is the author of American States of Mind and co-author of Cocaine Changes and Crack in America: Demon Drugs and Social Justice. He has published widely on drug use, addiction, law, treatment, and policy.

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Expanding Addiction Critical Essays Edited by

Robert Granfield and Craig Reinarman

First published 2015 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2015 Taylor & Francis The right of the editors to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Expanding addiction : critical essays / edited by Robert Granfield, Craig Reinarman. — 1 Edition. pages cm Includes bibliographical references and index. 1. Substance abuse. I. Granfield, Robert, 1955– editor of compilation. II. Reinarman, Craig, editor of compilation. HV4998.E967 2014 362.29—dc23 2014024678 ISBN: 978-0-415-84328-7 (hbk) ISBN: 978-0-415-84329-4 (pbk) ISBN: 978-0-203-75732-1 (ebk) Typeset in Sabon by Apex CoVantage, LLC

CONTENTS

Preface

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Acknowledgments

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INTRODUCTION 1

Addiction Is Not Just a Brain Disease: Critical Studies of Addiction Craig Reinarman and Robert Granfield

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The editors sketch an overview of the book beginning with the historical construction of addiction. They distinguish disease concepts of addiction from more sociological and contextual approaches they call critical addiction studies.

PART I: HISTORICIZING ADDICTION 2

Discovering Addiction: Enduring Conceptions of Habitual Drunkenness in America Harry G. Levine

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Levine’s classic history shows that the core features of the modern disease concept of alcoholism— its progressive character, loss of control over drinking, the necessity for abstinence—are all rooted in the ideology of the 19th-century temperance movement.

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The Cultural Framing of Addiction Robin Room

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Room shows how the concept of addiction was a culturally specific frame for understanding drinking problems in early 19th-century America, one which offered a secular equivalent for possession as an explanation of how a good person can behave badly and how a hero can triumph over an inner demon.

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Deviant Drinking as Disease: Alcoholism as a Social Accomplishment Joseph W. Schneider Schneider discusses the disease concept of alcoholism as an example of the medicalization of deviant behavior. He shows that the disease concept is more a social and political accomplishment than an achievement of medical science.

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The NIDA Brain Disease Paradigm: History, Resistance, and Spinoffs David T. Courtwright

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Historian Courtwright traces the lineage of the “chronic, relapsing brain disease” framework that now dominates addiction research and shows that while the theory has yielded important insights on addictive behaviors, it remains contested terrain.

PART II: LOCATING ADDICTION 6

What Neurobiology Cannot Tell Us about Addiction Harold Kalant

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Dr. Kalant provides a detailed account of neurological research on addiction. He argues that while neuro-biochemical research offers a wealth of information about how substances act on the brain, it is doubtful that such approaches alone are sufficient to explain addiction.

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Praxis, Interaction, and the Loss of Self-Control Darin Weinberg

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Based on his rich ethnographic observations in addiction treatment programs, Weinberg explores the nature of the evidence of loss of control and addiction that are produced by the members of these programs in their everyday interactions.

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Framing Nicotine Addiction as a “Disease of the Brain”: Social and Ethical Consequences Molly J. Dingel, Katrina Karkazis and Barbara A. Koenig

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Dingel, Karkazis, and Koenig examine the biological framing of nicotine addiction, which depicts addiction as isolated within our bodies and neurochemistry as opposed to a lived experience within a complex social and political-economic context, including the marketing of harmful products by the tobacco industry.

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The Roots of Addiction in Free Market Society Bruce K. Alexander

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Alexander locates addiction in an individual’s response and adaptation to the lack of psychosocial integration and a resulting sense of cultural dislocation that are characteristic of modern capitalist societies.

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The Extraordinary Science of Addictive Junk Food Michael Moss

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New York Times journalist Michael Moss shows that major food companies spend vast sums perfecting the blend of sugar, salt, fat, and starch to create addictive food products. The consumption of these products is killing us at a rate that surpasses drug overdose deaths and constitutes a public health crisis.

PART III: TREATING ADDICTION 11

Financing and Ideology in Alcohol Treatment Constance Weisner and Robin Room Weisner and Room show how cuts in government funding for treatment combined with entrepreneurial investors moving into human services led to shifts in the ideology and functioning of alcohol treatment. These shifts expanded the definition of alcoholism, changed the clientele admitted, and increased use of coerced treatment.

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C O N T EN T S

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Ideological Implications of Addiction Theories and Treatment Kathryn J. Fox

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Fox examines how social class figures in the treatment of alcoholics and heroin addicts. The abstinence approach of Alcoholics Anonymous taps into middle-class values of self-control, redemption, and inner strength while methadone maintenance sees heroin addicts as indolent, incompetent, hedonistic, lacking self-discipline, and prone to crime—values allegedly associated with the lower classes.

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Disciplining Addictions: The Bio-Politics of Methadone and Heroin in the U.S. Philippe Bourgois

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Following up on his classic ethnography of crack use in New York City, Bourgois analyzes heroin addicts’ experience of methadone programs, showing the power relations that shape drug treatment in the U.S., which tend to make it a hostile exercise in disciplining unruly pleasures and controlling economically unproductive bodies.

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Drug Courts and the Logic of Coerced Treatment Rebecca Tiger

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In her study of drug courts, Tiger shows how the logics of punishment and rehabilitation are deployed to coerce defendants into a treatment system that masks the racial and class-based aspects of drug control and thus de-politicizes drug use and addiction.

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Social Capital and Natural Recovery: Overcoming Addiction Without Treatment Robert Granfield and William Cloud

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Granfield and Cloud focus on addicts who overcame their addiction without the assistance of formal treatment services or self-help groups. They show how middle-class individuals were able to rely on social capital to aid them in their natural recovery.

PART IV: EXPANDING ADDICTION 16

A Disease of One’s Own: Life Stories, Identity, and the Emergence of Co-Dependency John S. Rice

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By closely examining how knowledge functions as power in the co-dependency canon, Rice shows how co-dependents’ life stories can serve as both a form of empowerment and a form of subjection to an alternate authority.

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Regulated Passions: The Invention of Inhibited Sexual Desire and Sex Addiction Janice M. Irvine

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Irvine suggests that sex addiction is a signifier of cultural anxieties about sexuality and desire. She traces the conceptual development of sex addiction as a form of contested knowledge and explores the complexities of the definition and treatment of sex addiction for people said to be afflicted.

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Gambling and the Contradictions of Consumption: A Genealogy of the “Pathological” Subject Gerda Reith Reith interprets the social construction of the modern “problem gambler” in terms of the contradictions of consumer capitalism. As the gambling industry became de-regulated, individual gamblers were expected to self-regulate.

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Governing (through) the Internet: Pathological Computer Use as Mobilized Knowledge Lori Reed

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Reed examines how definitions of “healthy” and “unhealthy” computer use are produced and mobilized through American cultural ideals. This normalizing discourse is an apparatus of governance that draws on the “culture of addiction” to make “computer addiction” an intelligible thing.

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Constraint Theory: A Cognitive, Motivational Theory of Dependence Richard Hammersley

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Hammersley provides a novel approach to addiction, arguing that it is not so much the presence of some factor that predisposes some people to addictive behavior but rather the lack of compelling constraints in their daily lives.

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The More the Merrier: A Multi-Sourced Model of Addiction Velibor Bobo Kovac

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Kovac outlines a grand interdisciplinary synthesis of the many theories and models of what is called addiction. He makes a compelling case that these approaches are not mutually exclusive but rather all interact and contribute pieces of the larger puzzle.

Credit Lines Contributor Biographies Index

313 315 319

PREFACE

The concept of addiction has gone viral, taking in more and more behaviors, at the same historical moment that public understanding of the location of addiction has narrowed to the neurological. We think this leaves out crucial pieces of the puzzles now lumped under the heading of “addiction,” as if that were one thing. We assembled this anthology in the hopes of reintegrating the social, political, and cultural components of addiction to show how various modalities of addiction have been and are being constructed. While there is a voluminous literature in the fields of alcohol and drugs, deviance, and mental health, the sociological analysis of addiction remains underdeveloped. The chapters we have assembled for this anthology present alternative perspectives to the dominant views of addiction typically represented in psychology, medicine, and the neurosciences. Most of the chapters were written by sociologists who were influenced by pioneers in critical addiction studies such as Alfred Lindesmith, Howard Becker, Robin Room, and others. These authors tend to see addiction not merely as an individual pathology, but rather as a social, historical, interactive, and political phenomenon. Some chapters were not written by sociologists but nevertheless raise critical questions about the etiology, progression, and treatment of addiction. Each of the authors in their own way also raises important questions about social policy regarding addictive behaviors. We selected their work because it provides robust interpretations of both addictive experiences and how such experiences are conceptualized, interpretations that highlight the contextual and sociologically contingent nature of addiction. We have organized this book into four parts. We begin in Part I with the historical examination of the genealogy of the concept of addiction as a distinct disease. First and foremost, addiction is a concept that is applied to a set of behaviors that are considered “deviant” by a significant number of people. It is also a concept that has not remained stable over time. Peeling back history, we see that addicts have been described as sinners, as criminals, or as having a sickness, most recently a brain disease. More often than not, these viewpoints have overlapped. What is important as a starting point in understanding addiction is not the “truthfulness” of any particular perspective, but rather a recognition that both addiction and concepts of addiction are subject to the winds of historical change. The chapters in Part II consider the location of addiction. From where do addictive behaviors emanate? For years, this simple but fundamental question has been of central concern among scholars in the neurobiochemical sciences as well as those in the psychosociocultural sciences. While some scholars see the potential for an integrated approach (Rose, 2012), the field of addiction remains mostly divided into these two intellectual landscapes, although unevenly. Nancy Campbell, a leading figure in the history of addiction, has argued that placing addiction in the brain has effectively displaced it from the social body. Writing about the rise of the “chronic relapsing brain disease” (CRBD) perspective, Campbell (2010) notes that this view has “provided

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PREFACE

scaffolding for a new optics that reorganized the federal research apparatus, reorienting it toward neuroscience with the goal of pinpointing molecular ‘targets’ for medications development. The new optics did not solely consist of deployment of neuroimaging technologies, for it was not simply a new way of seeing, but a new way of explaining what was seen.” The chapters in this section raise vital questions about the location of addiction, questions that push beyond the brain/ environment binary to conceptualize addiction in a more critical and synthetic way (see Kovac’s “multi-sourced model” of addiction in Chapter 21). The chapters in Part III focus on the social responses to and treatment of people classified as addicts. Assorted religious, legal, and medical constructs have all influenced societal responses to substance misuse and addiction. Casting deviant substance users as “sinners,” “criminals,” or “sick” has determined how they were treated—stocks and pillories, incarceration, therapy, or medication. These chapters demonstrate that the choice among these various approaches has not been driven by science so much as the institutional and ideological interests of the professions and agencies of the state with the power to define “legitimate” or “deviant” use of consciousnessaltering substances. Social responses to the use of and addiction to drugs are never solely about drugs; they are guided by normative assumptions that impute moral character to those defined as addicts. However noble the intentions of those who intervene, all forms of addiction treatment are deeply imbued with power relations; hidden beneath the surface of “helping those in need” lie the usual class, racial, gender, and other disparities. This section explores an assortment of these power issues as they are revealed through the financial interests of the treatment industry, the ideological and class-based assumptions embedded within treatment approaches, the bio-politics of treating/controlling addicted persons, and the subjugated knowledge and practices employed by those who forego addiction treatment but still manage to exit addiction. Finally, in Part IV the chapter authors broaden the focus by examining how addiction has expanded into numerous other areas of life. They explore how the logic of the disease concept of addiction has come to be applied to sexual desire, gambling, compulsive computer use, and even our dependence on other human beings. The section ends with two unusual theoretical approaches to addiction, each outlining a conjunctural model of addiction that synthesizes many other approaches. As the editors of this book, each of us sociologists who have worked in the field of drug use, treatment, and policy for over thirty-five years, we know the power that a sociological understanding can have in providing a more holistic view of addiction. Like most sociologists, we were raised on C. Wright Mills, who taught us that what appear to be personal troubles are invariably linked to public issues. To understand the personal experience of addiction we must grapple with the public conditions under which addictions arise. In selecting the chapters for this book we hope to give you, the readers, a sense of how sociologists think about addiction so that you may judge for yourselves the value of such an approach. Robert Granfield and Craig Reinarman

ACKNOWLEDGMENTS

We have assembled this anthology to broaden public understanding of addiction by including the social, political, and cultural components of addiction, to show how various modalities of addiction have been and are being constructed. Beginning with Alfred Lindesmith in the 1940s, sociologists who study drug use and addiction have produced a body of knowledge that demonstrates the inherently contextual character of addiction. Although we are only able to include a small number of such scholars in this short anthology, we are indebted to all those working in the same “vineyard.” We are specifically grateful to the authors whose articles we reproduce in this anthology. While not all are sociologists, they all nevertheless help advance a critical perspective on addiction and we are thankful for their efforts. Many personally assisted us in our efforts to negotiate permission fees with publishers, and all help advance a much needed critical perspective on addiction. We thank Bruce Alexander, Philippe Bourgois, David T. Courtwright, Molly J. Dingel, Katherine Fox, Richard Hammersley, Janice Irvine, Harold Kalant, Velibor Kovac, Harry Levine, Lori Reed, Gerda Reith, John Rice, Robin Room, Joseph Schneider, Rebecca Tiger, Darin Weinberg, and Constance Weisner. We are also grateful to other colleagues who took the time to comment on our proposal, suggest key readings on addiction, and help refine our introductory chapter, particularly Julie Netherland, Jim Baumohl, Marsha Rosenbaum, and Alex Wodak. We also wish to extend our deepest appreciation to several publishers who not only gave us permission to include articles but graciously lowered or even waived permission fees. Without the cooperation of the following publishers, we could not have completed this anthology: Trivium Publishers, Sage Publications, the Canadian Centre for Policy Alternatives, Palgrave/Macmillan, University of California Press, Wiley/Blackwell Publishers, Kluwer Press, and Duke University Press. Finally, we wish to thank our editor at Routledge, Steve Rutter, for whose support and encouragement we greatly appreciate. This project could not have been possible without Steve and his wonderful staff at Routledge, especially Margaret Moore, who worked closely with us every step of the way.

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CHAPTER 1

Addiction Is Not Just a Brain Disease Critical Studies of Addiction1 Craig Reinarman and Robert Granfield The concept of addiction has crept into the crevices of our culture. We hear it everywhere in everyday speech. People say they are “hooked” on a favorite activity or TV show, that they are “Facebook addicts” or “junk food junkies.” Millions of members of 12-step groups interpret their trials and tribulations in terms of addiction to one thing or another. Beyond the flagship of Alcoholics Anonymous, there are now dozens of other such groups including Overeaters Anonymous, Gamblers Anonymous, Shoppers Anonymous, and Clutterers Anonymous. So called “behavioral addictions” include “Internet addiction disorder” suffered by “onlineaholics,” which is seen as a serious problem in the U.S., as it is in China, South Korea, and elsewhere.2 Addiction is commonly invoked by an ever-widening array of professionals including physicians, scientists, lawyers, psychotherapists, police, judges, and social workers. Ordinary citizens regularly refer to addiction to help explain the sometimes inexplicable acts of their neighbors. Celebrities often claim to suffer from one addiction or another and enter rehab when their misdeeds are exposed. Addiction is conceptually seductive. This book suggests that more and more people find the notion of addiction useful because it serves as an explanation for a great variety of difficulties. Many of the contributors explore why this is so and what it says about modern society. All of the authors understand that the terrain of addiction has expanded dramatically. Addiction now includes not only more and more drugs but more and more behaviors—exercise, sex, shopping, work, and even attachments to other human beings (“co-dependency”). It is tempting to say that we are addicted to addiction; we seem to use it and need it more and more, and it takes the place of other ideas. At the very least addiction has become an all-purpose meta-metaphor for the often troubling relationships we have with what we love, enjoy, desire, or require, and thus find hard to control.3 Despite its prominent place in our lexicon, however, addiction is a relatively recent invention. As subsequent chapters will show, the concept of addiction has had its own career marked by some surprising shifts in meaning and focus. Specific actors and institutions with particular interests and ideologies have constructed and reconstructed understandings of addiction. Various interest groups continue to fight over who owns “addiction,” how it should be defined, and what should be done about it. In many Western industrialized societies in the 21st century, addiction is said to be a “disease.” Virtually everyone in the U.S. treatment industry embraces this view. They teach the millions of people who enter treatment to understand their problems as stemming from the disease of addiction. Officials of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have long held that alcoholism is a disease. Their colleagues at the National Institute on Drug Abuse (NIDA) have adopted the claim that “addiction is a brain disease” as a kind of mantra, ritualistically repeating it at every public opportunity.4 In the U.S., even advocates of decriminalization in the drug policy reform movement invoke the disease concept of addiction when pushing for treatment instead of

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prison for drug offenders.5 The idea that addiction is a disease is now so widely believed, so taken for granted in public discourse about drug-related problems, it is difficult to imagine that it hasn’t always been part of the basic stock of human knowledge. But it hasn’t.

HISTORICIZING ADDICTION The concept of addiction-as-disease has a history, a genealogy. It was not a scientific discovery; it did not emerge from the accumulation of research findings. Its current ubiquity is a different species of social accomplishment (Schneider 1978). It was invented, elaborated, redefined, and reproduced by specific actors and institutions using specific language. As medical historian Charles Rosenberg has noted, a “disease does not exist until we have agreed that it does—by perceiving, framing, and responding to it” as such. Defining something as a disease is part of “a generation-specific repertoire of verbal constructs” that reflect “medicine’s intellectual and institutional history.” He shows that physicians frequently choose “to label certain behaviors as disease even when a somatic basis remains unclear—and possibly non-existent” (1989: 1–2). The concept of “disease,” Rosenberg argues, is a kind of social actor in that its application can change the narrative and thereby rearrange how we understand the person or behavior. He gives the intriguing example of suicide in early modern England, which was then defined as a crime requiring forfeiture of the property of the deceased to the state. But once medicalized, suicide came to be interpreted as “retrospective evidence of exculpatory disease” (i.e., mental illness), which must have been a great relief to the relatives who stood to inherit the property. A more current example is what is now called chronic fatigue syndrome. People who suffer from the many and often ambiguous symptoms now lumped together under this name had to push organized medicine for years to have their pain officially recognized as a discrete disease. Once physicians defined it as such, those suffering from it became viewed as patients entitled to sympathy and reimbursement rather than suspected as malingerers and denied health insurance coverage. Defining something as a disease gives it a moral legitimacy that can alter how we perceive and react to it. Clinical constructions of addiction contain a set of moral assumptions (May 2001: 386) that are carried over into addiction treatment programs, public policy, and the collective conscience (Gowan & Whetstone 2012).6 This anthology begins with some of the little-known or long-forgotten history of how addiction got discovered and defined as a disease. To understand addiction, both as a pattern of behavior and as a way of thinking about that behavior, the concept must be situated in time and space. As Robin Room suggests in Chapter 3, addiction is “a set of ideas which have a history and a cultural location.” Peter Breugel’s famous painting of 1559, “The Fight between Carnival and Lent,” offers a way into this history. It depicts an agrarian village in pre-industrial Flanders in full celebration. Feasting, drinking, and drunkenness are everywhere. This was often the case with numerous peasant holidays throughout the Western world that were traditionally passed in varying degrees of intoxicated revelry. Drinking was a common part of everyday life, engaged in by most people. A few monk-like figures can be seen in Breugel’s painting in dark robes stepping solemnly toward the church, but most of the other villagers appear to frolic in drink-crazed abandon. Breugel captures a moment at the dawn of European modernity (Burke 1978) when a few key groups first attempted to problematize intoxication. Around 1600, ascetic Protestant sects and early capitalists began to oppose the ancient Bacchanalian drinking traditions that had held sway across the Western world from classical antiquity through the Middle Ages (Levine 2006). They called for the renunciation of pleasure for the sake of religious piety and economic productivity. The notion that a substance might “cause” a person to “lose” self-control became broadly thinkable only after this shift took hold in the U.S. in the 19th century.7

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Photo 1.1 “The Fight between Carnival and Lent,” 1559.

In tracing this history, the chapters in Part I help explain how addiction-as-disease came to be so widely adopted as an explanation. They illuminate the main historical, cultural, and institutional processes that made addiction-as-disease the dominant framework for understanding drug problems. In Chapter 2, Levine shows that regular or “habitual” drunkenness began to be defined as addiction only at the end of the 18th century, when a new way of understanding the individual self began to emerge in the U.S. For over a century and half from the first Puritan settlement through the American Revolution, drunkards were assumed to have will, to have the capacity to make choices about whether or not to drink. They were not regarded as having a disease that robbed them of their will or their self-control, but rather as people who simply loved to drink and get drunk more than most others. In the early 19th century, immigration, urbanization, and the development of market capitalism were transforming U.S. society—straining traditional family and community support networks such that one’s economic fate increasingly depended upon self-control (see Room, Chapter 3). As Levine notes, it was in this context that the moral enterprise of Dr. Benjamin Rush and the early temperance crusaders gave a specific form to anxieties about self-control by focusing on alcoholic drink, intoxication, and addiction. They proselytized the view that drunkards were stricken with a disease of the will (Valverde 1998)—a disease that rendered them powerless over their behavior. In the early decades of the 19th century, the religious revival known as the Second Great Awakening contributed to a growing temperance movement. In temperance ideology, alcoholic drink was

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transformed from what even leading Puritan preachers in the 17th and 18th centuries had called “the good creature of God” into a destructive “demon” that they believed to be the direct cause of crime, violence, poverty, insanity, divorce, and most other problems in America. The notion that an intoxicating substance could cripple self-control and directly cause bad behavior that would not otherwise occur, is a culture-specific attribution. As Room shows in Chapter 3, “not all cultures make this kind of causal connection.”8 The notion that drinking or other drug use can cause people to neglect other important activities makes sense in “the context of a culture attuned to the clock, a cultural frame in which time is viewed as a commodity that is used or spent rather than simply experienced.” As an explanation of habitual drunkenness, addiction-as-disease has taken different forms. In the 17th and 18th centuries, Levine shows, most people believed that the evil that drove drunkenness resided in the moral character of the individual drunkard. In the 19th century, Temperance crusaders popularized the view that the evil was in the bottle—that anyone “whose lips touch liquor” was likely to become a drunkard. Everyone was vulnerable to this disease. That view led ultimately to national alcohol prohibition in 1919. Shortly after Prohibition was repealed in 1933, Alcoholics Anonymous and a growing movement of medical and scientific collaborators developed a new formulation of the relationship between alcohol and addiction. In this view, most people could drink in moderation, but certain individuals were exceptionally susceptible to addictive drinking and thus likely to lose control. This put the evil back in the individual, the alcoholic, who suffered from a person-specific disease. In Chapter 4, Joseph Schneider describes the modern medicalization of deviant drinking as a “social accomplishment.” The idea that deviant drinkers had a disease and should receive treatment, he shows, was the product of Alcoholics Anonymous, the Yale Center for Alcohol Studies, and E. M. Jellinek’s formulation of alcoholism as a disease. The scientific research said to support the idea that alcoholism is a disease, as well as its endorsement by the American Medical Association, generally followed the alcoholism movement’s assertion of this view (Room 1983). As John Seeley long ago noted, “The statement that ‘alcoholism is a disease’ is most misleading, since it conceals that a step in public policy is being recommended, not a scientific discovery announced” (1962a: 587). Seeley supported the notion that drinkers who needed help should have it, but he balked when this sort of compassion made its case by masquerading as science.

DEFINING ADDICTION: A CHRONICLE OF CONCEPTUAL ACROBATICS In another essay, Seeley asks whether alcoholism is “a moral failure, a deviation, self-comforting behavior, an addiction, a disease, a disorder, a crime or misdemeanor, a cultural pattern, or a defect of socialization . . .?” His answer is “perhaps every one of these” (1967: 157), but his point is that what we call it and how we define it affect how alcoholics understand themselves, how others see them, and thus what alcoholism actually is. Applying the disease concept of addiction beyond alcoholism to the use of other drugs led to a regular reworking of the definition—and not in the direction of greater precision as is typically the case with other diseases. In the early 20th century, addiction to morphine, heroin, and other opiates came to be defined as physiological dependence as indicated by tolerance and withdrawal symptoms. But this once widely accepted definition eventually proved too restrictive. For one thing, tolerance and withdrawal are not universal even among regular heroin users; some do not develop tolerance and some remain controlled users, as do most users of cocaine.9 In 1950, an expert committee of the World Health Organization (WHO) defined drug addiction as chronic or periodic intoxication, a compulsion to continue, a tendency to increase dose, psychic and physical dependence, and detrimental effects on the user and society. But faced

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with the recalcitrant fact that some forms of illicit drug use do not entail these characteristics, the WHO proposed the concept of “drug habituation” in 1957. They defined drug habituation in much the same way as drug addiction but without compulsion, increasing doses, or societal consequences. By the 1960s, the WHO’s search for an expanded definition of addiction-as-disease that would encompass the broadening array of illicit drug use led them to drop these concepts in favor of the looser notion of “drug dependence.” They defined this simply as psychic and/or physical dependence on a drug, the characteristics of which varied by drug type (Christie and Bruun, 1968: 66–7). By 1981, the WHO definition of “dependence” was redefined still more loosely as a syndrome in which drug taking is “given a much higher priority than other behaviors that once had a higher value” (Shaffer and Jones, 1989: 42). Most everyone would agree that this is true of addictive behaviors, but this conception is so broad that it fits virtually any behavior that is substituted for any prior behavior—even behaviors that entail no use of psychoactive substances. Like their counterparts at the WHO, other experts continued to hunt for a definition of addiction malleable enough to encompass both the growing range of illicit drug use and stubborn empirical anomalies. For example, in 1972, the American Psychiatric Association (APA) shifted away from the term “addiction” toward a broader concept of “drug abuse,” which it defined as the nonmedical use of drugs that alter consciousness in ways that “are considered by social norms and defined by statute [as] inappropriate, undesirable, harmful . . . or culture-alien”.10 But most of these terms are normative, not scientific, and the definition itself rests on a troubling circularity: When lawmakers write drug laws they justify them in terms of medical expertise on drug abuse, but here the medical scientists defined drug abuse in terms of law. The latest edition of the APA’s Diagnostic and Statistical Manual (DSM-5) drops the term addiction altogether in favor of “substance use disorder.”11 To be diagnosed as having it, a drug user can meet any two or three of eleven criteria within the past year, ranging from classical tolerance and withdrawal to vague and context-dependent behavioral indicators such as using more of a drug than intended. One key DSM criterion for substance use disorder is persistent use despite harmful consequences. This seems sensible enough until we consider that such “harmful consequences” are not always attributable to drug use alone. Many of the harms taken as indicators of drug abuse and addiction depend upon the relative social instability and marginalization of the user, and these are often shaped as much by drug law as by drug use. Moreover, the latest DSM-5 diagnostic criteria are likely to create even more ambiguity about the meaning of addiction. The “disorder” can range from mild to severe and its configuration varies from drug to drug. As Stanton Peele has noted, some “behavioral addictions” like gambling are included, but not Internet fixation, while college students who have five drinks at one sitting more than a few times—a pattern most leave behind soon after graduation—are now defined as alcoholics under the newly slackened diagnostic criteria.12 The repeated redrawing of the definitional boundaries of addiction-as-disease helps account for its elasticity and how it has come to be applied to such an extraordinary range of behaviors. Our point here is not to disparage the hard work of scientists who have long tried to identify the essential features of addiction, nor to imply that their criteria are entirely arbitrary. Behavioral problems and mental disorders are intrinsically more difficult to define than most physical disorders. The point is to call attention to the fact that the fundamental concepts and categories that many assume to be clear, objective, and universal indicators of addiction are in fact fuzzy, fluid social constructions that reflect the beliefs of a particular group of experts at a particular time and place. This matters, for as Darin Weinberg suggests in Chapter 8, it is the everyday deployment of such concepts and categories that discursively produces—helps make visible and legible—the phenomenon they claim to describe, “the disease of addiction.”

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A “CHRONIC RELAPSING BRAIN DISEASE” Attending to the genealogy of addiction-as-disease is more important than ever because those who work within the latest dominant paradigm in addiction research believe they have finally discovered the Holy Grail: the location and operation of addiction-as-disease in the human brain. Although EEG technology was deployed during the 1930s and 1940s in an unsuccessful attempt to locate addiction in the brain, the current paradigm rests on new neuroscience technologies pioneered in the 1990s (e.g., Belliveau et al. 1991). These technologies allow the imaging or “mapping” of neural activity in real time through functional magnetic resonance imaging (fMRI). This imaging provides digitized representations of traces of hemodynamics or cerebral blood volume, which indicates brain activity. It is worth noting that this technology directs our focus to what it can illuminate and away from what it cannot illuminate. This shift in focus inevitably entails detaching brains from bodies and from the social contexts in which bodies and brains develop.13 But there is no doubt that fMRIs have opened up a new world of experiments that have yielded novel insights on how the brain’s so-called pleasure center and reward circuitry react and how they develop longer-term adaptations to psychoactive substances.14 In this paradigm, addiction is defined as a “chronic relapsing brain disease” or CRBD. The general trend in this neuroscience research has been toward the “common pathway” hypothesis (e.g., Nestler and Malenka 2004). That is, the brain imaging techniques show that the brain responds to psychoactive drugs in very similar ways to how the brain responds to other pleasurable activities. And therein lies a key limitation. While this research documents a fundamental neurobiological piece of addiction, it cannot easily distinguish one pleasurable activity from another. The result has been an embarrassment of riches. As Harold Kalant demonstrates in Chapter 6, changes in brain function along this common pathway occur with the use of a wide variety of very different drugs, licit and illicit, but also with many adrenaline-inducing and other pleasurable or satisfying activities involving no drugs at all. These activities include gambling, acts of cooperation and generosity, maternal support, talk therapy, and even looking at beautiful faces.15 Indeed, Dr. Roy Wise, a NIDA scientist who studies addiction, notes that people will find pleasurable and thus tend to repeat “anything you can do that turns on these dopamine neurons” (Kolata 2002). Whether this repetition becomes a problem for an individual or the larger society, however, is a separate matter that depends upon many factors other than brain circuitry or physical dependence. Functional magnetic resonance imaging has also documented that brain functions are affected by the cumulative toll of trauma and other forms of psychic pain, which so many other genres of research have found to be a recurring theme in the life histories of drug addicts. Early-life stress and many other problems associated with poverty, for example, correlate with a shrunken hippocampus and amygdala, the regions of the brain that are important for memory and emotional well-being, respectively. Clearly the brain is centrally involved in drug use behaviors. But as Dr. Kalant suggests, this does not necessarily mean there is a site of pathology in the brain that distinguishes repetitive drug taking from, say, sex, sailing, symphonic music, and other activities people find pleasurable and therefore tend to repeat. It is true that addictive behaviors tend to be chronic, that addicts who try to quit often relapse, and that the brain’s circuitry is important in these processes. But several of the contributors to this book suggest that what is called addiction is more contingent on contextual factors—and therefore more indeterminate and potentially alterable—than we might imagine from looking at the brain in isolation.16

MISSING CONTEXTUAL VARIABLES The brain is obviously important for understanding addiction, but when brain-based theories exclude or neglect the contextual factors that influence what gets into the brain, they risk biological reductionism. The fact that there is neuronal or brain activity associated with human

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thoughts, feelings, and behaviors does not mean that these things are reducible to or the same as that neuronal activity (McGinn 2013). Biology cannot eclipse culture because it always operates within and in interaction with culture. The brain is an infinitely complex set of systems that serve as a reflexive repository of lived experiences. Brains are embedded in bodies, and bodies in turn in families, and families are nested in communities and in particular niches in the wider social structure. All of these things shape the conditions under which drug users live, and thus impinge upon their psyches, their situations, and their practices. If we reduce the aperture of attribution through which we view addiction so that only individual brain activity comes into view, we sever the brain from the webs of meaning in which it is enmeshed and through which its inputs flow.17 At the broadest level, biological models of addiction extract addictive behaviors from the historical and cultural contexts that shape them. Virtually all explanations of addiction-as-disease stress the individual’s loss of self-control. Explanations of such behaviors should, then, take into account the conditions under which self-control came to be so important and yet so difficult to maintain. For example, a core aspect of modern society is the proliferation of pleasures and the idea that ordinary citizens have a right to pleasure. Modern market economies have constructed mass consumption cultures in which immediate gratification—in effect throwing self-control to the wind—is actively encouraged by a vast machinery of marketing that reaches all the way into our cell phones to persuade us that shopping itself is a core leisure activity. At the same time, however, as Alexander shows in Chapter 8, the market dynamism of modern societies creates various forms of social and cultural dislocation—from families of origin, from communities, from traditions and ways of life that orient and constrain individuals (see Chapter 20). Such cultural dislocation loosens the bonds that anchor the self in a coherent community and thereby tends to make obsessive behaviors both more likely and more destructive. Market societies expect individuals to “take responsibility” for their own actions by means of self-control, yet those societies are organized in part precisely to undermine that self-control. Under such circumstances, the regulation of the self and its desires has grown increasingly difficult for more and more people. Indeed, if asked to design a society so as to maximize addictive behaviors, you could hardly do better than the contradictory culture we have. Theories of addiction-as-disease also tend to ignore the long-term process of social learning through which cultures teach their members how they might tame or domesticate the use of intoxicants to reduce risk (Reinarman 2013). Norbert Elias’s classic study, The Civilizing Process (1994), showed how the fierce warrior behaviors that were seen by people in the Middle Ages as fixed in “human nature” were in fact mutable over time. As the structure of society changed, the more genteel norms of courtier culture spread across society as a whole and were eventually internalized by increasing numbers of people (see also Pinker 2011). When the scientific and medical focus is on the individual addict’s brain, often too little attention is paid to the long-term development of drug user knowledge and culture (Becker 1967). These user cultures can help individuals learn to moderate their doses, use protective practices, and develop informal rules that help them to regulate appetites so their drug use doesn’t interfere with social functioning or reach a state of addiction. Of course, user cultures do not prevent drug abuse and addiction in all cases, but they do reduce the likelihood of abuse and addiction across the population. The fact that the majority of people who use drugs do not move on to chronic abuse suggests that much more is producing addiction than drug molecules landing in receptor sites in the brain. Addiction-as-brain-disease proponents often claim that chronic drug use decreases brain metabolism and causes “brain deficits” in the prefrontal cortex, which then help keep addicts addicted. A recent editorial in Nature, for example, made this kind of argument: Drug addiction is a disease. Images of the brains of addicts show alterations in regions crucial to learning and memory, judgment and decision-making, and behavioral control. Drugs imitate natural neurotransmitters, resulting in false or abnormal messages being sent around neural circuits. The brain’s central reward

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system is overstimulated and flooded with dopamine. The brain adapts to this flood by turning down its ability to respond to dopamine—so addicts take more and more of the drug to push dopamine levels higher. (Nature 2014)

But if it is chronic drug use that causes such maladaptation in the brain, then that maladaptation cannot also be the initial cause of the chronic drug use. Certainly genetic and biological variation make some individuals more susceptible to repeated drug use and thus more vulnerable to addiction (e.g., because they have fewer dopamine receptors). But a wide range of other factors usually have to fall into place and remain in place before drug use becomes sufficiently chronic to alter routine brain functioning in the first place. Take as an example the career of a stereotypical “street addict.” Before he could become addicted to, say, heroin or crack cocaine, those drugs had to be available—geographically and culturally—in the neighborhoods and the social circles in which he moved. He had to learn from others that such drug use was acceptable and desirable, how to ingest the drugs so as to produce effects, and how to interpret and appreciate those effects (Becker 1953). The use of the drug had to be within his comfort zone and behavioral repertoire. Not just anyone in any peer group is likely to regularly smoke crack cocaine or inject heroin into their vein. For a drug user to then repeat such drug use often enough to damage his brain or become physically dependent he would have to find the effects sufficiently appealing and functional to continue using regularly. Most people who try these drugs don’t continue for long. For one thing, most people have a stake in conventional life that constrains their use (e.g., Waldorf et al. 1991). Surgery patients routinely ingest enough opioid painkillers to become physiologically dependent, yet they rarely become addicts. Continued use is far more likely when the person is using a drug to numb physical pain from chronic conditions or psychic pain from trauma, abuse, humiliation, violence, poverty, depression, or despair. In their classic study of Vietnam veterans who used heroin in Vietnam, Lee Robbins and her colleagues (1974) found, to everyone’s surprise, that the vast majority did not continue to use heroin once they were removed from the horrors of the war zone. As Richard Hammersley suggests in Chapter 20, drug use is most likely to become chronic when the person lacks compelling constraints or counterweights—for example, meaningful work, respected roles, possibilities for a better life—that help keep most people away from problematic drug use. Neither the conditions that increase the likelihood of addiction nor the constraints that decrease the likelihood of addiction are evenly or randomly distributed across the population. The characteristics of culture and social structure interact with the genetic and neurological characteristics of individuals to yield a range of strengths, vulnerabilities, and possible outcomes. Among developed countries, for example, mental disorders of all sorts are far more common in those societies with greater economic inequality. Nations with the biggest income differences show the highest incidence of anxiety disorders,18 many of which are associated with addiction. Specific regions of the brain and neural mechanisms process information about social rank.19 Low status and subordination appear to be linked to anxiety, depression, and other disorders that are highly correlated with chronic drug use. Understanding addiction purely or even mainly in terms of its biological factors—genetic, physiological, or neurological—tends to push social factors off stage and into the shadows. The chapters in this anthology generally share the view that one cannot understand the use and abuse of drugs apart from the social meanings that users attach to drug use. Alfred Lindesmith’s classic study of opiate addiction (1947) showed the crucial cognitive and cultural components of becoming an addict. Withdrawal pangs alone were not enough. He found that opiate users had to use frequently enough to become physiologically dependent. But then they had to learn, usually from other addicts, to recognize that they were experiencing withdrawal and that another dose would alleviate those withdrawal symptoms. Finally they had to decide to take that other dose, and to do

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so repeatedly, until they came to understand themselves as addicts and to accept the addict identity. These are social processes that are not reducible to drug molecules “hijacking” the brain; they require interaction with and learning from other addicts in particular cultural contexts. Preble and Casey (1969) made a similar point in their influential research on the heroin addict’s life in the streets. Their study upended the long-held view of opiate addicts as passive, withdrawn, and “on the nod” by virtue of their addiction. By close ethnographic observation Preble and Casey showed instead that so-called street addicts had to engage in a challenging round of activities every day in order to avoid being dope sick, and that, however illegal and destructive, their cycles of stealing, scoring, and shooting often provided meaningful and even rewarding lives compared to the limited array of legal options available to them. Why is crack use confined largely to the most marginalized and impoverished populations? A key part of the answer is that crack’s extremely intense but fleeting high tends to lead to bingeing, which can be destructive. The crack rush does not have as much appeal for people who have everyday lives in which they are invested.20 Conversely, why does regular coca leaf chewing among Andean peasants so seldom escalate to extreme modes of ingesting cocaine such as smoking crack? A large part of the explanation is that coca chewing is an ancient ritual practice that is well integrated into peasant culture rather than a means of escaping or coping with the consequences of dislocation or marginalization from that culture. In short, just as drug addiction is typically contingent upon a pattern of chronic use, that chronic drug use is itself contingent upon the presence of numerous sociological precursors. These precursors do not show up on an fMRI, but they, too, are essential pieces of the puzzle of addiction. By truncating these contextual precursors, addiction-as-disease discourse has helped to conceal a wide array of evidence about controlled drug use and natural recovery (see Granfield and Cloud, Chapter 14). People who use drugs do indeed alter their consciousness, but neither neuroscientific nor genetic approaches can explain why most people who use drugs with high “addictive liability” do not in fact become addicted, or why even many who do become addicted find ways of reducing their use or stopping on their own without imprisonment or treatment. This is one of the heretical little secrets of the drug war, a kind of subjugated knowledge that is kept outside the disease paradigm. We hope this anthology will help drag this subjugated knowledge out into the light of day and make it part of a larger and more informed conversation about addiction. Proponents of the disease approach claim that by demonstrating how addiction operates in the brain—placing it beyond the realm of free will and conscious choice—they have finally freed us from the old moralistic conceptions and shifted the framing of addiction from badness to sickness (Conrad and Schneider 1992). The medicalization of addiction has, this argument goes, placed addiction where it belongs, in the realm of public health rather than criminal law, and improved access to and the effectiveness of addiction treatment. We agree that addiction is far better understood as a health issue than a criminal one, but as historian David Courtwright suggests in Chapter 5, such claims of “beneficent medicalization” are mostly wishful thinking; what we have seen so far is at best “contested medicalization.” The recent advances in neuroscience have not made much of a dent in the earlier vilifying views of addicts. Treatment is not always successful and usually takes more than one attempt, but in any event it remains unavailable to many who seek it while hundreds of thousands of drug users continue to be arrested and incarcerated each year. Most Americans and most policy makers seem quite comfortable seeing addicts as sick and bad at the same time. Medicalization has not yet posed a serious threat to punitive prohibition, which remains the core of U.S. drug policy despite long-standing evidence of its ineffectiveness, enormous costs, and destructive consequences. Brain disease advocates have not changed how addicts are viewed nor the policies that shape addicts’ options -- even though they have demonstrated that the brain works in much the same way with so-called behavioral addictions like gambling and compulsive Internet use that don’t involve drugs. Like the earlier iterations of addiction-as-disease, the brain disease model has functioned

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as more of an adjunct to the war on drugs than an alternative. Indeed, policy makers routinely invoke the horrors of addiction-as-disease in order to justify punishing illicit drug users. However, such prohibitionist policies tend to push many popular forms of drug use into deviant subcultures where the moderating influences of the broader society have little or no sway and where extreme or problematic use becomes more likely. Arrest and imprisonment reduce the life chances of those incarcerated such that the likelihood of their future drug abuse often increases. Moreover, defining addiction as an individual pathology helps institutionalize regimes of self-governance that emphasize individual solutions to problems that are, in important respects, inherently social. While the implications of the CRBD model are still unfolding, it is important to consider the new forms of governance—power, authority, knowledge, expertise, and therapeutic practices—that are justified by invoking “the addicted brain.”

THE PATHOLOGIZING GAZE Reductionist understandings of human troubles are also troubling because they have a tendency to pathologize feelings that were once understood as part of the ordinary variation in human behavior. Nicolas Rose has called this “the recoding of everyday affects and conducts in terms of their neurochemistry” (2003: 46, 2013). Children who were once described as “fidgety” or as having “ants their pants” have been redefined as patients suffering from Attention Deficit Hyperactivity Disorder (ADHD) and prescribed amphetamine-like stimulants such as Ritalin and Adderall.21 People who are said to lack self-esteem are now often diagnosed as having mild depression and prescribed Prozac or similar drugs that make them feel better by increasing the amount of serotonin in their systems. In many cases this amounts to what Kramer (1993) calls “cosmetic psychopharmacology.” People who feel acutely shy are increasingly seen as suffering from “social anxiety disorder” or SAD, which is then “treated” with Valium. Others who feel especially anxious are increasingly diagnosed as having panic attacks, which are managed with Xanax, a benzodiazapine that is chemical cousin to Valium. Having trouble sleeping becomes insomnia and warrants prescriptions for Ambien, Lunestra, etc. Older men said to suffer from “erectile dysfunction” have long been prescribed Viagra and similar drugs. Now an even wider range of men are being told in pharmaceutical ads that they might suffer from the new “disease” of “low T” (testosterone). Prescriptions for testosterone have tripled since 2001, now surpassing 3 million, despite a heightened risk for heart attacks.22 Drug companies are using the same pathologizing pitch on older women whose libidos may lag for any number of quite normal reasons (see Chapter 16). The ads claim such women suffer from a female version of this “disease,” which the pharmaceutical companies have labeled “hypoactive sexual desire disorder.” The solution? A prescription for Lybrido. Whether it is hyperactivity, sadness, shyness, insomnia, or gradual declines in sexual desire in old age, the pharmaceutical industry defines those who report any such “symptoms” and are not taking psychoactive medications as “under-treated.” Down this road lies diagnostic promiscuity (Peele 1989; Rose 2003). The risks of over-drugging aside, this pathologizing lens tends to limit the scientific focus to characteristics of the individual patient. As with addiction-as-disease, the contributions of cultural and social structural factors to such human troubles tend, ironically, to be chemically camouflaged by prescription medications. To understand ADHD, for example, as a pathological condition of individual “patients” is to rip its etiology out of history. The percentage of young people who were diagnosed with and prescribed stimulants for ADHD tripled in the 1990s and almost doubled again between 2008 and 2012. Such increases are “far beyond reasonable rates” (Schwarz 2014). Nearly one in five boys and one in ten girls in the U.S. have been diagnosed with ADHD— more than 6 million children, over two-thirds of whom have been prescribed stimulants.23 Nor is this ostensible epidemic limited to antsy adolescents. Amphetamine-type stimulants are now prescribed for more than 10,000 children as young as 2 or 3 (Schwarz 2014) and their use for ADHD

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among adults is also “soaring” (Harris 2005). There is evidence that severe ADHD is a biological condition, but why ADHD appears to be spreading so rapidly, and why over 90% of the stimulant prescriptions for it are written in the U.S., are rarely discussed.24 Prescribing amphetamine-type stimulants may help control unwanted behaviors, but it leaves many of the underlying sources of such behaviors unexamined. The explosive escalation of stimuli in modern life isn’t considered, nor is the relentless ratcheting up of the minimum threshold at which we feel entertained in our “rapid fire culture” (DeGrandpre 2000). Seeing ADHD as an individual pathology is, however, appealing and functional for families. Something can be done. A simple pill can improve school performance and thereby help children maintain or even raise their social position in an increasingly competitive world. No need to consider the impact of stressed-out households where both parents need to work because middleclass salaries have been stagnant for decades. No need to take into account the effects of reduced school funding, bigger classes, fewer teachers, cuts in after-school programs, or the shortage of meaningful jobs for young people, all of which make whatever behavioral symptoms may exist appear more problematic. No need to think about the multiplication of media and digital devices that constantly beckon for attention. Pharmaceutical companies are only too happy to try to persuade physicians and parents that a long-term prescription will manage the symptoms and ensure children’s success. For genuinely serious cases of ADHD, such pills have great therapeutic value. But they have been widely over-prescribed to many who do not fit even the loosened diagnostic criteria for the disorder. It is certainly true that the neuroscientific reformulation of human beings and the attendant proliferation of new medical and pharmaceutical technologies have the potential to reduce human suffering, including addiction, in individuals. But as we have argued above, human brains do not develop or exist in individualized isolation. As Rose and Abi-Rached write, “[B]rains are constitutively embodied in living creatures, dwelling in space and in time, interacting in small and large groups on which they depend for their existence, striving to survive inhabiting and remaking their milieu across the course of their lives.” Any neuroscientific account of the brain “that does not recognize that human capacities and competencies emerge out of, and are possible only within this wider milieu made and remade by living creatures, shaped by history, marked by culture in ways ranging from design of space and material objects to the management of action and interaction and organization of time itself, will be scientifically flawed” (2013: 233).

WHY THIS MATTERS The chapters in Section 4 illustrate how the concept of addiction has been expanded to encompass ever more behaviors beyond drug use—unhealthy dependence on other people (Chapter 15), sex addiction (Chapter 16), and compulsive gambling (Chapter 17), Internet use (Chapter 18), and eating (Chapter 19). As addiction comes to loom ever larger in culture and public policy, how we define and understand it, the meanings we attach to it, become increasingly important because these shape how we perceive the behaviors said to constitute it and how we, as citizens and as a society, respond to them. We have argued that to conceive of addiction as an attribute of the individual addict—whether situated in physiology, psychology, genes, brains, or all of the above—is to neglect the contextual causes of addiction. This matters because without these contextual contributions our basic understanding of the etiology of addictive behaviors will remain partial at best. We have noted the constellation of conditions having to do with poverty and trauma that so often factor into both the onset and the maintenance of drug addiction. But there are other such social ingredients, often less obvious, that have little to do with poverty or trauma. For example, iatrogenic addiction— addiction that originates in the course of medical treatment—has always been more prevalent than is commonly believed. Most opiate addiction in the late 19th and early 20th centuries began

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when doctors prescribed morphine and other opiates for a broad array of conditions (Duster 1970; Musto 1987). In recent years methamphetamine has taken its place next to heroin and crack cocaine atop the pantheon of “most addictive substances.” But in the 1950s amphetamines were widely promoted by pharmaceutical companies and prescribed by physicians as a pick-me-up and dietary aid. In the 1960s, Valium and other benzodiazepines were promoted as a less dangerous alternative to barbiturates, but they were prescribed for so many different symptoms to so many patients that millions became addicted.25 Beginning in the 1990s, OxyContin, a synthetic opiate, has been increasingly prescribed for pain. By 2010 it had become the fastest growing form of drug addiction and often led to illicit heroin use. Neuroscience shows us what happens in the brain when such drugs are used chronically, but no theoretical model of drug addiction will be scientifically adequate if it ignores the conditions that increase the likelihood of the initial chronic use across the population, including the role of medical practice and the aggressive marketing strategies of pharmaceutical companies that influence physician prescribing. The same point holds for the so-called behavioral addictions. Every aspect of gambling systems from the basic architecture of casinos down to the inner logic of games, slot machines, and even state-sponsored lotteries are designed to induce addictive patterns of behavior (Schull 2012). This is also true of many online games that are often key to what is called Internet addiction. With regard to eating disorders, whatever genetic vulnerabilities individuals may have and whatever social-psychological factors trigger compulsive eating patterns, Michael Moss shows in Chapter 19 that addictiveness has been literally engineered into many food products. Corporate scientists continuously experiment to achieve just the right mix of sugar, salt, spice, fat, and starch to engender repetitive eating and maximum sales.26 The public health consequences—on rates of obesity, diabetes, heart disease, and other conditions—rival those of the riskiest drugs. We ignore the many social conditions that contribute to addictive behaviors at our peril. Similarly, when addiction is narrowly conceptualized as a disease that resides in individuals, the range of possible responses shrinks. People who struggle with overeating, for example, often benefit from support groups and exercise programs, but they might also benefit from intelligent regulation of the supply side of the equation, for example, policies that require posted calorie counts for sugary soft drinks and fast food. Individual OxyContin addicts may well benefit from treatment, but tighter regulation of pharmaceutical industry marketing and better education of prescribing physicians are also likely to reduce the overall prevalence of the problem. As we noted above, in most cases several sociological precursors have to fall into place before there is sufficient drug use to cause the maladaptation in the brain that is said to perpetuate chronic drug use. If addiction treatment sees the problem as residing in the genes or the brains of individual addicts, then the contextual factors that so often help make addiction possible in the first place are likely to remain unaddressed. Lack of education, skills, and job opportunities, for example, usually increase the likelihood of chronic drug use and are nearly always impediments to lasting recovery. Treatment professionals know well that addicts too often leave treatment to return to lives in which little else has changed, and that this increases the likelihood of relapse. Addiction treatment programs that neglect such broader conditions facing those who struggle with addiction will remain incomplete. Without integrating a range of social services into treatment regimes to speak to addiction-generating needs beyond the brain, treatment success rates will remain lower, and relapse rates higher, than they might be. The chapters in Part III call attention to the politics of addiction treatment. Treatment is understood as a response to a disease, but insofar as it deploys expertise to alter behavior and relies on some degree of coercion, it is also an act of power and a mode of governance. Addiction treatment has changed dramatically over the years, and often for reasons having little or nothing to do with science or evidence of effectiveness. As Weisner and Room point out in Chapter 10, the very definition of addiction, the clientele to be served, as well as the nature of treatment protocols are fundamentally related to the funding structure of treatment. The growth of the privatized

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treatment industry had less to do with the emerging science of addiction than with the emerging opportunities for profit in an expanding healthcare marketplace—particularly the discovery of addiction among the middle class, whose treatment costs were covered by third-party insurers. It is often said that addiction is an “equal-opportunity disease,” and it is certainly true that addicts can be found in all social groups. But when we look at the consequences of addiction, social class matters. As Fox points out in Chapter 11, social class differences are evident in the differential treatment of alcohol addicts and heroin addicts. Alcoholics Anonymous taps into middle-class values of self-control and redemption, while methadone maintenance constructs the images of heroin addicts as indolent and lacking in self-discipline. Bourgois’s ethnographic analysis in Chapter 12 suggests similarly that methadone clinics tend to see heroin addicts less as human beings afflicted with a disease and needing medical care than as unruly deviants in need of discipline and control. Indeed the disciplining nature of treatment is especially evident in drug courts. As Rebecca Tiger shows us in Chapter 13, these courts typically highlight a disease ideology of addiction while simultaneously ignoring the racial and class biases that are built into the criminal justice system. For all their good intentions, drug courts, like criminal courts from which they claim to be a therapeutic departure, too often end up subjugating a disproportionate number of poor people and people of color. Those who live in communities where drug misuse and addiction are more likely are also are more likely to lack the skills, resources, and other forms of social capital needed for overcoming addiction. As Granfield and Cloud suggest in Chapter 14, “natural recovery” is the most common pathway out of addiction, and here social capital matters as much as whether addicts are understood or responded to as having a brain disease. The understanding of addiction that undergirds drug control policy is one of crime, disease, and death—the things people fear most about drug addiction. Ironically, however, the media, politicians, and citizens typically speak of these problems as if they are “caused” directly by drug use, but the consequences that seem to flow from drug use are shaped in crucial ways by punitive drug policies. Research has long shown that much “drug-related” property crime by opiate addicts originates in the dehumanizing funnel of narrowing options and deepening desperation that result more from the context of criminalization than from addiction per se. Cycles of arrest and incarceration of addicts set in motion what Cohen (1991) has called “junkification,” a process in which the choices available to those dependent on illicit drugs shrink. Jobs are lost, family lives disrupted, hygiene and health deteriorate, and the capacity for self-management and care atrophy to the point of general immiseration (see Rosenbaum 1981). Similarly, most of what were called “crack-related homicides” turned out to result less from the effects of the drug, as harsh as these could often be, than from the context of illicit crack markets in impoverished inner cities (Goldstein et al. 1997). Widespread unemployment, intense competition for potentially high profits, easy availability of guns, and no recourse to legal means of commercial dispute resolution add up to a virtual recipe for violence. Most overdose deaths are a function of the absence of potency labeling and quality controls in illicit drug markets, and to some extent policies that have not allowed the distribution of opioid antagonists like naloxone, which can reverse overdoses and save lives. The spread of HIV/AIDS and hepatitis C among injection drug users stems from the criminalization of injection equipment, which makes it artificially scarce and thereby encourages unsafe injection practices such as syringe sharing. This sort of policy reflexivity is particularly acute in the broader context of extreme poverty, inequality, and socio-cultural dislocation from which so much problematic drug use arises. In short, over time our drug control policies are in some measure self-ontologizing, that is, they help bring into being the very outcomes that are then invoked to justify those policies. Any full understanding of addiction requires understanding how drug control laws and policies feed back, often in unanticipated ways, upon the behaviors they set out to control by influencing the social settings in which drug use occurs, the psychological sets of the drug users in those settings (Zinberg 1984), and thus decision-making calculus that informs their drug-taking behaviors. We

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have drawn most of our examples of policy reflexivity from drug addiction, but parallel points can be made about the links between food addiction and the proliferation of fast food, links designed to lead to endless other links on the Internet, and the mass promotion of gambling as a strategy of public finance. Reductionist conceptualizations of addiction build blinders and biases into research in ways that can be self-fulfilling. Seen in whole and in its full complexity, the sprawling list of behaviors now lumped under what is called addiction looks more like a messy mosaic than a neat gene sequence or a brain scan. But truncating contextual variables and ignoring the ways in which drug policies feed back upon chronic drug use, certain forms of knowledge end up in a privileged position with regard to research funding and publication. Funding decisions determine what sorts of studies get conducted, studies which in turn shape the scientific literature.27 Subsequent rounds of research funding decisions are then made on the basis of how well investigators situate their research questions in this existing literature and address the “normal science” puzzles within a dominant paradigm (Kuhn 1962). Over time, some issues get included and result in valuable research, but other, potentially valuable issues get excluded or marginalized. The result is often a winnowing of scientific knowledge that can cascade into a deeper misunderstanding of the phenomena. We need to attend to the ways in which this skews the scientific knowledge base in certain directions as that knowledge informs treatment, policy, and the media. One genre of science is getting in the way of science in general. The contributors to this volume generally share the view that what are called addictive behaviors need to be put back into history, back into their myriad social contexts, back into cultural motion. If addiction researchers can do this, we will gain a much richer understanding of the nature of addictions and with it more hopeful possibilities for prevention, harm reduction, controlled drug use, treatment, and recovery.

BUT WHAT ABOUT THE LIVED EXPERIENCE OF ADDICTION? Attending to the social and political processes that produce knowledge about addiction and showing that addiction-as-disease is an historically and culturally specific social construction should not be taken to mean that the lived experience of what is called addiction is therefore somehow less “real,” less powerful, or less deserving of attention. People decide to ingest drugs in part because drugs are consciousness-altering chemicals that make people feel different in ways they find pleasurable or valuable. But again, the material substratum where molecules meet receptor sites cannot by itself adequately explain patterns of drug using behaviors. Regular ingestion does not always or inevitably lead to the sorts of chronic or problematic use patterns that are called addiction; even physiological dependence does not always lead to the desperate “junkie” behaviors that are so often taken as the defining feature of the disease. As we noted above, these are common yet still sociologically contingent outcomes. What are taken to be the physiological and neurological effects of a drug do not present themselves to users in some raw, pre-categorical form, without the linguistic encasements provided prior to ingestion by culture.28 While neuro-imaging research has documented some of the preconscious neural processes involved in the craving reported by addicts (see Campbell 2010), the conscious subjective effects they describe are produced in important part by their own active interpretations of the often ambiguous physiological cues that follow the ingestion of a drug. These interpretations are assembled from the conceptual categories available to them in culture. The particular features of and the meanings attributed to drug experiences, as well as the behavior thought to follow from them, are culturally specific. MacAndrew and Edgerton’s (1969) pioneering cross-cultural research on drunken comportment, for example, demonstrated that people come to understand their experience of altered states—and learn how to behave in those states— from their culture. As Peele has argued, the cultural belief that “alcohol has the power to addict a person goes hand in hand with more alcoholism. . . . What people believe about their drinking

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actually effects how they react to alcohol” (1989: 170, original emphasis). Conversely, cultures in which people do not believe drugs can cause the “loss of control” exhibit far less uncontrolled drinking. However, just because “loss of control” is a cultural construct does not imply that users’ feelings of “loss of control” are any less acute or troubling or worthy of assistance (see Weinberg, Chapter 9). Most of those who get defined as addicts and come to adopt the addict or ex-addict identity have learned to interpret their experience in terms of the reigning addiction-as-disease paradigm. It is fair to say that the disease model resonates with many different kinds of people who have come to see themselves as addicts; disease discourse fits their experience reasonably well. The core notion of “loss of control” helps them understand their seemingly inexplicable decisions to persist in problematic behaviors in the face of harmful consequences. But part of this resonance has to do with the functionality of the disease model. Gamblers, over-eaters, alcoholics, heroin addicts, and others all find addiction-as-disease to be a useful way to put distance between their old addicted selves who behaved badly and their new recovering selves who have changed their ways. That said, cognitive fit and resonance are matters of culture, too, not an external validation of the concept of addiction-as-disease. Which came first, the lived experience of addiction or the culturally available frameworks for making sense of it, is difficult to disentangle. Human beings are born and reared inside their culture, and there is no simple way to separate their lived experience from the discursive practices operating in that culture which name and give specific shape and valence to that experience. The selections in this anthology call attention to the historical, political, economic, and cultural aspects of what is called addiction and to the procedures by which knowledge about addiction and its treatment are socially produced. None of these chapters, however, should be taken to imply that the lived experience of suffering among those who struggle with the manifold forms of addiction is any less real.

SOME ELEMENTARY PRINCIPLES OF CRITICAL ADDICTION STUDIES We have selected the chapters in this anthology from a much broader array of critical scholarship on addiction. Some of the chapters are classics written long ago, others newly published. With limited space and many worthy candidates, it was painful to have to choose. Our selections only scratch the surface of what is out there. We conclude this introductory chapter by sketching the contours of the basic sensibility of a tradition of research we will call critical addiction studies. This tradition was formed from many intellectual tributaries, but one key starting point was Alfred Lindesmith’s research on opiate addicts (1947), which forced open the biologically deterministic models of opiate addiction that held sway in the first half of the 20th century by showing that addicts were human actors and that addiction was a sociologically contingent outcome. The critical addiction studies tradition would also include many of the scholars and scientists we cite, including John R. Seeley (1959, 1962a,b, 1967), who questioned whether alcoholism is a disease entity beginning in the late 1950s; Howard Becker (1953, 1967), who demonstrated the inherently social character of both subjective experience of drug effects and societal responses to them; Norman Zinberg (1984), whose research on controlled intoxicant use theorized the importance of users’ psychological sets and the social settings of drug use in shaping the felt effects and patterns of use; Robin Room, whose voluminous writings about the nature of problem drinking and drug taking and their interaction with public policies have long enriched the field; and many younger scholars such as Nancy Campbell (2010), a historian of science who currently uses ethnographic methods to analyze the “laboratory logics” of biomedical and neuroscientific research that produce knowledge about addiction. The scientists and scholars working in this tradition have interrogated the fundamental concepts and categories of the field and found far more fluidity and far less solidity than others had

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supposed. In this tradition, the new neuroscientific narrative of addiction as a “chronic relapsing brain disease” is only the most recent in a long and ever-shifting line. Each provides a piece of the puzzle of addiction, and it is fair to say there has been some cumulative progress. Yet the chapters collected here remind us that the road remains more crooked than the conventional narrative of ever more precise scientific knowledge would have it. The pieces of addiction’s history presented in what follows suggest that alongside whatever progress has been achieved, each model of addiction reflects the taken-for-granted premises, prejudices, and politics of the institutions, the epoch, and the culture in which it was born. Most of the chapters that follow share this sensibility and fall within the tradition of critical studies of addiction. Below we sketch in summary form six basic principles that characterize this approach to addiction, most of which we have mentioned in passing in this introduction. 1.

2.

3.

4.

Historical and cultural specificity: Drug use practices are reproduced and re-invented in the crucible of changing conditions and so they vary and evolve across time and space, history and culture. The same may be said of ways of thinking about addiction, including science and medicine. Concepts of addiction are social constructions, built by actors and deployed by institutions that have specific cultural locations, interests, and ideologies, all of which also evolve over time. People who ingest consciousness-altering substances or engage in consciousness-altering behaviors learn, and sometimes resist, what their cultures and epochs have to teach about the nature of and meanings attached to their experiences. Their beliefs and behaviors also evolve over time. A critical analysis of addiction begins with the principle “that ‘addiction’ has multiple valences that are best understood within a broader social, political, economic, and historical context” (Netherland, 2012: xvii). The contextual is integral: Addictive behaviors are nested within a number of contextual containers that range from the epochal to the interactional—from industrial modernity, mass consumption culture, and globalizing neo-liberalism to subcultures, countercultures, and the repertoires of intoxication, both pleasurable and problematic, that are negotiated with intimates. While such sociological precursors are never wholly determinative, they surely influence the specific structure, valence, and consequences of addictive behaviors. In this sense, addictions cannot be understood as merely the behavior patterns of individuals, as if they were the product of personal choices or personality characteristics alone, but also must be conceptualized as collective probabilities that are woven into the social fabric. Addiction is sociologically contingent and indeterminate: As we have tried to suggest in this introduction, human brains, as part of human bodies, are inevitably embedded in a web of social relations that influence decisions and behaviors and thus the experiences that enter the brain. Addictive behaviors are sociologically contingent in multiple ways and therefore emergent and indeterminate to a greater degree than is commonly recognized. The regular ingestion of consciousness-altering, dependence-inducing substances and the physiological and neurological effects thought to follow from this are neither necessary nor sufficient by themselves to constitute the effective “cause” of addictive behaviors. There are multiple trajectories into, within, and out of addiction. Social inequality and differential consequences: Whether or not drugs are involved, addictive behaviors entail very similar bio-chemical processes in the body and brain. But the lived experience of these processes, the behaviors thought to follow from them, and especially their consequences, are not directly determined by the pharmacological properties of drugs or by neurological processes in the addicts’ brains. Rather these outcomes vary according to one’s position in social structure. Critical addiction studies, therefore, attend to the uneven probabilities of onset, trajectories, and consequences of addictive behaviors that are associated with race, class, gender, and other axes of social inequality.

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6.

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Multi-disciplinary and multi-vocal investigative strategy: Because there are many nonpharmacological, non-neurological variables that affect the probabilities and trajectories of addictive behaviors, addiction studies must be multi-disciplinary and holistic, not reductionist. Moreover, because risks and consequences of addiction vary according to social position, a critical addiction studies approach is necessarily multi-vocal. Attending to the voices of those who experience addiction and society’s responses to it is essential, as they are the primary sources of subjugated knowledge about addiction, including knowledge about the routes into addiction, informal social controls that reduce risk, strategies for controlled use, and natural recovery. Consequentialist conceptualization of policy: Consequentialism is a particular philosophical approach to ethics according to which the rightness or wrongness of an act must be evaluated according to its actual consequences rather than the initial intent. Critical addiction studies take this approach to drug policy. For example, the single most important driver of the largest wave of imprisonment in American history was harsh drug laws passed at the peak of the crack cocaine scare, laws based on what turned out to be racialized, fear-driven myths and misconceptions. Those who embrace the medicalization of addiction often proudly claim to have shifted the frame around addiction from crime needing punishment to disease needing treatment. Some small steps have been taken in this direction, but the claim that addiction is a disease still walks arm in arm with the punitive prohibition laws that have led to the mass incarceration of the powerless. The disease model is invoked daily in drug courts to justify imprisonment, albeit as a spur to treatment “for their own good.” As we have noted, drug policies influence both the psychological sets of drug users and the social settings of use and thus have consequences that feed back into the behavior patterns to which they claim to be merely a rational response. Critical addiction studies foreground these relationships because drug policies have so often had profoundly negative effects on human rights and social justice. Critical addiction studies seek to imagine more humane alternative drug policies that can integrate rather than ostracize problem drug users and better reduce drug-related harm.

With the addiction-as-disease paradigm expanding to annex ever more behaviors, it is more important than ever to think critically about the framing of and response to addictions. For if we become pre-occupied with understanding gambling, over-eating, “pathological” Internet use, compulsive sex, or any of a host of other behaviors that may soon be labeled “addiction,” as matters of brain chemistry alone, we will end up chasing a phantom. And if laws and public policies are designed to react to these behaviors as if the citizens who engage in them are “diseased,” we need to attend to what new forms of social control we are imposing, on what sorts of people, with what consequences.

NOTES 1. Some pieces of this chapter are drawn from Reinarman’s article, “Addiction as Accomplishment,” Addiction Research and Theory 13 (2005). 2. For a useful overview of “behavioral addictions,” see Holden (2001); Kershaw (2005) reports on Internet addiction in places like South Korea. 3. Alexander notes that the traditional meaning of addiction was “legally given over to somebody as a bondslave,” or, more broadly, “to have given oneself over, or devoted oneself, to somebody or something.” Its definition as a disease appeared for the first time in the Oxford English Dictionary in the supplement to the 1933 edition, which happened to be the moment when U.S. alcohol prohibition was repealed (2000), 1. 4. For example, Leshner (1997; 2001); Volkow (2003); Enos (2004). 5. See, e.g., Bertram et al. (1996): 233–41. 6. The disease narrative has also been used to excise moral legitimacy. An extreme example is the use of the “disease” narrative to describe the antebellum condition known as “drapetomania,” an alleged “disease” said to cause slaves to flee captivity. This obviously racist, medical junk-science had real-world consequences since one of the prescribed “treatments” was the removal of both big toes to make running away physically impossible.

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7. 8. 9. 10. 11.

12. 13.

14. 15. 16.

17. 18. 19. 20. 21. 22.

23. 24.

25. 26. 27. 28.

See also Cohen (2000); Schivelbusch (1992). See also MacAndrew and Edgerton (1969); Peele (1989); Davies (1992, 1997). See, e.g., Blackwell (1983, 1985); Hanson et al. (1985); Waldorf et al. (1991); Zinberg (1984). Cited in Zinberg (1984: 39). The APA website for the DSM-5 notes that this new definition “combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe,” for each specific substance. http://www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%20Sheet.pdf. Accessed 15 May 2014. http://www.huffingtonpost.com/stanton-peele/. Accessed 5 March 2014. These points are insightfully developed by Jose van Dijck (2005), who notes that “Medical imaging technologies not only shape our individual perceptions, but also indirectly contribute to our collective view on disease and therapeutic intervention. . . . Medical imaging technologies play a constitutive role in the formation of norms concerning the perfectibility and modifiability of the human body . . .” although “better pictures do not automatically imply a solution” (2005: 8, 17–18). For a useful overview, see Volkow (2003). For journalistic overviews of these findings on gambling, see Goleman (1989) and Blakeslee (2002); on acts of cooperation and generosity, see Angier (2002); on maternal support, see Moles et al. (2004); on talk therapy, see Brody et al. (2001); on beautiful faces, see Aharon et al. (2001). Alexander and colleagues (1981) demonstrated that in lab experiments where rats are given morphine, the quantity and frequency of use depended on the characteristics of the setting. Rats housed in a rich environment where other rats lived and where other activities were possible (“rat park”) consumed dramatically less morphine than rats housed alone in cages where there was nothing to do but ingest morphine. See also the insightful analyses of the neuroscience/brain disease model by Campbell (2007), Levy (2013), and Netherland (2012). Wilkinson and Pickett (2009) and Stiglitz (2012) synthesize a wide array of evidence on this point. See, e.g., Johnson, Leedom, and Muhtadie (2012). See, for example, Reinarman and Levine (1997): 77–97. See Schwarz (2013b) on how this idea, and these drugs, were marketed. A physician’s recent essay in the New York Times noted that “low T,” as it has been constructed, “isn’t nearly as common as the drug ads for prescription testosterone would have you believe. Pharmaceutical companies have seized on the decline in testosterone levels as pathological and applicable to every man. They aim to convince men that common effects of aging like slowing down a bit and feeling less sexual constitute a new disease, and that they need a prescription to cure it” (La Puma 2014). See, e.g., Hinshaw and Scheffler (2014); Getahun et al. (2013). The cover story of the July 18, 1994, edition of Time magazine was headlined “Disorganized? Distracted? Discombobulated? Doctors Say You May Have Attention Deficit Disorder. It’s Not Just Kids Who Suffer from It.” Four years later, Time did another cover story headlined “The Latest on Ritalin: Scientists Last Week Said It Works. But How Do You Know if It’s Right for your Kids?” Inside, the article asked “If this little pill makes everything a bit easier, not just for children with severe attention deficit disorders but for more and more kids who are just a little too spacey or jumpy, is there something wrong with the kids, or with us?” (November 30, 1998). The headline for the March 6, 2000, cover story of U.S. News and World Report was “Paxil, Prozac, Ritalin . . . Are These Drugs Safe for Kids? Many Parents Are Using Powerful Pills to Control Behavior.” See, e.g., Bargemann, Wolfe, and Levin (1982); Haafkens (1997). See Guthman (2011) for an insightful political-economic analysis of food industry processes. For example, Koren et al. (1989) found a systematic acceptance bias against studies that found no effects of cocaine on reproductive health. See Rhodes et al. (2010) on the institutionalized bias against ethnographic and other qualitative research in the scientific literature on drug use. See, e.g., Becker (1967), Weil (1972), and Davies (1992) on these attributional processes.

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Koren, G., Graham, K., Shear, H., & Einarson, T. Bias Against the Null Hypothesis: The Reproductive Hazards of Cocaine. Lancet, 2:1440–1442 (1989). Kramer, P. Listening to Prozac (New York: Viking, 1993). Kuhn, T. The Structure of Scientific Revolutions (Chicago, IL: University of Chicago Press, 1962) La Puma, J. Don’t Ask Your Doctor about ‘Low T.’ New York Times, February 3, 2014. Leshner, A. Addiction is a Brain Disease, and it Matters. Science, 278:45–57 (1997). Levine, H.G. Drunkenness and Civilization, in Kriminalitats-Geschichten, Hamburger Studien zur Kriminologie und Kriminalpolitik, Band 41, R. Behr, H. Crèmer-Schafer, & S. Scheerer, eds. (Hamburg: Lit Verlag, 2006). Levine, H.G. Global Drug Prohibition: Its Uses and Crises. International Journal of Drug Policy, 14:145–153 (2003). Levy, N. Addiction Is Not a Brain Disease (and it matters). Frontiers in Psychiatry, 4:1–7 (2013). Lindesmith, A.R. Opiate Addiction (Bloomington, IN: Principia Press, 1947). MacAndrews, C., & Edgerton, R., Drunken Comportment (Chicago, IL: Aldine, 1969). McGinn, C. What Can Your Neurons Tell You? New York Review of Books, January 11, 2013, pp. 49–50. Moles, A., Kieffer, B.L., & D’Amato, F.R. Deficit in Attachment Behavior in Mice Lacking the Muopiod Receptor Gene. Science, 304(5679):1983–1986 (2004). Musto, D. The American Disease: Origins of Narcotics Control (New York: Oxford University Press, 1987). Nature. Animal Farm: Europe’s Policy-Makers Must Not Buy Animal-Rights Activists’ Arguments that Addiction Is a Social, rather than a Medical, Problem. Nature, 506:5 (2014). Netherland, J. Introduction: Sociology and the Shifting Landscape of Addiction, in Critical Perspectives on Addiction: Advances in Medical Sociology, 14, J. Netherland, ed., pp. xi–xxv (Bingley, UK: Emerald Group, 2012). Peele, S. Diseasing of America: Addiction Treatment Out of Control (Lexington, MA: Lexington Books, 1989). Pinker, S. The Better Angels of Our Nature: Why Violence Has Declined (New York: Viking, 2011). Preble, E., & Casey, J. ‘Taking Care of Business’: The Heroin Addict’s Life on the Street. International Journal of the Addictions, 4:145–169 (1969). Reinarman, C. The Accomplishment of Addiction: Discursive Construction of Disease. Addiction Research and Theory, 13:307–320 (2005). Reinarman, C. On the Cultural Domestication of Intoxicants, in Intoxication and Society: Problematic Pleasures of Drugs and Alcohol, J. Herring et al., eds., pp. 153–171 (London: Palgrave Macmillan, 2013). Reinarman, C., & Levine, H.G. Crack in America: Demon Drugs and Social Justice (Berkeley: University of California Press, 1997). Rhodes, T., Stimson, G., Moore, D., & Bourgois, P. (2010). Qualitative Social Research in Addictions Publishing: Creating an Enabling Journal Environment. International Journal of Drug Policy, 21(6):441–444. Rice, J.S. A Disease of One’s Own: Psychotherapy, Addiction, and the Emergence of Co-Dependency (New Brunswick, NJ: Transaction, 1996). Robbins, L., Davis, D.H., Goodwin, D.W. Drug Use in U.S. Army Enlisted Men in Vietnam: A FollowUp on Their Return Home. American Journal of Epidemiology, 99:235–249 (1974). Room, R. Sociological Aspects of the Disease Concept of Alcoholism. Research Advances in Alcohol and Drug Problems, 7:47–91 (1983). Room, R., & Collins, G., Eds. Alcohol and Disinhibition: Nature and Meaning of the Link, National Institute of Alcohol Abuse and Alcoholism Research Monograph 12 (Washington, DC: U.S. Department of Health and Human Services, 1983). Rose, N. Neurochemical Selves, Society 41/1:46–59 (2003). Rose, N. and Abi-Rached, J.M. Neuro: The New Brain Sciences and the Management of the Mind (Princeton, NJ: Princeton University Press, 2013).

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Rosenbaum, M. Women on Heroin (New Brunswick, NJ: Rutgers University Press, 1981). Rosenberg, C. Disease in History: Frames and Framers. The Milbank Quarterly, 67(suppl):1–15 (1989). Schivelbusch, W. Tastes of Paradise: A Social History of Spices, Stimulants, and Intoxicants (New York: Vintage, 1992). Schull, N. D., Addiction by Design: Machine Gambling in Las Vegas (Princeton, NJ: Princeton University Press, 2012). Schwarz, A. Report Says Medication Use Is Rising for Adults With Attention Disorder. New York Times, March 12, 2013a. Schwarz, A. The Selling of Attention Deficit Disorder. New York Times, December 14, 2013b, A1. Schwarz, A. Thousands of Toddlers Medicated for A.D.H.D., Report Finds, Raising Worries. New York Times, May 16, 2014, p. A11. Seeley, J.R. Alcoholism is a Disease: Implications for Social Policy, in Society, Culture, and Drinking Patterns, D. Pittman and C. Snyder, Eds., pp. 586–589 (New York: Wiley, 1962a). Seeley, J.R. The W.H.O. Definition of Alcoholism. Quarterly Journal of Studies on Alcohol, 20/2:352–356 (1962b). Seeley, J.R. Thirty-Nine Articles: Toward a Theory of Social Theory, in The Critical Spirit: Essays in Honor of Herbert Marcuse, K. Wolff and B. Moore, Jr., eds., pp. 150–171 (Boston, MA: Beacon Press, 1967). Stiglitz, J. The Price of Inequality (New York: Norton, 2012). Valverde, M. Diseases of the Will: Alcohol and the Dilemmas of Freedom (Cambridge, UK: Cambridge University Press, 1998). Van Dijck, J. The Transparent Body: A Cultural Analysis of Medical Imaging (Seattle, WA: University of Washington Press, 2005). Volkow, N. The Addicted Brain: Why Such Poor Decisions? NIDA Notes, 18:3–4 (2003). Waldorf, D., Reinarman, C., & Murphy, S. Cocaine Changes: The Experience of Using and Quitting (Philadelphia, PA: Temple University Press, 1991). Weil, A. The Natural Mind (Boston: Houghton Mifflin, 1972). Wilkinson, R., & Pickett, K., The Spirit Level: Why Greater Equality Makes Societies Stronger (New York: Bloomsbury, 2009). Zinberg, N. Drug, Set, and Setting: The Basis of Controlled Intoxicant Use (New Haven, CT: Yale University Press, 1984).

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PART I

Historicizing Addiction

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CHAPTER 2

Discovering Addiction Enduring Conceptions of Habitual Drunkenness in America1 Harry G. Levine INTRODUCTION In the last years of the eighteenth century, European culture outlined a structure that has not yet been unraveled; we are only just beginning to disentangle a few of the threads, which are still so unknown to us that we immediately assume them to be either marvelously new or absolutely archaic, whereas for two hundred years (not less, yet not much more) they have constituted the dark, but firm web of our experience. –Michel Foucault2

The essentials of the contemporary understanding of alcoholism actually first emerged in American popular and medical thought at the end of the 18th century and beginning of the 19th century. At that time a new paradigm or model first defined addiction as a central problem in drug use and diagnosed it as a disease or as disease-like condition. The idea that alcoholism is a progressive disease—the chief symptom of which is loss of control over drinking behavior, and whose only remedy is abstinence from all alcoholic beverages—is now about 200 years old, but no older. This new paradigm constituted a radical break with traditional ideas about habitual drunkenness. During the 17th century and for most of the 18th century, the assumption was that people drank and got drunk because they wanted to and not because they “had” to. In colonial-era thought, alcoholic drinks did not permanently disable the will, they were not addicting, and habitual drunkenness was not regarded as a disease. With very few exceptions,

17th- and 18th-century Americans did not use a vocabulary of compulsion with regard to alcoholic beverages. At the end of the 18th century and in the early years of the l9th century, some Americans began to report that they were addicted to alcoholic drinks: They said they experienced overwhelming and irresistible desires for liquor. Laymen and physicians associated with newly created temperance (or anti-alcohol) organizations developed theories about addiction and brought the experience of it to public attention. Throughout the l9th century, people associated with the temperance movement argued that intemperance, inebriety, or habitual drunkenness (they used all three terms) was a disease and a natural consequence of the moderate use of alcoholic beverages. The idea that drugs are inherently addicting was first systematically worked out for alcohol and then extended to other substances. Long before opium was popularly accepted as addicting, alcohol was so regarded.3 Contrary to what many have believed,4 I am suggesting that present-day American medical, scientific, and popular thought about alcoholism is of a piece with a major strand of 19th-century thought, the ideology of the temperance movement. Both temperance thought and modern conceptions of alcoholism agree about the progressive character of addiction, the alcoholic’s experience of loss of control, and the necessity for total abstinence by addicts. The most important difference between tem perance conceptions of addiction and 20thcentury alcoholism thought is the location of the

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source of addiction.5 The temperance movement found the source of addiction in the drug itself; alcohol was viewed as an inherently addicting substance, much as heroin commonly is today. Contemporary medical, scientific, and popular understandings locate the source of alcohol addiction in the individual body; only some people, it is argued, for reasons still unknown, become addicted to alcohol. Although that change represents a major development in thought about addiction, the contemporary ideas are still well within the paradigm first established by the temperance movement. Insofar as Alcoholics Anonymous and temperance advocates share the concept of addiction and recommend abstinence as the only solution, their differences remain in-house or intra-paradigmatic.6 This chapter traces the history of American thought about habitual drunkenness and alcohol addiction. Traditional 17th- and 18thcentury (colonial-era) ideas are contrasted with the new conceptions that emerged in the 19th century and developed further in the 20th century. Finally, there is a brief discussion of the social and historical context in which the concept of addiction came to be an acceptable and intelligible way to define problems associated with drinking alcohol.

TRADITIONAL VIEWS: THE WORLD WITHOUT ADDICTION In the 17th-century and especially 18th-century America was notable for the amount of alcoholic beverages consumed, the universality of their use, and the high esteem they were accorded. Alcoholic drink was food, medicine, and social lubricant. Even a Puritan divine such as Cotton Mather called it the “good creature of God.” It flowed freely at weddings, christenings, and funerals, at the building of churches, the installation of pews, and the ordination of ministers. For example, in 1678 at the funeral of a Boston minister’s wife, mourners consumed 51 1/2 gallons of wine;7 at the ordination of Reverend Edwin Jackson of Woburn, Massachusetts, the guests drank 6 1/2 barrels of cider, along with 25 gallons of wine, 2 gallons of brandy, and 4 gallons of rum.8 Heavy drinking was also part of special

occasions like corn huskings, barn raisings, court and meeting days, and especially militia training days. Workers received a daily allotment of rum, and certain days were set aside for drunken bouts; in some cases, employers paid for the liquor. The tavern was a key institution in every town, the center of social and political life, and all varieties of drink were available. Americans drank wine, beer, hard cider, and distilled spirits, especially rum. They drank at home, at work, and while traveling; they drank morning, noon, and night. And they got drunk.9 During the 17th and 18th centuries, most people were not concerned with drunkenness; it was neither especially troublesome nor stigmatized behavior. Even the prominent physician Benjamin Rush,10 when still urging moderation in 1772, noted how common and acceptable drunkenness was. “Why all this noise about wine and strong drink?” he wrote, anticipating his readers’ complaints. “Have we not seen hundreds who have made it a constant practice to get drunk almost everyday for thirty or forty years, who, not withstanding, arrived to a great age and enjoyed the same good health as those who have followed the strictest rules of temperance?” Dr. Rush was willing to grant that there were indeed “some instances of this kind.” In his rich and thorough study of early American drinking practices, Rorabaugh concluded that “to most colonial Americans inebriation was of no particular importance. William Byrd, for example, noted with equal indifference intoxication among members of the Governor’s Council and his own servants.” Rorabaugh found that Byrd’s attitude was typical and that for most Americans in the period “drunkenness was a natural, harmless consequence of drinking.”11 From time to time, however, some wealthy and powerful individuals complained about excessive drinking and drunkenness. In 1637 there was concern about “much drunkenness, waste of the good creatures of God, mispense of time, and other disorders, which took place at taverns.”12 In 1673 the Puritan minister Increase Mather published his sermon, “Wo to Drunkards,” deploring the frequency of excessive drinking in the colonies.13 By 1712 things

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had gotten even worse and he reissued his pamphlet. Around the same time, his son, Cotton Mather, worried about drunkenness among members of his own congregation.14 By the 1760s John Adams was so concerned about the level of drunkenness that he proposed limiting the number of taverns, and Benjamin Franklin labeled taverns “a Pest to Society.” Despite such complaints, and despite regulations on the amount of time one could spend in a tavern, how much one could drink there, and penalties for drunkenness including public whippings and the stocks, Americans continued to drink and get drunk.15 Ministers and political leaders sometimes singled out individuals who were periodically or frequently drunk; they called such people drunkards, common drunkards, or habitual drunkards. Occasionally they described drunkards as addicted to drunkenness or intemperance, as in Danforth’s statement in 1709 that “God sends many sore judgments on a people that addict themselves to intemperance in Drinking.”16 In the 17th and 18th centuries, “addicted” meant habituated, and one was habituated to drunkenness, not to liquor. Almost everyone “habitually” drank moderate amounts of alcoholic beverages; only some people habitually drank to the point of drunkenness. Towns circulated lists of common drunkards, and landlords who sold liquor to them could be fined or have their licenses revoked.17 Some drunkards were punished severely, others were treated quite kindly, and some did reform. In general, however, drunkards as a group or class of deviants were not especially problematic for colonial Americans. If they had property or were able to support themselves, they were treated much like anyone else of their class. And those who could not support themselves were grouped among the dependents in every community. As Rothman has shown, colonial Americans did not make major distinctions among the poor and deviant: The fact of need was the important issue, not why someone happened to be needy. Further, colonials did not expect society to be free from crime, poverty, insanity, drunkenness, or other deviance. According to Rothman “they did not interpret its presence as symptomatic of

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a basic flaw in community structure or expect to eliminate it. They would combat the evil, warn, chastise, correct, banish, flog, or execute the offender. But they saw no prospect of eliminating deviancy from their midst.”18 The clergy, especially the educated and scholarly Puritans, did most of the warning and chastising about habitual drunkenness—about what they called the “Sin of Drunkenness” and the “Vice of Drunkenness.” In the writings of men like Increase and Cotton Mather, Thomas Foxcroft, Samuel Danforth, and Jonathan Edwards, we can see the seeds of a modern view of habitual drunkenness, as well as the absolute limits to which colonial and Puritan thought could go on the question. With the Bible as their guide, ministers warned of the eternal suffering awaiting drunkards. Puritans also argued that drunkards tended to commit “all those Sins to which they are either by Nature or Custom inclined.” Cotton Mather called drunkenness “this engine of the Devil.” Some ministers noted the difficulty of getting drunkards to give up their habit. “It is a Sin that is rarely truly repented of and turned from,” wrote Increase Mather. Finally, Puritans observed that drunkards suffered in this world as well; they frequently became sick or injured, and they tended to ignore their economic, religious, and family responsibilities. “Those that follow after Strong Drink have not the Art of getting or keeping Estates lawfully,” Danforth warned in 1710. “They cannot be diligent in their Callings, nor careful to improve all fitting Opportunities of providing for themselves and for their families.”19 In terms of external behavior, there is little to distinguish the contemporary idea of alcoholism or inebriety from the traditional, colonial view of the drunkard. The modern reader translates the behavioral description of the habitual drunkard into modern terms— into the alcoholic. But the understanding we have of the drunkard is not the understanding of the 17th and 18th centuries. The main differences lie not so much in the external form as in the assumptions made about the inner experiences and inner condition of the drunkard.20

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Beginning in the 19th century, terms like “overwhelming,” “overpowering,” and “irresistible” were used to describe the drunkard’s desire for liquor. In the colonial period, however, these words were almost never used. Instead, the most commonly used words were “love” and “affection,” terms seldom used in the 19th and 20th centuries. In the modern definition of alcoholism, the problem is not that alcoholics love to get drunk, but that they cannot help it—they cannot control themselves. They may actually hate getting drunk, wishing only to drink moderately or “socially.” In the traditional view, however, the drunkard’s sin was the love of “excess” drink to the point of drunkenness. Thus did Increase Mather distinguish between one who is “merely drunken” and a drunkard: “He that abhors the sin of Drunkenness, yet may be overtaken with it, and so drunken; but that one Act is not enough to denominate him a Drunkard. And he that loveth to drink Wine to Excess, though he should seldom be overcome thereby, is one of those Drunkards.”21 This is one important characteristic of 17thand 18th-century thought that radically separates it from modern ideas. Insofar as the traditional view raised the question of the drunkard’s experience or feelings, it described the drunkard as one who loved to drink to excess, who loved to drink and get drunk: “Solomon’s description of a Drunkard is that he is a lover of wine, Prov. 21.17,” wrote Increase Mather. “[He] is an habitual Drunkard; and he whose practice is according to that inordinate affection, is actually so.”22 Further, because in the traditional view there was nothing inherent in either the individual or the substance to prevent someone from drinking moderately, drinking was ultimately regarded as something over which the individual had final control. Drunkenness was a choice, albeit a sinful one, that some individuals made. Perhaps the most articulate statement of the traditional position was in Jonathan Edwards’s masterpiece Freedom of the Will, first published in 1754. He started his critique with Locke, whose ideas were indeed to be those of the modern world, by countering Locke’s argument that it is possible to differentiate between “Desire” and “Will.”

This distinction is important to much modern thought; it is also at the heart of the concept of addiction. In 19th- and 20th-century versions, addiction is seen as a sort of disease of the will, an inability to prevent oneself from drinking. As alcoholism expert Mark Keller explained in 1972, “An alcoholic cannot consistently choose whether he shall drink or not. There comes an occasion when he is powerless, when he cannot help drinking. For that is the essence or nature of drug addiction.”23 For Jonathan Edwards, however, desire and will must be seen as identical: “A man never, in any instance, wills any thing contrary to his desires, or desires any thing contrary to his Will. . . . His Will and Desire do not run counter at all: the thing which he wills, the very same he desires.”24 Edwards went on to confront the related philosophical issues of why people make the choices they do, and whether the words “impossible,” “irresistible,” or “unable” could rightly be used with reference to moral choices—and he used the drunkard to illustrate his points. He concluded that people choose things that “appear good to the mind,” by which he meant “appear agreeable, or seem pleasing to the mind.” Thus, when a drunkard has his liquor before him, and he has to choose whether to drink or no. . . . If he wills to drink, then drinking is the proper object of the act of his Will; and drinking, on some account or other, now appears most agreeable to him and suits him best. If he chooses to refrain, then refraining is the immediate object of his Will and is most pleasing to him.25

According to Edwards, in choosing to drink or to get drunk, drunkards choose their pleasure, their “love.” And Edwards explicitly rejected the idea that drunkards can be compelled by appetite or desire to do something against their will.26 It cannot be truly said, according to the ordinary use of language, that a malicious man, let him be never so malicious, cannot hold his hand from striking, or that he is not able to show his neighbor kindness; or that a drunkard, let his appetite be never so strong, cannot keep the cup from his

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mouth. In the strictest propriety of speech, a man has a thing in his power, if he has it in his choice or at his election. . . . Therefore, in these things, to ascribe a non-performance to the want of power or ability is not just.27

That Edwards felt it necessary even to raise the question of volition with regard to the drunkard suggests that by 1750 some people were beginning to view drunkards as individuals who had completely lost their ability to drink moderately. The concept of addiction was not an invention of Dr. Benjamin Rush; rather, it was the result of a long process of development in social thought. Whatever the level of “folk” wisdom on the subject, however, in 1750 the idea that someone could become an alcohol addict in the modern sense of the term had not yet been fully articulated. Of all colonials, Puritan ministers were the most troubled by habitual drunkenness, and in some scattered phrases and sentences we can find evidence of their trying to stretch beyond the ideas of their days. Increase Mather declared that habitual drunkenness was a kind of madness, and Foxcroft warned moderate drinkers that they were “in danger of contracting an incurable Habit.”28 But the ministers were not able to synthesize their observations; they were bound by the categories of their theology and psychology. As the historian Perry Miller pointed out, for Puritans, other than God’s will, “there can be no compulsion upon man.”29 The individual was always viewed as having the freedom to choose to sin or not. There were, in summary, two ways in which 17th- and 18th-century Americans viewed habitual drunkenness, and neither view lent itself to a definition of it as a diseased condition beyond the control of the will. For most people frequent drunkenness was not troublesome or sinful behavior. On the other hand, some individuals did see drunkenness as troublesome and sinful, but they did not regard it as therefore surprising or requiring explanation. Neither view led people to seek elaborate biological, chemical, or social explanations for the drunkard’s behavior. Whether seen as sin or blessing, habitual drunkenness was regarded

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as natural and normal—as a choice made for pleasure.30

THE DISCOVERY OF ADDICTION AND THE IDEOLOGY OF THE TEMPERANCE MOVEMENT During the 18th century there were anticipations of a modern way of seeing the drunkard, especially among preachers. In 1774 Quaker reformer Anthony Benezet wrote the first American pamphlet urging total abstinence from distilled liquor.31 But for the most part, the new view of addiction was developed by a group of Americans free from certain traditional assumptions about human behavior—who tended to see deviance in general, and drunkenness in particular, as problematic and unnatural. The modern conception of addiction was first worked out not by ministers, but by physicians, especially those interested in mental illness— practitioners whose orientation led them to look for symptoms and behavior beyond the control of the will, and whose interests lay precisely in the distinction between Desire and Will.32 It is in the work of Dr. Benjamin Rush, taken as a whole, that we can find the first clearly developed modern conception of alcohol addiction. While some of his observations had been made by others (especially Benezet), Rush organized the developing medical and common-sense wisdom into a distinctly new paradigm. According to Rush, drunkards were “addicted” to spirituous (distilled) liquors. He said they became addicted gradually and progressively: It belongs to the history of drunkenness to remark that its paroxysms occur, like the paroxysms of many diseases, at certain periods, and after longer or shorter intervals. They often begin with annual, and gradually increase in their frequency until they appear in quarterly, monthly, weekly, and quotidian or daily periods.33

The “paroxysms” are bouts of drunkenness characterized by an inability to refrain from drinking. “The use of strong drink is at first the effect of free agency. From habit it takes place

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from necessity,” said Rush. This condition he designated a “disease of the will,” and he gave a superb example of what nowadays is called “inability to refrain” or “loss of control”: When strongly urged by one of his friends to leave off drinking, [a drunkard] said, ‘Were a keg of rum in one corner of a room, and were a cannon constantly discharging balls between me and it, I could not refrain from passing before that cannon in order to get at the rum.’34

Finally, having diagnosed the disease, Rush offered the cure: My observations authorize me to say that persons who have been addicted to them should abstain from them suddenly and entirely. ‘Taste not, handle not, touch not’ should be inscribed upon every vessel that contains spirits in the house of a man who wishes to be cured of habits of intemperance.35

Rush’s contribution to a new model of habitual drunkenness was fourfold. First, he identified the causal agent—distilled liquor. Second, he clearly described the drunkard’s condition as loss of control over drinking behavior—as compulsive activity. Third, he declared the condition to be a disease. And fourth, he prescribed total abstinence as the only way to cure the drunkard. In the bulk of his writings about alcohol, Rush was not mainly concerned with diagnosing the condition of the drunkard or prescribing cures. He wanted to awaken Americans to an entire catalog of pernicious consequences that he felt followed from the consumption of distilled liquor—disease, poverty, crime, insanity, and broken families. However, the notion that the drunkard was a victim of the widespread and socially approved custom of drinking an addicting substance remained central to Rush’s entire case against liquor. He concluded his famous pamphlet, “Inquiry into the Effects of Ardent Spirits Upon the Human Body and Mind” with an appeal to “ministers of the gospel, of every denomination” to aid him in the campaign against spirits in order to “save our fellow men from being destroyed by the great destroyer of their lives and souls.”36

The temperance movement rightly claimed Benjamin Rush as its founder. His writings on the relationship between intemperance and distilled spirits, his descriptions of the individual and social consequences of the use of liquor, as well as his recommendation of total abstinence, formed part of the essential core of temperance ideology throughout the l9th century. As one pro-temperance historian explained in 1891: “Dr. Rush laid out nearly all the fundamental lines of argument along which the present temperance movement is pressed.”37 The antialcohol movement grew slowly in the early years of the 19th century; there was still considerable resistance, even among elite groups, to the need for abstinence. But by the mid-1830s, over half a million Americans had pledged not to drink any liquor, and the temperance movement had become firmly committed to the necessity for total abstinence from all alcoholic beverages.38 The eventual willingness of large numbers of people to accept the idea that alcohol was an addicting substance may have been influenced by the growing numbers of habitual drunkards who claimed to be unable to control their impulse to drink.39 The first public announcement that any temperance writers could find (and they looked hard) of someone admitting loss of control was by a James Chalmers of Nassau, New Jersey, who in 1795 made the following sworn and witnessed statement: Whereas, the subscriber, through the pernicious habit of drinking, has greatly hurt himself in purse and person, and rendered himself odious to all his acquaintances, and finds that there is no possibility of breaking off from the said practice but through the impossibility to find liquor, he therefore begs and prays that no person will sell him for money or on trust any sort of spirituous liquors.40

While no colonial-era drunkards seem to have made such declarations, 19th-century tales of compulsive drinking were commonplace. Especially in the 1840s, when the Washingtonian total abstinence society demonstrated that many drunkards could indeed be reformed, the speech by the reformed drunkard, telling of his trials and tribulations and his eventual victory over his appetite for alcohol, became a major

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organizing technique for the movement.41 In their autobiographies drunkards wrote of their battles with liquor. Popular fiction writers incorporated the drunkard’s struggle into their format, and a whole variety of temperance literature devoted to the subject blossomed.42 For example, Walt Whitman’s only novel was a first-person account of the life of an alcohol addict in which the main character explains that “None know—none can know, but they who have felt it—the burning, withering thirst for drink, which habit forms in the appetite of the wretched victim of intoxication.”43 By the mid-1830s, certain assumptions about the inner experience of the drunkard had become central to temperance thought. The desire for alcohol was seen as “overpowering” and frequently labeled a disease. In 1833 Lewis Cass, Andrew Jackson’s Secretary of War, discussed the alcohol addict’s illness at a large temperance meeting in Washington, DC: As the habit of intoxication, when once permanently engrafted on the constitution, affects the mind and body, both become equally debilitated. . . . The pathology of the disease is sufficiently obvious. The difficulty consists in the entire mastery it attains, and in that morbid craving for the habitual excitement, which is said to be one of the most overpowering feelings that human nature is destined to encounter. This feeling is at once relieved by the accustomed stimulant, and when the result is not pleasure merely, but the immediate removal of an incubus, preying and pressing upon the heart and intellect, we cease to wonder that men yield to the palliative within their reach.44

In 1838, Samuel B. Woodward, the Superintendent of the famed asylum at Worcester, Massachusetts, and probably the leading American physician concerned with mental health at that time, published a series of articles describing alcohol addiction as a “physical disease”: The appetite is wholly physical, depending on a condition of the stomach and nervous system, which transcends all ordinary motives of abstinence. The suffering is immense, and the desire of immediate relief so entirely uncontrollable, that it is quite questionable whether the moral power of

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many of its victims is sufficient to withstand its imperative demands.45

Woodward argued that “The grand secret of the cure of intemperance is total abstinence from alcohol in all its forms.” And he claimed it had been learned only relatively recently that abstinence was the cure for intemperance. Similarly, Walter Channing, in an address before the Massachusetts Temperance Society in 1836, observed how little had been known about intemperance when the organization had first been founded 24 years earlier: The direct connection between moderate drinking and intemperance, or the extreme liability of the production of the last by the first, were but vaguely understood. The giant power of habit, beneath which the strongest will almost surely be made to bow, and the total inefficacy of partial abstinence to weaken this power, the absolute certainty of fatal relapse where the smallest after indulgence is permitted—upon all this and much connected with it the bright light of our day had not yet beamed.46

Many observations made by temperance advocates did not differ significantly from those made by contemporary students of alcoholism and by Alcoholics Anonymous. One temperance writer, for example, described a case of loss of control after one drink: All have seen cases of this kind, where a longer or shorter interval of entire abstinence is followed by a paroxysm of deadly indulgence. . . . In their sober intervals they reason justly of their own situation and its danger; they know that for them there can be no temperate drinking: They resolve to abstain altogether and thus avoid temptation they are too weak to resist. By degrees they grow confident and secure in their own strength, and . . . they taste a little wine. From that moment the nicely adjusted balance of self control is deranged, the demon returns in power, reason is cast out, and the man is destroyed.47

The disease theme was often woven into temperance literature and speeches. In 1829 Nathan Beman declared that “drunkenness is

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itself a disease. . . . When the taste is formed, and the habit established, no man is his own master.”48 John Marsh raised the rhetorical question “of whether there can be any prudent use of a poison, a single portion of which produces the same disease of which the drunkard dies, and a disease which brings along with it a resistless desire for a repetition of the draught.”49 In 1881 one authority was quoted as saying that most moderate drinkers eventually experience a diseased “craving for drink” and that “it is the nature of intoxicating liquors to produce the disease.”50 Famous temperance lecturer John B. Gough said that he considered “drunkenness a sin, but I consider it also a disease. It is a physical as well as moral evil.”51 The notion that habitual drunkenness was hereditary was also quite common. One speaker told the Young Men’s Temperance Society of New Haven that “Drunkenness itself is a disease, and sometimes a hereditary disease.”52 A National Circular sent out in the 1830s made the argument which was repeated throughout the century: Unlike the appetite which God gave for water, for bread, and for nourishing food and drinks . . . [which] will not increase their demands, this cries continually ‘Give, give.’ And no man can form it without being in danger himself of dying a drunkard. Not that every man who forms it dies a drunkard. Some may withstand it; but the appetite which a father may withstand, may kill his children, and the children’s children, to the third and fourth generation.53

Nineteenth-century Americans believed in a particular version of the heritability of acquired characteristics. The disease of the parents would be passed on to later generations, but it was thought the traits could be unacquired as well, over several more generations.54 Thus liquor could be viewed as the cause of habitual drunkenness because any individual may have been weakened by his or her ancestors drinking habits. Mother Stewart, one of the early leaders of the Woman’s Christian Temperance Union, told in her memoirs of addressing boys and girls during the Woman’s Crusade which swept Ohio in 1873:

Here, as everywhere, the children were greatly excited and interested in the crusade. Ah, many of them knew what it meant to be a drunkard’s child. Many had the inherited taint coursing through their veins, and if they did not surrender to the inborn craving they would only escape through a lifelong battle.55

The efforts to develop inebriate asylums were supported by important temperance organizations and leaders. Benjamin Rush had been the first to recommend a “sober house” where drunkards could get special treatment.56 Samuel Woodward also argued strongly for the idea.57 In 1865 and again in 1867 the Massachusetts Temperance Alliance issued strong statements of support for the work being done by the Washingtonian home, one of the first functioning inebriate asylums.58 In 1873 the National Temperance Society, the major umbrella temperance organization, responded to the formation of an association for the promotion of asylums and the study of inebriety by writing in its annual report: “The temperance press has always regarded drunkenness as a sin and a disease—a sin first, then a disease; we rejoice that the Inebriate Association are now substantially on the same platform.”59 In addition, the National Temperance Society published several pamphlets arguing that asylums were needed because of the very nature of the disease of inebriety.60 “The inebriate is the victim of a positive disease, induced by the action of an alluring and deceptive physical agent, alcohol,” said one writer, and he urged that the law “provide well-appointed asylums, in which the victims of alcoholic disease can be legally placed, until . . . the disease and morbid appetite are effectually removed.”61 In his famous and influential book, The Disease Concept of Alcoholism, first published in 1960 (p. 6), E. M. Jellinek argued that temperance supporters felt “the idea of inebriety as a disease weakened the basis of the temperance ideology.” This chapter is suggesting precisely the opposite. While not every temperance writer called intemperance a disease, many did. And, more important, the core of the disease concept—the idea that habitual drunkards are alcohol addicts, persons who have lost control

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over their drinking and who must abstain entirely from alcohol—was also, from Rush on, at the heart of anti-alcohol ideology during the 19th century. In The Disease Concept of Alcoholism, Jellinek cited an 1882 pamphlet by a Reverend John E. Todd as evidence of an anti-disease view of inebriety. What Jellinek may not have understood is that Todd was not a temperance supporter. Indeed, Todd’s position was one temperance reformers had been fighting since the beginning of the century. The 17th- and 18th-century view had not died out; rather, the belief that habitual drunkards simply loved to drink and get drunk, and that they retained the capacity to stop drinking, continued to exist alongside the addiction— that is, the temperance—model. Echoing Jonathan Edwards, Todd wrote: I consider it certain that the great multitude of drunkards could stop drinking today and for ever, if they would; but they don’t want to. . . . I observe then there is no apparent difference between drunkenness in its first and drunkenness in its last stages. In both cases there is an appetite, and a will to gratify it. The man drinks simply because he likes to drink, or likes to be drunk.62

Todd’s pamphlet was reviewed and critiqued a year later by an anonymous Connecticut minister. “The whole question pivots, thus,” wrote the pastor, “on the power or powerlessness of the will in the confirmed drunkard to resist his propensity to drink.”63 Defending the temperance position, the minister argued that drunkards are unable to control their drinking. He cited the testimony of eminent physicians and temperance supporters, and he also referred to the experience of drunkards as evidence: “Many of these declare that they wish to refrain from liquor, that they choose to, and that they try to, that they put all the strength of their wills into the endeavor to, but that their craving for liquor is stronger than their wills and overpowers them.”64 Finally, like many other temperance supporters, the pastor believed that the drunkard’s condition should be called a disease. He observed that “the essence of disease is involuntariness” and

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suggested that inebriety was therefore a disease because drunkards are “physically helpless to refrain from drink.”65 Because the source of addiction was thought to reside in alcohol, and because liquor was a readily available and still somewhat socially acceptable substance, the possibilities of someone yielding to the temptation to drink, and becoming addicted, seemed quite real. Thus, in temperance speeches and literature the habitual drunkard was routinely viewed as a victim, and until the end of the 19th century the temperance movement held an essentially sympathetic view of the drunkard’s plight. Indeed, it is fair to say that temperance advocates were the Americans most openly sympathetic to and supportive of habitual drunkards. Moderate drinkers, not drunkards, came in for the most scorn in temperance literature. “And if there be any difference in the degrees of guilt between moderate drinkers and drunkards,” asserted a Good Templar tract, “the moderate drinker is worse than the drunkard.”66 Anti-temperance writers of the time also complained of the movement’s sympathetic attitude. As Dr. Howard Crosby, one of the most famous of such writers, explained in 1881: “You will find the principal shafts of the total-abstinence literature are directed not at the drunkard, but at the moderate drinker. The drunkard is pitied and coddled, while the moderate drinker is scourged.”67 This sympathetic attitude carried over into temperance activities. Contrary to some earlier writing on the temperance movement,68 I want to suggest that in the 19th century temperance was not only an attempt by one class or status group to change the behavior of another. It was also quite a self-interested activity. Because they regarded liquor as such a powerful and destructive substance, temperance supporters believed it could, and often did, destroy the lives of even the finest citizens. Members of temperance organizations were deeply concerned with the pernicious effects of alcohol on their own group—primarily the Protestant middle class; they worried about themselves, their relatives, friends, and neighbors. Thus support work for habitual drunkards comprised an important part of temperance activity, not only during the

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Washingtonian period of the 1840s, but for the rest of the century as well. From the end of the Civil War to the turn of the 20th century, the majority of people in temperance organizations belonged to fraternal groups—highly organized secret societies requiring total abstinence and aimed primarily at helping members stay sober, improving their character, and helping other drunkards reform. As the Most Worthy Scribe of the Sons of Temperance explained, the Sons “sprang from the lap of the Washingtonians,” and were dedicated to carrying on the reformation work by providing greater organizational structure and support. The organization was concerned with helping “reformed inebriates”; its first purpose was “to shield its members from the evils of intemperance.”69 Similarly, the Independent Order of Good Templars, the largest temperance membership organization in American history, was so involved in reform work that it worried about being branded solely as an association of exdrunkards.70 While lifelong abstainers were important to the organization, a central focus of the Good Templars was helping inebriates to become and stay abstinent. Good Templars were urged to “run and speak to that young man who is contracting vicious habits—gain his consent that you shall propose his name for membership in the lodge.”71 In the initiation ritual of the Good Templars, those members “free from the undying curse of appetite” were encouraged to “fully sympathize with the confirmed inebriate.”72 Those being initiated into the Charity Order were urged to “study well the nature of this appetite”; they were told that reformed individuals sometimes relapsed, and reminded that their task was to go to “thy reclaimed brother” in his “awful hour.” And they took pride in pointing out “the many official positions now filled by worthy men who have been reclaimed and reformed, given back to their families and community . . . by the labors of the Good Templars.”73 In the latter half of the 19th century the Sons of Temperance, the Good Templars, and a host of smaller fraternal groups functioned in much the same manner that Alcoholics Anonymous does today. They provided addicts who

joined their organizations with encouragement, friendship, and a social life free from alcohol. They went to inebriates in times of need, and in some cases offered financial support as well.

CHANGES IN THE PARADIGM In the last decade or so of the 19th century, temperance movement leaders began to shift their ideology away from its broad reformist orientation, toward a single-minded concern with passing laws prohibiting the production and sale of alcoholic beverages. The older organizations, especially the fraternal ones, declined markedly. The leaders who had guided the movement since the end of the Civil War died and were replaced by a new generation which prided itself on its practical and scientific attitudes. In the early 20th century under the leadership of the Anti-Saloon League, all activities became secondary to the drive for local, state, and then national constitutional alcohol prohibition.74 As Gusfield75 has rightly pointed out, the temperance movement shifted from “assimilative reform” to coercion. One aspect of this transformation was that addiction came to occupy a less central role in the ideology of the anti-alcohol movement. Thus the alcohol prohibition campaign of the early 20th century focused on the evil effects of alcohol other than addiction, especially those tied to conditions of life in industrializing America. Twentieth-century prohibitionists stressed alcohol’s role in industrial and train accidents, its effects on business and worker efficiency, its cost to workers and their families. Prohibitionists focused on the power and wealth of the “liquor trust,” and especially on the role of the urban saloon as a breeding place for crime, immorality, labor unrest, and corrupt politics. In a sense, the “demon rum” became less the enemy than the “liquor trust” and the saloon.76 One aspect of the shift away from a focus on the addicting qualities of alcohol was the weakening, and in many cases the loss, of the movement’s longstanding sympathetic attitude toward the habitual drunkard. The drunkard came to be viewed less and less as a victim, and more and more as simply a pest and menace.

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Of course the concept of addiction did not disappear from American life. In the second-half of the 19th century, opium was increasingly regarded as inherently addicting. After the Harrison Act of 1914, federal drug agencies emphasized the addicting qualities of opium and its derivatives, of cocaine, and later of marihuana.77 However, by the early 20th century, the original moral entrepreneurs of alcohol addiction, the temperance movement, had lost much of their interest in forwarding the idea. In Gusfield’s terms78 no one “owned” the addiction model of alcoholism. While there seemed to be a general acceptance at that time within psychiatric and social work circles for a disease conception of alcoholism, the details and specifics of it were not yet clearly worked out.79 Further, in order for a disease conception to be acceptable to masses of people in the 20th century, the idea that alcohol was an inherently addicting substance could not be retained. There was, therefore, a vacuum which remained unfilled until the creation of Alcoholics Anonymous. The “rediscovery” of alcoholism as an addiction and a disease in the 1930s and 1940s by Alcoholics Anonymous and the Yale Center of Alcohol Studies was indeed a significant change within the addiction paradigm. Now alcohol could be understood as a socially acceptable, “domesticated” drug that was addicting only to some people for unknown reasons. Thus alcoholism became the only popularly and scientifically accepted person-specific drug addiction. For the first time, the source of addiction lay in the individual body, and not in the drug per se. The result has been a somewhat “purer” medical model with less of a tendency to view addiction as a self-inflicted disease. This “new disease conception”80 of alcoholism rising in the mid-20th century was both novel and yet based on a 150-year-old commonsense understanding of habitual drunkenness. As I have suggested, this new medical and popular view of addiction has more in common with 19th-century temperance thought than with either pre-temperance or anti-temperance formulations (e.g., Jonathan Edwards and Reverend Todd). Besides the belief in the necessity of abstinence, the essential commonality

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between the ideas of Alcoholics Anonymous and of the temperance movement lies in the importance they attributed to, as well as their way of interpreting, the inner experiences of the alcoholic. Ultimately one is only certain that a heavy drinker has passed over the line to alcohol addiction if that person reports experiencing irresistible desires for the substance—if there is, as in Jellinek’s view, loss of control. From such a definition of the problem—as behavior beyond the control of the will—stems the tendency to view habitual drunkenness as disease, and the potential for a sympathetic attitude toward the alcoholic.81

THE SOCIAL CONTEXT OF ADDICTION A thorough discussion of why the concept of addiction emerged as and when it did is necessarily somewhat speculative and is not possible here. However, I want to suggest the outlines of a sociology of knowledge approach to this question. In the last 200 years, definitions of habitual drunkenness have been shaped by developments in thought about deviance in general, and about mental illness in particular. Benjamin Rush, for example, is best known today for his work on mental illness—for his reinterpretation of madness as disease. A number of writers, notably Foucault and Rothman, have suggested that the medical model of madness first established at the end of the 18th century and beginning of the 19th century in Europe and the U.S., was in fact a medical model of deviance in general, and part of the new worldview of the middle class. French physician Philippe Pinel, British merchant William Tuke, as well as Dr. Benjamin Rush, are usually credited with the simultaneous and mostly independent discovery that, within the asylum, the mad could be freed from their chains and taught to constrain themselves. The therapy they developed was called “moral treatment” and it replaced the traditional mechanisms of social control, chains, with fear and guilt. The mad were now expected to control themselves.82 Foucault argued that the establishment of the new view of madness was made possible by the

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achievement of economic and political power by the bourgeoisie. Grounded in the optimistic world view of the Enlightenment, the middle class assumed that evil need not exist—social problems were solvable or curable. However, the conditions of a “free society,” meaning individual freedom to pursue one’s own interests, required shifting social control to the individual. Social order, it was now said, depended upon self-control. “The madman as a human being originally endowed with reason, is no longer guilty of being mad,” Foucault wrote, “but the madman, as madman, and in the interior of the disease of which he is no longer guilty, must feel morally responsible for everything within him that may disrupt morality and society.”83 Madness had become a curable disease, the chief symptom of which was loss of self-control. The asylum was constructed as a place to restore the power of self-discipline to those who had somehow lost it.84 In the U.S. the importance attributed to individual responsibility has usually been identified with the Protestant and Puritan heritage. Yet by the beginning of the 19th century the value of inner discipline had become increasingly divorced from its religious scaffolding. In the colonial era even Puritans believed that social control had to be maintained by a complex and hierarchical web of community relations.85 In the 19th century, however, the ideological and structural features of life shifted the locus of social control to the individual. Max Weber cited Benjamin Franklin as the archetypal example of the capitalist spirit—the disciplined and rational pursuit of money. Weber argued that the conditions of life in capitalist society required individuals to methodically regulate their activities in order to survive and succeed.86 The conditions and experiences of daily life in a market society meant that everyone in the middle class had to try to become like Franklin. Because the U.S. was an especially or even uniquely middle-class nation,87 the redefinition of evil or deviance as a disease of the will was carried even further here. That is, because self-control (“self-reliance” as Ralph Waldo Emerson proclaimed) had become so important to the middle class, its negation had to

be more clearly defined and combated. Daniel Boorstin observed that “when the Jeffersonian came upon the concept of evil in theology or moral philosophy, he naturalized it into another bodily disease; a disease indeed of the moral sense, but essentially no different from others.”88 In the 1830s, Americans troubled by the disorder they perceived in their society built almshouses, penitentiaries, orphan asylums, and reformatories to administer “moral treatment” to the dependent and deviant. The idea, in all cases, was to build up the dormant or decayed powers of self-control through discipline, routine, and hard work. The asylum managers explained that their purpose was to provide inmates with a “healthy moral constitution capable of resisting the assaults of temptations,” and to “aid them in forming virtuous habits, that they may finally go forth clothed as in invincible armor.”89 The technique developed for treating the mentally ill was extended to all who had failed to regulate themselves properly. Like asylum advocates, temperance supporters were interested in helping people develop and maintain control over their behavior and actions. Temperance supporters, however, believed they had located, in alcoholic drink, the source of most social problems. The temperance movement, it should be remembered, was the largest enduring mass movement in 19th-century America. And it was an eminently mainstream middle-class affair. The anti-alcohol movement appealed to so many people in part because it had become a “fact of life” that one could lose control of one’s behavior. Even the use of the word “temperance” for a total abstinence movement is understandable when we realize that the chief concern of temperance advocates, and of the middle class in general, was self-restraint. Liquor was evil, a demon, because its short- and long-run effect was to prevent drinkers from living moderate, restrained, temperate lives. In the terminology of Alcoholics Anonymous, it made their lives “unmanageable.” In the 19th century, the concept of addiction was interpreted by people in light of their struggles with their own desires in an increasingly competitive market society. The idea of

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addiction “made sense” not only to drunkards, who came to understand themselves as individuals with overwhelming desires they could not control, but also to great numbers of middle-class people who were struggling to keep their desires in check—desires that at times seemed “irresistible.” Given the structural requirements of daily life for self-reliant, self-making entrepreneurs and their families, and the assumptions of the individualistic middle-class worldview, it seemed a completely reasonable idea that liquor, a substance believed to weaken inhibitions when consumed (intoxication), could also deprive people of the ability to control their behavior over the long run (addiction). In their classic study The Lonely Crowd, Riesman and his coauthors characterized the property-owning middle class as “inner directed,” by which they meant both the particular way in which conformity was assured, and a concern with the integrity and inner experiences of the individual.90 Thus the distinctively middle-class literary form, the novel, made its domain the exploration of the nuances of daily life and inner experiences.91 The novel, therefore, became one important place where the inner struggle of the drunkard was portrayed.92 The rise of middle-class society was the precondition for a literature based on everyday life and experience, and also a precondition for the new way of seeing the drunkard. The invention of the concept of addiction, or the discovery of the phenomenon of addiction, at the end of the 18th century and beginning of the 19th century, can be best understood not as an independent medical or scientific discovery, but as part of a transformation in social thought grounded in fundamental changes in social life—in the structure and organization of society. For those interested in criticizing and transcending the addiction model of drug use, it is important to understand that the medical model has much deeper roots than has previously been thought. The ideas of Alcoholics Anonymous, and of Jellinek, Keller, and many modern alcoholism experts, are only the most recent articulations of much older ideas.93 Further, the structural and ideological conditions that made addiction a “reasonable”

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way to interpret behavior in the l9th century have not disappeared in the 21st: Many people still face the problem of controlling their own “compulsive” behavior. The proliferation of “Anonymous” groups, based on the A.A. format, is testimony to the continued effectiveness of such organizational methods of helping people control themselves. In all cases, the focus is on the interaction between the individual and the deviant activity (compulsive drinking, gambling, drug use, sexual encounters) and with helping the individual to stop being deviant. On the other hand, there is the beginning of what might be termed a “post-addiction” model of drug and alcohol problems emerging. A new formulation of drug and alcohol problems does not look primarily at the interaction between individual and drug, but at the relationship between individual and social environment. Deviance, therefore, is not simply defined as an issue of individual control and responsibility, but can be seen as a social and structural process. Indeed, exactly who or what is deviant can now be reexamined. In part, the rise of a new popular and scientific “gaze” is rooted, as the old one was, in changes in the organization of daily life. The different conditions facing people in the 20th and 21st centuries, in particular the obviousness of giant organizations and of the degree of human interdependence, begin to make it possible to see the “social” nature of what had formerly been viewed as “individual” problems. Take, for example, the issue of drunken drivers. An individualistic perspective looks at those who have lost their ability to “manage” in the world because of drink; an alternative view focuses, instead, on the interaction between social life and transportation. If drinking is “normal” activity, then perhaps the phenomenon of drunken drivers is not a drinking problem, but a transportation problem. Indeed, if one thinks about it, we live with a bizarre system of transportation: In order to get from one place to another people are often required, at all hours of the day and night, to execute high-speed maneuvers, through a maze of obstacles, with a ton of machinery. There would, of course, be serious opposition to a redefinition of the problem of drunken drivers

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as a transportation problem—from automobile companies, for example. As was true at the beginning of the 19th century, developing a new model of alcohol problems would necessarily be part of a reformulation of social problems in general. Thus even if a new paradigm or model does emerge, it will have to compete and coexist with the addiction perspective for a long time—just as, for the last 200 years, the addiction model has had to compete and coexist with the pre-addiction view.94

7. 8. 9.

NOTES 1. This chapter is based on “The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America,” Journal of Studies on Alcohol 15:493–506 (1978), which was edited and revised for this book; most references are retained from the original. 2. Foucault, M. The Birth of the Clinic: An Archaeology of Medical Perception. New York: Vintage, 1975, p. 199. 3. Hayter, A. Opium and the Romantic Imagination. Berkeley: University of California Press, 1970; Musto, D. F. The American Disease: Origins of Narcotic Control. New Haven: Yale University Press, 1973; Coleman, J. W. The myth of addiction. Journal of Drug Issues 6:135–141 (1976); Duster, T. The Legislation of Morality: Law, Drugs, and Moral Judgment. New York: Free Press, 1970; Hess, A. G. Deviance theory and the history of opiates. International Journal of the Addictions 6:585–598 (1971). 4. Jellinek, E. M. The Disease Concept of Alcoholism. Highland Park, NJ: Hillhouse, 1960; Wexberg, L. E. Alcoholism as a sickness. Quarterly Journal of Studies on Alcohol 12:217–230 (1951); Siegler, M., Osmond, H. and Newell, S. Models of alcoholism. Quarterly Journal of Studies on Alcohol 29:571–579 (1968). 5. The classic description of alcoholism is: Jellinek, The Disease Concept of Alcoholism, 1960. 6. This chapter uses as equivalents the terms drunkard, habitual drunkard, intemperate, inebriate, and alcoholic to describe people who regularly got drunk. All those terms have been commonly used in America. Drunkard and habitual drunkard were common in the 17th, 18th, and 19th centuries, and habitual drunkard is still sometimes used today. Inebriate appears to have come into usage in the early 19th century. Alcoholic was coined in the mid19th century but did not come into regular usage until the 20th century. The phrase alcohol addict was not ordinarily used by temperance sources. I use it to make my meaning clear. For a discussion of the various ways Puritans responded to habitual drunkards, see: Lender, M. Drunkenness as an Offense in Early New England: A Study of

10. 11. 12. 13. 14. 15. 16. 17.

18. 19.

20.

“Puritan” Attitudes. Quarterly Journal Of Studies On Alcohol 34:353–366 (1973). Dorchester, D. D. The Liquor Problem in All Ages. New York: Phillips & Hunt, 1888, p. 124. Kohler, J. Ardent Spirits: The Rise and Fall of Prohibition. New York: Putnam’s, 1973, p. 18. See, for example: Rorabaugh, W. J. The Alcoholic Republic: An American Tradition. New York: Oxford University Press, 1979; Krout, J. A. The Origins of Prohibition. New York: Knopf, 1925; Dulles, F. R. America Learns to Play; A History of Popular Recreation, 1607–1940. New York: Appleton, 1940; Field, E. The Colonial Tavern. Providence, RI: Preston & Rounds, 1897; Earle, A. M. Stage Coach and Tavern Days. New York: Dover, 1969 [Orig. 1900.] Tyrell, I. Sobering Up: From Temperance to Prohibition in Antebellum America, 1800-1860. Westport, CT: Greenwood Press, 1979. Rush, B. Sermons to Gentlemen upon Temperance. Philadelphia: John Dunlap, 1772, p. 22. Rorabaugh,1979, chapter 2. Also see: Krout, 1925; Dulles, 1940; Earle, 1900; Field, 1897. Quoted in Earle, 1900, p. 3. Mather, I. Wo to Drunkards. Cambridge, MA: 1673. [2d ed., 1712.] Mather, C. Sober Considerations on a Growing Flood of Iniquity. Boston: 1708. Rorabaugh, 1979, discusses the complaints and concerns of Mather, Adams, Franklin and others. Also see Krout, 1925. Danforth, S. The Woful Effects of Drunkenness: A Sermon Preached at Bristol, October 10, 1709. Boston: B. Green, 1710, p. 10. Lender, M. Drunkenness as an Offense in Early New England: A Study of “Puritan” Attitudes. Quarterly Journal Of Studies On Alcohol 34:353–366 (1973); Earle, 1900; Rorabaugh, 1979 Rothman, D. J. The Discovery of The Asylum: Social Order and Disorder in the New Republic. Boston: Little, Brown, 1971, p. 15. Mather, I., 1673. [2d ed., 1712]. Mather, C., 1708, p. 23; Foxcroft, T. A Serious Address to Those Who Unnecessarily Frequent the Tavern. Boston: S Gerrish, 1726; Danforth, S., 1710, pp. 14 and 22. This is not to imply that some new style of drinking emerged that had not existed before and which was then labeled addiction. The 17th and 18th centuries displayed as great a variety of styles of habitual drunkenness as the 19th century. Further, some alcoholism experts have read descriptions of drunkards as far back as ancient Greece and concluded that the drinking patterns now identified with alcoholism existed then. What was new in the l9th century was the legitimacy of a particular way of interpreting the experience and behavior of drunkards. In the 17th and 18th centuries, there may have been individuals who felt “overwhelmed” by their desires for drink, but there was no socially legitimate vocabulary for organizing and talking about the experience; it remained an inchoate and extremely private experience. In the

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21. 22. 23. 24. 25. 26.

27. 28. 29. 30.

31. 32.

19th century, the drunkard’s experience was so familiar it became stereotyped. McCormick has noted that in 18th-century English novels drunkenness was treated casually and comically. Only in 19th-century fiction does the modern alcohol addict appear. For example, a woman in Gaskell’s Mary Barton (1848) reports, “I could not lead a virtuous life if I would. . . . I must drink. . . . Oh! You don’t know the awful nights I have had in prison for want of it.” Quoted in: McCormick, M. First representations of the gamma alcoholic in the English novel. Quarterly Journal of Studies on Alcohol 30:957–980 (1969). See pp. 975–6. Mather, I., 1673 [2d ed., 1712], p. 21. Mather, I., 1673 [2d ed., 1712], p. 7. Keller, M. On the Loss-of-Control Phenomenon in Alcoholism. British Journal of Addiction 67:153–166 (1972). Edwards, J. Freedom of the Will. In: Edwards, J. Basic Writings. New York: New American Library, 1966, p. 199. Edwards, 1966, p. 203. Jonathan Edwards was a determinist, but determinism as he defined it was not inconsistent with liberty with regard to moral choices. For a discussion of Edwards’s argument see Ramsey’s introduction to Freedom of the Will, in: Ramsey, P. Editor’s introduction. In: Edwards, J. Freedom of the Will. New Haven: Yale University Press, 1957. For a more general discussion see Miller’s biography: Miller, P. Jonathan Edwards. Westport, CT: Greenwood, 1973. [Orig. 1949]. Edwards, 1966, pp. 218–219. Mather, I., 1673 [2d ed., 1712]. Foxcroft, 1726, p. 8. Miller, P. The New England Mind: The Seventeenth Century. Boston: Beacon Press, 1961, p. 232. For follow up on this discussion, see James Nicholls’s thoughtful review of some recent scholarship on conceptions of disease and addiction in England and America in the 18th century. He finds that modern conceptions of addiction as articulated in the late 18th and early 19th centuries were indeed the product of a long development in social thought. Nicholls, J. Vinum Britannicum: The “Drink Question” In Early Modern England. Social History of Alcohol and Drugs, 22(2) Spring 2008. http://alcoholanddrugshistorysociety.files. wordpress.com/2010/11/shad-22-2-nicholls.pdf; accessed 8/29/14. Benezet, A. The Mighty Destroyer Displayed. Philadelphia: Joseph Crukshank, 1774. The role of doctors in the development of temperance thought was so important that Wilkerson called the early period “the physicians’ temperance movement.” Wilkerson, A. E. A History of the Concept of Alcoholism as a Disease. D.S.W. dissertation, University of Pennsylvania, 1966. Following Rush’s lead were some of the most eminent physicians in the United States. Krout (1925, p. 140) reports that by 1830 the Philadelphia College of Physicians and Surgeons had introduced a course on the pathology of intemperance. For

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34.

35. 36. 37. 38. 39.

40. 41. 42. 43. 44. 45. 46.

47. 48. 49. 50. 51.

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further discussion of the role of the medical profession in the temperance movement see: Cassedy, J. H. An Early American Hangover: The Medical Profession and Intemperance, 1780–1860. Bulletin of the History of Medicine 50:405–413 (1976); and Asbury, H. The Great Illusion: An Informal History Of Prohibition. Garden City, NY: Doubleday, 1950, p. 27. Rush, B. An Inquiry Into The Effects Of Ardent Spirits [8th edition, 1814], pp. 185–221. In: Henderson, Y. A. A New Deal in Liquor: A Plea For Dilution. New York: Doubleday, 1934, p. 192. Rush, 1814, reprinted 1934, p. 266. For an important contemporary discussion of “loss of control” see: Keller, M. On the Loss-of-Control Phenomenon in Alcoholism. British Journal of Addiction 67:153–166 (1972). Rush, 1814, reprinted 1934, p. 221. Rush, 1814, reprinted 1934, p. 211. Quoted by Asbury, H. The Great Illusion: An Informal History Of Prohibition. Garden City, NY: Doubleday, 1950, p. 9. Krout, 1925, p. 129. Over the course of the l9th century this process worked the other way as well. That is, people came to identify themselves as alcohol addicts, as drunkards who had lost the ability to control their drinking. They did so as a result of the ideological and organizational efforts of the temperance movement, just as today alcoholics regularly learn in Alcoholics Anonymous groups that they are individuals who cannot drink moderately. Quoted in Cherrington, E. H. The Evolution of Prohibition in the U.S.A. Westerville, OH: American Issue Press, 1920, p. 56. Maxwell, M. A. The Washingtonian Movement. Quarterly Journal of Studies on Alcohol 11: 410– 451 (1950). Brown, H. R. The Sentimental Novel in America; 1789–1860. New York: Pageant, 1959. Whitman, W. Franklin Evans or the Inebriate. New York: Random House, 1929. [Orig. 1842.], p. 148. Cass, L. Secretary Cass’s speech. American Quarterly Temperance Magazine 2:121–125 (1833): 124. Woodward, S. B. Essays on Asylums for Inebriates. Worcester: S.l. s.n, 1838, p. 2. Woodward, 1838, p. 8; Channing, W. Annual Address Delivered before the Massachusetts Temperance Society. In: Annual Report of the Society. Boston, 1836, p .9. Review of Dr. Scott’s address. American Quarterly Temperance Magazine 2:144–147 (1833): 145. Beman, N. S. Beman on intemperance. New York: John P. Haven, 1829, p. 67. Marsh, J. Putnam and the wolf, or, the monster destroyed. In: Select Temperance Tracts. New York: American Tract Society. [c. 1859], pp. 14–15. Foster, J. E. A Reply to Dr. Crosby’s “Calm View of Temperance.” In: Moderation vs. Total Abstinence. New York: National Temperance Society, 1881, p. 67. Gough, J. B. Sunlight and Shadow. Hartford: Worthington, 1881, p. 443.

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52. Stone, J. S. An Address Delivered before the Young Men’s Temperance Society of New Haven, Connecticut, in Trinity Church. New Haven: S. Babcock, 1830, p. 15. 53. National Circular. In: The Temperance Volume. New York: American Tract Society. [c. 1835], p. 2. 54. Rosenberg, C. E. Science and American Social Thought. In: Van Tassel, D. and Hall, M. G. Science and Society in the United States. Homewood, IL: Dorsey, 1966. pp. 135–162. 55. Stewart, E. D. Memories of the Crusade. Columbus, OH: Hubbard, 1888, p. 275. 56. Rush, B. An Inquiry into the Effects of Ardent Spirits [8th edition, 1814], pp. 185–221. In: Henderson, Y. A. A New Deal in Liquor; A Plea For Dilution. New York: Doubleday, 1934. Rush discussed “sober houses” briefly in Rush, B. Medical Inquiries and Observations upon the Diseases of the Mind. New York: Hafner, 1810. 57. Woodward, S. B. Essays on Asylums for Inebriates. Worcester, 1838. 58. Massachusetts Temperance Alliance. Fourteenth Annual Report. Boston, 1865. Massachusetts Temperance Alliance. Sixteenth Annual Report. Boston, 1867. 59. National Temperance Society and Publication House. Eighth Annual Report. New York, 1873, p. 26. 60. The Curability of Drunkenness. (National Temperance Society Pamphlet No. 82.) New York: [c. 1875]. Hereditary Intemperance. (National Temperance Society Pamphlet No. 60.) New York: [c. 1875]. Davis, N. S. The Nature of Inebriation and the Means of Cure. (National Temperance Society Pamphlet No. 56.) New York [c. 1875]. 61. Davis, N. S., 1875, pp. 7–8. Beyond such statements of support, however, temperance organizations did relatively little to develop inebriate asylums and they did not make asylums a major part of their programs. Some temperance people opposed asylums because of their cost and because of questions about their effectiveness. Like many middle-class Americans in the l9th century, temperance supporters believed strongly in the power of voluntary associations and self-help societies. Thus local temperance groups, especially the fraternal organizations, made reform work an important part of their community activities. 62. Todd, J. E. Drunkenness a Vice, Not a Disease. Hartford: Case, Lockwood & Brainard, 1882, pp. 7–8. 63. A Connecticut Pastor, pseud. Drunkenness a Curse, Not a Blessing: A Review of a Paper by Rev. John E. Todd on “Drunkenness a Vice, Not a Disease.” Hartford, Case, Lockwood & Brainard, 1883, p. 3. 64. A Connecticut Pastor, pseud., 1883, p. 15. 65. A Connecticut Pastor, pseud., 1883, p. 22. 66. Independent Order of Good Templars. It is a Great Sin to Drink Moderately of Alcoholic Beverages. (Good Templar Tract No 9.) [n.d.] 67. Crosby, H. Moderation vs. Total Abstinence or Dr. Crosby and His Reviewers. New York: National Temperance Society, 1881, p. 17.

68. See for example: Gusfield, J. Symbolic Crusade: Status Politics and the American Temperance Movement. Urbana: University of Illinois Press, 1966; Sinclair, A. Era of Excess: A Social History of the Prohibition Movement. New York, Harper, 1964; Furnas, J. C. The Life and Times of the Late Demon Rum. New York: Capricorn, 1965. 69. National Temperance Society. One Hundred Years of Temperance: A Memorial Volume of the Centennial Temperance Conference held in Philadelphia, Pennsylvania, September, 1885. New York, 1886, pp. 491–492. 70. Turnbull, W. W. The Good Templars: A History of the Rise And Progress of the Independent Order of Good Templars. International Supreme Lodge, 1901. 71. Independent Order of Good Templars. Good Templar Tract No. 3. Upper Alton, IL: [c. 1860], p. 8. 72. Independent Order of Good Templars. The Degree Book of the Independent Order of Good Templars. Detroit, 1867, p. 67. 73. Independent Order of Good Templars. Good Templar Tract No. 3. Upper Alton, IL: [c. 1860], p. 6. For much of the period, the Good Templars claimed a membership in the U.S. of around 300,000 (Turnbull, 1901, p. 6.). For many years, the lack of understanding of the self-help activities of the Good Templars and other fraternal groups obscured the real continuities between the temperance and alcoholism movements. For example, like Alcoholics Anonymous, Good Templars believed that in order to ensure his own sobriety the reformed inebriate “must go to work to save others. To help himself he must help others. To grow stronger himself, he must give strength to others.” In: Independent Order of Good Templars. Good Templar Tract No. 3. Upper Alton, IL [c. 1860]. A.A. is not only similar in form and purpose to self-help temperance groups, it is of a historical piece with them. For a discussion of the Good Templars’ approach to reform work see: Sibley, F. J. Templar at Work: What Good Templary Is, What It Does and How to Do It. 2d ed. Mauston, WI, 1888, ch XIV. David M. Fahey has done pioneering research about the Good Templars. Among other works see: Temperance And Racism: John Bull, Johnny Reb, and the Good Templars. Lexington: University Press of Kentucky, 1996. 74. Sinclair, A. Era of Excess: A Social History of the Prohibition Movement. New York, Harper, 1964; Odegard, P. H. Pressure Politics: The Story of the Anti-Saloon League. New York: Columbia University Press, 1928; Timberlake, J. Prohibition and the Progressive Movement: 1900–1920. New York: Atheneum, 1970. Jack S. Blocker, Jr. Retreat from Reform: The Prohibition Movement in the United States, 1890-191. Westport, CT: Greenwood Press, 1976. 75. Gusfield, J. Symbolic Crusade.

DISCOVERING ADDICTION 76. Many works about the rise of alcohol prohibitionism in the late 19th and early 20th centuries make this observation. See, for example: Timberlake, 1970; Blocker, 1976; Odegard, 1928; Sinclair, 1964. 77. Musto, 1973; Duster, 1969. Bonnie, R. J. and Whitebread, C. H. The Marijuana Conviction: A History of Marijuana Prohibition in the United States. Charlottesville: University of Virginia Press, 1974. 78. Gusfield, J. Categories of Ownership and Responsibility in Social Issues: Alcohol Abuse and Automobile Use. Journal of Drug Issues 5:285–303 (1975). 79. Wilkerson, A History of the Concept of Alcoholism as a Disease, 1966. 80. The “new disease conception” is E. M. Jellinek’s term in his 1960 book The Disease Concept of Alcoholism. 81. I am not suggesting that an addiction model is invariably couched in disease language or that it always is coupled with a sympathetic attitude toward the addict. I am saying that the first modern addiction conception (Rush) employed disease language, that many temperance people used disease language, and that in general temperance supporters were sympathetic to the drunkard’s plight. 82. Rothman, D. J. The Discovery of The Asylum: Social Order and Disorder in the New Republic. Boston: Little, Brown, 1971; Foucault, M. Madness and Civilization: A History of Insanity in the Age of Reason. New York: Vintage, 1975; Dain, N. Concepts of Insanity in the United States: 1789– 1865. New Brunswick, NJ: Rutgers University Press, 1964. 83. Foucault, Madness and Civilization,1975, quotes from pp. 245–246. 84. Rothman, 1971, discusses the importance of self control to those who designed and ran asylums in the U.S. 85. Two excellent works on colonial era and Puritan conceptions of order are: Miller, P. Errand into the Wilderness. Cambridge, MA: Belknap, 1956; and Rothman, 1971. 86. Weber, M. The Protestant Ethic and the Spirit of Capitalism. New York: Scribner’s, 1958, p. 72. 87. Mills, C. W. White Collar: The American Middle Classes. New York: Oxford University Press, 1951; Hartz, L. The Liberal Tradition in America. New York: Harcourt, Brace & World, 1955; Riesman, D., Denny, R. and Glazer, N. The Lonely Crowd: A Study of the Changing American Character. New Haven: Yale University Press, 1950. 88. Boorstin, D. J. The Lost World of Thomas Jefferson. Boston: Beacon, 1948, p. 137. 89. Rothman, 1971, p. 212. 90. Riesman, Denny, and Glazer. The Lonely Crowd, 1950. 91. Watt, I. The Rise of the Novel. Berkeley: University of California Press, 1957. 92. Brown, H. R. The Sentimental Novel in America: 1789–1860. New York: Pageant, 1959; McCormick, M. First Representations of the Gamma

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Alcoholic in the English Novel. Quarterly Journal of Studies on Alcohol 30:957–980 (1969). 93. This chapter focuses on the development of the idea of addiction in the U.S. However, much of the process described here applies to Europe as well. That is, there was no popular or medical concept of addiction before the l9th century. While the temperance movement developed first and most completely in the U.S., its arguments, literature and organizational forms were picked up by Europeans, especially the British and Scandinavians; see: Harrison, B. Drink and the Victorians: The Temperance Question in England, 1815–1872. Pittsburgh: University of Pittsburgh Press, 1971. Cherrington, E. H., Johnson, W. E. and Stoddard, C. F. Standard Encyclopedia of the Alcohol Problem. 6 vols. Westerville, OH: American Issue. 1825–1930. Eighteenth-century England, for example, had a “gin epidemic” and the high level of public drunkenness among the poor prompted efforts to cut consumption: Coffey, T. G. Beer Street: Gin Lane: Some Views of 18th-Century Drinking. Quarterly Journal of Studies on Alcohol 27:669–692 (1966). Yet England developed no addiction model of habitual drunkenness and no temperance movement until the 19th century. Thomas Trotter is probably the most important of the early European physicians who forwarded an addiction model of drunkenness: Wilkerson, A. E. A History of the Concept of Alcoholism as a Disease. D.S.W. dissertation, University of Pennsylvania, 1966; Jellinek, E. M. An Early Medical View of Alcohol Addiction and Its Treatment: Dr. Trotter’s “Essay, Medical, Philosophical and Chemical, on Drunkenness.” Quarterly Journal of Studies on Alcohol 2:584– 591 (1941). For medical definitions in Europe see: Bynum, W. F. Chronic alcoholism in the first half of the l9th century. Bulletin of the History of Medicine 42:160–185, 1968. Also see the recent work cited above: Nicholls, J. Vinum Britannicum: The “Drink Question” In Early Modern England, 2008. http://alcoholanddrugshistorysociety.files. wordpress.com/2010/11/shad-22-2-nicholls.pdf; accessed 8/29/14. For prominent classic alcoholism field writings about addiction see: Isbell, H. and White, M. W. Clinical Characteristics of Addictions. American Journal of Medicine 14:558–565 (1953). Jellinek, The Disease Concept of Addiction, 1960; Isbell, H. and White, M. W. Clinical Characteristics of Addictions. American Journal of Medicine 14:558–565, 1953; Chafetz, M. and Demone, H. Alcoholism and Society. New York: Oxford University Press, 1962; Keller, M. Definition of Alcoholism. Quarterly Journal of Studies on Alcohol 21:125–134, 1960; Keller, M. and McCormick, M. A Dictionary of Words about Alcohol. New Brunswick, NJ: Rutgers Center of Alcohol Studies, 1968. For important early alternative views to the alcoholism field see: Lindesmith, A. R. Addiction and Opiates. Chicago: Aldine, 1968; Fingarette,

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H. R. The Perils of Powell: In Search of a Factual Foundation for the “Disease Concept Of Alcoholism.” Harvard Law Review 83:793–812 (1970); Szasz, T. Alcoholism: A Socio-Ethical Perspective. Washburn Law Journal 6:258–268 (1967): 99; Szasz, T. Ceremonial Chemistry. Garden City, NY: Anchor Press, 1974; Room, R. Drinking and Disease: Comment on “The Alcohologist’s Addiction.” Quarterly Journal of Studies on Alcohol 33:1049–1059 (1972); Peele, S., Brodsky, A. Love and Addiction. New York: Signet, 1976. A few of the more recent works offering alternative or broader views of addiction than the modern alcoholism field include: Peele, S. The Meaning Of Addiction: Compulsive Experience and Its Interpretation. Lexington, MA: Lexington Books, 1985; Room, R. The Cultural Framing of Addiction. Janus Head, 6(2), 221–234 (2003) [Ch. 3 in this volume]; Reinarman, C. Addiction as Accomplishment: The Discursive Construction of Disease. Addiction Research & Theory, 13(4) (2005): 307–320. 94. In the years since this essay was first published a whole field of historical research on temperance, prohibition, and alcohol has grown up. See the rich web site of the Alcohol and Drugs History Society at http://alcoholanddrugshistorysociety. org/. Among the large body of scholarship since

1989 that touches upon themes in this chapter, see Blocker, J. S. American Temperance Movements: Cycles of Reform. Boston: Twane Publishers, 1989; Rumberger, J. J. Profits, Power and Prohibition: Alcohol Reform and the Industrializing of America, 1800–1930. Albany: State University of New York Press, 1989; O’Reilly, E. B. Sobering Tales: Narratives of Alcoholism and Recovery. Amherst: University of Massachusetts Press, 1997. Since 1998, five fine books have been published by Johns Hopkins University Press: Murdock, C. F., Domesticating Drink: Women, Men, and Alcohol in America, 1870–1940 (1998); Crowley, J. W., ed., Drunkard’s Progress: Narratives of Addiction, Despair, and Recovery (1998); Salinger, S. V. Taverns and Drinking in Early America (2004); Tracy, S. W. Alcoholism in America From Reconstruction to Prohibition (2009); Parsons, E. F. Manhood Lost: Fallen Drunkards and Redeeming Women in the Nineteenth-Century United States (2007). Finally, in 2003, three historians released an extraordinary two-volume work synthesizing older research and more than a generation of new historical scholarship on temperance and drink: Blocker, J. S., Fahey, D. M., Tyrell, I.R. Alcohol and Temperance in Modern History: An International Encyclopedia. Santa Barbara: ABC-CLIO, 2003.

CHAPTER 3

The Cultural Framing of Addiction1 Robin Room

This paper is concerned with addiction as a set of ideas that have a history and a cultural location. “Addiction” is used here as a general term to cover a territory for which a number of other terms have been used: notably “alcoholism”; before that, “inebriety,” in the long history of thinking about alcohol; and “dependence,” in current nosologies. We are not concerned here with the truth value of addiction and cognate terms or with their empirical applicability. Thus we are not concerned, for instance, with whether there is really a single entity called “alcoholism” or whether alcoholism is really a disease.2 Instead, the concern is with what is meant when we talk about addiction and with the ways in which this conceptualization of behavior and events may be culturally framed. In this context, I will also consider some of the functions that addiction and related concepts serve in storytelling in the modern era.

ADDICTION AS A HISTORICALLY AND CULTURALLY SPECIFIC CONCEPT In 1978, Harry Levine published his landmark paper on “The Discovery of Addiction.”3 Applying to alcohol an analysis parallel to the analyses by Foucault and Rothman for mental disorders, Levine argued that the idea of addiction emerged at a specific point in history and in a specific cultural context. The time was the early part of the nineteenth century, and the place was the Jacksonian U.S. In colonial America, Levine argued, it was well recognized that certain people liked to drink and that their drinking was often habitual, but these characteristics were not

accorded more significance than other personal preferences or habits; they were not seen as a disease or affliction that could take control of the drinker’s behavior or life. In Levine’s analysis, the new understanding of drinking was very much associated with the newly emerging temperance movement. In turn, the temperance movement emerged as a vehicle for society’s great concern about personal self-control, particularly for adult males. The concept of addiction was thus seen as brought to the foreground in this period by social conditions in the new American republic—by growing population mobility and thus the stretching of extended family ties and the weakening of social support networks for the nuclear family, which objectively made the fortunes of family members more dependent on the self-control of the husband/father. The idea that a concept of addiction in its modern sense first appeared in the early nineteenth century had been foreshadowed in an earlier paper published by Mairi McCormick in 1969. McCormick attributed the shift in framing, to which she gave about the same dating as Levine, to the effects of the industrial revolution: “When we look at fiction about 1830, when the industrial revolution was in full swing, we find that the same drinking may be described as existed 80 years before but that a new and more desperate kind of solitary, tragic and inexplicable drinking has come into existence beside it” (958–59). Levine’s analysis has not gone without challenge. Porter4 and Warner5 have pointed to discussions of habitual intoxication in Europe and North America in earlier centuries in terms

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that prefigure modern addiction concepts. But in my view the main thrust of the analyses by Levine and McCormick holds up, at least in terms of popular conceptions applied by broad sections of the population in everyday life.6 As an accepted way of understanding human behavior, addiction concepts are a phenomenon specifically of the late modern period. If we broaden the frame to a global one and take into account conceptualizations of problems from drinking and drugs in other cultures, again we find good evidence that the concept of addiction is culturally specific. In fact, I have argued that, in the terminology used in considering classifications of disease in a crosscultural perspective, it may be considered a “culture-bound syndrome,” a phenomenon 0. A precondition for addiction concepts: Drug use as able to cause behavior that would not occur otherwise. PHENOMENOLOGY OF ADDICTION 1. Repeated use of a drug as cumulating to a condition causing bad behavior or events: *1a. Continuing use despite health, psychological, or social role problems attributable to repeated drug use 2. Impairment (or loss) of self-control: *2a. Over drug use 2b. Over behavior and life *3. Neglect of other activities for drug use, or misuse of time on drug use. INTERPRETATIVE FRAMES FOR ADDICTION 4. Biological underpinning of the condition; momentum provided by: *4a. Withdrawal, drug use to relieve withdrawal *4b. Tolerance *5. Psychological underpinning of the condition; craving: “a strong desire or sense of compulsion to take the substance.” * These are the six criteria of the dependence syndrome in the ICD-10. Figure 3.1 Elements in the Cultural Framing of Addiction.

that is specific to particular cultures.7 While the term “culture-bound syndrome” has primarily been applied to conceptualizations in non-European societies, in the case of addiction we have a condition that is tied to ways of thinking in European cultures.

ELEMENTS OF ADDICTION, AND THEIR CULTURAL FRAMING Invoking the concept of addiction implies attributing considerable power to the substance involved, to alcohol or another drug. Intoxication with the drug on any particular occasion is seen as potentially causing bad behavior or events that would not occur otherwise (see Figure 3.1). To put this the other way around, when bad things happen, we are willing to contemplate the explanation that they happened because of intoxication with a drug. This causal attribution is a matter of cultural construction. Not all cultures make this kind of causal connection, and choosing drinking or drug use as the significant cause, when typically there are a variety of potentially contributing causes to the bad event or behavior, is a further cultural choice. In a second article, Levine argues that here again there was a shift in American culture at the time of the rise of the temperance movement.8 In the context of that movement, Levine argues, drinking came into focus as a potential explanation of bad events or behavior. Americans came to see alcohol as an exceptionally powerful substance that not only made drinkers clumsy but also made them behave in ways in which they would not wish to behave when sober. Once the connection of drinking or drug use to bad behavior and events is made, this becomes a powerful two-fold argument against drinking or drug use and for the user to give up such use. In its early, optimistic phase, the temperance movement followed this line. Through thousands of temperance pamphlets and novels and innumerable presentations by “experience lecturers” dramatizing the degradations of the drinking life and the rewards of the sober one, the early temperance movement sought to build a sober society by education and example.

THE CULTURAL FRAMING OF ADDICTION

Once the drinker could be taught the error of his ways, he would give up what he must now recognize as harmful behavior. Conceptually, the idea of addiction may be seen as following from the less-than-complete success of this logic. For not all drinkers did reform, despite the harm their drinking could now be seen as causing. The addiction concept emerges as a way of understanding this failure: the failure of the drinker or drug user to behave rationally (from the perspective of the observer), the failure to stop a recurrent pattern of use despite the harm it is seen as causing. As Edwin Lemert put it half a century ago, “in a given society, . . . in order for chronic alcohol addiction or compulsive drinking to develop, there must be strong disapproval of the consequences of drinking or of drinking itself beyond a certain point of intoxication, so that the culture induces guilt and depression over drinking and extreme drunkenness per se.”9 The addiction concept is, then, a term used to describe what is perceived and defined as a mystery:10 the mystery of the drinker or drug user continuing to use despite what is seen as the harm—such as casualties, damage to health, and failures of work and family roles— resulting from use.11 So far I have emphasized the inception of these ideas well over a century ago, but it is worth reemphasizing their vitality today. In the two major current classifications of psychiatric disorders, the International Classification of Diseases, 10th revision (ICD-10),12 and DSMIV, the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association13, alcohol or drug “dependence,” the currently preferred technical term for addiction, is described in terms of a list of criteria, six in ICD-10 and seven in DSM-IV. One of the criteria for dependence in these lists is exactly this circumstance that I have described as the startingpoint for addiction concepts: continued use despite knowledge of harmful consequences of the use (item 1a on Figure 3.1). Closely associated conceptually with this criterion for dependence is the criterion that is at the heart of addiction concepts: the loss of control, or, in recent formulations, impairment of control. For Jellinek, who in the 1950s

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formulated into scholarly language the concept of alcoholism propounded in the fellowship of Alcoholics Anonymous, loss of control was the “pathognomic symptom” of alcoholism.14 In Jellinek, as well as in ICD-10 and other professional discussions, the emphasis is on loss of control over drinking or drug use (item 2a in Figure 3.1). But the first step of the twelve steps of Alcoholics Anonymous acknowledges there is a dual loss of control, not only over one’s drinking, but also over one’s life because of one’s drinking. It is this dual sense that has resonance in American culture in general: not only is the alcohol or drug use behavior seen as in itself out of control—the user is failing to stop or regulate the use despite the problems it is causing—but it is also seen as having taken over the user’s life, so that the recurrent problems themselves also become part of the condition. The ideas that good behavior is a matter of individual self-control, and that the individual is responsible for control of his or her own life, are very much embedded in a particular cultural matrix. They make sense in a culture where individuation and individualism are taken for granted, where each citizen has the right to “life, liberty, and the pursuit of happiness.” The idea of losing control over one’s own life makes less sense in a cultural matrix where social control is more an external than an internalized matter and where individual aspirations and autonomy are subordinated, for instance, to the collective interests of the family. On the other hand, addiction as a loss of control has resonance with ideas that are widespread in other cultures and were well established in earlier periods in European cultures. Addiction can be seen as a secularized and rationalized form of ideas about possession, which had traditionally been thought of in terms of usurpation of a person’s being by an alien spirit, something which entered the afflicted person from the outside and took control of the person’s behavior against his or her will. The continuity between these ways of thinking is suggested, indeed, by the temperance movement’s characterization of alcohol as the “demon rum.” Emerging in a secularizing and rationalistic cultural milieu, addiction

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concepts to some extent filled the ideological gap left by the decline of traditional ideas about possession with a tangible substance— a drug or alcohol—as the alien presence that takes over the afflicted person’s personality and behavior.15 A third criterion for dependence in ICD-10 relates to the use of time: the neglect of alternate activities in favor of drinking or drug use and the amount of time spent seeking, using, or recovering from use of the drug (item 3 in Figure 3.1). This criterion is particularly culture specific. It makes sense as an indicator or component of addiction only in the context of a culture attuned to the clock, a cultural frame in which time is viewed as a commodity that is used or spent rather than simply experienced. Implicit in the criterion is also a set of norms about preferences among activities, with drinking or drug use seen as derogated. For that matter, there is an assumption that desirable activities are alternatives to drinking or drug use, whereas in some cultural contexts most leisure activities involve drinking. So far our focus has been on the elements of addiction that are primarily descriptive of what is to be characterized: repeated behavior despite adverse consequences, the neglect of alternative functions or pleasures in life, the loss of control over oneself that these are seen to entail. The other elements of addiction or dependence in modern characterizations can be seen as built-in assumptive explanations of these characterizations. In a modern, secularized cultural frame, it is not very satisfying simply to describe a pattern of behavior and leave it as a mystery. One direction of explanation has been biological. To classify alcoholism or addiction as a disease puts the affliction into the territory of physicians and health, and in our culture this in itself automatically involves a strong privileging of the biological. There are two primarily biological criteria in current concepts of addiction. One centers on withdrawal symptoms, that is, on the physical and psychological discomforts that often occur when use of a drug is ceased and that can usually be relieved by further use of the drug (item 4a in Figure 3.1). The existence of these withdrawal symptoms

is taken as a criterion for addiction, and the fact that further drug use relieves them offers an explanatory mechanism for understanding why use might continue despite adverse consequences. The extent to which this mechanism has been viewed as an important factor in addiction has varied over time and by drug in American culture. On the one hand, in thinking about heroin, the classic image of the “monkey on the back,” the need for the drug arising out of the fear of going into withdrawal, has often been seen as all that needs to be known to understand addiction. On the other hand, the present-day scientific literature on alcohol tends to assign “taking the hair of the dog that bit you” a rather peripheral role in explaining addictive behavior.16 The other at least apparently biological criterion for addiction is tolerance, that is, that an experienced and habitual user reports needing a stronger dose of the drug to get the same effect as before (item 4b on Figure 3.1). There is no doubt about the existence of the various phenomena lumped together as tolerance, but their meaning as an explanation of addiction is quite unclear. Needing a larger dose to get the effect sought from using the drug does not explain much at all about why the drug use would be continued despite adverse consequences or apparently against the will of the user. In many cultural milieus, having built up a tolerance is a valued rather than a derogated personal attribute. Even in our culture, there are those who would find it peculiar to view as a sign of pathology that a drinker is able to remain upright and decorous even after many drinks or that he or she is able to drink others under the table. The second direction of explanation is psychological. Here the master concept is of a craving or compulsion: the idea that there is something in the mind of the user that compels use, overriding apprehensions of the adverse consequences, the self-control of the user, and often even the user’s will (item 5 in Figure 3.1). We are again back in the territory where other centuries or cultures might invoke ideas of witchcraft or possession by evil spirits to explain what appears to be a compulsion that is not subject to the addict’s control. Not all cultures

THE CULTURAL FRAMING OF ADDICTION

would find congenial the assumption, built into ideas of craving and loss of control, that desires are something distinct from the will.17 As a concept, craving appears to offer an explanation of loss of control over drinking or drug use. But it begs any questions it appears to answer. It is descriptive of what many heavy drinkers or drug users report experientially, but it does not offer any explanation of the experience beyond a label for it. The mystery of addiction is still maintained. The concept of craving simply pushes it one step further back, offering an apparently empirical and secular identification and firmly locating the source of addiction in the mind of the drinker or drug user. Efforts to operationalize it have found the concept elusive.18 In this discussion of addiction, I have taken as my guide to its deconstruction the criteria for dependence or addiction identified in a current authoritative source, the ICD-10. I have tried to give some sense of how strongly addiction and related concepts are framed by the outlook and experiences of American cultures and others like it. In the light of these differences, a group of us did set out in recent years, under World Health Organization auspices, to study the question of the cross-cultural applicability of these concepts empirically in nine societies, chosen to be unlike both in their cultures and in their language groups. We found that there were indeed substantial difficulties in applying the concepts crossculturally.19

FUNCTIONS OF ADDICTION IN AMERICAN STORYTELLING The criteria for the addiction concept do, however, work in American culture, as they have, indeed, to a greater or lesser extent for almost two centuries. It can be argued, in fact, that they are now more central than ever; Stanton Peele, among others, has complained about “the diseasing of America”20: the expansion in recent years of addiction concepts beyond alcohol and other drugs to cover a variety of behavioral and relationship problems. Addiction concepts may have become part of American culture early in the nineteenth century, but they seem to find a special resonance today.

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In general, the depiction of drinking and drug use, and of the phenomena surrounding them, is very widespread in American literature and other cultural products. As symbolically charged behaviors, drinking and drug use serve many functions in telling a story: in setting a context, as indicators of character, as motivators of the plot, and sometimes simply as a technical device for the storyteller.21 Going to get a new drink, in art as in life, is often simply the signal of the end of a conversation. But our focus here is on one aspect of the depiction of drinking and drug use: the depiction of addiction. Addiction, particularly alcohol or drug addiction, is a commonplace in American storytelling. As a thematic emphasis, addiction has a long history. The line of descent, indeed, is unbroken between modern cultural products and the cautionary tales of the temperance movement, with their “drunkard’s progress” to the poorhouse and grave.22 The overarching image of addiction is degradation. Without further explanation, we can expect a character we have been told is an addict to do terrible things because of the addiction. The character will lie, cheat, steal, and indeed betray, maim, or kill, while in the grip of craving or withdrawal and of the addiction. Often these terrible things break the normal expectations of trust in intimate relationships: they are done to parents, lovers, or children. Often the actions are obviously self-defeating: a writer will try to pawn his typewriter (as in the film The Lost Weekend, 1945); an actor will be so drunk he is unable to stay in character on stage (as in the film A Star Is Born, 1954). For the storyteller, then, addiction is an extremely serviceable plot motivator. The most outlandish and outrageous situation, episode, or action can be made believable by portraying one of the characters as an addict. In stories, as in life, the addiction concept offers an apparent explanation of the otherwise inexplicable. Beyond these general functions as a cause of evildoing, addiction also has a more specific place in the storyteller’s armamentarium. The sense of mystery that surrounds addiction as an explanation of bad behavior has not escaped the attention of storytellers. Addiction allows the telling of a gothic tale or horror story in

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what is seen as a naturalistic fashion. There is no need for a clanking impedimentia of ghosts, devils, and zombies, demanding a suspension of disbelief from the audience. Instead, all that is needed to set off the drama is a pill or a draught or even the absence of a pill or a draught. R. L. Stevenson’s Dr. Jekyll and Mr. Hyde is the archetype of this kind of horror story, where the explanation of the transformation into evil incarnate is in naturalistic terms. With its eerie horror music signaling each fit of craving, the film The Lost Weekend set a standard for modern representations of alcoholism as a kind of sporadic possession—a possession that needs no full moons or bat’s blood.23 As a kind of secular possession, addiction also offers a further advantage to the storyteller: it is defined as alien to the “real” character of the afflicted person, and potentially it can be cast off. Except for the addiction, then, an addict can be a basically sympathetic character. Often addiction is presented as something that the character fell into unawares, rather than as a foreseeable outcome of behaviors the character sought out. Once the addiction is present, overcoming it then potentially becomes a test of character and fortitude. In many modern stories, this background provides the raw material for the presentation of an alcoholic or addict as hero. As Marcus Grant notes, the addiction becomes “a credible and readily comprehensible tragic flaw.” The “lowest common denominator” of alcoholics as heroes, Grant continues, “is that they should transcend their alcoholism. Yet, perversely, it is their compulsive drinking which opens the door for them to heroic action.”24 Addiction is, then, both an explanation of failure, indeed of evildoing and also an arena for struggle and triumph. From a storyteller’s point of view, the most satisfying form of this struggle seems to be a lonely battle with interior demons. From The Lost Weekend onward, there has been a strong tendency for stories about alcoholism and addiction to present the eventual victory as a triumph of willpower, achieved by a hero acting alone. This tendency often creates problems of consistency in presentation. At the heart of the addiction concept, as we have discussed, is the idea that craving and

loss of control have proved stronger than the addict’s will. The storyteller faces the problem of presenting an eventual triumph of will in such a way that it does not undercut the representation and explanatory power of addiction in the story. Related to this problem is a problem in real life for those who go through the experience of addiction. For Bill W. and others in Alcoholics Anonymous, the active alcoholic’s besetting delusion is that he or she can control his drinking by willpower, and the first step in recovery is to let go of that illusion and the illusion of selfsufficiency.25 However, AA’s approach is not universal: Much cognitive behavioral therapy and the ideology of groups such as Women for Sobriety emphasize strengthening willpower as a treatment approach.26 Not all American stories of triumph over addiction present it as a lonely battle. Often, instead, there is a little help from friends. In particular for the male addict, in a paradigm that dates back to the nineteenth-century temperance tales,27 there is help from a longsuffering good woman.28 In modern popular psychology, this scenario is seen a good deal more skeptically: the good woman is now defined as “codependent.” On the basis of this archetypal plot, indeed, Anne Wilson Schaef has developed a theory of gender relations in American society as a whole.29 Turning our attention back to the uses of addiction in storytelling, we see the paradigm implies, as Denise Herd has discussed, that addiction fits well into the classic development of the love story. The addiction serves as the impediment that comes between the lovers before their eventual reconciliation, often after they work through the problem together.30 The depiction of addiction in American stories evokes familiar images and is built from materials accessible to participants in the culture. In turn, depictions of addiction in the stories have a teaching function. Addiction as an explanation of behavior at once naturalistic and mysterious; addiction as a cause of degradation and battleground for redemption; addiction as a cause of alienation from social bonds and recovery as a reintegration: Such themes become familiar to anyone who

THE CULTURAL FRAMING OF ADDICTION

watches, listens to, or reads American cultural products. With their worldwide diffusion, these products play a major role in the diffusion of addiction concepts across cultural boundaries. Although addiction emerged as a culture-bound syndrome, we may suspect that the bounds are fast fading.

THE EXPERIENCE OF ADDICTION Let me finish with a caveat. In this discussion I have put addiction and related concepts into a constructivist frame: I have argued that addiction and related concepts make sense only in particular cultural circumstances and that indeed there have been changes in this regard even within a single society, that of the U.S. Let me make clear that my argument does not amount to an attempt to explain away addiction. Nor, in particular, would I want to deny the experience of the many thousands of people in American society and elsewhere who have felt that they could not control their drinking or drug use and thus their lives. For many, addiction and related concepts have both given them a way of understanding their experience and also has been of therapeutic value. To argue that a concept is culturally constructed and framed is not to argue that it is wrong or useless.

NOTES 1. Revised from a paper presented at a conference on Addiction and Culture, Claremont Graduate School, Claremont, California, February 29–March 2, 1996. 2. For an interpretation of sociological thinking on these topics, see: Robin Room, “Sociological Aspects of the Disease Concept of Alcoholism,” pp. 47–91, in R. Smart et al., eds., Research Advances in Alcohol and Drug Problems, vol. 7 (New York & London: Plenum, 1983). 3. Harry Gene Levine, “The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America,” Journal of Studies on Alcohol (1978) 39:143–74. 4. Roy Porter, “The Drinking Man’s Disease: The ‘Pre-history’ of Alcoholism in Georgian Britain,” British Journal of Addiction (1985) 80: 385–96. 5. Jessica Warner, “‘Resolv’d to drink no more’: Addiction as a Preindustrial Concept,” Journal of Studies on Alcohol (1994) 55: 685–91.

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6. See Peter Ferentzy, “From Sin to Disease: Differences and Similarities between Past and Current Conceptions of Chronic Drunkenness.” Contemporary Drug Problems (2001) 28: 363–90. 7. Robin Room, “Dependence and Society,” British Journal of Addiction (1985) 80: 133–39. 8. Harry Gene Levine, “The Good Creature of God and the Demon Rum: Colonial American and 19th Century Ideas about Alcohol, Crime and Accidents,” pp. 111–161, in R. Room and G. Collins, eds., Alcohol and Disinhibition: Nature and Meaning of the Link, NIAAA Research Monograph No. 12. (Washington D.C.: USGPO, 1983). 9. Edwin Lemert, Social Pathology: A Systematic Approach to the Theory of Sociopathic Behavior (New York: McGraw-Hill, 1951). 10. Robin Room, “Bring Back Inebriety?” British Journal of Addiction (1987) 82:1064–68. 11. Robin Room, “The Social Psychology of Drug Dependence,” pp. 69 75, in The Epidemiology of Drug Dependence: Report on a Conference: London, 25–29 September, 1972 (Copenhagen: Regional Office for Europe, World Health Organization). 12. The ICD–10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines (Geneva: World Health Organization, 1992). 13. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV (Washington, DC: American Psychiatric Association, 1994). 14. E. M. Jellinek, “Phases of Alcohol Addiction,” Quarterly Journal of Studies on Alcohol (1952) 13: 673–84. 15. See Robin Room, “Intoxication and Bad Behaviour: Understanding Cultural Differences in the Link,” Social Science and Medicine (2001) 53:189–98. 16. Tim Stockwell, “Alcohol Withdrawal: An Adaptation to Heavy Drinking of No Practical Significance?” Addiction (1994) 89:1447–53. 17. On desire versus will in addiction concepts, see Pertti Alasuutari, Desire and Craving: A Cultural Theory of Alcoholism (Albany: State University of New York Press, 1992). 18. D. Colin Drummond, Raye Z. Litten, Cherry Lowman and Walter A. Hunt, “Craving Research: Future Directions.” Addiction (2000) 95 (Supplement 2): S247–S255. 19. Robin Room, Aleksandar Janca, Linda Bennett, Laura Schmidt and Norman Sartorius, with 15 others, “WHO Cross-Cultural Applicability Research on Diagnosis and Assessment of Substance Use Disorders: An Overview of Methods and Selected Results [with commentaries and a response],” Addiction (1996) 91: 199–30; Laura Schmidt, Robin Room and collaborators, “Cross-Cultural Applicability in International Classifications and Research on Alcohol Dependence,” Journal of Studies on Alcohol (1999) 60: 448–62. 20. Stanton Peele, The Diseasing of America: Addiction out of Control (Lexington, MA and Toronto: Lexington Books, 1989).

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21. Denise Herd and Robin Room, “Alcohol Images in American Film 1909–1960,” Drinking and Drug Practices Surveyor (1982) 18. 22. Mark E. Lender and Karen R. Karnchanapee, “‘Temperance Tales’: Antiliquor Fiction and American Attitudes toward Alcoholics in the Late 19th and Early 20th Centuries,” Journal of Studies on Alcohol (1977) 38: 1347–70. 23. Denise Herd and Robin Room, “Alcohol Images in American Film 1909–1960,” Drinking and Drug Practices Surveyor (1982) 18: 24–35. 24. Marcus Grant, “The Alcoholic as Hero,” pp. 30–36, in Jim Cook and Mike Lewington, eds., Images of Alcoholism (London: British Film Institute and Alcohol Education Centre, 1979). 25. Klaus Mäkelä, Ilkka Arminen, Kim Bloomfield, Irmgard Eisenbach-Stangl, Karin Helmersson Bergmark, Noriko Kurube, Nicoletta Mariolini, Hildigunnur Ólafsdóttir, John H. Peterson, Mary Phillips, Jürgen Rehm, Robin Room, Pia Rosenqvist, Haydée Rosovsky, Kerstin Stenius, Grazyna Swiatkiewicz, Bohdan Woronowicz and Antoni

26.

27.

28.

29. 30.

Zielinski, Alcoholics Anonymous as a MutualHelp Movement: A Study in Eight Societies (Madison: University of Wisconsin Press, 1996). Keith Humphreys and Lee Ann Kaskutas, “World Views of Alcoholics Anonymous, Women for Sobriety, and Adult Children of Alcoholics/AlAnon Mutual Help Groups,” Addiction Research (1995) 3: 231–243. Joan Silverman, “I’ll Never Touch Another Drop”: Images of Alcoholism and Temperance in American Popular Culture 1874–1919 (Ph.D. dissertation, New York University, 1979). Robin Room, “Alcoholism and Alcoholics Anonymous in U.S. films, 1945–1962: The Party Ends for the ‘Wet Generations’,” Journal of Studies on Alcohol (1989) 50: 368–83. Anne Wilson Schaef, When Society Becomes an Addict (San Francisco: Harper and Row, 1987). Denise Herd, “Ideology, Melodrama, and the Changing Role of Alcohol Problems in American Films,” Contemporary Drug Problems (1986) 13: 213–47.

CHAPTER 4

Deviant Drinking as Disease Alcoholism as a Social Accomplishment Joseph W. Schneider This chapter presents a brief social history of the idea that certain kinds of deviant drinking behavior should be identified by the label “disease.” I define the claim that such behavior is a disease as a social and political construction, warranting study in its own right (Berger and Luckmann, 1966; MacAndrew, 1969; Mulford, 1969; Freidson, 1970; Spector and Kitsuse, 1977). Whether such drinking “really” is a disease and, as such, what its causes might be, are not at issue. The analysis will trace the connection between ideas and social structures that appear to support or “own” them (Gusfield, 1975). This study is an investigation of the social bases of an assertion about a drinking behavior. More generally, this discussion is a case example of the medicalization of deviance and social control (Pitts, 1968, Szasz, 1970; Freidson, 1970: 244–277; Kittrie, 1971; Zola, 1972; Conrad, 1976) wherein a form of nonnormative behavior is labelled first a “sin,” then a “crime,” and finally a “sickness.”1

CLARIFICATION OF THE PROBLEM To those who treat problems caused by alcohol, debates about the definition of alcoholism as a disease are tedious and academic. After all, if one is employed in a hospital clinic treating alcoholics, then alcoholism must be a disease. However, whether something is a disease depends on significant portions of the medical community accepting the definition or not opposing its use by those in other fields. Because physicians represent the dominant healing profession in most

industrialized societies, they have control over the use of the labels “sickness,” “illness,” and “disease,” even if they are sometimes unable to treat those conditions effectively (Freidson, 1970: 251). As such, these designations become political rather than scientific achievements (Spector and Kitsuse, 1977). Zola (1972) captures the expansive quality of medical jurisdiction clearly: My contention is that if anything can be shown in some way to effect the inner workings of the body and to a lesser extent the mind, then it can be labelled an “illness” or jurisdictionally a “medical problem.”

This becomes particularly likely when the effects Zola describes are defined as negative rather than positive. The label “sick,” although free from the opprobrium and implied culpability of “criminal,” nevertheless involves a clearly disvalued moral condition, a deviation from “health, and a threat to the on-going network of interaction” (Parsons, 1951). This common moral dimension provides the foundation for the historical shift from one system of social control (the church and state) increasingly to another (science and medicine). I focus on the idea that a particular pattern of repetitive, usually heavy, and always consequential drinking behavior should, of itself, be considered an instance of disease.2 I am concerned with the assertion that there is a disease called alcoholism that is identifiable independent of the specification of any conditions believed to be causes or effects of it.

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COLONIAL FOUNDATIONS AND ORIGINS OF THE DISEASE CONCEPT Drinking in seventeenth and eighteenth century America was normative, and although disapproved, drunkenness was far from rare (Lender, 1973 Levine, 1978; Paredes, 1976; Keller, 1976b). If anything was “bad” about drinking it was not drink itself, which even prominent clergy called a “good creature of God.” Churches and drinking houses, as social centers of the community, were often close together. Concern about public drunkenness was expressed by a small few scholarly, aristocratic church leaders who warned against the sin of drunken excess, sometimes attributed to the work of the Devil. Punishment was initially a clerical admonition, followed by the extreme sanction of suspension, and finally by excommunication as the ultimate, although probably infrequently used, religious control. Civil authorities affirmed the church’s judgment and meted out various forms of public degradation: fines, ostracism, whippings, and imprisonment (Lender, 1973). The colonists, like their ancestors and descendants, distinguished between being drunk and habitual drunkenness. The latter not only made the drinker a public spectacle but had deleterious effects on health, family, and the larger community. Historically, it is this puzzling—and apparently irrational—pattern of repeated, highly consequential drinking that calls for an explanation (MacAndrew, 1969). The proposed solution reflects the interests and ideologies of the time as well as the “world views” of specialists charged with providing such answers (Holzner, 1968: 122– 162). The religious heritage of the colonies defined such behavior as due to the drinker’s will, freely operating in terms of a rational, hedonistic calculus. This kind of drinking, if repeated was often taken as an indicator of moral degeneration. The “ownership” of the problem of drunkenness during this period fell to leading clergy and civil authorities, joined occasionally by prominent citizens concerned about the use of spirituous liquors among workers, farmhands, and other persons of lesser station.

The idea that extended drunkenness might be the joint result of the drink and qualities of the drinker that might be beyond his control was first synthesized by the highly respected physician Benjamin Rush in his An Inquiry of the Effects of Ardent Spirits Upon the Human Body and Mind, published originally in 1784 (Levine, 1978; Wilkerson, 1966: 42–50). Rush studied the bodily effects of various forms of alcoholic drink and provided what is probably the first systematic, clinical picture of intoxication. Most significant in Rush’s description of inebriety was the connection between drinker and drink defined as an “addiction” to distilled liquors. He believed the disease developed gradually and was progressive, ultimately producing a “loss of control” over drinking. He called inebriety a “disease of the will,” assuming that one’s will and desire were independent of each other and that the former became weakened and ultimately debilitated by excessive drink. The first step in treatment was abstinence from alcohol. Although Rush did not specify the mechanisms by which this disease of the will developed, his ideas provided an alternative to the traditional morality of the church. In trying to solve the puzzle of habitual drunkenness, some physicians began to employ science as a framework in which new solutions might be found. They avoided the traditional description of the drinker’s “love” of drink and supplied new terms, such as “craving” and “insatiable desire,” to describe the link between the individual and alcohol. Important for questions of individual responsibility, this conceptualization implied that since such persons are not willful in their chronic drunkenness, punishment is not an appropriate strategy of control. Treatment and therapy, allegedly employed in the individual’s and the community’s interest, became the “reasonable” and humanitarian solution. The historical trend whereby persons deemed incapable of willful criminal or wrong intent have been subjected to “treatment” rather than punishment has been called the “divestment” of the criminal justice system and the rise of the “therapeutic state” (Kittrie, 1971; Szasz, 1970). Rush’s concept of alcohol addiction represents the beginning of this divestment

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process for habitual deviant drinking behavior in America.

THE DISEASE CONCEPT AND THE AMERICAN TEMPERANCE MOVEMENT Rush and his fellow “temperance physicians” provided two themes that became particularly important in the nineteenth-century temperance movement. First, they established that alcohol causes both deviant physiology and deviant behavior. Their descriptions became grist for the temperance mill. Facing arguments on both physical and social grounds, the “social drinker” found it more difficult to resist the temperance call. The second theme was the statement that inebriety is a disease, which quickly became a slogan of the movement (Levine, 1978). The plausibility of Rush’s interpretation depended on the decline of the philosophy of free will and the rise of the idea that one’s behavior could be determined by forces beyond one’s control; that one’s will and desire were distinct (Levine, 1978). Demonic possession was an unacceptable solution. The apparently irrational nature of repetitive drunkenness remained a puzzle. However, science slowly provided some solutions. Although crude by contemporary standards, medical explanations referred to natural laws in an “objective,” non-mystical fashion. Loss of control was increasingly assumed to be the result of an unknown but natural disease process, an idea that supplied at least the borders of the habitual drunkenness puzzle. Such a characterization allowed temperance leaders to draw on a cultural universal. Disease, however defined, is undesirable. It should be opposed, controlled, and if possible, eradicated, and by logical extension, so should all known or suspected causes of disease. The physicians who called inebriety a disease provided the movement with an evil more pervasive than sin itself. Rush’s prescription of abstinence was also turned to use as “the” temperance solution for any problem drinking. An important consequence of the use, politically, of the disease concept was that the idea was not examined as

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an intellectual or scientific claim during most of the nineteenth century. As a moral slogan it allowed advocates both to pity the sick inebriate who required treatment and to rail against “Demon Rum” and even moderate drinking as something that demanded control. An intellectually noteworthy but politically inconsequential exception did occur toward the end of the century. Trying to succeed where traditional institutions such as prisons and mental asylums had failed, a small group of physicians founded the inebriate asylum: a special place to provide physical and moral care to regenerate inebriates’s diseased wills. The first was opened in Binghamton, New York, in 1867, although the Washingtonian Home for inebriates in Boston had begun operation about two decades before. By 1900, there were more than fifty such institutions operating in the U.S. (Wilkerson, 1966: 142–151). They were regarded skeptically both by the temperance movement and the medical community; the general public was even more hostile because of the use of public monies (Jellinek, 1960). It was not until 1872, when the superintendent physicians formed an association to study and combat the problem of inebriety as a disease caused by sinful indulgence, that the National Temperance Society issued its reserved endorsement: The Temperance press has always regarded drunkenness as a sin and a disease—a sin first, then a disease; and we rejoice that the Inebriate Association are now substantially on the same platform. (Quoted in Levine, 1978)

The physician-superintendents and a number of interested colleagues, mostly psychiatrists, began to publish a journal devoted to the belief that inebriety is a disease. The Journal of Inebriety was first published in 1876, and continued, on a precarious basis, until 1914. Its approach was distinctly psychiatric. It reinforced the idea that inebriety was a special kind of mental illness. Neither the Journal nor the association received the support of the psychiatric community or medical profession. Although one explanation of this reception might be the poor quality of research reported in the journal, it is

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more insightful to consider: the relatively low status of psychiatry in American medicine; the moral stigma attached to working with and in support of inebriates; the political controversy surrounding the inebriate hospitals coupled with the weak position of the medical profession in the public consciousness. Regardless of the scientific quality of the disease-advocates’ work, these conditions would preclude professional and popular support.

THE POST-PROHIBITION REDISCOVERY: THE YALE CENTER, ALCOHOLICS ANONYMOUS, AND THE JELLINEK MODEL As Gusfield (1975) has suggested, there was virtually no organized interest in the disease concept from the end of the nineteenth century until after prohibition. There was considerable interest, however, in science and the professionalization of scientific research in American universities (Ben-David, 1971: 139–168). As the moral crusade against alcohol waned, science and scientific work became established. This trend had a great impact on the solutions Americans would pose for a variety of problems. It was not likely that alcohol, popular and again legal after 1933, would be seen as the source of deviant drinking. Intoxication and drunkenness, when requiring control, were problems assigned to civil authorities or the state. But with the rise and achievements of science, the apparent irrationality of chronic drunkenness became a more intriguing and less tolerable mystery. In this context even more than during Rush’s time, science and medicine seemed to hold promise. Three developments, all beginning within a decade after repeal, provided the foundation on which a “new” conceptualization of chronic deviant drinking was to rise in the twentieth century: the Yale research center; the self-help group, Alcoholics Anonymous; and a more careful, largely non-psychiatric, specification of the claim “alcoholism is a disease,” referred to here as the Jellinek model. These developments provided the moral and political foundation for the subsequent rise

of the more than two hundred million dollar federal bureaucracy, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and an “alcoholism industry” (Trice and Roman, 1972: 11–12) of professional and other workers devoted to treating this disease.

The Yale Research Center The major body coordinating support for scientific work in the mid-1930s was the Research Council on Problems of Alcohol, organized shortly after repeal (Keller, 1976a). This council was composed disproportionately of physicians and natural scientists interested in finding the causes of alcoholism. One member of the committee was Howard Haggard, the physician-director of the Laboratory of Applied Physiology at Yale University. Although the Council was unsuccessful in raising substantial monies for alcohol research, the prominence of its members gave the work scientific respectability. One grant, however, was consequential. It was for a review of the literature on the biological effects of alcohol on humans. The Council called on E. M. Jellinek, who had been doing research on neuroendocrine schizophrenia, to administer the project. Haggard and his colleagues at the Yale Laboratory were involved in alcohol metabolism and nutritional research, a study which was gaining attention through the journal he founded in 1940, The Quarterly Journal of Studies on Alcohol.3 As this work became more interdisciplinary within the natural sciences, Haggard came to believe that adequate study required an even more comprehensive approach. He invited E.M. Jellinek to Yale where he became the director of a truly multidisciplinary Yale Center for Alcohol Studies. The Center, the Laboratory, and the Journal became the core of American research on alcohol.4 One of the Center’s most significant contributions to the idea that alcoholism is a disease was its Summer School program, begun in 1943. These annual sessions were educational programs for concerned citizens from around the country who were involved in policy formation

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in their local communities. A common concern was what to do about alcoholism and alcohol-related problems. Straus (1976) and Chafetz and Demone (1962) suggest that the slogan “alcoholism is a disease” was introduced intentionally by Center staff in an attempt to reorient local and state policy and thinking about “alcoholics.” These summer sessions were a good opportunity to disseminate the idea and point out its moral and political implications for treatment and cure. Although only a small segment of the summer program was devoted to the disease question, it soon became a topic of interest among the lay audience. Critics of this idea (Seeley, 1962; Pattison, 1969; Room, 1972; Robinson, 1976) suggest that its appeal must be seen in historical perspective and should be understood in terms of its practical, humanitarian, and administrative consequences rather than on the basis of scientific merit.5 These sessions also provided an established organizational foundation for the rise of the National Council on Alcoholism, the leading voluntary association in the U.S. devoted to public education about the disease (Chafetz and Demone, 1962; Paredes, 1976). The National Council, known initially as the National Committee for Education on Alcoholism, was established in 1944 by three women: a former alcoholic, a journalist, and a psychiatrist. Mrs. Marty Mann, a one-time member of Alcoholics Anonymous, saw the National Committee as supplementing the work of A.A. for public education against ignorance about alcoholism’s disease status. In the spring of 1944, these women met with Jellinek and determined that the National Committee “plan” be introduced in the Yale Summer School program. Although the National Council become organizationally independent of the Yale Center in 1950, the association was propitious for the disease concept, as suggested by Chaftez and Demone (1962: 142): NCA then began to search for a formula, something which would translate the basic facts of alcoholism into easily understood and remembered phrases. This resulted in the well known concepts or credo: Alcoholism is a disease and the alcoholic a sick person. The alcoholic can be

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helped and is worth helping. This is a public health problem and therefore a public responsibility.

Alcoholics Anonymous In 1935 Alcoholics Anonymous was founded by two men, one of whom was a physician. Another physician, Dr. W. D. Silkworth, suggested to these founders the idea that alcoholism is an allergy of the body, the result of a physiological reaction to alcohol (Jellinek, 1960: 160). Although medical opinion was generally skeptical of this questionable formulation (Jellinek, 1960: 86–88), the concept of alcoholism as a mark of physiological sensitivity rather than moral decay was appealing and the allergy concept came to occupy a central although implicit place in A.A. ideology. This theory had an additional advantage over other versions of the disease concept common during the early decades of the century that suggested alcoholism was a mental illness, a notion opposed strongly by A.A. (Trice and Roman, 1970). The appeal of allergy rests precisely in its identity as a bona fide medical or “disease” condition; people with allergies are victimized by, not responsible for, their condition. Trice and Roman (1970) suggest that much of the apparent success of A.A. involves the process of removing a stigmatized label and replacing it with a socially acceptable identity, such as “sick,” “repentant,” “recovered,” or “controlled.” Two themes relevant to A.A.’s implicit disease concept are found in the first and third of the famous “Twelve Steps” to recovery, printed originally in Alcoholics Anonymous (1939). The first and most important step is, “We admitted we were powerless over alcohol—that our lives had become unmanageable.” This is precisely the concept of “loss of control,” a key idea in the early writing on alcoholism as a disease. Step three is “(We) have made a decision to turn our will and our lives over to the care of God as we understood him.” Representatives of A.A. are quick to note that although this language sounds traditionally religious, such terms are to be interpreted broadly and on the basis of the individual’s own biography. In discussing

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the interpretation of step three, Norris (1976) says: This turning over of self direction is akin perhaps to the acceptance of a regimen prescribed by a physician for a disease. The decision is made to accept reality, to stop trying to run things, and to let the “Power greater than ourselves” take over.

This partial description of the role of A.A. recalls Parsons’s (1951) discussion of the sick role. Norris’s suggestion that “God” might be interpreted to be a physician is perhaps not an extreme exaggeration given a doctor’s control over the legitimacy of sickness and disease designations and admission to treatment. The success attributed to the A.A. program in helping drinkers “recover” from alcoholism has become part of popular wisdom and is largely unchallenged, despite the lack of systematic empirical evidence. The effect of A.A. programs and ideology on thinking about alcoholism has been humanitarian and educational. The generally high regard for the program throughout the country serves to reinforce the disease concept implied in its approach. This pattern of regard is evidenced by recent research showing that a majority of physicians who agreed that alcoholism is a disease felt that referring such cases to A.A. was the best professional strategy ( Jones and Helrich, 1972).

The Jellinek Model The Yale Center and Alcoholics Anonymous provided important structural vehicles for the spread and popularization of the disease definition. Without the research and writing of Jellinek, and later Mark Keller (neither of whom, incidentally, are physicians), this idea would probably have remained largely undeveloped. By comparison with previous efforts, Jellinek’s work on the disease concept was brilliant and stimulated further research and writing. His reputation as a medical researcher, coupled with his being the director of the Yale Center, established his work as worthy of serious consideration. In a series of articles beginning shortly after his arrival in New Haven and subsequently

in a comprehensive manuscript, The Disease Concept of Alcoholism (1960), Jellinek (1941, 1946, 1952) set out his understanding of what it meant to call alcoholism a disease. In the early paper with psychiatrist Bowman (1941) as first author, Jellinek raised the question of alcoholism as an addiction. Using data obtained from a questionnaire in an issue of the A.A., Grapevine, he constructed his well-known phase progression of the disease ( Jellinek, 1946). A revision and extension was published in 1952 titled “The Phases of Alcohol Addiction,” which appeared initially under the auspices of the Alcoholism Subcommittee of the World Health Organization, of which Jellinek was a member. Five phases of the progressive disease of alcohol addiction6 were presented in terms of characteristic drinking and drinking-related behaviors. A major purpose of this paper, beyond presenting the phase progression, was to resurrect and clarify a distinction central to the disease concept. Drinking behavior that results in problems of living, or problem drinking, while important in its own right, was to be kept quite distinct from drinking behavior indicative of disease.7 Such a distinction is important for the viability of the disease view: first because it serves to define the boundaries within which medicine could (and should, according to Jellinek) operate; second, because it suggests that forms of deviant drinking not properly called disease should be “managed only on the level of applied sociology, including law enforcement” (Jellinek, 1952). Non-disease forms of drinking behavior are here defined as moral problems to be met on moral terms; disease forms are, by contrast, medical problems and deserve the attention and treatment of the medical profession. Without defining alcoholism, Jellinek proposes two subcategories of this larger entity: “alcohol addicts” and “habitual symptomatic excessive drinkers.” Although both types have “underlying psychological or social pathology” that leads to drinking, only the former, after a number of years, develops a “loss of control,” becomes addicted to alcohol, and is therefore diseased. “Loss of control” as the distinction between the disease and non-disease types of alcoholism is elaborated in Jellinek’s major work, The

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Disease Concept of Alcoholism (1960), which provides an exhaustive review of relevant research and a clearer description of the kinds of behaviors typically called “alcoholism.” Using Greek letters to designate distinct types, Jellinek describes four major categories: Alpha, Beta, Gamma, and Delta (1960: 36–39). The first two, Alpha and Beta, are not distinct disease entities: Alpha is the symptomatic drinking discussed in the 1952 essay; Beta refers specifically to all physical disease conditions resulting from prolonged substantial drinking, for example, polyneuropathy, gastritis, and cirrhosis of the liver. Only the Gamma and Delta types qualify as disease entities and are defined by four key elements, three of which are unambiguously physiological and common to both: (1) acquired increased tissue tolerance to alcohol, (2) adaptive cell metabolism, and (3) withdrawal symptoms. These three conditions lead to “craving” or physical dependence on alcohol. In addition, Gamma alcoholics lose control over how much they drink, which involves a progression from psychological to physiological dependence. Jellinek identified this type as most typical of the U.S.; as causing the greatest personal and social damage; and as the type of alcoholism recognized by Alcoholics Anonymous. The Delta alcoholic differs from Gamma in losing control not over quantity of intake, but rather over the ability to abstain for a significant period. As a result, this type of alcoholic, while suffering from the disease of alcoholism, rarely experiences the devastating consequences of the Gamma type. Jellinek suggests that the Delta drinking pattern is characteristic in certain European countries, particularly France. Although the disease is seen as a product of drinking, in neither case are the initial causes important in identifying the disease itself. Jellinek’s explicit development of addiction as the defining quality of the disease was a necessary condition for the contemporary medicalization of deviant drinking. Although addiction is itself not a particularly precise concept (see Coleman (1976) and Grinspoon and Bakalar (1976: 177–178) for recent critiques), its contemporary association with narcotics and their physiological effects renders it a medicalized condition. Use of the term serves

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to locate the above forms of alcoholism in the body,8 thus identifying them as legitimate problems for medical attention and intervention. Medicine reluctantly assumed responsibility. In 1956, The American Medical Association’s Committee on Alcoholism (The American Medical Association, 1956) issued its well-known statement encouraging medical personnel and institutions to accept persons presenting the syndrome of alcoholism defined by excessive drinking and “certain signs and symptoms of behavioral, personality, and physical disorder.” A key sentence in the statement asserts: The Council on Mental Health, its Committee on Alcoholism, and the profession in general recognizes this syndrome of alcoholism as illness which justifiably should have the attention of physicians. (A.M.A., 1956:750)

State and local medical societies soon created their own committees on alcoholism based on this reaffirmation of an idea that had already achieved a certain degree of official recognition. Keller (1976a) notes that “Alcohol Addiction” and “Alcoholism” were included in the first volume of the Standard Classified Nomenclature of Disease issued by the National Conference on Nomenclature of Disease in 1933 and approved by the American Medical Association. The significance of the 1956 statement was to reiterate this and other previous definitions. Regardless of how many American physicians agreed with the A.M.A. statement, the formal re-endorsement of the idea that alcoholics fall properly within medical jurisdiction became compelling “evidence” in support of the disease concept.9 In this context, Jellinek’s (1960: 12) comments on whether his Gamma and Delta types are “really” diseases are instructive: Physicians know what belongs in their realm. . . . a disease is what the medical profession recognizes as such. . . . the medical profession has officially accepted alcoholism as an illness, whether a part of the public likes it or not, and even if a minority of the medical profession is disinclined to accept the idea.

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Almost impatiently, the concept’s leading proponent argues that diseases are what physicians say they are and since physicians, as represented by their major professional organization, have said so, alcoholism is a disease and that should settle the matter! Since Jellinek’s death in 1963, the leading spokesman for the disease concept has been Mark Keller, longtime colleague of Jellinek at the Yale Center and editor of the Journal of Studies on Alcohol, a position he has held since its inception in 1940.10 In two early essays, Keller (1958, 1962) attempted to develop a definition of alcoholism consistent with the disease view but useful also in epidemiological and survey research. In the first essay, he defines alcoholism as a “chronic behavioral disorder” in which repeated drinking exceeds “dietary and social uses of the community” and causes harm to the drinker’s health and social and economic functioning. The two key and familiar elements are that the drinking is deviant and causes harm. Although ambiguous on the question of disease, Keller agrees with Jellinek’s position that persons apparently addicted to alcohol suffer from the disease of alcoholism. In a subsequent essay, Keller (1962) provides a “medical definition” of alcoholism as a “psychogenic dependence on or a physiological addiction to” alcohol, the defining characteristic of which is “loss of control.” He translates the latter idea in behavioral terms: “Whenever an alcoholic starts to drink it is not certain that he will be able to stop at will.” In an attempt to show the links between harm due to drinking, loss of control, and the existence of disease, Keller gives revealing insight into the intellectual core of the idea that chronic drunkenness is a disease: The key criterion, for all ill effects, is this: Would the individual be expected to reduce his drinking (or give it up) in order to avoid the injury or its continuance? If the answer is yes and he does not do so, it is assumed—admitting it is only an assumption—that he cannot, hence that he has “lost control over drinking,” that he is addicted to or dependent on alcohol. This inference is the heart of the matter. Without evident or at least reasonably inferred loss of control, there is no foundation for the claim that “alcoholism is a

disease,” except in the medical dictionary sense of diseases . . . caused by alcohol poisoning. (Keller, 1962)

In order to extend the research use of the disease concept, Keller applies canons of reason and medicine to the behavioral puzzle of repeated, highly consequential drinking: (1) If one drinks in an excessive, deviant manner, (2) so as to bring deprivation and harm to self and others (3) while remaining impervious to pleas and admonitions based on this “obvious” connection, (4) the person is assumed not to be in control of his or her will (regardless of desire); (5) such lack of control is then “explained” by the medical concept disease and the medicalized concept addiction, inherent in which is the presumption of limited or diminished responsibility. Resting on the inference of loss of control in a cultural system in which values of rationality, personal control, science, and medicine are given prominence, the assertion that alcoholism is a disease becomes an affirmation of dominant cultural and institutional values on which empirical data are never brought to bear. Indeed, it is precisely this quality of the question that holds the key to its viability as well as its controversy: it is a statement not for scientific scrutiny but for political debate.

CONCLUSIONS The purpose of this paper has been to develop a social historical overview of the major structural and cultural supports of the idea that certain forms of deviant drinking behavior should be considered as instances of disease. I have not attempted to defend the empirical validity of this idea. Indeed, such an attempt would produce a tautological discussion. The question of whether or not a given condition constitutes a disease involves issues of politics and ideology—questions of definition, not fact. The disease concept of alcoholism has a long history in America and has been supported both by medical and non-medical people and organizations for a wide variety of reasons. That certain forms of deviant drinking are now or have been for more than one hundred and fifty years medicalized is not due to a medical

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“hegemony,” but reflects the interests of the several groups and organizations assuming, or being given, responsibility for behaviors associated with chronic drunkenness in the U.S. The disease concept owes its life to these variously interested parties, rather than to substantive scientific findings. As such, the disease concept of alcoholism is primarily a social rather than a scientific or medical accomplishment.

NOTES 1. The medicalization of a variety of forms of deviance and social control is discussed in Conrad and Schneider (1980), which contains a considerably expanded version of this chapter. 2. Seldon Bacon (1976) has pointed out to me that the recent controversy over alcohol use among pregnant women attests to the political nature of even these “obvious” medical questions. 3. This journal, which in 1975 became The Journal of Studies on Alcohol and is issued monthly, is perhaps the key international publication on alcohol research, its tenure of continuous publication being second only to the British Journal of Addiction, which began in 1892 as The British Journal of Inebriety. 4. In 1962 the Yale Center was moved to Rutgers— the State University, where it remains one of the most prestigious of the few such centers in the world. Straus (1976) provides some insight into the social and political history leading to this move. He suggests that the wide publicity the Yale Center received was an embarrassment to the University because of the substance of the Center’s work, and that its interdisciplinary quality was perceived as inappropriate in the context of the traditional departmental structure of the University. 5. Trice and Roman (1968) suggest some unintended consequences of adopting the sick role that may serve to perpetuate and perhaps reinforce the individual’s self-definition as one who cannot control his or her drinking. 6. Jellinek called these phases the prealcoholic symptomatic phase, the prodromal phase, the crucial phase (wherein loss of control develops), and the chronic phase. The retrospective “discovery” of these phases is not unlike similar discovery processes discussed recently for hyperactivity (Conrad, 1976) and child abuse (Pfohl, 1977). Analysis of such diagnostic categories from a sociology of knowledge perspective suggests that they represent a particular organization of information that serves or reinforces values, assumptions, or beliefs held by the discoverers. Using disease as his guiding assumption, Jellinek decidedly increased the probability of “discovering” phase movement and progression, given the processural, temporal imagery that this concept conveys (Fabrega, 1972; Room, 1974).

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7. Recent research by Cahalan and Room (1974) on problem drinking among American men suggests the importance of distinctions between “problem drinkers” and “alcoholics” to be less than once thought and perhaps misleading in terms of the typical history of drinking problems. This and previous research (Trice and Wahl, 1958) also questions the popular notice of the inevitable progression of alcoholism. For a thorough, critical review of these and other disease propositions, see Pattison, et al. (1977). 8. The medicalization of deviance does not depend solely on the presence of physiological dimensions. Other conditions, such as the availability of relevant and efficacious technology, moral and ethical considerations, and a supportive political context, must be considered (see Conrad, 1976:92–100, for a preliminary discussion). 9. Fingarette (1970) discusses the impact of the disease concept of alcoholism in the law and in key U.S. Supreme Court rulings based thereon. 10. Keller subsequently assumed the position of editor emeritus for the Journal.

REFERENCES Alcoholics Anonymous 1939 Alcoholics Anonymous. New York: A.A. World Services. The American Medical Association 1956 “Report of the board of trustees: Hospitalization of patients with alcoholism.” Journal of the American Medical Association 162(October 20):750 Bacon, Selden D. 1976 “Concepts.” Pp. 57–134 in W. Filstead, J. Rossi, M. Keller (eds), Alcohol and Alcohol Problems. Cambridge, M.A.: Ballinger. Ben-David, Joseph 1971 The Scientist’s Role in Society. Englewood Cliffs, N.J.: Prentice-Hall. Berger, Peter L., and Thomas Luckmann 1966 The Social Construction of Reality. Garden City, N.Y.: Anchor. Bowman, K.M., and E.M. Jellinek 1941 “Alcohol addiction and chronic alcoholism.” Quarterly Journal of Studies on Alcohol 2:98–176. Cahalan, Don, and Robin Room 1974 Problem Drinking Among American Men: A Monograph. New Brunswick, N.J.: Rutgers Center for Alcohol Studies. Chafetz, Morris E., and Harold W. Demone, Jr. 1962 Alcoholism and Society. New York: Oxford University Press. Coleman, James W. 1976 “The myth of addiction.” Journal of Drug Issues 6(Spring):135–141. Conrad, Peter 1976 Identifying Hyperactive Children: The Medicalization of Deviant Behavior. Lexington, M.A.: D.C. Heath.

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Conrad, Peter and Joseph W. Schneider 1980 Deviance and Medicalization: From Badness to Sickness. St. Louis, M.O.: C.V. Mosby. Fabrega, Horacio Jr. 1972 “Concepts of disease: Logical features and social implications.” Perspectives in Biology and Medicine 15(Summer):583–616. Fingarette, Herbert 1970 “The perils of Powell: In search of a factual foundation for the ‘disease concept of alcoholism.’ ” Harvard Law Review 83:793–812. Freidson, Eliot 1970 The Profession of Medicine. New York: Dodd, Mead. Grinspoon, Lester, and James B. Bakalar 1976 Cocaine. New York: Basic Books. Gusfield, Joseph 1975 “Categories of ownership and responsibility in social issues: alcohol use and automobile use.” Journal of Drug Issues 5(Fall):285–303. Holzner, Burkart 1972 Reality Construction in Society. Revised Edition. Cambridge, M.A.: Schenkman. Jellinek, E. M. 1946 “Phases in the drinking history of alcoholics.” Quarterly Journal of Studies on Alcohol 7:1–88. Jellinek, E. M. 1952 “Phases of alcohol addiction.” Quarterly Journal of Studies on Alcohol 13:673–684. Jellinek, E. M. 1960 The Disease Concept of Alcoholism. Highland Park, N.J.: Hillhouse. Jones, R. W., and A. R. Helrich 1972 “Treatment of alcoholism by physicians in private practice: a national survey.” Quarterly Journal of Studies on Alcohol 33:117–131. Keller, Mark 1958 “Alcoholism: nature and extent of the problem.” The Annals of the American Academy of Political and Social Science 315:1–11. Keller, Mark 1962 “The definition of alcoholism and the estimation of its prevalence.” Pp. 310– 329 in D. J. Pittman and C. R. Snyder (eds), Society, Culture and Drinking Patterns. New York: Wiley. Keller, Mark 1976a “The disease concept of alcoholism revisited.” Journal of Studies on Alcohol 37(September):1694–1717. Keller, Mark 1976b “Problems with alcohol: An historical perspective.” Pp. 5–28 in W. Filstead, J. Rossi, M. Keller (eds.), Alcohol and Alcohol Problems. Cambridge, M.A.: Ballinger.

Kittrie, Nicholas 1971 The Right to be Different. Baltimore, M.A.: Johns Hopkins Press. Lender, Mark 1973 “Drunkenness as an offense in early New England: A study of Puritan attitudes.” Quarterly Journal of Studies on Alcohol 34:353–366. Levine, Harry Gene 1978 “The discovery of addiction: Changing conceptions of habitual drunkenness in America.” Journal of Studies on Alcohol 39 (January):143–174. MacAndrew, Craig 1969 “On the notion that certain persons who are given to frequent drunkenness suffer from a disease called alcoholism.” Pp. 483–501 in S. C. Plog and R. B. Edgerton (eds.), Changing Perspectives in Mental Illness. New York: Holt, Rinehart and Winston. Mulford, Harold 1969 “Alcoholics,” “Alcoholism,” and “Problem Drinkers”: Social Objects in the Making. Washington, D.C.: National Center for Health Statistics, Department of Health, Education and Welfare. National Conference on Nomenclature of Disease 1933 A Standard Classified Nomenclaure of Disease. H.B. Logie (ed.) New York: Commonwealth Fund. Norris, John L. 1976 “Alcoholics anonymous and other self-help groups.” Pp. 735–776 in R. Tarter and A. Sugerman (eds.), Alcoholism. Reading, M.A.: Addison-Wesley. Paredes, Alfonso 1976 “The history of the concept of alcoholism.” Pp. 9–52 in R. Tarter and A. Sugerman (eds.), Alcoholism. Reading, M.A.: Addison-Wesley. Parsons, Talcott 1951 The Social System. New York: The Free Press. Pattison, E. M. 1969 “Comment on the alcoholic game.” Quarterly Journal of Studies on Alcohol 30:953. Pattison, E. M., Mark Sobell, and Linda Sobell 1977 Emerging Concepts of Alcohol Dependence. New York: Springer. Pfohl, Stephen J. 1977 “The ‘discovery’ of child abuse.” Social Problems 24(February):310–323. Pitts, Jesse 1968 “Social control: the concept.” International Encyclopedia of the Social Sciences. no. 14. New York: Macmillan. Robinson, David 1976 From Drinking to Alcoholism: A Sociological Commentary. New York: Wiley. Roman, Paul M., and H. M. Trice 1968 “The sick role, labelling theory, and the deviant drinker.”

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International Journal of Social Psychiatry 14:245–251. Room, Robin 1972 “Drinking and disease: Comment on ‘the alcohologist’s addiction’.” Quarterly Journal of Studies on Alcohol 33(December):1049–1059. Room, Robin 1974 “Governing images and the prevention of alcohol problems.” Preventive Medicine 3:11–23. Seeley, John R. 1962 “Alcoholism is a disease: implications for social policy.” Pp. 586–593 in D. J. Pittman and C. R. Snyder (eds.), Society, Culture and Drinking Patterns. New York: Wiley. Spector, Malcolm, and John I. Kitsuse 1977 Constructing Social Problems. Menlo Park, C.A.: Cummings. Straus, Robert 1976 “Problem drinking in the perspective of social change 1940–1973.” Pp. 29–56 in W. Filstead, J. Rossi, M. Keller (eds.),

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Alcohol and Alcohol Problems. Cambridge, M.A.: Ballinger. Szasz, Thomas 1970 The Manufacture of Madness. New York: Dell. Trice, H.M., and Paul Roman 1970 “Delabeling, relabeling, and alcoholics anonymous.” Social Problems 17:538–546. Trice, H.M., and Paul Roman 1972 Spirits and Demons at Work: Alcohol and Other Drugs on the Job. Ithaca, N.Y.: New York State School of Industrial and Labor Relations, Cornell University. Trice, H. M., and Richard J. Wahl 1958 “A rank order analysis of the symptoms of alcoholism.” Wilkerson, A. E. 1966 A History of the Concept of Alcoholism as a Disease. Unpublished doctoral dissertation, University of Pennsylvania. Zola, Irving K. 1972 “Medicine as an institution of social control.” Sociological Review 20:487–504.

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CHAPTER 5

The NIDA Brain Disease Paradigm History, Resistance, and Spinoffs David T. Courtwright INTRODUCTION It is a commonplace in the history of science that new paradigms generate both opposition and unexpected insights (Kuhn, 1970). The National Institute on Drug Abuse (NIDA) paradigm of addiction as a brain disease has done both. The research behind it has expanded our knowledge of motivation and learning, of normal as well as abnormal behavior. Yet it has also been met with indifference, suspicion, and, in some cases, open resistance. I am particularly interested in why politicians, clinicians, and social scientists have been slow to embrace what the neuroscientific community generally regards as a major breakthrough. The key elements of the NIDA brain disease paradigm can be simply stated. They are that addiction is a chronic, relapsing brain disease with a social context, a genetic (or, more precisely, a gene-environment-stress-interactive) component, and significant comorbidity with other mental and physical disorders. Although drug use often begins voluntarily, and develops over time, users lose control with the onset of addiction. According to the former NIDA director, Alan Leshner, addiction is defined, not by physical withdrawal symptoms, but by “uncontrollable, compulsive drug craving, seeking, and use, even in the face of negative health and social consequences.” Persistent use leads to long-term changes in brain structure and function. Neurons become more responsive to the biochemical changes triggered by drug consumption. Imaging studies have shown specific patterns of abnormal activity in the

brains of many addicts. In essence, addiction is a brain disease because addicts exhibit a behavioral disorder that can be linked to observable pathological changes in their brains. To again quote Leshner, addiction is “the quintessential biobehavioral disorder” (Leshner, 2001).

HISTORY Where did this paradigm come from? Here is the official version, from the NIDA publication Drugs, Brains, and Behavior: The Science of Addiction. It bears the signature of Nora Volkow, the current NIDA director: Throughout much of the last century, scientists studying drug abuse labored in the shadows of powerful myths and misconceptions about the nature of addiction. When science began to study addictive behavior in the 1930s, people addicted to drugs were thought to be morally flawed and lacking in willpower. Those views shaped society’s responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punitive rather than preventative and therapeutic actions. Today, thanks to science, our views and our responses to drug abuse have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of drug addiction, enabling us to respond effectively to the problem. (National Institute on Drug Abuse, 2008, p. 1)

The statement evokes the Whiggish history of psychiatry. Substituting “mental illness” for addiction gives a textbook account of beneficent

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medicalization. We used to treat mentally ill people as wicked or possessed, but now, thanks to neuroscience, we treat them as patients. The paradigm shift was progressive in another way. It tidied things up. Making the brain the affected organ, as historian Nancy Campbell has written, provided “a unified framework for a problem-based field in conceptual disarray” and enabled addiction researchers to draw on the technical resources and social authority of neuroscience (Campbell, 2007, p. 200). The political subtext of Volkow’s statement is plain enough: keep funding our research. What may be less obvious is that virtually every historical claim in the statement is either factually incorrect or a form of wishful thinking. Let me start with the state of things before the 1930s, a decade presumably chosen because it corresponds to the opening of the federal narcotic hospitals and their research facilities. Neither popular nor medical opinion then regarded all addicts as morally flawed. People distinguished between medical cases and nonmedical addicts with underworld or delinquent backgrounds. All junkies were addicts, but not all addicts were junkies. There was also a good deal of scientific investigation before the 1930s. Psychiatrist Lawrence Kolb, whom one colleague called “the Osler of drug addiction,” and who labored longer and harder than anyone to establish that addiction was a true mental disease, began his federally funded researches in 1923. These involved lab work with monkeys as well as the systematic study of 230 human cases (Kolb, 1962; Courtwright, 2001, Chapter 5; Acker, 2002, Chapter 5). The relegation of Kolb’s work to the dustbin of prescientific history may not have been entirely accidental. His primary finding, that nonmedical addiction was rooted in psychopathy and other preexisting (and hard-to-treat) personality disorders, fit poorly with the politics of medicalization and the NIDA paradigm’s foundational metaphor, that drugs could flip the addiction “switch” in even normal brains. Ultimately, it may turn out that the tension between the personality and brain disease models is more apparent than real. Recent research has found that impulsive, thrill-seeking

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individuals have fewer D2 and D3 dopamine receptors in the ventral midbrain region, which means they have less inhibition of dopamine and experience more reward when stimulated by risky behavior (Sanders, 2008). The propensity to addiction and certain kinds of personality disorder may have genetic and/or epigenetic common denominators. This possibility also has been debated for a long time. Early twentiethcentury researchers investigating cigarettes and health pondered whether the type of individual attracted to smoking might be as causally important in explaining the moral and physical harms of the habit as tobacco itself (Brandt, 2007, Chapter 4). Other researchers—mostly asylum proprietors, psychiatrists, and public-health physicians— were thinking systematically about the nature of addiction even before Kolb began his work in the 1920s. What happened in the late twentieth century was essentially the confirmation and recasting of a series of shrewd hypotheses that these pioneers ventured. They held that alcohol, tobacco, and other drug addictions were related through a common pathological action on the nervous system, which was permanently altered by the repeated use of drugs. Indeed, they often referred to nicotine and alcohol as “narcotics” or “deadly narcotics.” They believed that loss of control was the most important and troubling aspect of addiction. They knew how to get patients through withdrawal. The big challenge was how to prevent relapse. They postulated that some individuals were more vulnerable to addiction than others, whether through an inherited vulnerability or through an acquired, stress-related impairment of their nervous systems. In short, they believed that addiction was a chronic, recurrent nervous disease with both an environmental and hereditary component. What they lacked was the means to prove it (Courtwright, 2005). The history of addiction as a brain disease looks a lot like the history of atoms or germs, insofar as these were all older and controversial ideas for which scientific confirmation later became available. Improved instrumentation and new laboratory techniques, together with the infusion of money and research talent into the field, made possible the fundamental

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discoveries in the second half of the twentieth century that served as the building blocks of the current NIDA paradigm. Among these were the observation of intracranial self-stimulation in rats; the discovery of an endogenous opioid system; the mapping of specific receptors and description of their functions; an understanding of drug sensitization and dendritic morphology; the piecing together of a mesolimbic dopamine reward pathway that was distinct from the anatomical pathways responsible for physical dependence and withdrawal syndromes; and, more recently, the location of single-nucleotide polymorphisms (“snips,” or minute variations in DNA sequences) that seem to correlate with the risk of becoming an addict. Dramatic improvements in neuroimaging also made possible the equivalent of Giovanni Morgagni’s clinico-pathological studies. Morgagni pioneered the anatomical concept of disease. He based his classic 1761 study, De Sedibus et Causis Morborum, on some 700 case studies that showed how diseases with characteristic symptoms affected particular organs that exhibited characteristic lesions on postmortem examination. Imaging made it possible to show patterns of pre-mortem change on the primary organ that addiction afflicts, the brain. This idea is made explicit in Drugs, Brains, and Behavior, which juxtaposes positron emission tomography (PET) scans of a healthy and diseased heart with those of a healthy brain and the ‘diseased brain’ of a cocaine abuser. “Addiction is similar to other diseases, such as heart disease,” the caption explains. “Both disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, are preventable, treatable, and if left untreated, can last a lifetime” (National Institute on Drug Abuse, 2008, p. 5). Some individuals do respond well to treatment. Yet the new paradigm has not led to a large increase in our ability to “respond effectively to the problem,” as Volkow claims. Here is the practical heart of the matter. The prevalence and incidence of drug abuse are largely determined by demographic variables like migration, family stability, and birth cohort size, as well as social forces like drug-financed civil wars within failed states, pharmaceutical

marketing strategies, bohemian fashion, and generational learning (and forgetting) about the dangers of certain drugs. Pathological understanding is still disconnected from disease control, which is unusual in the history of medicine and public health. As psychiatrist Sally Satel puts it, a disease concept is not of much use unless it leads to “actionable etiology” (Satel, 2009).

RESISTANCE Volkow makes another questionable claim. With the exception of medical marijuana and marijuana decriminalization initiatives in some states, there is little evidence that popular attitudes toward drug abuse have “changed dramatically” in the U.S. in the recent past. Strikingly, federal policy toward illicit drugs became more, not less, punitive as the brain disease paradigm was solidifying in the 1980s and 1990s. Volkow’s statement boils down to a claim about successful medicalization. But the drug-abuse field is characterized by, at best, incomplete and contested medicalization. As the French sociologist, Robert Castel, has observed, Western medicine turned madness into a disease during the nineteenth century, and created institutions and therapies for managing it. But this has not happened for addiction, at least not to the same extent (Castel, 2008). Instead, at least four important groups continue to wrestle for control of the addiction field. Medical personnel are concerned with addicts as patients. Police have a stake because addictive behavior often leads to crime and personal and social harms. Social scientists regard addiction as a social construction as well as a form of social behavior. Political actors, by which I mean organized interest groups as well as appointed officials and elected politicians, are in some ways the most important players, because they ultimately determine the details of drug control and addiction treatment policies. One way to describe the modern history of U.S. policy toward nonmedical drug use and addiction is to describe the varying fortunes of these four groups. Law enforcement dominated from the early 1920s to the mid-1960s, a period historians call “the classic era of

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narcotic control”—classic in the sense of simple and rigid (Acker, 2002, p. 7). But, from the mid-1960s to the mid-1970s, medical and, to a lesser degree, social-scientific actors gained in influence. This was a time of promising new therapeutic approaches, methadone maintenance, the birth of NIDA, the efflorescence of drug ethnography, and a growing audience for the work of sociologists and historians who dissented from the official line. Yet the era of drug glasnost was brief. Law enforcement personnel regained their influence in the late 1970s and 1980s, even as NIDA was gathering the early fruits of the new scientific investigations. That raises an obvious question: Why did the politicians not jump on the medicalization bandwagon? They were, after all, providing the funding that made the brain disease breakthrough possible. The short answer is that American politicians had discovered an even more appealing bandwagon, that of selective reaction. What was being reacted against was the rise in crime, race riots, youthful drug experimentation, sexual permissiveness, and liberal fecklessness broadly associated with the 1960s. Beginning with Ronald Reagan’s successful run for the California governorship in 1966 and Richard Nixon’s successful run for the presidency in 1968, appeals to popular illiberalism became an important part of Republican electoral strategy. Yet Republicans faced a dilemma. They could run for office as social reactionaries, but they could not govern as social reactionaries, at least not across the board. No one was going to recriminalize abortion, bring back mandatory prayer in school, roll back civil rights, reimpose censorship, and hang on to centrist voters. What they could and eventually did do was to selectively address backlash issues where a large majority, centrists included, demanded change. The three most important of these, all intertwined with race, class, and gender, were criminal sentencing, welfare reform, and the drug war. Richard Nixon was the first Republican president to declare and fight a drug war, albeit one that initially combined novel medical and law enforcement approaches to the problem.

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The political appeal of a more narrowly punitive policy became apparent in January 1973 when New York governor and perennial presidential hopeful Nelson Rockefeller proposed mandatory life sentences for drug traffickers. Enough was enough, Rockefeller said. Polls showed that two-thirds of the state’s residents agreed with him (Massing, 1998, pp. 126–128). Nixon immediately grasped the electoral logic of strict mandatory sentences. “Rocky can ride the thing for all it’s worth,” he told his aides Bob Haldeman and John Ehrlichman (Nixon, 1973). Three months later Nixon imitatively proposed his own increases in federal penalties for heroin trafficking. The escalation of the Watergate scandal in the spring and summer of 1973 derailed Nixon’s proposal, and much else in his domestic program. However, when Republicans returned to the White House in 1981, the drug issue still afforded excellent political opportunities. It gave First Lady Nancy Reagan the means to make over her image, and to ultimately win approval ratings higher than her popular husband’s. It gave President Reagan the chance to deliver one of his most dramatic and popular speeches, the 14 September 1986 drug war declaration, which he made jointly with the first lady. It gave President George H. W. Bush the occasion for his first nationally televised address, in which he displayed a bag of crack seized near the White House. It gave drug czar Bill Bennett a bully pulpit and the opportunity to burnish his “culture warrior” credentials. And it gave President George W. Bush, who approved annual drug control budget increases, another outlet for his big-stick, big-government conservatism. What the drug war gave Democrats was mostly headaches. It contributed to the 1994 downfall of Surgeon General Jocelyn Elders who, among her other liberal sins, had suggested the possibility of studying drug legalization. It prevented President Bill Clinton from moving too fast to embrace medicalization or harm reduction for fear that he would be judged a weak drug warrior. For reasons of ideology and moral temperament, Democrats were (and remain) the party most open to medicalization. But Democratic politicians knew, from bitter

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experience, that they would pay a price for looking soft on drugs—just as Clinton understood that he would pay a price if he did not sign the 1996 welfare reform bill passed by a Republican Congress (Courtwright, 2010). Beyond partisan calculation, there was a more subtle reason why NIDA officials failed to lure political actors away from the drug war. It was that their paradigm reinforced the logic of strict supply reduction. Like the sheet that has been dyed, the addicted brain could never become unaddicted. It was possible to learn to live with the new color, but the surest answer was prevention: Keep the dye away from the sheet. As John D. Rockefeller Sr. liked to tell his Sunday school classes, you cannot become a drunkard if you never take your first drink (Chernow, 1998, p. 190). Harry Anslinger, longtime head of the Bureau of Narcotics, made a similar point about morphine and other medicinal narcotics. Why, Anslinger wanted to know, did doctors have rates of addiction that were so much higher than lawyers? Was it because doctors as a class were weaker or more sociopathic than lawyers? No, it was simply that doctors were exposed to drugs in a way that lawyers were not. At bottom, the rate of addiction was a function of availability. Controlling availability was therefore priority one (Maisel, 1945). The same reasoning applied to cannabis or cocaine or any other addictive substance. The ultimate point of spraying illicit crops and hunting down traffickers and imposing prison terms was to reduce the prevalence of addiction and related problems like overdose and accidents. Tellingly, the Drug Enforcement Administration all but plagiarized NIDA’s language to describe the long-term dangers of drugs like methamphetamine. Abuse could trigger addiction, “a chronic, relapsing disease, characterized by compulsive drug-seeking and drug use which is accompanied by functional and molecular changes in the brain” (Drug Enforcement Administration, 2009). The flipped switch served as both a warning to the unwary and a policy trump card. Drug war critics could still criticize specific tactics as ineffectual or counterproductive or too costly. But, if the brain disease model was correct, and

drug exposure led ineluctably to catastrophic addiction in a significant percentage of cases, the fundamental strategy of prosecution to reduce supply was hard to fault. The usual rebuttal was that law enforcement efforts to reduce supply often backfired. Legal pressure in one place encouraged clandestine manufacturing in others, just as the disruption of existing trafficking routes encouraged smugglers to find alternatives. Sooner or later, illicit drugs began “leaking out” wherever they were manufactured or transshipped. The result was more widespread abuse among previously low-use populations—as happened in Mexico, where the number of addicts reportedly doubled between 2002 and 2009 (Beith, 2009). The surrebuttal was that drug use spread even faster when unregulated or poorly regulated, as evidenced by the many and far-flung drug epidemics of the nineteenth century. Concomitants or not, the principle of utility dictated that modern states punish those who sold dangerous drugs outside approved medical channels. More practically, the “push-down, pop-up” effects of enforcement were often remote, a problem in someone else’s backyard. What Republicans responded to in the 1970s and 1980s was growing pressure from organized and influential middle-class constituents to do something right now about the threat to their children. That the policy response got caught up in the current of competitive moral politics and overshot the falls of legislative reaction was in no way NIDA’s doing. Yet, in hindsight, the agency’s new science backed up the message of the old drug-frying-pan commercial: once your kid’s brain plopped into sizzling neurotoxic grease, it stayed fried. The metaphor can be turned around: Authorities do not ordinarily punish juvenile burn victims, even if they happened to be playing with matches. Although the brain disease paradigm offered aid and comfort to the supply-siders, it also furnished a moral argument to their opponents. If addiction was beyond the individual’s control, then criminal punishment was as inappropriate as jailing a schizophrenic who wandered into an emergency room. “The initial decision to take drugs is mostly voluntary,” explains Drugs, Brains, and Behavior.

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“However, when drug abuse takes over, a person’s ability to exert self control becomes seriously impaired. Brain imaging studies from drug-addicted individuals show . . . physical changes in areas of the brain that are critical to judgment, decisionmaking [sic], learning and memory, and behavior control” (National Institute on Drug Abuse, 2008, p. 7). Pathological loss of control has long been a fundamental consideration of medical ethics. Moreover, it seems unlikely that post-1973 U.S. policy would have assumed such a punitive character if physicians had actively opposed it. Organized medicine was hardly without political influence. It had successfully exercised that influence on other occasions—notably in opposition to national health insurance—to block legislation that commanded widespread support. If it was becoming clear in the 1980s and 1990s that addiction really was a brain disease, why did the medical profession and its allies fail to put up much of a fight against the prison-oriented drug war? Why, for that matter, are they still largely acquiescent? The most obvious answer is that the brain disease model has so far failed to yield much practical therapeutic value. Clinicians have acquired some drugs, such as Wellbutrin and Chantix for smokers, Campral for alcoholics, or buprenorphine for heroin addicts, but no magic bullets. Stuck in therapeutic limbo, with pathological insight but little ability to cure the underlying pathology, they have had no routine clinical alternative to the dominant supply-side approaches. Counterfactually, if the brain disease model ever yields a pharmacotherapy that curbs craving, or a vaccine that blocks drug euphoria, as some researchers hope (Condon, 2006), we should expect the rapid medicalization of the field. Under those dramatically cost-effective circumstances, politicians and police would be more willing to surrender authority to physicians. Even if they were not so disposed, the fiscal burden of mass imprisonment has reached the point where voters might force them to do so. Pharmaceutical companies would also have a financial interest in using any therapeutic discoveries to medicalize addiction, as they have with Viagra and “erectile dysfunction,”

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human growth hormone and “idiopathic short stature,” and Paxil and shyness, rechristened “social anxiety disorder” (Conrad, 2007). Another reason for clinicians’ acceptance of the status quo was that the drug war, for all its excesses, never seriously endangered their ability to prescribe mood-altering drugs. Richard DeGrandpre has criticized the division of the pharmacopeia into nonmedical “devil” drugs and medical “angel” drugs. The latter, he argues, were protected and privileged by pharmaceutical interests, bureaucrats, and medical researchers, including the NIDA brain disease establishment. Whether or not current drug scheduling is actually irrational (or, for that matter, dichotomous), it has never been so aggressive that organized medicine felt it had to revolt. On the contrary, many critics think that prescribing remains underregulated. Doctors, abetted by big-name researchers in the pay of pharmaceutical companies, have been prescribing far too many unproven and dangerous psychoactive drugs for far too many patients, including young children (DeGrandpre, 2006; Angell, 2009). Finally, why were social scientists slow to embrace the NIDA paradigm? Some of them, like psychologists Stanton Peele (1998) and Bruce Alexander (2008), simply thought it was wrong on its merits, that it was reductively inattentive to individual values and social context. DeGrandpre has similarly argued that it is set and setting that matter, not just neurons pickled in a sea of exogenous toxins. Beyond that, there were strong disciplinary biases at work. Social scientists have long been collectively suspicious of anything that smacks of biological essentialism. Biological explanations, after all, have a notorious dark side, having been used to stigmatize, exploit, and exterminate minority groups. On one level, social-scientific skepticism about the NIDA paradigm was part of a broader post-World War II pattern of resistance against biological explanations of behavior, genetic research, and the neo-Darwinian renaissance (Degler, 1991). Although that resistance has recently shown signs of abating, it is still very much in evidence among social science’s old guard. Troy Duster, an influential sociologist who has written on

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drugs, deviance, race, and science, highlighted the concern in his 2005 presidential address to the American Sociological Association. He spoke frankly of the challenge of scientific authority and “the attendant expansion of data bases on markers and processes ‘inside the body.’” For Duster, reductionist science was the enemy at the gates, threatening to further defund and marginalize sociology, draw attention from the decisive social and economic forces, and dominate the policy process (Duster, 2006, p. 1). Another way to say this is that both social scientists and neuroscientists still live in their own gated academic communities, that they engage in vigorous boundary maintenance, and that they champion their own disciplinary and subdisciplinary master variables. There is a lot more at stake in the brain disease debate than our understanding of addiction. At bottom, it is really a high-stakes argument about how we ought to understand human behavior, motivation, and pleasure—and about what policies we should adopt to regulate it.

REFERENCES Acker, C.J. (2002) Creating the American Junkie: Addiction Research in the Classic Era of Narcotic Control. Baltimore, MD: Johns Hopkins University Press. Alexander, B. (2008) The Globalization of Addiction: A Study in Poverty of the Spirit. New York: Oxford University Press. Angell, M. (2009) Drug companies and doctors: A story of corruption. New York Review of Books 56(15 January): 8–12. Beith, M. (2009) Mexico needs an intervention. Newsweek 154(10 August/17 August): 8. Brandt, A.M. (2007) The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America. New York: Basic Books. Campbell, N.D. (2007) Discovering Addiction: The Science and Politics of Substance Abuse Research. Ann Arbor, MI: University of Michigan Press. Castel, R. (2008) Closing remarks, International Conference on Drugs and Culture, Sciences Po, Paris, 13 December. Chernow, R. (1998) Titan: The Life of John D. Rockefeller, Sr. New York: Random House.

Condon, T.P. (2006) Reflecting on 30 years of research: A look at how NIDA has advanced the research, prevention, and treatment of drug abuse and addiction. Behavioral Healthcare 26(May): 14–16. Conrad, P. (2007) The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders. Baltimore, MD: Johns Hopkins University Press. Courtwright, D.T. (2001) Dark Paradise: A History of Opiate Addiction in America. Cambridge, MA: Harvard University Press. Courtwright, D.T. (2005) Mr ATOD’s wild ride: What do alcohol, tobacco, and other drugs have in common? Social History of Alcohol and Drugs 20: 105–140. Courtwright, D.T. (2010). No Right Turn: Conservative Politics in a Liberal America. Cambridge, MA: Harvard University Press. Degler, C.N. (1991) In Search of Human Nature: The Decline and Revival of Darwinism in American Social Thought. New York: Oxford University Press. DeGrandpre, R. (2006) The Cult of Pharmacology: How America Became the World’s Most Troubled Drug Culture. Durham, NC: Duke University Press. Drug Enforcement Administration. (2009) Methamphetamine, http://www.usdoj.gov/dea/concern/ meth.html. Duster, T. (2006) Comparative perspectives and competing explanations: Taking on the newly configured reductionist challenge to sociology. American Sociological Review 71: 1–15. Kolb, L. (1962) Drug Addiction: A Medical Problem. Springfield, IL: Charles C. Thomas. Kuhn, T.S. (1970) The Structure of Scientific Revolutions, 2nd ed. Chicago, IL: The University of Chicago Press. Leshner, A.I. (2001) Addiction is a brain disease. Issues in Science and Technology Online, http:// www.issues.org/17.3/leshner.htm. Maisel, A.Q. (1945) Getting the drop on dope. Liberty (24 November), unpaginated reprint, ‘US Bureau of Narcotics—History,’ vertical files, DEA Library, Arlington, VA. Massing, M. (1998) The Fix. New York: Simon and Schuster. National Institute on Drug Abuse. (2008) Drugs, Brains, and Behavior: The Science of Addiction, revised ed. Washington DC: National Institute on Drug Abuse.

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Nixon, R. (1973) Tape 393-11B, Nixon Presidential Library and Museum, http://www.nixonlibrary. gov/forresearchers/find/tapes/tape393/tape393. php. Peele, S. (1998) The Meaning of Addiction: An Unconventional View. San Francisco, CA: Jossey-Bass.

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Sanders, L. (2008) Fewer dopamine receptors makes for risky business. Science News, 30 December. Satel, S. (2009) The addicted patient. Presentation at Addiction, the Brain, and Society, Emory University, February 2009. Vrecko, S. (2010) ‘Civilizing technologies’ and the control of deviance. BioSocieties 5(1): 36–51.

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PART II

Locating Addiction

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CHAPTER 6

What Neurobiology Cannot Tell Us about Addiction Harold Kalant

WHAT IS ADDICTION? Although the World Health Organization (WHO) Expert Committee recommended many years ago that the term “addiction” be replaced by the term “dependence” [1], both terms have continued in use and have generally become accepted as synonymous. The DSM-IV-TR definition of dependence includes only one fundamental element: compulsive use of the drug despite the occurrence of adverse consequences [2]. However, a more detailed description of the “dependence syndrome” includes both physical components (increased tolerance to the drug; repeated experience of withdrawal symptoms; use of the drug to prevent or relieve withdrawal symptoms) and behavioural signs of loss of control over drug use (e.g., increasing prominence of drug-seeking behaviour, even at the cost of disruption of other important parts of the user’s daily life; use of larger amounts than intended; inability to cut down the amount used, despite persistent desire to do so; and awareness by the user of frequent craving). Other definitions by various expert bodies have generally been similar in content. An ad hoc committee set up by the Royal Society of Canada to review the evidence concerning tobacco/nicotine [3] concluded that the only elements common to all definitions of addiction are a strongly established pattern of repeated self-administration of a drug in doses that produce reinforcing psychoactive effects reliably, and great difficulty in achieving voluntary long-term cessation of such use, even when the user is strongly motivated to stop.

The emphasis here is on the word “selfadministration.” Physical dependence can be produced by large doses of an opioid analgesic administered therapeutically by a health care professional to a patient with severe pain, yet such patients rarely become compulsive drug-seekers. The situation was different for wounded veterans of the American Civil War, who were issued syringes and morphine tablets for self-administration; many of them did indeed become victims of what was later known as “soldier’s disease” [4]. In other words, addiction is not produced by a drug, but by self-administration of a drug; the difference is of fundamental importance. There are, of course, other important differences between the two groups. The Civil War veterans’ self-administration of morphine was socially approved, and they were provided with the means of carrying it out. In contrast, the administration of morphine on a doctor’s prescription to patients for relief of pain is also socially approved, but the patients would be socially disapproved of if they sought to obtain and self-administer illicit opioid for other purposes. Nevertheless, in either case it is the self-administration that underlies the definition of addiction or dependence. It is regrettable, therefore, that one still finds in the experimental literature many studies carried out with the most sophisticated modern techniques, but with the basic flaw that animals are presumed to have been rendered “addicted” by continuous exposure to alcohol vapour in a closed chamber, or by repeated intraperitoneal or intravenous injection of an opioid, or

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cocaine, or some other presumably “addictive drug.” Such experiments may yield important information about biological mechanisms of tolerance or physical dependence, but these are not the same as addiction [5,6].

NEUROBIOLOGICAL RESEARCH ON ADDICTION Leaving aside such flawed studies, what can we hope to learn about “real” addiction from research on the interaction of drugs with the whole spectrum of phenomena that constitute the field of neurobiology. The past two decades have seen dramatic and rapid progress in the field of neurobiology, resulting from the application of a dazzling array of new techniques ranging from in vitro molecular methods to brain imaging procedures in intact, conscious subjects performing a variety of behavioural tasks. It would be impossible to cover here the whole range of new knowledge arising from such work, but here I will briefly review two of the major areas in which these modern methods have been applied to the study of addiction. These are the role of dopaminergic and other constituents of the so-called reward system and its various modulators in the brain and the role of genetic factors in addiction.1

Dopamine and the “Reward System” Not only in the scientific literature, but even in the popular press, it has become the accepted dogma that people take drugs such as nicotine, alcohol, cannabis, heroin, cocaine, and amphetamines because all of these potentially addictive substances act on certain cells in the ventral tegmental area (VTA) of the brainstem, causing them to release increased amounts of dopamine at their axon terminals, resulting in the production of a pleasurable or rewarding state in the user. This “reward” is presumed to be what motivates the first-time user to repeat the drug-taking experience, and thus to incur the risk of becoming dependent. All such drugs have indeed been shown to act on various parts of these dopaminecontaining cells, causing them to release dopamine from their axonal terminals onto cells in

the nucleus accumbens and in the prefrontal cortex that have specific dopamine receptors [7, 8, 9]. The various drugs do so by different means, but with similar end results [10]. For example, opioid drugs act through opioid receptors on certain interneurones that release the inhibitory transmitter gamma aminobutyric acid (GABA) on to the dopamine-producing cell bodies in the VTA or on their nerve endings in the nucleus accumbens. The opioids inhibit the release of GABA and thus disinhibit the dopamine-releasing cells, so that they release more dopamine. Ethanol may similarly disinhibit the VTA dopamine neurones by removing the inhibitory influence of noradrenaline. In contrast, cocaine and amphetamine act directly on the dopaminergic nerve endings to increase the net release of dopamine in the nucleus accumbens. In all cases, however, the end result is an increase in dopamine activity in the nucleus accumbens and prefrontal cortex. This “reward system” was first identified by its responses to natural reinforcers such as food in a hungry animal or water in a thirsty one, or to electrical self-stimulation via electrodes implanted in certain pathways in the brain. Drug reinforcers can give rise to apparent sensitization of the drug effect on the mesolimbic dopaminergic pathways, which is thought to lead to progressively more intense and more persistent drug self-administration. This sensitization has been attributed to synaptic plasticity in the mesolimbic dompaminergic pathways [11,12], or to a qualitative change in the drug effect that is said to give rise to an allostatic rather than homeostatic response [13]. What might constitute such a qualitative change must be investigated in animals that self-administer the drug, and even in such models there may be confusion with qualitative changes produced by the drug itself when administered by the investigator. For example, in animals that have been made physically dependent on opioids, the action of an opioid on the dopamine neurons causes the latter to respond not through the dopaminergic pathway to the nucleus accumbens but through a non-dopaminergic pathway to the pedunculopontine nucleus [14]. In this example the opioids were not selfadministered by the animals, so that the change

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in cell response cannot be part of the process of addiction, although it may help to explain neuronal responses involved in tolerance and physical dependence. There is a substantial amount of evidence, moreover, which suggests that the release of dopamine is not a reward mechanism per se, but rather a process that arouses and alerts the brain to new or novel stimuli arising from the internal or external environment [15]. These stimuli are not always related to potential rewards. Some motivationally neutral but intense novel stimuli, and in some cases even punishing or aversive stimuli, can be associated with increased dopamine release [16]. Moreover, dopamine neurons can emit various types of responses, differing in latency, duration and direction, to different types of stimuli. Schultz [17,18] suggests that the role of the dopamine neurones in relation to reward is to assess the difference between an anticipated reward and the experienced reward. This assessment would then serve as the basis of experiential learning. For example, when an animal experiences an unanticipated reward in the presence of previously nonsignificant stimuli, the reward elicits a large response by the midbrain dopamine neurones; but with repeated pairing of the same cues with the reward, the dopamine release becomes steadily greater in response to the cues that predict the reward and steadily less to the reward itself. If the experienced reward matches the prediction in time and intensity, the reward stops eliciting any dopamine increase, and if the reward fails to match the prediction the dopamine output actually decreases [18]. The cognitive experience of positive reinforcing effects versus punishing aversive effects occurs presumably at some distal site downstream from the alerting effect of dopamine, but there is no persuasive evidence pointing to a single most probable site or mechanism. Modern functional magnetic resonance imaging (fMRI) techniques are being used widely in efforts to identify the probable site, and they have certainly pointed to a number of forebrain areas that appear to be activated during drug self-administration, but as Vengeliene et al. [19] have pointed out, after prolonged alcohol

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consumption practically all central neurotransmission seems to be affected. Moreover, fMRI may identify which regions or structures are activated during a given behaviour or set of stimuli [20], but in light of the complex neuronal interconnections described above, the occurrence of activity in a given area or pathway does not reveal whether the activity is primary or secondary to activity in some other structure. A further problem is that equating “reward” with motivation for drug use, although seemingly a reasonable concept, is almost certainly too simple. It has been known for many years that under certain circumstances experimental animals and humans will press a lever to self-administer an electric shock or other painful stimulus that is ordinarily aversive [21,22]. One may postulate that under conditions of paucity of external stimulation the animal experiences something akin to boredom and that in this state it finds even a painful stimulus somehow rewarding, but that is at best an anthropomorphic conjecture. Therefore, the whole concept of the dopaminergic mesolimbic and mesocortical pathways as a “reward system” must be regarded as a convenient label rather than literal fact, and it provides no insight into the reasons why some drug users become addicted while the great majority of users, in whom the drugs also stimulate dopamine release in the nucleus accumbens, never pass from use to compulsive use. A more recent hypothesis is that these drugs also modulate brain stress and antistress mechanisms involving such factors as corticotrophin-releasing factor, orexin, neuropeptide Y, nociception, and others, and that both positive and negative reinforcement by drug-taking enter into the generation of addiction [23]. This is clearly a more comprehensive approach than focusing exclusively on dopaminergic mechanisms, but the same actions of these drugs can be elicited when they are administered by the experimenter rather than self-administered by the animal. Recent clinical observations have shown that treatment of Parkinson’s disease with drugs that act directly as agonists on dopamine receptors can induce compulsive behaviours in

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a small percentage of patients, but in some it takes the form of compulsive eating, in others compulsive sex, and in still others compulsive gambling [24], rather than compulsive self-administration of the drugs. Although opinions differ on whether compulsive eating and compulsive sexual activity should be interpreted as addiction, there is some evidence that they are associated with the same responses in the brain ‘reward system’ as drug addiction [25–28]. It is therefore necessary to reconsider whether there is anything unique in the addictiveness of drugs as opposed to natural reinforcers.

GENETIC ASPECTS OF ADDICTION It has been known for centuries that alcoholism runs in families, but it is only since the middle of the 20th century that evidence from twin studies, adoption studies, and family pedigrees has demonstrated clearly a genetic component to this familial incidence. Within the past decade or so, comparable evidence has begun to accumulate with respect to addiction to other drugs, including opioids, cocaine, other central stimulants, sedatives, nicotine, and cannabis. As there is much more information available for alcohol, however, this discussion will concentrate on alcohol. Early studies of the genetic mechanisms involved were directed mainly to the enzymes metabolizing alcohol and acetaldehyde, because these enzymes exist in multiple forms that differ greatly in their rates of metabolism of their respective substrates. Special interest attached to the very low-activity form of acetaldehyde dehydrogenase, because individuals homozygous for this form (about 10% of Asian populations) suffer a severe disulfiramlike reaction on drinking alcohol, characterized by nausea, severe headache and even vascular collapse [29]. This highly aversive reaction appears to protect its bearers against the risk of alcoholism [30]. However, the much more numerous heterozygous individuals have a milder form of this reaction, and social and other pressures can induce them to drink alcohol despite the reaction, even to the point of becoming alcoholic.

Most of the recent studies, both in humans and in laboratory animals, have focused on genes related to individual components of potential vulnerability to become addicted. Starting with standard strains of laboratory rat, several groups have bred lines selectively which differ strikingly in voluntary consumption of alcohol, such as the UchA (low drinker) and UchB (high drinker) lines [31] and the Alko drinker (AA) and non-drinker (ANA) lines [32]. Perhaps the most thoroughly explored such lines are the P (alcohol-preferring) and NP (non-preferring) lines, which have been used widely to study genetic influences on alcohol intake and effects [33]. It was found later that the P rats also self-administer nicotine much more than do the NP rats, that they lose the nicotine-seeking behaviour less readily than the NP and that when given a small dose of nicotine they relapse into nicotine self-administration much more readily [34]. On the other hand, the P and NP do not differ with respect to cocaine self-administration, but do differ with respect to self-administration of sweet sugar solutions, which have no known drug actions. Literally hundreds of genes have been identified that may contribute individually to increased vulnerability to drug use and drug addiction, some more than others. Some of these genes appear to be associated statistically with behavioural or personality traits that are associated with increased risk of addiction to various drugs. For example, many (but not all) studies have found that impulsivity (defined as decreased ability to inhibit behavioural responses voluntarily when it would be advantageous to do so) predicts increased consumption of alcohol, both in humans and in mice and other experimental animals, and also predicts greater risk of relapse in those who have undergone extinction of dependent drinking [35]. In recent studies impulsivity was found to be correlated with reduced numbers of dopamine D2/3 receptors in the nucleus accumbens, more rapid acquisition of cocaine self-administration [36], and greater risk of continuing to self-administer cocaine even when this behaviour was punished by electric shock [37]. However, impulsivity has also been found to be influenced strongly by serotonin, and other neurotransmitters and modulators probably also

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affect it [35]. Impulsivity is also manifested in a variety of other behaviours that are not related specifically to addiction. The nature of the connection between impulsivity and addiction therefore is still unclear. It must be remembered that a gene does not encode a trait; it encodes RNA for synthesis of a specific protein, either the dominant form of that protein or a structural variant of it. For many of the genes that have been correlated with a behavioural trait the protein product has not yet been identified, and for most of those gene products that have been identified, the mechanistic relation to the trait is not known. It is also highly probable that for most behavioural traits several different gene products play a role in the generation of a single trait. In addition, genes are not necessarily continuously active, i.e., they may be switched on (“expressed”) or off under different circumstances. The pattern of protein expression in the nucleus accumbens of alcohol-preferring P rats, for example, is quite different when they self-administer alcohol on their own schedule during continuous access than when they consume the same total amount but during limited-duration drinking periods scheduled by the investigators [38]. There are now numerous examples of environmental factors controlling the expression of genes, so that an individual with a given genetic make-up may be vulnerable to induction of addiction or relapse under some circumstances and not under others. For example, both clinical observations and experimental models have demonstrated that addicted individuals, after undergoing successful extinction of heavy drinking behaviour, experience a greater risk of relapse when exposed to stress [39]. They presumably have the same genetic make-up at all times, but various genes related to vulnerability appear to be switched on when they are under stress and not in its absence.

WHAT CAN ALL THIS TELL US ABOUT ADDICTION? It is self-evident that a drug alone does not cause addiction because the great majority of those who experience its effects do not become addicted, even if the drug is one that is regarded

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as “highly addictive,” such as heroin or cocaine. Only some users become addicted, and much research is directed towards learning what factors determine greater or lesser vulnerability of different individuals or populations. Neurobiological studies have identified a very large number of cellular and synaptic changes that occur in relation to the acute and chronic administration of potentially addicting drugs. As noted above, the changes that have been studied involve the basic machinery of neurones, including practically every neurotransmitter, many cell membrane receptors, enzymes, ion channels, intracellular signalling systems, immediate early genes, gene expression, protein synthesis, and so on. The neurobiological changes are consistent with Mark Keller’s famous dictum that in alcoholism everything that one measures is either increased or decreased [40]. All one can conclude is that the occurrence of so many changes is indicative of the very widespread involvement of many different nuclei and pathways in the actions of drugs. Many of the changes are probably secondary to the drug actions, or may be part of the adaptive responses underlying tolerance and physical dependence; but unless they are specifically linked to self-administration, they may not tell us much about the generation and expression of addiction. This is still useful information, however, and one cannot agree so readily with Keller’s later extension of his original “Law,” that “Alcoholics are different in so many ways that it makes no difference.” Elucidation of the mechanisms involved in neuronal adaptations to drugs has yielded valuable knowledge about the workings of the brain. It may also suggest pharmacological interventions to prevent the production or function of some of the gene products that contribute to vulnerability to addiction or relapse, and thus help to maintain treatment-induced abstinence [41]. A useful analogy has been drawn with the workings of a motor vehicle: It takes many hundreds of parts, working as a well-integrated system, to make a car run properly, but knocking out only one essential part can prevent it from running (Y. Israel, personal communication). Naltrexone, acamprosate, and buprenorphine

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are examples that come to mind of agents that block one important part of the integrated system that gives rise to addiction. The problem is that the parts that they block individually are important but not uniquely so, so that none of these agents is certain to halt the dependence completely or permanently [42,43]. Therefore the development of new agents of this type may continue to be a helpful but limited approach to the treatment of addiction. Hope for more effective methods of treatment, and especially of prevention, probably rests on discovering primary causes of addictive behaviour rather than mechanisms by which it is expressed. Causes, in this context, means the factors that set the machinery in motion and, as pointed out earlier, the drug itself is clearly not a sufficient cause. Exploration of genetic factors will probably also not provide such knowledge, for reasons discussed above. Genes generate the proteins that constitute the building blocks of the cellular mechanisms discussed earlier. Therefore identification of genes linked to addiction carries the analysis of these mechanisms one step deeper, but is still not likely to explain causation. Every behaviour that may contribute to the production of addiction will have a cellular mechanism involving many different genes, and the more that are found the less clear will be the specific role of any single one in the generation and maintenance of addiction. A recent study of the literature encountered 1,500 genes linked in some way to addiction; 396 of these were used to construct a map of genes and gene products constituting five major molecular pathways that appear to be common to addiction to various drug classes [44]. The resulting map bears a striking resemblance to the known pathways of cell response to a wide variety of stimuli. Moreover, the fact that gene expression is affected by environmental and contextual factors, as well as by the drugs that are self-administered, means that addiction cannot even be conceptualized exclusively in terms of the interaction between the drugs and the genetic constitution of an individual vulnerable user. A variety of elements of the environmental context must also be taken into account.

For example, sensitization of locomotor activity by cocaine, amphetamine, morphine, or low doses of ethanol in rodents is thought to be one manifestation of the postulated “rewarding” motivational effects of these drugs. However, this sensitization occurs more readily when the drug is given in a novel environment rather than in the animal’s home cage, and the enhancing effect of environmental novelty is most evident when relatively low doses of the drugs are used [45]. A different type of example is provided by Robins et al.’s studies of American veterans of the Vietnam War who had returned to the U.S. as heroin addicts [46]. A surprisingly high proportion of those who became abstinent during treatment have remained abstinent since returning to their normal home environments. This is in striking contrast with Wikler’s [47] observations of addicts who had long been free of withdrawal symptoms and drug craving during their confinement in U.S. Public Health Service hospitals, but relapsed abruptly on their return to the environments associated with their previous drug use. One concludes inevitably that addiction is a behavioural disorder generated within an extremely complex interactive system of drug, individual user, environment, and changing circumstances [48]. This is no longer the terrain of pharmacology or neurobiology or psychology or sociology, but an amalgam of all of them. The challenge for research is to find a conceptual framework that can generate the appropriate methods for investigating such an immensely complex system. Science includes two opposite processes, the reductive or analytical process [49] and the integrative or synthetic process. The analytical approach is much the more widely practised, and has unquestionably yielded enormous gains in our understanding of basic mechanisms. In the present context, it has explored the molecular elements that constitute the machinery of living cells and helped to explain how they work. However, to understand how living organisms acquire and perform highly complex behaviours such as drug addiction, under all the various environments and circumstances to which they are exposed, it is necessary to understand how the

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subcellular, cellular, organ system, and whole organism components interact with the external environmental influences. The early hope and promise of neurobiology was that it would do exactly that, and thus explain animal behaviour in its entirety, at all levels of organization. In the case of drug addiction it has not yet done so, and as long as the emphasis remains chiefly on the reductive analytical approach, it cannot do so. The type of process that is required to explain addiction can perhaps be suggested by an analogy with aeronautical engineering. In order to build an aircraft that will fly successfully, efficiently, rapidly, safely, and economically, it is not sufficient to put together a fuselage, wings and a jet motor. It is necessary to take into account the aerodynamics of wing shape, the tensile strength and brittleness of a wide variety of metals and alloys of different densities, the energy generated by combustion of different fuels relative to their weight, the interaction of the proposed design with atmospheric resistance and turbulence at different altitudes, the ability of humans to monitor and operate all the controls accurately and safely, the ability of the operators to assess the potential market and carry enough passengers at reasonable prices to cover the costs of operation and generate a profit, and so on, with hundreds or thousands of separate contributory types and pieces of information. These must all be studied analytically, but then they must all be integrated into model interactive systems that allow the researchers to predict and explain all aspects of the aircraft’s behaviour and responses under all imaginable conditions. This process has been facilitated enormously by the development of highly sophisticated and powerful computer theory and instrumentation. Similarly, it is inherently impossible to explain addiction by pursuing only the analytical study of drug interactions with the nervous system at ever-finer levels of molecular structure and function. It is also necessary to integrate that knowledge into more and more complex models that include interactions at all levels, from the submolecular to the environmental and social, so that one can test predictions of how the complex system will

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behave under all the possible influences which are known to modify risk of addiction and of relapse, both in individual cases and in society as a whole. That is a very tall order, but it is not inherently impossible for neurobiologists, sociologists, psychiatrists, pharmacologists, economists, and relevant others to tackle the problems of addiction in a manner analogous to the engineers’ approach. In the long term, it is likely to be more fruitful than concentrating on a search for medications by studying receptor subtypes or gene variants.

NOTE 1. Editors’ note: Dr. Kalant’s original article contained two highly technical sections on “intracellular signaling systems” and “synaptic plasticity,” which have been omitted here in the interest of accessibility and length. In the first, Dr. Kalant shows that “all living cells, especially nerve cells, have an innate ability to adapt to changes produced by influences external to them,” that this is part of “the cell’s basic machinery for responding to a wide variety of functional disturbances of different kinds,” whether from a drug or other type of stimuli, and that these “adaptive changes in the cell’s messenger systems are mechanisms of cellular adaptive responses. . . .” He notes, however, that “A mechanism is not the same as a cause.” In the second omitted section, Dr. Kalant shows that “alterations of synaptic function,” like intracellular adaptations, “are not produced only by chronic drug exposure” but are rather “basic parts of the processes of learning, memory and forgetting. . . .” The key point in these sections is that “Knowledge of these mechanisms can tell us how the change is brought about, but not why” (pp. 790–791, original emphases). Readers who want to see these sections in full with references should refer to the original journal article, “What Neurobiology Cannot Tell Us About Addiction,” Addiction 105(5) (2010):780–789.

REFERENCES 1. World Health Organization (WHO). 13th Report of the World Health Organization Expert Committee on Drug Dependence. WHO Technical Report Series No. 273. Geneva: WHO; 1964. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IVTR). Washington, DC: American Psychiatric Association Publishers; 2000.

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16. Mirenowicz J., Schultz W. Preferential activation of mid-brain dopamine neurons by appetitive rather than aversive stimuli. Nature 1996; 379: 449–51. 17. Schultz W. Multiple dopamine functions at different time courses. Annu Rev Neurosci 2007; 30: 259–88. 18. Schultz W. Behavioral dopamine signals. Trends Neurosci 2007; 30: 203–10. 19. Vengeliene V., Bilbao A., Molander A., Spanagel R. Neuropharmacology of alcohol addiction. Br J Pharmacol 2008; 154: 299–315. 20. Logothetis N. K. What we can do and what we cannot do with fMRI. Nature 2008; 453: 869–78. 21. Speakman R. D., Kelleher R. T. Behavioral effects of self-administered cocaine: responding maintained alternately by cocaine and electric shock in squirrel monkeys. J Pharmacol Exp Ther 1979; 210: 206–14. 22. Belvedere E., Pasewark R. A. Conformity and modeling in an aversive task. J Clin Psychol 1976; 32: 265–7. 23. Koob G. F. A role for brain stress systems in addiction. Neuron 2008; 59: 11–34. 24. Dodd M. L., Klos K. J., Bower J. H., Geda Y. E., Josephs K. A., Ahlskog J. E. Pathological gambling caused by drugs used to treat Parkinson disease. Arch Neurol 2005; 62: 1–5. 25. Corwin R. L., Grigson P. S. Symposium overview—food addiction: fact or fiction? J Nutr 2009; 139: 617–19. 26. Rogers P. J., Smit H. J. Food craving and food ‘addiction’: a critical review of the evidence from a biopsychosocial perspective. Pharmacol Biochem Behav 2000; 66: 3–14. 27. Blum K., Braverman E. R., Holder J. M., Lubar J. F., Monastra V. J., Miller D. et al. Reward deficiency syndrome: a biogenetic model for the diagnosis and treatment of impulsive, addictive, and compulsive behaviors. J Psychoact Drugs 2000; 32(Suppl i–iv): 1–112. 28. Keane H. Disorders of desire: addiction and problems of intimacy. J Med Hum 2004; 25: 189–204. 29. Li T.-K., Bosron W. F. Genetic variability of enzymes of alcohol metabolism in human beings. Ann Emerg Med 1986; 15: 997–1004. 30. Li T.-K. Pharmacogenetics of responses to alcohol and genes that influence alcohol drinking. J Stud Alcohol 2000; 61: 5–12.

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31. Mardones J., Segovia-Riquelme N. Thirtytwo years of selection of rats by ethanol preference: UChA and UChB strains. Neurobehav Toxicol Teratol 1983; 5: 171–8. 32. Eriksson K. Genetic selection for voluntary alcohol consumption in albino rats. Science 1968; 161: 739– 41. 33. Li T.-K., Lumeng L., Doolittle D. P. Selective breeding for alcohol preference and related responses. Behav Genet 1993; 23: 163–70. 34. Lê A.D., Li Z., Funk D., Shram M., Li T.-K., Shaham Y. Increased vulnerability to nicotine self-administration and relapse in alcoholnaive offspring of rats selectively bred for high alcohol intake. J Neurosci 2006; 26: 1872–9. 35. Poulos C. X., Parker J. L., Lê A.D. Dexfenfluramine and 8-OH-DPAT modulate impulsivity in a delay-of-reward paradigm: implications for a correspondence with alcohol consumption. Behav Pharmacol 1996; 7: 395–9. 36. Dalley J. W., Fryer T. D., Brichard L., Robinson E. S. J., Theobald D. E. H., Lääne K. et al. Nucleus accumbens D2/3 receptors predict trait impulsivity and cocaine reinforcement. Science 2007; 315: 1267–70. 37. Belin D., Mar A. C., Dalley J. W., Robbins T. W., Everitt B. J. High impulsivity predicts the switch to compulsive cocaine-taking. Science 2008; 320: 1352–5. 38. Bell R. L., Kimpel M. W., Rodd Z. A., Strother W. N., Bai F., Peper C. L. et al. Protein expression changes in the nucleus accumbens and amygdala of inbred alcohol-preferring rats given either continuous or scheduled access to ethanol. Alcohol 2006; 40: 3–17. 39. Breese G. R., Chu K., Dayas C. V., Funk D., Knapp D. J., Koob D. F. et al. Stress enhancement of craving during sobriety: a risk for relapse. Alcohol Clin Exp Res 2005; 29: 185–95.

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40. Keller M. The oddities of alcoholics. Q J Stud Alcohol 1972; 33: 1147–8. 41. Wallner M., Olsen R. W. Physiology and pharmacology of alcohol: the imidazobenzodiazepine alcohol antagonist site on subtypes of GABA receptors as an opportunity for drug development? Br J Pharmacol 2008; 154: 288–98. 42. Mason B. J. Acamprosate and naltrexone treatment for alcohol dependence. Eur Neuropsychopharmacol 2003; 13: 469–75. 43. Anton R., O’Malley S., Ciraulo D. A., Cisler R. A., Couper D., Donovan D. M. et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence. The COMBINE study: a randomized clinical trial. JAMA 2006; 295: 2003–17. 44. Li C.-Y., Mao X., Wei L. Genes and (common) pathways underlying addiction. PLoS Comput Biol 2008; 4: e2. 45. Badiana A., Robinson T. E. Drug-induced neurobehavioral plasticity: the role of environmental context. Behav Pharmacol 2004; 15: 327–39. 46. Robins L. N., Helzer J. E., Davis D. H. Narcotic use in Southeast Asia and afterward: an interview study of 898 Vietnam returnees. Arch Gen Psychiatry 1975; 32: 955–61. 47. Wikler A. Narcotics. In: Braceland F. J., editor. The Effect of Pharmacologic Agents on the Nervous System. Baltimore, MD: Williams & Wilkins; 1959, p. 334–55. 48. Edwards G. Addiction, reductionism and Aaron’s rod. Addiction 1994; 89: 9–12. 49. Stanford University. Reductionism in biology. Stanford Encyclopedia of Philosophy. Available at: http://plato. stanford.edu/archives/ spr2009/entries/reduction-biology/ (accessed 30 April 2009).

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CHAPTER 7

Praxis, Interaction, and the Loss of Self-Control Darin Weinberg1

INTRODUCTION In this chapter, I want to focus on the self as social agent or as active participant in social interaction and how addictions to intoxicants emerge in the course of social interaction as surrogates for that self. My argument is that by so doing, we may begin to address an element of addiction that, while central to the meaning of this concept, has proven equally elusive to both the biomedical and the social sciences of addiction. That is, the identification of instances in which people are empirically observed not only to have engaged in socially disapproved or even dangerous drug use but to have actually succumbed to addiction, or to have lost control of their drug use. Because it is in and through social interaction with one another, rather than esoteric analyses of our minds or bodies, that evidence of addiction is normally gathered, a systematic understanding of what counts as interactional evidence of addiction should be a particularly important scientific priority. In the first section of the paper I demonstrate that both the ascendant medical and social scientific accounts of addiction curiously leave aside the question of self-control in favour of alternative framings of addiction and addictive behaviour. In the second section I explore the possibility of a sociology of the loss of self-control. Drawing upon ethnographic data collected in three treatment programmes, I examine the empirical grounds upon which members of these programmes in practice based their findings that either they or their peers had lost control of their drug use. I then

consider how to best explain these indigenous findings sociologically.

BIOMEDICAL THEORIES OF ADDICTION AND THEIR LIMITATIONS For most of the twentieth century, mainstream scientific research on addiction was agreed on the importance of distinguishing between hard drugs (defined by the fact that they produce physiological withdrawal symptoms) and soft drugs (defined by the fact that they do not do so). In addition to their capacity to produce physiological withdrawal symptoms, continued usage of hard drugs was also observed to produce a physiological tolerance such that users required ever-increasing quantities to produce the same effect. Along with their capacity to produce intensely rewarding psychological effects, the combination of physiological withdrawal symptoms and tolerance to hard drugs were said to foster development of powerful visceral compulsions that often destructively eclipse people’s regard for other aspects of their lives. Hence, it was that these three effects, the development of physiological withdrawal symptoms, tolerance, and continued persistence in use despite harmful effects became the hallmark of genuine addictions as opposed to the mere bad habits that one might acquire with respect to soft drugs. But the era has now passed when people could speak confidently of a distinction between drugs that produce genuine, or physical, addictions

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and drugs that produce only a more nebulous psychological addiction. The single most important catalyst to this era’s passing was the advent of crack. Crack cocaine is widely recognized as extremely addictive by clinical professionals and non-professionals alike but, oddly enough, it produces no gross physiological withdrawal symptoms (Gawin, 1991). By “gross physiological withdrawal symptoms” I mean symptoms like vomiting, cramping, delirium tremens, runny nose, itchy eyes, and so on that implicate specific physiological effects of withdrawal (this is in contrast to more psychological effects like anxiety or stress headaches which are less clearly linked to specific physiological effects of withdrawal). The same can also be said of nicotine, and all of the so-called behavioural addictions like sex, gambling, eating, etc. Furthermore, reliance on the distinction between physical and psychological addiction always suffered another serious analytic problem: relapse. Many consider relapse, or the resumption of a dis-preferred pattern of behaviour despite one’s desire not to, as the defining mark of addiction. Theories that trade on the distinction between genuine physical addiction and a much less severe psychological addiction cannot remain consistent in their explanations of relapse. Insofar as relapse occurs after withdrawal symptoms have cleared and have ceased to exert an influence on behaviour, our explanations of relapse must inevitably turn to prospective causal variables above and beyond physiological withdrawal and physiological tolerance. So exactly how do current biomedical theories account for relapse? They do so neurologically (cf. Koob et al., 1989; Koob, 2006). According to neurologists working in this area, prolonged drug use may induce a compensatory neurological adaptation that, in effect, amounts to the production of not only a physiological tolerance but also an anatomical tolerance to the drug in the nervous systems of heavy drug users. While the development of this type of tolerance may or may not induce gross physiological withdrawal symptoms upon removal of the drug, it does produce what neurologists call anhedonia, or a marked decrease in the capacity of one so afflicted to experience pleasure after drug use has been discontinued. During

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this period former substance users remain in a comparatively depressed state and thus significantly more vulnerable than they might otherwise be to stimuli that cue them to consider the analgesic effects of drug use. This approach is instructive in a number of important ways. First and foremost, it has important practical payoffs in that it informs our efforts to generate pharmacological therapeutic interventions. Drugs like Naloxone have proven to be life-saving for people in acute stages of opiate overdose and others like Methadone and various anti-depressant medications have improved the quality of life for former heavy drug users who might otherwise have remained without help. However, this said, the neurological model does suffer from significant theoretical limitations. Most fundamentally, insofar as they seek to predicate their theories of compulsive drug use on the presumption that the ingestion of certain chemicals invariably produces pleasurable experiences (cf. Gardner, 1992), neurologists systematically neglect how cultural learning and social context shape whether and how drug use becomes pleasurable or compelling for people. If our effort is to understand patterns of drug use in people, then blindness to the socially contingent meanings and practical relevances that drug use has for users is a rather serious theoretical handicap. More specifically, if our effort is to understand how people might lose self-control over their drug use, understanding the meaning and practical relevance of drug use and drug-induced experiences is absolutely indispensable. Let me make the case for this position in a bit more detail. Most neurological research on addiction assumes the existence of a mechanism or mechanisms common to all human nervous systems that causally link the physical events caused by drug ingestion in the brain, on the one hand, and the drug-seeking activities of particular users on the other. This assumption jibes rather poorly with the manifest empirical fact that not all people enjoy drug-induced experiences.2 It also jibes rather poorly with the fact that particular people may enjoy these experiences under some circumstances and wholly detest them under other circumstances

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(an example I often give to students is to contrast the experience of being drunk at a party to the experience of being drunk in a final exam). These facts cast considerable doubt on the prospects of ever fully reducing subjective and particular experiences of pleasure, pleasure seeking, pain, or pain avoidance to the generic functions or dysfunctions of generic neurological structures. Above and beyond the challenges of providing for the social contextual variability of drug effects neurologically, it must also be noted that current neurological theories of addiction speak only to the hypothesis that heavy drug use increases the propensity of drug users to pursue further drug use. For those of us interested in addiction per se, it is important to note that this hypothesis remains silent as to the nature of self-control and the capacities of certain drugs or activities to threaten our selfcontrol. If, then, we wish to conduct research into the nature of addiction as such, we cannot rest content with theories that speak only to increases or decreases in our desire for various things or activities. If the loss of self-control is the defining criterion of addiction, as most leaders in the field now readily acknowledge (cf. O’Brien et al., 2006; West, 2006), then it is absolutely indispensable for addiction research to include clear concepts of what the self actually is such that we find it capable of moving into and out of control of human actions in the first place. It is only then that we will learn how things like addictions might come to attenuate the causal relationship between selves and their actions. To date, neurological theories have remained conspicuously silent on the nature of the self, self-control, or the manner in which drugs might undermine them.

(cf. Lindesmith, 1938; Becker, 1953; 1967; Denzin, 1993). However, it conspicuously fails to speak to two essential questions that arise from listening to addicts describe their problems and from observing them in the conduct of their lives. First, it does not explain how we are to understand addicts’ reports that, under certain circumstances, they feel they are truly overwhelmed, rather than just rationally persuaded, by their desire to use drugs. And, second, it does not account for the repeated cycle of abstinence and relapse. We should expect to see all addicts who experience serious and recurrent drugrelated problems “mature out” (Winick, 1962), but unfortunately we don’t. What is it about some people’s drug involvements that compel continuance even after repeated association of the behaviour with negative experiences and despite their stated desires to abstain? Marsh Ray (1961) is the sociologist who most explicitly addressed the cycle of abstinence and relapse, and his is probably also the most widely cited theoretical statement of how relapse can be understood from a sociological vantage point. According to Ray’s theory, the cycle of abstinence and relapse should be understood as a process during which the former user consciously oscillates between a commitment to his using and non-using selfconcepts. Ray concludes his classic essay,

SOCIOLOGICAL THEORIES OF ADDICTION AND THEIR LIMITATIONS

This theory suggests relapse is a process necessarily involving conscious deliberation and comparisons between one’s using and non-using identities. As one can see, Ray’s is an extremely cognitivist and, indeed, rationalist, construal of the relapse process. The relapser is an individual who rationally evaluates the pros and cons of being an addict versus being an abstainer before deciding to relapse. But does this sound

In contrast to neurological research on addiction, sociological research has exhibited a sustained concern with social meaning, the social contextual variability of drug effects and the relationship between addiction and the self

socially disjunctive experiences bring about a questioning of the value of an abstainer identity and promote reflections in which addict and nonaddict identities are compared. The abstainer’s realignment of his values with those of the world of addiction results in the redefinition of self as an addict and has as a consequence the actions necessary to relapse. (Ray, 1961, p. 140)

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like addiction? If Ray is correct, what sense is there in thinking that addicts require any kind of therapeutic assistance whatsoever? The difficulty is that Ray, like most social scientists, fails to entertain as even the most remote possibility the prospect that human behaviour might not always issue directly from the conscious reflections and deliberate assertions of the self. The recurrent reports made by addicts themselves of feeling overwhelmed, and indeed afflicted, by their addictions are categorically dismissed in favour of an axiomatic theoretical commitment to conceptualizing all human action as the product of a fully conscious cost-benefit analysis wherein the self remains, by definition, unassailably secure as the inevitable and irreplaceable origin of everything people do. So whereas biomedical theorists lack any concept of self or self-control that might facilitate their explanation of how heavy drug use might attenuate our self-control, extant sociological self-centric theorizing requires that we axiomatically dismiss any possibility of a loss of self-control altogether. If addiction is to be taken seriously as a genuine cause of human suffering and as a problem deserving of therapeutic assistance rather than societal indifference or merely coercive social control, we need a theoretical approach that is supple enough to provide for the manifest variety of ways in which drug use fosters further drug use, the variety of ways in which patterns of drug use cause users to suffer, and, most importantly, that can somehow provide for the causes of that suffering without automatically reducing them to either the neurologists’ universal structures and functions/dysfunctions of the human nervous system nor to the sociologists’ invariant construal of all human behaviour as inevitably self-governed.

TOWARD A SOCIOLOGY OF THE LOSS OF SELF-CONTROL Quite unlike the depictions of addicted behaviour we find in received sociological accounts, the people I studied did not uniformly depict relapse as a self-governed act but often characterized it as a deeply troubling and mysterious loss of self-control. This can be seen,

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for example, in the following field-note excerpt from my research with homeless people presumed to suffer from addictions: I’ve promised myself I wouldn’t use a thousand times and really meant it. And then I use. I mean it’s like there are two sides of me. The rational reasonable person who knows he’s gonna die if he keeps on living the way he is and the insane one who just doesn’t care. My reasonable side of me can be as sure as it wants to be but when those drugs appear in front of me the insane one takes over and all those reasons I had not to use are just gone. They just disappear. And I use. It’s like my mind just goes dead and my addiction takes over. I hate myself right afterwards and I’m completely confused by the fact that I just used. I didn’t want to but I did. It’s all well and good to say you need to make a commitment but for some of us that’s not enough. We need something more than that and it doesn’t help for people to be all smug about how we need to make a commitment and it’s all that simple.

Well-known writers on addiction like Stanton Peele (1989) and John Davies (1992) have suggested that such accounts are in no way valid descriptions of the reality of addiction but merely socially functional for those who provide and/or believe them. Cultures like our own furnish people with the narrative of addiction that they embrace and apply strategically to fulfil their own self-interests. I dispute neither the claim that these accounts are socially functional nor that they reflect conceptual commitments prevalent in the cultures to which putative addicts belong. What I do dispute is the claim that either of these facts necessarily forecloses on an account being also descriptively valid (Haraway, 1991). Moreover, the radical reduction of such accounts to mere tokens of a priori conceptual commitments and/or the instrumental strategies of those who provide them systematically fails to account for either the phenomenology of addiction as a source of suffering or for the ways in which addictions become empirically observable as consequential causal agents over the course of ongoing social interaction. In what follows I propose one way of overcoming both of these rather serious failings.

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DISTINGUISHING SELVES AND ADDICTIONS IN THERAPEUTIC PRACTICE In the treatment programmes within which I have conducted ethnographic research, people distinguished human agency, or self-governed action, from the nonhuman agency of people’s addictions primarily on the basis of three discretionary considerations: 1. provisional assessments of the distinctive character of people’s addictions (or in the terms of the local vernacular, their particular ‘patterns’); 2. provisional assessments of people’s particular practical circumstances; and 3. provisional assessments of who particular programme participants were as individuals (Weinberg, 2005). Space constraints preclude a thorough discussion of these elements of recovery work but a few examples should suffice to make my case. Because they believed one of the distinctive characteristics of addiction to be denial, programme members expected one another to exhibit openness to the opinions of other programme members regarding their problems and not display too much commitment to their own sense of their relative vulnerability to relapse. In the following data excerpt, Sean (all programme participants’ names are pseudonyms) interprets Tony’s failure to acknowledge that addiction is a “sneaky disease” as a failure to display competent human agency within the practical context of their recovery programme, and, hence, as evidence that Tony was presently under the influence of his addiction. This determination appears to reflect both Sean’s understanding of addiction as a particular type of mental affliction and the manner in which Tony should have been undertaking to recover from it. Tony had been opining that he was no longer vulnerable to craving because he was taking a new medication. Sean replied: “. . . be careful, ‘cause this disease we got is sneaky. And you know a lot of the times when you’re the most confident that you got it licked, that’s when it jumps on you ‘cause you start subjectin’ yourself to risks you don’t need . . .” Tony said “Oh man, that’s bullshit. I mean I know what you’re sayin’ and I’ve heard it before

but I don’t agree with that shit. Nobody can tell me what I feel . . . ” After Tony got up Sean looked over to me, shook his head and said “That boy’s in trouble. Did you see how defensive he got when I just said be careful? I mean that is classic, classic, addict behavior. If I had to isolate one symptom that was classic addicted thinking, that’d be it.”

In stark contrast to the received sociological wisdom, Sean’s estimation of the boundaries of Tony’s human agency in this episode was not predicated upon a simple one-to-one correspondence between Tony’s personal conduct, on the one hand, and his self-government on the other. Rather, it was predicated upon his expectations regarding the distinctive manner in which Tony’s putative addiction would, if it did, exercise its nonhuman agency in and through Tony’s personal conduct. Sean exhibits his expectation that there were in fact at least two potential causal agents that might become manifest in Tony’s conduct: 1. Tony’s own human agency as a self-governing actor; and 2. the nonhuman agency of Tony’s addiction, which might very well overpower Tony’s human agency—hence the remark that Tony was “in trouble.” In the same sense that Sean was interacting with Tony as a fellow human agent in this exchange, he was also interacting with Tony’s addiction as a nonhuman agent. Indeed, in noting to me the trouble he felt Tony was in, Sean was responding to the causal influence he seemed to see Tony’s addiction exercising in that very encounter (“If I had to isolate one symptom that was classic addicted thinking, that’d be it”). The social interactions that took place in my research settings suggest the wisdom of regarding human and nonhuman agencies as equally capable of driving personal experience and conduct, rather than viewing one as necessarily epiphenomenal of the other (Weinberg, 1997b; 2005). In the above data excerpt we see how basic expectations regarding the nature of addiction could colour people’s interpretations of one another’s behaviour. However, these expectations were not the only sources of such interpretations. Instead, they competed for attention with provisional assessments of people’s practical

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circumstances in governing whether people’s actions were seen to exhibit their addictions or sound personal judgments. In the following instance, for example, a client had dropped out of the programme and was accumulating considerable debts using crack cocaine. She was contacted by a counsellor but resisted this counsellor’s efforts to place her into an inpatient recovery setting. In the absence of mitigating factors, counsellors usually regarded such resistance to treatment as evidence of the fierce hold individuals’ addictions had over them. However, in this case there were mitigating circumstances and, despite the intensity of this client’s relapse and continuing drug use, her resistance was treated as evidence of competent human agency rather than addiction, She’s resisting it because she doesn’t want to lose her apartment. You know she moved into that apartment next to her parents’ place, and it’s kind of a good situation for her. If she goes into inpatient treatment she’s afraid she’ll lose her place. I can understand how she feels. She’s in a tough situation.

In addition to provisional assessments of the nature of one another’s addictions and personal circumstances, distinctions between human agency and the nonhuman agency of addiction were also based on programme members’ provisional assessments of one another’s unique personal characteristics as individuals. Programme members drew upon their knowledge of the details of one another’s unique biographical histories to inform assessments of whether, and specifically how, the causal effects of their addictions were or were not evident in their behaviour. In the following data excerpt taken from a group therapy session, Sherry’s recent “willfulness” is read as evidence of her addiction reasserting itself. Paula, a counsellor, had mentioned her surprise when she saw Sherry’s name on a list of people recently written up for poor behaviour. Paula said: “Let’s start with you Sherry. I was surprised to see your name on this list. What’s up?” Sherry said, “I’m surprised too, I don’t know.” Sherry mentioned what she thought she had been written up

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for—things like not going to meetings and refusing to get to her kitchen assignment on time. Paula said, “Sounds like a lot of ’em you got behind that willful behavior of yours . . .” Sherry nodded, smiled, and said, “Yep, it does look like that. I think it is my being willful.” Paula said, “When you start having good ideas, when you start thinking that you know better than everybody else what’s good for you, that’s a good time to start getting suspicious and to check yourself. When you start saying ‘I don’t think I need to go to group.’ or ‘I don’t think I need to get up and do my chore.’ that’s the kind of thing that’s gonna get you kicked out of here and you’ll be right back out there where you were. That’s your disease talkin’ and tryin’ to get you to relapse. It’s real important that when you start getting those willful feelings that you find somebody to talk to and check yourself.” Sherry nodded sheepishly in agreement.

It was only thanks to Sherry’s otherwise encouraging performance of late, coupled with a known history of putatively drugrelated obstinance, that it became reasonable to attribute her recent and “willful” misbehaviour to her addiction’s nonhuman agency rather than her own human agency. If we view diagnosis as a strictly technical rational enterprise (see Kirk and Kutchins, 1992, pp. 220–3), then clinical judgments like this may be considered aberrations—at best, mistakes, and at worst, deeply disturbing instances of personal oppression carried out under the auspices of clinical medicine (cf. Szasz, 1961). However, if we view such diagnoses as grounded in the moral order of community living, then things cease to appear quite so grave. Seen in this light, Sherry’s “willfulness” resisted being construed as an exhibit of her own human agency because it was inconsistent with the human agent Paula perceived Sherry to have become (“I was surprised to see your name on this list.”). Given its inconsistency with Paula’s current impressions of Sherry, Sherry’s “willfulness” became eminently available for reading as an effect of her “disease” that was “tryin’ to get [her] to relapse.” While by strictly technical rational lights, “willfulness” may seem a very odd category of behaviour indeed to

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attribute to nonhuman causes, the practical circumstances in which Paula and Sherry found themselves allowed for this attribution without a hitch. Most fundamentally, these circumstances involved the sustenance of moral community between them. In opposition to the dogmatic libertarian commitments of authors like Thomas Szasz, I want to suggest that interventions like that taken by Paula with Sherry above can indeed be understood as empowering rather than repressive. They can be understood as empowering to the extent that we take seriously, as did Paula and Sherry, the notion that particular people actually can periodically lose control of their behaviour, that they actually can be overwhelmed by the nefarious influence of intra-personal nonhuman agents in the form of addictions. By these lights, quelling addictions per se is not an act of repression. It is an act of freeing people from the havoc wreaked upon them by an unwelcome affliction. Of course, different commentators, including putative addicts themselves, may very well debate the characteristics of their addictions and the relative influence that these nonhuman agents have over their personal conduct in any given instance. In fact, such debates formed the bulk of what passed for clinical work in my research settings. But the fact that the characteristics and relative influence of people’s addictions on their activities are intrinsically contestable hardly disqualifies them from being taken seriously as nonhuman agents. Indeed, it might be argued that it is precisely in this resistance to unequivocal description and human control that the nonhuman agency of addictions is most robustly in evidence.

CONCLUSION In contrast to received sociological accounts, the moral economy of therapeutic practice in the treatment programmes in which I conducted ethnographic fieldwork did more than simply inform how programme participants produced, sustained, and amended their linguistic descriptions and/or cognitive beliefs about the respective addictions from which they were presumed to

suffer. It actually gave empirical form to these addictions as causally influential things-in-theworld. Addictions were observed to exercise causal influences over people’s perceptions and behaviours and, in so doing, altered not only people’s descriptions and beliefs but also the course of specific interactions and the contours of therapeutic community life itself. Rather than merely observing or describing their addictions, programme members undertook strident campaigns to subdue the actions they attributed to them (see also Mol and Law, 2004). This work, in effect, animated their addictions as nonhuman agents, and engaged programme participants in interactional struggles with these disorders as collectively confirmed realities. Hence, the work of recovery amounted to a good deal more than a process of ideological or cultural conversion. Instead, it consisted in collective struggles to overcome particular troubles conceived and, indeed, empirically observed as the effects of addictions as materially embodied causal agents. Equally, though, in contrast to biomedical accounts, the nonhuman agents with which residents struggled were constituted only in and through the moral economy of programme practice. Not only did people’s addictions often take forms bearing no evident relationship to formally codified psychiatric nosologies (e.g., willfulness), but assessments of both their presence and absence in people’s behaviour were dictated only by the locally meaningful organization of programme affairs and participants’ expectations regarding themselves and one another as collaborators in those affairs. Thus it should be resolutely noted that genetic, neurological, and other forms of biological evidence that might be used to great advantage in other settings for the treatment of addiction had absolutely no part in it. This is by no means to argue that the loss of self-control can be scientifically understood only within the context of social praxis and interaction. It is, rather more modestly, simply to assert that praxis and interaction constitute a fundamental medium within which the loss of self-control emerges as an empirically observable event and that this medium is not easily explained by means of the analytic tools provided by the scientific disciplines of biology

PRAXIS, INTERACTION, AND SELF-CONTROL

or psychology. Insofar as the social sciences do provide a distinctively effective set of analytic resources for systematically analysing and explaining this medium, they should hold considerable promise among those of us who would hope to bring a more robust understanding of the loss of self-control to the scientific study of addiction.

NOTES 1. Some passages in this chapter have been variously adapted from Weinberg, 1997a; 1997b; 2002; 2005. 2. The Harvard philosopher Richard Moran (2002) writes incisively on this matter: “It is sometimes said that certain drugs ‘produce’ pleasure, but this is true only in the same sense that either string quartets or ripe cheeses ‘produce’ pleasure. In both cases we can provide the cause without producing the effect, because the person exposed to either the drug or the music doesn’t like it, doesn’t see what there is to enjoy in it. What was the very form of hazy, druggy pleasure for someone else is for this person merely some unpleasant dizziness and disorientation. Even here, when we speak of drugs ‘doing’ this or that, finding pleasure in the experience is a matter of being inclined to take pleasure in what is given. And the fact that such ‘know-how’ may simply come naturally or spontaneously to the person does not make his engagement any the less active, any more than it does for ordinary physical skills or habits of inference.”

REFERENCES Becker, H. S. (1953) ‘Becoming a Marijuana User’ 59 American Journal of Sociology 235–42. Becker, H. S. (1967) ‘History, Culture and Subjective Experience: An Explanation of Social Bases of Drug-Induced Experiences’ 8 Journal of Health and Social Behavior 163–76. Davies, J. B. (1992) The Myth of Addiction (Amsterdam, Netherlands: Harwood). Denzin, N. K. (1993) The Alcoholic Society (New Brunswick NJ: Transaction). Gardner, E. L. (1992) ‘Brain Reward Mechanisms’ in J. Lowinson et al. (eds.), Substance Abuse: A Comprehensive Text (Baltimore MD: Williams & Wilkins). Gawin, F. (1991) ‘Cocaine Addiction: Psychology and Neurology’ 251 Science 1580–6.

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Haraway, D. J. (1991) Symians, Cyborgs and Women (New York: Routledge). Kirk, S. A. and H. Kutchins (1992) The Selling of DSM (Hawthorne NY: Aldine de Gruyter). Koob, G. F. (2006) ‘The Neurobiology of Addiction’ 101 Addiction 23–30. Koob, G. F., L. Stinus, M. LeMoal and F. E. Bloom (1989) ‘Opponent Process Theory of Motivation: Neurobiological Evidence from Studies of Opiate Dependence’ 13 Neuroscience and Biobehavioral Reviews 135–40. Lindesmith, A. R. (1938) ‘A Sociological Theory of Drug Addiction’ 43(4) American Journal of Sociology 593–609. Mol, A. and J. Law (2004) ‘Embodied Action, Enacted Bodies: The Example of Hypoglycaemia’ 10(2–3) Body & Society 43–62. Moran, R. (2002) ‘Frankfurt on Identification: Ambiguities of Activity in Mental Life’ in S. Buss and H. Overton (eds.), Contours of Agency (Cambridge MA: MIT Press), pp. 189–217. O’Brien, C. P., N Volkow and T. K. Li (2006) ‘What’s in a Word?: Addiction versus Dependence in DSM V’ 163(5) American Journal of Psychiatry 764–5. Peele, S. (1989) Diseasing of America (Lexington MA: Lexington Books). Ray, M. (1961) ‘The Cycle of Abstinence and Relapse Among Heroin Addicts’ 9 Social Problems 132–40. Szasz, T. (1961) The Myth of Mental Illness (New York: Hoeber-Harper). Weinberg, D. (1997a) ‘Lindesmith on Addiction: A Critical History of a Classic Theory’ 15(2) Sociological Theory 150–61. Weinberg, D. (1997b) ‘The Social Construction of Non-Human Agency: The Case of Mental Disorder’ 44(2) Social Problems 217–34. Weinberg, D. (2002) ‘On the Embodiment of Addiction’ 8(4) Body and Society 1–19. Weinberg, D. (2005) Of Others Inside: Insanity, Addiction and Belonging in America (Philadelphia PA: Temple University Press). West, R. (2006) Theory of Addiction (Oxford: Blackwell). Winick, C. (1962) ‘Maturing Out of Narcotic Addiction’ 14(5) Bulletin on Narcotics 1–7.

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CHAPTER 8

Framing Nicotine Addiction as a “Disease of the Brain” Social and Ethical Consequences Molly J. Dingel, Katrina Karkazis and Barbara A. Koenig In this article we draw on in-depth interviews with 86 experts in tobacco control, nicotine addiction research, or smoking cessation to examine how genetic research on addiction (and addiction more broadly) shapes the meaning ascribed to smoking and thus affects the scope and structure of tobacco control policy. This article is organized around four key questions raised by critical analyses of this body of research. First, will genetic research change how we understand addiction? We argue that most stakeholders hold a medicalized view of addiction, though a cultural shift that would locate addiction solely within the body, especially with regard to initiation, has not occurred. However, biology is widely understood to be a factor in the strength and speed with which one becomes addicted after initiation. Second, will increased focus on addiction as a disease of the brain lead to unrealistic expectations for treatment? Our data suggests that this is not likely, but for teenagers, it may reinforce expectations that quitting smoking is not difficult. Third, will it change the way people understand cessation, cessation options, and their personal responsibility for or ability to quit smoking? We argue that this research will change what people understand to be the most effective cessation techniques, with increased emphasis on pharmaceuticals and decreased emphasis on “willpower” and modification of behaviors and environments. Finally, will it increase or decrease stigmatization of smoking? We predict that it is unlikely this research will either increase or decrease smoking stigma, but that individuals will utilize the research to buttress their existing

view of stigmatization and smoking. Because of the complex nature of smoking and addiction, we join the voices of those from a wide variety of disciplines studying addiction who are calling for an interdisciplinary understanding of addiction as a biosocial or biocultural phenomenon (Acker, 2010; Courtwright, 2010; Keane and Hamill, 2010; Kushner, 2010; Vrecko, 2010; Windle, 2010).

BACKGROUND For more than two centuries in the U.S. there has been conflict over how to understand the excessive use of consciousness-altering drugs or substances, which has been understood variously as a sin, crime, bad habit, moral weakness, disease, and, most recently, as a disease of the brain (Dackis and O’Brien, 2005). Tobacco use has followed alcohol and other drugs in a conceptual shift from being viewed as a habit to, in many scientific and medical circles, a disease (cf. Kessler et al., 1997; Kmietowicz, 2000). Smoking, with roots in spiritual and medicinal ceremonies in native New World cultures, has long been considered a “habit,” possibly even beneficial to one’s health and capable of stimulating virility and vigor and staving off syphilis (Robicsek, 2004). In contrast to alcoholism, which physicians Benjamin Rush and Thomas Trotter defined as a “disease” in the late 1700s (Conrad and Schneider, 1980), for much of the 20th century smoking was considered socially acceptable. Massive advertisement and propaganda campaigns by the tobacco industry (Brandt, 2007), coupled with the

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addictive nature of nicotine and its widespread use, blunted moral objections to smokers and smoking (Courtwright, 2001). In the past 30 years, however, smoking has become both more stigmatized and considered an addiction in need of intervention (Chapple et al., 2004; Goldstein, 1991; Hines, 1996; Markle and Troyer, 1979). The perception that smokers can and should be treated as patients has risen in large part from overwhelming data implicating cigarette smoke in serious health problems like emphysema, heart disease, and various cancers (Welshman, 2004). Like other drugs of abuse, smoking has been codified as a clinical problem by the American Psychiatric Association (American Psychiatric Association, 2000). Current scientific views of addiction, including nicotine addiction, are consistent with the standard “medicalization” framework where problems and behaviors “become defined and treated as medical problems” (Conrad, 1992:209). Medicalization has moved drug use and abuse from being understood as a “choice” to one in which the addict is understood as suffering from a “disease” (Conrad and Schneider, 1980; Keane, 2002). There has been another turn in the past 20 years to what Clarke and colleagues (2003) label “biomedicalization.” Biomedicalization encompasses the medicalization of traits, behaviors, and bodily processes, but with special attention toward the “increasingly technoscientific” nature of medicine, the economic drive behind such new technologies and drugs, and the transformation of bodies in such a way that creates new “individual and collective technoscientific identities” (Clarke et al., 2003:163). It is within the context of widespread biomedicalization that the “NIDA paradigm”—the idea that addiction is a “disease of the brain”— has arisen. In this paradigm, addiction is the result of heavy drug use that changes the structure and function of the brain, making cessation difficult (Courtwright, 2010; Leshner, 1997). The NIDA paradigm is supported by prominent biological theories of addiction that implicate the “brain reward” dopamine, serotonin, and glutamate systems (including associated genes, neurotransmitters, receptors, transporters, and enzyme targets) (Li, Mao,

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and Wei, 2008; Nestler, 2005; Schnoll, Johnson, and Lerman, 2007), and memory-related processes (Uhl et al., 2008). Further, many of these systems are also implicated in a variety of diseases and disorders, such as schizophrenia, which is considered a risk factor for smoking (O’Daly et al., 2005). The NIDA paradigm does not preclude and, in fact, seems to include, genetic predispositions to addiction; NIDA publications cite the estimate that 40 to 60 percent of a person’s vulnerability to addiction is due to genetic factors (National Institute on Drug Abuse, 2007:8). Further, NIDA funds research that seeks to identify genetic predispositions that were initially identified through classic approaches such as twin studies: Genome-wide association studies (GWAS) (Bierut et al., 2007) and recent meta-analyses of GWAS (Thorgeirsson et al., 2010) are part of the body of literature that utilizes the most recent techniques for examining possible genetic influences on smoking initiation, maintenance, and cessation (Amos, Spitz, and Cinciripini, 2010). Smoking thus parallels a common understanding of alcoholism: Certain people are vulnerable, and once an individual begins smoking, those with certain genetic variants are at higher risk to drink or smoke heavily and have extreme difficulty quitting (Amos, Spitz, and Cinciripini, 2010). Smoking research examines not just the effect of smoking and drug use on higher brain functions or genetic susceptibility to addiction after initiation, but also the effect of genes on higher brain function as it relates to susceptibility to initiate drug use. Recent studies indicate that genes in the chromosomal region that code for brain-derived neurotropic factor (BDNF) are associated with smoking initiation (Tobacco and Genetics Consortium, 2010). Similarly, some NIDA-funded researchers argue that genetically-based personality traits like risk taking and impulsivity may predispose certain individuals to experiment with drugs, including tobacco (Kreek et al., 2005). Neurogenetic research claims that people may become addicted to drugs for reasons that include genetic predispositions, personality predilections, and risks from a variety of comorbid disorders and diseases such as schizophrenia

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(Courtwright, 2010; Keane and Hamill, 2010; Kushner, 2010). Taken together, this research, including, but not limited to, the NIDA paradigm, implies that the potential to become addicted is an inherent part of our bodies—addiction rests within us waiting to be triggered (Schull, 2003) and everyone is at risk. Individuals become addicted not just to the drug, but to neurotransmitters like dopamine and serotonin released in the brain (Keane and Hamill, 2010; Schull, 2003). Even for those without genetic or other risk factors, because of the power of the reward system of the brain, these artificial substances purportedly “flip a switch” in the brain such that, once activated, drug use moves from being voluntary to involuntary and “beyond one’s control” (Brower, 2006), especially as continued heavy use changes an individual’s brain structure and function. Imaging studies, including positron emission tomography (PET), magnetic resonance imaging (MRI), and functional MRI (fMRI) (Illes, Kirschen, and Gabrieli, 2003; Li and Sinha, 2008; Volkow et al., 2007) have intensified understandings of addiction as a brain disease in profound ways because of the power of brain images to make objective claims not only about our brains, but also about who we are (Dumit, 2004). As Wayne Hall has noted, “a ‘disease’ that can be ‘seen’ in the many-hued splendour of a PET scan carries more conviction than . . . self-reports of addicts who claim they are unable to control their drug use” (Hall, Carter, and Morley, 2003:867). Because brain images are fluid signifiers that are easily (if at times inaccurately) made meaningful by society and laypersons (McCabe and Castel, 2007), they can serve different meanings simultaneously (Dumit, 2004). As Campbell states, “the social power of this tool is lodged in its potential to change public perceptions— to effectively change the ‘truths’ upon which members of the public proceed on the path to recovery” (Campbell, 2010:100). As a consequence, independent of researchers’ intentions and prior to any clinical applications, neuroimaging research on addiction is creating novel relationships between brain images, “brain types,” and individual perceptions of self and

disease that have implications for societal and clinical responses to nicotine addiction as well as for the subjectivity of smokers. A conception of addiction as a disease of the brain also has potential legal implications, though these are more relevant to illicit drugs and alcohol than to nicotine. Legal responsibility is distinct from the public or lay understandings of responsibility discussed earlier, and the courts have consistently ruled that addicts are responsible for illegal behavior (Powell v. Texas, 1968; Traynor v. Turnage, 1988; United States v. Moore, 1973). However, the disease model of addiction has influenced sentencing—addicts are still legally responsible for their actions, but the consequences of a guilty verdict may be mediated by their addiction. For example, the rise of drug courts presents a significant deviation from traditional adjudication, in which nosologic categories were irrelevant (Nolan, 2002). Drug courts offer an alternative that provides a space for law and therapy to be “a fully collaborative enterprise” (Nolan, 2002:1726). In drug courts, addiction is understood as a disease and not the result of poor moral choices; this model provides the basis for the courts to “coerce” treatment and replace prison with heavy surveillance and treatment (Tiger, 2011). These new biological connections are products of novel scientific approaches and provide insights that may help in the development of new cessation technologies; however, it is critical to contextualize them within the sociology of science, which details the intimate relationship between scientific research and its sociocultural context (Haraway, 1988; Harding, 1986; Latour, 2004; Longino, 2002; Sprague, 2005). But as Kushner points out, “the fact that science, like everything else, is socially constructed in no way diminishes its explanatory power” any more than it limits the value of social or historical analyses (Kushner, 2006:138). Although some social analyses of addiction have eschewed the work of biologists (cf. Levine, 1978; Moore, 1992), the definitive language used by the biological model also often excludes the important social, cultural, and structural influences on drug use and abuse. Because of the social and economic

FRAMING NICOTINE ADDICTION AS A DISEASE

power of biomedical research and its centrality as an explanatory frame accounting for socially undesirable behavior, focusing on the biological may in fact broadly influence both stakeholder and public opinion about addiction in ways that yield unintentional consequences for addiction prevention, treatment, and research.

METHODS To discern how stakeholders concerned with nicotine addiction understand neurogenetic research, we interviewed 86 professionals from around the U.S. (20 scientists, 25 tobacco prevention specialists, 19 clinicians who specialize in nicotine addiction and smoking, 11 representatives of pharmaceutical companies with tobacco

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cessation products on the market or in development, and 11 health payers; see Table 8.1). Because of the diverse nature of tobacco use as a health problem, it was essential to include stakeholders across a wide variety of professions: those developing and marketing new therapies, those treating patients seeking help for addiction, those creating prevention programs or formulating public policy, and those who make decisions about what products will be insured by health payers. Interviews with key informants provide an account of their understanding of genetic research and suggest how they might act in the face of emerging genetic findings, thus providing critical insight into the potential impact of genetic research on policy, clinical practice, and prevention (Patton, 1987).

Table 8.1 Description of Sample and Recruitment Title

Description

Sampling and Recruitment

Number of Interviews

Scientists

Psychiatrists (n = 13), neuroscientists (n = 4), geneticists (n = 1), and other researchers (n = 2) who investigate neurogenetic links to nicotine addiction

Identified through scientific publications, professional meetings, and National Institutes of Health (NIH) grant awards, participation in Transdisciplinary Tobacco Use Research Centers (TTURCs), and by “snowball” sampling

20

Clinicians

Clinicians and researchers involved in smoking cessation, tobacco management, and the treatment and prevention of tobacco-related disease

Sampled from each of the 10 regions outlined by the Department of Health and Human Services (HHS), with two participants from each region (U.S. Department of Health and Human Services, n.d.)

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Tobacco prevention specialists

Policy makers in the public and private spheres, including federal (n = 2), state (n = 19), and local (n = 2) health policy officials in tobacco control and health prevention; public health educators involved in developing and administering nationwide tobacco prevention programs (n = 2)

Sampled from the 10 geographic regions defined by the HHS (U.S. Department of Health and Human Services, n.d.) as well as federal sources; two stakeholders from each HHS region 1, 3, 5, 6, 7, 8, 10; three from each HHS region 9, four from HHS region 4, one each from HHS regions 3 and 2; two from federal sources

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(Continued)

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Table 8.1 (Continued) Title

Description

Sampling and Recruitment

Number of Interviews

Health payers

Individuals involved in making coverage decisions for large health-care providers

Identified using Internet resources and company media contacts; participants had ties with medical assistance programs or worked for one of six large health-care companies; state Medicaid program in HHS Region 1 (n = 1); state-level private healthcare companies in Region 9 (n = 4); state-level private healthcare companies in Region 5 (n = 1); people involved at national level (n = 5)

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Pharmaceutical employees

Bench scientists in research and development (n = 5), clinicians and others running trials (n = 4), communication and advertising specialist (n = 1), and drug representative (n = 1)

Recruited through personal contacts; represent 6 different pharmaceutical companies that market or are developing tobacco cessation products

11

Note: This table also appears in Dingel et al. (2011).

Experts were queried on a variety of topics, including: the etiology addiction; the potential effects of new technologies on public health campaigns; the stigmatization of smokers; and smoker and public conceptions of smoking, addiction, and smoking cessation.

RESULTS Will Genetic Research Change How We Understand Addiction? When asked what addiction was, about half of all stakeholders (almost all preventionists and health payers, half of clinicians and scientists, but only one pharmaceutical employee) described addiction in a way that placed it squarely within a medicalized realm, but that did not necessarily indicate etiology. These stakeholders defined addiction by either deferring to the current version of the Diagnostic and

Statistical Manual (DSM) (American Psychiatric Association, 2000), or utilizing concepts including compulsive use, “needing the drug to feel well,” loss of control, “bad decision making,” craving, inability or difficulty quitting, increased tolerance, or use that interferes with a productive lifestyle. These results may be consistent with either environmental variables or biological ones; etiology is not clear. Examples include: An addiction is something that once you start doing it, the behavior or the drug or whatever it is, that you find it hard to stop, despite it having negative impacts on your health or how you feel. (clinician practicing on the East Coast) Nicotine addiction . . . also leads to other diseases, . . . but I think in and to itself, it’s a disease. (tobacco cessation specialist in a state public health department in the Pacific Northwest)

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Our interviews show that addiction is widely understood as an uncontrollable behavior, with individuals unable to quit on their own. These statements are consistent with the fact that diagnosis for substanceuse disorders remains focused on behavior; although there is increasing use of pharmaceutical interventions for addiction (e.g., nicotine replacement therapy and non-nicotine pharmaceuticals like bupropion and varenicline), treatment programs continue to focus on behavior modification in order to facilitate smoking cessation. Probes about addiction etiology yielded a stakeholder view of addiction that is consistent with the conception that the potential for addiction exists in our bodies prior to drug use, waiting to be triggered, especially for those with certain genetic profiles. Most stakeholders believed the environmental factors (e.g., peers, family, stress) to be the primary causal factor for smoking initiation, but the speed and severity with which one became dependent on tobacco was determined by biology—once you initiate smoking, it flips a biological “switch” that perpetuates the behavior. A typical comment was: I think for initiation, stress and peer pressure [are most important]. For maintenance, once you start, then I think that’s when the genetics kick in. (pharmaceutical employee: director for development of a new cessation aid)

Only three stakeholders in our sample of 86 believed addiction was solely the result of social variables, which indicates a fairly high degree of medicalization in this sample of stakeholders. Almost everyone in our sample understood addiction as a disease or problem largely consistent with DSM diagnoses. However, stakeholders also identified environmental, social, and cultural variables underlying drug use and abuse, which indicates that they do not hold a view of addiction that is exclusively consistent with “biomedicalization.” Even so, most of our sample believed that the degree and speed with which one becomes addicted is governed by one’s genes.

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Will Genetic Research Lead to Unrealistic Expectations for Treatments? Addiction biology research increasingly relies on technological processes to probe etiology, including a variety of studies utilizing genetics, brain receptors, and new imaging technology. For example, in May 2006, the U.S. Food and Drug Administration (FDA) approved varenicline as a smoking cessation drug. Varenicline, marketed by Pfizer as Chantix, represents a new class of drugs whose development was possible only with increased understanding of nicotine’s effects on the brain. Varenicline mimics nicotine’s ability to bind to specific ion channels in the central nervous system, which both moderates craving and lessens the effect of nicotine if one smokes (Yarnell, 2005). Another potential therapy is a nicotine vaccine (NicVAX, by Nabi Biopharmaceuticals), currently in FDA Phase III clinical trials. The nicotine vaccine induces the body to produce antibodies that bind to nicotine and prevent it from acting on receptors in the brain (Hall, 2005). These pharmaceuticals are two among many: Spectra Intelligence reports that there are nearly 35 drug candidates in various stages of development and testing for treatment of nicotine, alcohol, and narcotic dependence (cited in Thayer, 2006). These numbers illustrate the economic potential of these drugs for the pharmaceutical industry: In 2005, nicotine addiction therapies alone totaled $1.5 billion in sales (Thayer, 2006). Although neurogenetic research is likely to lead to better smoking cessation therapies and targeted treatment, it may also lead to unrealistic ideas about the possibility for “magic bullet” treatment interventions that suggest anyone could quit smoking with minimal difficulty (Hall, Carter, and Morley, 2003). Although expanding options to help people quit smoking is useful and needed, even varenicline’s manufacturer acknowledges that in clinical trials over half of those who use this drug to quit smoking will return to smoking within 12 weeks, which demonstrates that even highly promising treatments are not magic bullet cures (Pfizer Inc., 2011). Further, varenicline’s side effects, which potentially include “changes in behavior,

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hostility, agitation, depressed mood, suicidal thoughts or actions” (Pfizer Inc., 2010), raise questions regarding the side effects of these promising treatments. Interviewees pointed to their concern about possible unrealistic expectations regarding the power of new drugs to “cure” addiction. Many stakeholders, for example, were concerned that scientific and public focus on the biological bases of addiction and new drugs to treat addiction, like the nicotine vaccine, would lead both clinicians and smokers to believe one could just prescribe or receive a pharmaceutical “fix” for addiction. Roughly half the clinicians and some of the prevention workers were concerned that the public (or smokers) would perceive such new pharmaceutical therapies as magic bullet cures, and thus leave them with a false sense of safety that they could quit smoking at any time without difficulty. [People might think that the vaccine is] a be all, end all, which is what they always think new drugs are. . . . it’s like, “Okay, I don’t have to change my behavior because there’s a magic fix at the end of the rainbow. (prevention worker: program manager for a state health department in the South) There’s no silver bullet to treat nicotine dependence. I think we need a retinue of agents. One could be potentially in quotes, a “vaccine,” some kind of antagonist that would block specific receptor sites. But, having said that, we have stuff that works. We know comprehensive, populationbased campaigns are highly effective. We know the current treatment of nicotine dependency is effective, despite what some folks would say. (prevention worker: teaching and researching at a public health department in the Northeast)

These quotations reflect a recurrent theme in the interviews: The biomedical model of addiction fails to provide all the tools necessary to address addiction—a fact acknowledged by neuroscientists and geneticists. Although genetic researchers accept that there is scientific support for both a neurobiological and environmental/social basis for addiction (Biglan et al., 1995; Graham et al., 2006), the certainty implied by biomedical language used

to describe addiction as a disease of the brain obscures and minimizes the many unknowns about the relationship between specific genes and nicotine addiction. Economic forces also provide strong motivation for the pharmaceutical industry and the tobacco industry to emphasize the biological and genetic nature of addiction, promote some drugs as acceptable to use and some as not, and to dictate what therapies are appropriate for addiction (Campbell, 2010; Gundle, Dingel, and Koenig, 2010; Kushner, 2010; Rasmussen, 2010). Social support and behavioral therapies, though often underplayed in these biological frameworks, are nevertheless critical to success (Acker, 2010; Benowitz, 2008).

Will Genetic Research Change the Way People Understand Cessation, Cessation Options, and Their Personal Responsibility for Quitting? Given that an individual’s expectations can influence his or her experience, physiology, and behaviors such that the individual’s expectations are confirmed (Barskey et al., 2002; Kirsch, 1985), knowledge of a genetic risk for addiction may predispose the individual to be more likely to smoke or less likely to quit smoking. Thus a critical part of anticipating the impact of neurogenetic research on existing medical and health practices will involve paying careful attention to issues stemming from the social significance and meanings attributed to neurogenetic information, and further recognizing that these meanings may vary significantly across social groups. In other words, those who feel “fated” to be addicted to nicotine may see no need to abstain. Stakeholders, in general, felt that overfocusing on a biomedical model of addiction may lead to a fatalistic attitude in some smokers. A typical comment was: One thing that might happen is that, just like the obesity stories, that folks will sort of default and say, “Well, it’s genetic, I can’t help it.” Or, “I have trouble quitting,” or, “I can’t quit.” Or, you know, “I was born with it.” I mean, there are all kinds of ramifications that spill from things. (clinician: from the Midwest)

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Despite these concerns, the most common response across all stakeholders was that genetics would make no overall impact on behavior at a population level, either because people would respond in diverse ways to genetic knowledge or, especially in the case of teenagers, because a predisposition would not be as pertinent to their choices as peer or other environmental influences. [Genetic information] won’t make a difference— they’re going to do whatever they want to do. There are some proportions of people, and we don’t know how many, who will actually be made more motivated not to smoke by that information. And there are some people who may in fact adopt a fatalistic approach: “Oh, well, I’ve got the gene. Nothing I do matters.” (scientist: head of a genetics lab, southern university) Teenagers are not able to make informed decisions about anything that has long-term consequences. We know that. So why give them the information when there’s very little chance that it’s actually going to help their behavior in a positive way? That there’s a chance that it could well alter it in a negative way. (prevention specialist: director of a midwestern state’s tobacco control program, emphasis in original)

Empirical investigations are beginning to explore how people will respond to genetic information about individual risks for tobacco dependence or smoking-related disease. Studies asking people to respond to hypothetical genetic information in the form of vignettes (Sanderson and Michie, 2007; Sanderson and Wardle, 2005; Wright, Weinman, and Marteau, 2003; Wright et al., 2006) and those providing individuals with actual genetic test results regarding risk for smoking-related disease (Bize et al., 2009; Carpenter et al., 2007; Hishida et al., 2010; McBride et al., 2002; Sanderson et al., 2008; Sanderson et al., 2009; Sanderson et al., 2010) indicate that genetic tests may increase people’s motivation to quit smoking. The latter studies, however, do not indicate an actual increase in long-term quit rates. Although many of the stakeholders we interviewed feared a fatalistic reaction among

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smokers to the genetics of addiction, there is little evidence of increased fatalism among these studies’ participants. This finding may have resulted from selection bias: those who choose to take part in these studies are eager to receive genetic information and, because motivation to quit increased regardless of the result of the genetic test, these smokers may already be more motivated to quit and use the genetic results as additional motivation (Sanderson et al., 2008; Sanderson and Wardle, 2005). Though the worst-case fear of widespread fatalism appears to be largely unfounded, if stakeholders believe that fatalism is a concern, they may resist integration of genetic information into tobacco prevention and treatment programs. These studies found mixed results for other concerns stemming from genetic tests, including depression (Sanderson et al., 2008; Sanderson and Wardle, 2005) or complacency in the face of negative genetic tests (Sanderson and Michie, 2007; Wright et al., 2006). Another consistent finding in these empirical studies is that patients who received positive genetic results are more likely to use pharmaceutical aids and, in one case, less likely to rely on willpower to quit smoking (Carpenter et al., 2007; Marteau and Weinman, 2006; Wright, Weinman, and Marteau, 2003). This finding is consistent with other studies investigating individuals’ responses to genetic tests, which indicate that receiving positive genetic tests make people less likely to attempt lifestyle or environmental changes to improve health and more likely to rely on pharmaceuticals (Marteau et al., 2004). This latter finding indicates that genetic tests are changing how we think about treatment options and, because biomedical models are increasingly central to how we view ourselves, new medical and genetic tests and treatments will inevitably change how we think about our bodies and express our identities (Rose, 2007). Within this larger historical context, genetic susceptibility operates as a new third option between normal and pathological; genomic medicine suggests a concept of symptom-less diseases and makes “hidden” traits central to our “diagnostic and therapeutic hopes” (Rose, 2007:84). Within this framework, our

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potential to become addicted becomes a trait in itself, independent of drug use (Schull, 2003). This conception of addiction fundamentally shifts addiction from compulsive drug use to something latent inside of us, detectable, independent of the presence or absence of substances in the environment or of any negative social or constitutional effect of our drug use. When addiction is thus embedded in the body, doctors become detectives who seek to understand the “truth” of addiction (Keane, 2002). The risk of these new conceptualizations of addiction lies in trying to “identify, treat, manage, or administer those individuals, groups, or localities where risk is seen to be high” (Rose, 2007:70). Disconnecting drug use from its cultural context drastically oversimplifies its causes and obscures the uneasy way we distinguish those who are “addicted” from those who are “not addicted” (Keane and Hamill, 2010; Kushner, 2010). The potential for individual fatalism obscures a more fundamental and basic risk about our perception of drug use as a disease of the brain instead of as a biosocial phenomenon.

Harm, Stigma, and Ethics: Will a Biological Understanding of Smoking Increase or Decrease Stigmatization? A major focus of many ethical analyses of the application of genetic knowledge is the potential for stigmatization and discrimination (Nelkin and Lindee, 1995). Many ethicists argue that the possibility of harm from disclosure of genetic information is augmented by the fact that researchers have reported correlations between the genes associated with nicotine addiction and addiction to other substances like alcohol (Dani and Harris, 2005; Lê et al., 2006), other behaviors like gambling (Petry and Oncken, 2002), and personality traits like risk taking (Kreek et al., 2005), as well as various mental states and diagnoses like schizophrenia (Martin and Freedman, 2007). As a result, genetic tests to determine an individual’s susceptibility to nicotine addiction or to tailor smoking cessation treatment could reveal collateral information about other susceptibilities. The potential for stigmatization

may increase given the perceived association of smoking with other behaviors and the degree to which any one behavior is stigmatized (Goffman, 1963). For about a quarter of stakeholders, the idea that genetic testing could help target those at “high risk” for nicotine addiction with education messages, prevention programs, and treatment outweighed the possibility of harm. [T]he basic idea is that a lot of diseases, including nicotine addiction, are heritable, and just knowing that there’s some family history can be informative. But if there’s a genetic test that can specifically identify someone’s risk, that’s even better. . . . Because there might be targeted preventative measures and targeted interventions. (physician/scientist: clinical researcher at a large midwestern university)

However, many stakeholders articulated problems that may arise from trying to quantify risks for complex behaviors, including the difficulty of assessing “risk” and the possibility of risk identification leading to privacy concerns, discrimination by employers or health insurance companies, or increased stigma for those deemed susceptible. [A test] can be used as a weapon, and not as a good thing . . . if we did identify it early, would it mean you wouldn’t have access to health insurance, or you would pay more for health insurance, or, or those kinds of things? (prevention specialist: from a state department of health, Pacific Northwest)

Other theoretical concerns raised by social scientists, however, were not raised by these stakeholders, including problems of living a life of “risk” devoted to disease surveillance (Koenig and Stockdale, 2000) or the psychological impact of the construction of new categories of “potentially” ill people (Rose, 2007). For instance, although stakeholders understood that some people may become fatalistic about their ability to quit smoking, no stakeholder mentioned that people may become depressed about learning about increased susceptibilities, which initial research indicates is a possibility (Sanderson and Wardle, 2005).

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In addition, racial differences in smoking rates and findings of genetic differences in drug metabolism must be contextualized within the historical context wherein drugs associated with marginalized racial groups have been more likely to fuel social concerns and criminalization (Acker, 2010; Courtwright, 2001). The biomedicalization of addiction could therefore promote racial discrimination and stereotyping (Dingel and Koenig, 2008). For example, African Americans are less likely to be prescribed pain medication than white counterparts with the same ailments (Anderson et al., 2004; Tamayo-Sarver et al., 2003), and regulatory surveillance of prescription drug use reduces legitimate use of legal drugs in African Americans (Pearson et al., 2006). Further, a reductionist framework that links smoking with genes promotes a biological view of human difference, ignoring a long history of racial oppression and targeted advertisement by the tobacco industry (Barbeau et al., 2005; Jain, 2003). Stakeholders’ opinions varied on whether the medicalization of addiction would decrease or increase the stigma associated with drug abuse. Roughly a third of prevention workers, scientists, and clinicians thought that a genetic understanding of nicotine addiction would increase stigma. When [genetic information] converges with the denormalization policies of the public health community, that could lead then to ultra-denormalization of people who have the genetic risk factors, and I’m concerned about that. (scientist: researcher from a large, nonprofit organization) Even if you have all the genes to prove that, yes, this group, or a particular race/ethnicity, or during this age group, or this gender, . . . is more likely to have [a genetic predisposition] . . . it is very important for us to know what is the percent [risk] from the genetic, versus what is the percent [risk] from the environmental factors, and what these environmental factors are affecting or influencing . . . There was a lot of stigma related to the Hantavirus. And it is something not needed. And the Native American did not need to be, once again, highlighted as, “this is

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an illness of the Native American.” And we do that too often. (prevention worker: state health department in the Southwest)

Alternately, the recognition of a genetic contribution to stigmatized conditions may result in destigmatization by shifting responsibility for the trait or disorder away from individuals’ choices or will, and onto their genetic makeup, over which they have no control (Lubman, Yucel, and Pantelis, 2004; Stein, 1999). Locating causal biological factors has brought funds and research to and alleviated stigma from disorders like epilepsy and depression (Jilek-Aall et al., 1997; Schreiber and Hartrick, 2002). In fact, about a third of our interviewees thought that new genetic research would destigmatize smoking. When the understanding is transferred from character and morality to physiology, it tends to affect a stigma. We saw that with HIV, where initially, most of the focus was on “what the people did,” if you will, and less focus on the course of the disease. It was once prevalent with epilepsy, where people with epilepsy were severely stigmatized, and the understanding that this was just a neurological disorder helped destigmatize [it]. (scientist: vice-president of research at a private health research and data analysis company)

However, individuals in our sample also recognized possible benefits from stigmatization. Not simply victim blaming, stigmatization is also an efficient and beneficial process for changing social norms when the stigmatized behavior is clearly unacceptable, or poses important public health risks (Kim and Shanahan, 2003). I guess this is a little bit anecdotal, but a lot of people come into my clinic and they want to quit [smoking] because their friends hate it. You know, I think the stigma is earned and well-deserved, and I think if that’s the truth, that’s fine. If it works, great. (scientist: researcher at a cancer center in a large, midwestern university)

Despite some ethicists’ warnings about increased stigma as a harm, our interviews suggest that different interest groups will use this

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knowledge for their own agenda. As such, a genetic etiology likely will both reinforce and diminish the stigma associated with smoking depending on the context and motivation of the stakeholders involved. Therefore, analyses of the social consequences of genetic explanations of smoking must also take into consideration the existing sociopolitical dynamic promoting the stigmatization of smoking as an integral (and successful) component of North American smoking control policies (Bayer and Stuber, 2006; Kagan and Nelson, 2001).

CONCLUSION With rapid changes in both genetic and imaging technology fueling research into the biology of substance use, drug addiction is increasingly understood and portrayed as a disease of the brain. The biomedicalization of addiction has positive implications, including the potential for novel therapies, an increased understanding of drugs’ effects on the brain, and an increased willingness of doctors and health-care providers to ensure that smokers have adequate medical assistance to quit. However, the ethical questions and social concerns raised by this conceptual shift are numerous. Focusing predominately on the biology of nicotine addiction may draw our attention away from social and contextual variables, which in turn may undermine the logic behind current public health and tobacco control efforts to curb smoking. These efforts have their genesis in the 1964 Surgeon General’s Report on Smoking and Health, which was the first official statement linking cigarette smoking to cancer and cardiovascular disease (U.S. Public Health Service, 1964). This report had an almost immediate effect on policy and, by many accounts, the anti-smoking campaigns that followed this report have been major public health successes (Jacobson and Zapawa, 2001; Zhang et al., 2006). Given resource constraints, decisions about how to invest resources—local, state, federal, and private—are highly political and subject to political framing. Based on empirical evidence, many would argue that the most cost-effective, as well as purely efficacious, programs to prevent

or treat nicotine addiction are in the realm of the social: smoke-free ordinances and increased cigarette taxes (Chaloupka, Wakefield, and Czart, 2001; Jacobson and Zapawa, 2001; Meyers, Neuberger, and He, 2009; Zhang et al., 2006). From a public health perspective, applications deriving from biologically based applications are not cost effective (Hall, Gartner, and Carter, 2008). The counterargument suggests that public health programs have “run their course” and pharmaceutical innovations, possibly individually tailored with genetic tests, may help with the approximately 20 percent of smokers who continue in the face of aggressive public health campaigns (Warner and Mendez, 2010). Even so, some scholars have argued that nicotine addiction may be one area where traditional public health measures are more effective than genetic-based therapies, particularly since studies have shown that the social transmission of smoking is at least as important as its heritable aspects (Carlsten and Burke, 2006; Merikangas and Risch, 2003). Genetic research and testing could shift resources and interventions away from upstream social, political, and economic causes of smoking behavior to downstream clinical interventions, making local and state governments less willing to invest in programs not consistent with the popular (genetic) theories of addiction. Given that some successful public health programs have already been de-funded (Givel and Glantz, 2000; LaPelle, Zapka, and Ockene, 2006), and state budgets are increasingly tight and contentious, de-funding proven public health programs may occur more often. Genetic and neuroscience research is but one more chapter in a long history of changing definitions and understanding of addiction. Most stakeholders in our sample subscribe to a medicalized vision of addiction that is generally consistent with DSM diagnoses. When asked about addiction etiology, most stakeholders believe social variables are paramount for smoking initiation, but understood biology to be more important for predicting the rapidity and severity with which an individual becomes addicted. This latter framework is consistent with a large body of research examining both genetic predispositions for smoking and pharmaceutical therapies for smoking cessation.

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Shifting our focus to the biological, individual aspects of drug addiction may increase teenagers’ beliefs that quitting is not difficult with the appropriate pharmaceutical aids, and create a widespread shift toward pharmaceutical therapies and away from considering an individual’s commitment to quitting, including the role of social and environmental variables. Our changing understanding of addiction is unlikely to either increase or decrease stigma in a straightforward way, but will be incorporated into existing frameworks of prevention and treatment in unique ways. Describing addiction as a disease of the brain and proposing institutionalizing this concept through a reorganization of our federal funding of addiction research promotes a simplistic vision of substance use, one that does not allow for the integration of neuroscientific and genetic approaches with a robust account of the social dimensions of addiction.

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Co-Morbidity: A Role for Dopamine Sensitization?” Journal of Dual Diagnosis 1(2):11–40. Patton, Michael Quinn. 1987. How to Use Qualitative Methods in Evaluation. Beverly Hills, CA: Sage Publications. Pearson, Sallie-Anne, Stephen Soumerai, Connie Mah, Fang Zhang, Linda Simoni-Wastila, Carl Salzman, Leon E. Cosler, Thomas Fanning, Peter Gallagher, and Dennis Ross-Degnan. 2006. “Racial Disparities in Access After Regulatory Surveillance of Benzodiazepines.” Archives of Internal Medicine 166:572–79. Petry, N. M., and C. Oncken. 2002. “Cigarette Smoking is Associated with Increased Severity of Gambling Problems in Treatment-Seeking Gamblers.” Addiction 97(6):745–53. Pfizer Inc. 2010. Important Safety Information. Available at (http://www.chantix.com/safetyinfo.aspx). ———. 2011. Chantix Is Proven to Work. Available at (http://www.chantix.com/proven-towork.aspx). Powell v. Texas. 1968. 392 U.S. 514. Available at (http://www.law.cornell.edu/supct/html/ historics/USSC_CR_0392_0514_ZS.html). Rasmussen, Nicolas. 2010. “Maurice Seevers, the Stimulants and the Political Economy of Addiction in American Biomedicine.” BioSocieties 5(1):105–23. Robicsek, Francis. 2004. “Ritual Smoking in Central America.” Pp. 30–37 in Sander L. Gilman and Zhou Xun, eds., Smoke: A Global History of Smoking. London: Reaktion Books Ltd. Rose, Nikolas. 2007. The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the Twenty-First Century. Princeton, NJ: Princeton University Press. Sanderson, Saskia C., and Jane Wardle. 2005. “Will Genetic Testing for Complex Diseases Increase Motivation to Quit Smoking? Anticipated Reactions in a Survey of Smokers.” Health Education &Behavior 32(5):640–53. Sanderson, Saskia C., and S. Michie. 2007. “Genetic Testing for Heart Disease Susceptibility: Potential Impact on Motivation to Quit Smoking.” Clinical Genetics 71(6):501–10. Sanderson, Saskia C., Steve E. Humphries, Christina Hubbart, Eluned Hughes, Martin J. Jarvis, and Jane Wardle. 2008. “Psychological and Behavioural Impact of Genetic Testing Smokers

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for Lung Cancer Risk.” Journal of Health Psychology 13(4):481– 94. Sanderson, Saskia C., Suzanne C. O’Neill, Della Brown White, Gerold Bepler, Lori Bastian, Isaac M. Lipkus, and Colleen M. McBride. 2009. “Responses to Online GSTM1 Genetic Test Results Among Smokers Related to Patients with Lung Cancer: A Pilot Study.” Cancer Epidemiology, Biomarkers and Prevention 18(7):1953–61. Sanderson, Saskia C., Suzanne C. O’Neill, Lori Bastian, Gerold Bepler, and Colleen M. McBride. 2010. “What Can Interest Tell Us About Uptake of Genetic Testing? Intention and Behavior Amongst Smokers Related to Patients with Lung Cancer.” Public Health Genomics 13(2):116–24. Schnoll, Robert A., Terrance A. Johnson, and Caryn Lerman. 2007. “Genetics and Smoking Behavior.” Current Psychiatry Reports 9(5):349–57. Schreiber, Rita, and Gwen Hartrick. 2002. “Keeping it Together: How Women Use the Biomedical Explanatory Model to Manage the Stigma of Depression.” Issues in Mental Health Nursing 23:91–105. Schull, Natasha Dow. 2003. “Machine Life: An Ethnography of Gambling and Compulsion in Las Vegas.” Ph.D. dissertation, Anthropology. Berkeley, CA: University of California, Berkeley. Sprague, Joey. 2005. Feminist Methodologies for Critical Researchers. New York: AltaMira Press. Stein, Edward. 1999. The Mismeasure of Desire: The Science, Theory, and Ethics of Sexual Orientation. New York: Oxford University Press. Tamayo-Sarver, J. H., S. W. Hinze, R. K. Cydulka, and D. W. Baker. 2003. “Racial and Ethnic Disparities in Emergency Department Analgesic Prescription.” American Journal of Public Health 93(12):2067–73. Thayer, Ann. 2006. “Drugs to Fight Addictions.” Chemical and Engineering News 84(39): 21– 44. Thorgeirsson, Thorgeir, Daniel F. Gudbjartsson, Ida Surakka, Jacqueline M. Vink, Najaf Amin, Frank Geller et al. 2010. “Sequence Variants at Chrnb3-Chrna6 and CYP2A6

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Affect Smoking Behavior.” Nature Genetics 42(5):448–53. Tiger, Rebecca. 2011. “Drug Courts and the Logic of Coerced Treatment.” Sociological Forum 26(1):169–82. Tobacco and Genetics Consortium. 2010. “Genome-Wide Meta-Analyses Identify Multiple Loci Associated with Smoking Behavior.” Nature Genetics 42(5):441–47. Traynor v. Turnage. 1988. 485 U.S. 535. Available at (http://supreme.justia.com/us/485/535/). Uhl, George R., Tomas Drgon, Catherine Johnson, Oluwatosin O. Fatusin, Qing-Rong Liu, Carlo Contoreggi, Chuan-Yun Li, Kari Buck, and John Crabbe. 2008. “‘Higher Order’ Addiction Molecular Genetics: Convergent Data from Genome-Wide Association in Humans and Mice.” Biochemical Pharmacology 75:98–111. United States v. Moore. 1973. 486 F. 2d 1139, U.S. App. D.C. Available at (http://Pow.justia. com/cases/federal/appellate-courts/F2/486/ 1139/287860/). U.S. Department of Health and Human Services. n.d. HHS Region Map. Available at (http://www. hhs.gov/about/regionmap.html). U.S. Public Health Service. 1964. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: Government Printing Office. Volkow, Nora D., Joanna S. Fowler, Gene-Jack Wang, James M. Swanson, and Frank Telang. 2007. “Dopamine in Drug Abuse and Addiction.” Archives of Neurology 64(11):1575–79. Vrecko, Scott. 2010. “‘Civilizing Technologies’ and the Control of Deviance.” BioSocieties 5(1):36–51. Warner, Kenneth, and David Mendez. 2010. “Tobacco Control Policy in Developed Countries: Yesterday, Today, and Tomorrow.” Nicotine & Tobacco Research 12(9):876–87. Welshman, John. 2004. “Smoking, Science and Medicine.” Pp. 326–31 in Sander L. Gilman and Zhou Xun, eds., Smoke: A Global History of Smoking. London: Reaktion Books Ltd. Windle, Michael. 2010. “A Multilevel Developmental Contextual Approach to Substance Use and Addiction.” BioSocieties 5(1):124–36. Wright, A. J., D. P. French, J. Weinman, and T. M. Marteau. 2006. “Can Genetic Risk Information Enhance Motivation for Smoking

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Cessation? An Analogue Study.” Health Psychology 25(6):740–52. Wright, A. J., J. Weinman, and T. M. Marteau. 2003. “The Impact of Learning of a Genetic Predisposition to Nicotine Dependence: An Analogue Study.” Tobacco Control 12:227–30.

Yarnell, A. 2005. “Design of an Antismoking Pill.” Chemical and Engineering News 83(23):36– 37. Zhang, Bo, Joanna Cohen, Roberta Ferrence, and Jurgen Rehm. 2006. “The Impact of Tobacco Tax Cuts on Smoking Initiation Among Canadian Young Adults.” American Journal of Preventive Medicine 30(6):474–79.

CHAPTER 9

The Roots of Addiction in Free Market Society Bruce K. Alexander

INTRODUCTION Developing an adequate policy for the problem of addiction requires a full recognition of its extent and an analysis of its causes. This undertaking is essential because the spread of addiction has become a genuine menace. The analysis is inevitably complex, because the burgeoning of addiction in the 21st century is not so much a matter of individual tragedy as it is a matter of underlying political and social dynamics. Addiction changed from being merely a nuisance in the ancient world to being a steadily growing menace in the modern world as society moved into free market economics and the industrial revolution. Analysing the stillgrowing menace of addiction entails examining the toxic side effects of “free markets” and the “new economy.” The link between the new economy and addiction is called “dislocation” in this report, although it has been given various other names by social scientists.1

FREE MARKETS, DISLOCATION, AND ADDICTION All children are intensely motivated to maintain close social bonds with their parents and other caretakers. Unless this drive is badly thwarted, older children and adults later strive to establish and maintain other close relationships, for example, with friends, school-mates, coworkers, and recreational, ethnic, religious, or nationalistic groups. Eric Erikson2 depicted this

as a life-long struggle to achieve “psychosocial integration,” a state in which people flourish simultaneously as individuals and as members of their culture. Erickson showed that psychosocial integration is essential for every person in every type of society—it makes life bearable, even joyful at its peaks. Insufficient psychosocial integration can be called “dislocation.” Severe, prolonged dislocation is hard to endure. When forced upon people, dislocation—i.e., ostracism, excommunication, exile, or solitary confinement—is so onerous that it has been used as a dire punishment from ancient times until the present. Severe, prolonged dislocation regularly leads to suicide. Dislocation can have diverse causes. It can arise from a natural disaster that destroys a person’s home or from a debilitating accident that bars the person from full participation in society. It can be inflicted by violence, e.g., by driving masses of people from their territory, or by abusing an individual child who thereafter shrinks from all human contact. It can be inflicted without violence, e.g., as when a parent instills an unrealistic sense of superiority that makes a child insufferable to others. It can be voluntarily chosen, e.g., in the singleminded pursuit of wealth in a “gold rush,” or in jumping at a “window of opportunity.” Finally, dislocation can be universal if a society systematically curtails psychosocial integration in all its members. Universal dislocation is endemic in free market society. Although any person in any society can become dislocated, modern western societies

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dislocate all their members to a greater or lesser degree because all members must participate in “free markets” that control labour, land, money and consumer goods. Free markets require that participants take the role of individual economic actors, unencumbered by family and friendship obligations, clan loyalties, community responsibilities, charitable feelings, or the values of their religion, ethnic group, or nation.3 The essential maxim of free market society, as proclaimed by Adam Smith, is that markets that are regulated primarily by the laws of supply and demand maximize everybody’s well being in the long run by multiplying the “wealth of nations.” Severe dislocation provokes a desperate response, whether it is universal or idiosyncratic. Dislocated people struggle to find or restore psychosocial integration—to somehow “get a life.” People who persistently fail to achieve genuine psychosocial integration eventually construct lifestyles that substitute for it. Substitute lifestyles entail social relationships that are not sufficiently close, stable, or culturally acceptable to afford more than minimal psychosocial integration. At best, these substitute lifestyles can be creative, as in the case of an eccentric artist or high-tech wizard, but more usually they are banal and dangerous, as in the case of a youth gang member or a street addict. Substitute lifestyles sometimes—but not always—center on excessive use of drugs.4 Even the most harmful substitute lifestyles serve an adaptive function. For example, devoted loyalty to a violent youth gang, offensive as it may be to society and to the gang member’s own values, is far more endurable than no identity at all. The barren pleasures of a street “junkie”—membership in a deviant sub-culture, transient relief from pain, the nervous thrill of petty crime—are more sustaining than the unrelenting aimlessness of dislocation. People who can find no better way of achieving psycho-social integration than through substitute lifestyles cling to them with a tenacity that is properly called addiction. The English word “addiction” came to be narrowly applied to excessive drug use in the 20th century, but was generally applied to

non-drug habits during many previous centuries. There is ample clinical evidence that severe addictions to non-drug habits are every bit as dangerous and resistant to treatment as drug addiction.5 Because western society is now based on free market principles that mass-produce dislocation, and because dislocation is the precursor of addiction,6 addiction to a wide variety of pursuits is not the pathological state of a few but, to a greater or lesser degree, the general condition in western society. Because western free market society provides the model for globalization, mass addiction is being globalized, along with the English language, the Internet, and Mickey Mouse. Of course, addiction can occur in any society, including tribal and socialist ones. For example, alcohol addiction was widely prevalent in the USSR, which did not have a free market economy. This may be because Soviet society shared with free market society the willingness to destroy psychosocial integration on a grand scale in the interest of economic development and ideological purity, as in the case of agricultural collectivization.7 There has been little analysis of free market society and dislocation among professional addiction researchers because their field has been fenced in on four sides by professional conventions. First, only experimental and medical research has been considered really valid, other approaches seeming too philosophical, political, literary, anecdotal, or unscientific. Second, attention has been lavished upon alcohol and drug addictions, although non-drug addictions are often as dangerous and far more widespread. Third, American examples, data, and ideology have provided most of the important guideposts in this field, although powerful political forces limit debate there more than other places. Fourth, although a few individual scholars do speak out, professional addiction researchers have rarely contradicted the mainstream media misinformation concerning drugs and addiction. Under these conditions, and since professionals are making little progress on the problem of addiction, society will do well to fall back on common sense and history.

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“TERMINAL CITY”: MICROCOSM OF DISLOCATION AND ADDICTION

VANCOUVER’S HISTORY OF DISLOCATION AND ADDICTION

About 6,000–10,000 ragged junkies in Vancouver’s “downtown eastside” are currently buying, selling, and injecting cocaine and heroin, panhandling aggressively, and dying on the streets in record numbers. A large and growing proportion of these junkies are HIV positive. Most are white, although there is a disproportionate number of native Canadians. Compared to the better known images of New York or Los Angeles, Vancouver’s downtown eastside drug scene is less one of racial contrast and hot violence than one of homogeneous, sodden misery. Spreading in every direction from the downtown eastside centre of hard drug addiction is a vast, doleful tapestry of less notorious, but often equally tragic forms of addiction. There are gambling addicts in the casinos, alcoholics in the bars, money and power addicts in the financial district, workaholics in the offices, cybersex and video game addicts at the monitors, ski bums in the resorts, television addicts on the couches, food addicts at the convenience stores, celebrity addicts in the theaters, relationship addicts working on their issues, religious fanatics spreading the Word, and on and on. Of course, most people who engage in these activities are not addicted to them, and some who are addicted manage to lead stable lives and contribute to society nonetheless. However, many people are disastrously and sometimes fatally addicted to one or more of these pursuits, and the mass of seriously addicted people is growing. The notorious downtown eastside junkies— the most publicized addicts in Canada—are not necessarily the most destructive ones. For example, some occupants of the country’s boardrooms feed their own habits by ruinously exploiting natural resources, polluting the environment, misinforming the public, and purveying modern weapons in third world countries. Severe addictions to power, money, and work motivate many of those who direct this destruction.8 Why is there so much addiction in Vancouver?

Although justly admired for its beauty, civility, and assiduous urban planning,9 Vancouver is also, more than most, a city of dislocation. From the arrival of the first English settlers to the area in 1862, the space for urban sprawl was acquired by forcing native people from nearly 100 villages around Burrard Inlet, False Creek, and the Fraser River. The natives’ lands, which had for centuries been sites for food gathering, communal houses, huge wood carvings, ancestral burial grounds, and invisible spirits became the basis of a free market in real estate almost overnight. Many of their complex cultural practices were outlawed or mocked out of existence.10 Their famous “potlatches,” elaborate ceremonies in which rich natives gave enormous amounts of food and goods to others according to complex traditional, clan, and personal obligations were the antitheses of free markets. They were prohibited by law from 1884 until 1951. These dislocated natives’ descendants populate the downtown eastside, and their ghosts continue to haunt the land’s new owners. A popular print by Roy Henry Vickers, a native artist, depicts Vancouver with the city’s landmark buildings dwarfed by enormous totem poles towering over them, just visible in the eternal drizzle. From its beginning until the present, Vancouver has been the landing point in Canada for a huge eastward migration of displaced east and south Asians, accelerating in the 1880s as shiploads of single Chinese men were imported en masse to labour on the railroad and in the coal mines. Asians, although always a substantial portion of the city’s labour market, were treated as aliens from its beginning through the Second World War, during which the entire Japanese-Canadian population was stripped of its property and scattered into internment camps. With the completion of Canada’s first transcontinental railway in 1886, Vancouver also became the terminus for the westward migration of European people in Canada—most

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of those who landed here came direct from Europe or migrated one or more times through eastern Canada or the U.S. Even today, it is a commonplace observation that the majority of people who live in Vancouver were born elsewhere. Vancouver was nicknamed “Terminal City” shortly after the railway was completed. The city of Vancouver was incorporated and given its present name in 1886, little more than a century ago. Sparked by completion of the railway in that same year, the scattered farms, mills, and shanties exploded into urbanity. Speculators rushed to buy land, the first newspaper was established, an urban water system was planned, and the first eastbound shipload of merchandise, 1,000,000 pounds of tea from China, arrived in the port and was loaded on railway cars for shipment. Markets were free and growth was unstoppable—the entire city of 400 wooden buildings burnt to the ground with several fatalities, but it was resurveyed and mostly rebuilt, including a new city hall, electric street lights, and a roller skating rink— all in the year 1886.11 Today, Vancouver is a prosperous and beautiful city. It has never known war, bombing, revolution, famine, or plague. Although it felt the full force of the economic depression of the 1930s, relative to most other parts of the world it has been only lightly brushed by industrial blight, class struggle, poverty, slums, and organized crime.12 Vancouverites’ complaints tend to target the provincial government and the long rainy season, although it is generally conceded that the government is well-intentioned and the climate is the most temperate in Canada. However, whereas dislocation is commonplace in modern cities, Vancouver’s is extreme. Populated by diverse immigrants, Vancouver’s values and institutions did not grow from a surrounding peasant culture, common religion, or single language. There has been too little time for extended families or clans to become important. The predominant occupations—logging, fishing, and mining—separated working men from their families for months on end. Vancouver might, in time, have developed a unique cultural fusion as did Canada’s older eastern cities, such as St. Johns and Quebec City, but its nascent culture seems to have been drowned in

its infancy by a flood of freely-imported music, temperance leaders, movies, figures of speech, textbooks, magazines, experts, computers, professional sports, fast food, and television. People from all over the world have come to Vancouver to join Canadian culture, but have instead found themselves adrift in “Lotusland.” If dislocation is the precursor to addiction, “Terminal City” should also be “Addiction City.” Alcohol and drug statistics suggest that it is. Vancouver has long been Canada’s most drug addicted city, and British Columbia its most drug addicted province, with respect to annual per capita consumption of alcohol, death rate attributed to alcohol, prevalence of alcoholism, death rate due to heroin and cocaine overdose, prevalence of HIV infection and Hepatitis C infection among injection drug users, availability of heroin and cocaine, selfreported use of all illicit drugs, arrest rates for drug crimes, etc. This is so currently and has been so throughout the 20th century.13 Heroin statistics provide the most notorious example. British Columbia is one of 10 provinces and three territories in Canada, yet in 1997, 61% of all heroin arrests in Canada were in British Columbia. Addictions that do not involve alcohol and drugs are far more common in Vancouver than is drug addiction.14 Unfortunately, it is as yet impossible to compare their prevalence with that of other places. This look at Vancouver’s history suggests that the so-called drug problem is merely a special case of a much larger addiction problem and that large-scale dislocation is the precursor to addiction. There is epidemiological and experimental support for these generalizations in the medical and psychological literature.15 However, the historical evidence of a causal relationship between free market society, dislocation, and addiction is even stronger.

THE MACROCOSM: FREE MARKET SOCIETY,16 DISLOCATION, AND ADDICTION Historical research provides many examples of causal links between (1) emergence of free market society and dislocation, and (2) dislocation and addiction of all sorts. The next two

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sections of this chapter provide some examples of each of these two causal links followed by an apparent counterexample, the drug “crack,” which—it is said—addicts everyone who uses it, dislocated or not.

FREE MARKET SOCIETY AS A CAUSE OF DISLOCATION In free markets, the exchange of labour, land, currency, and consumer goods must not be encumbered by clan loyalties, village responsibilities, guild rights, charity, family obligations, social roles, or religious values. Since cultural traditions “distort” the free play of the laws of supply and demand, they must be suppressed to establish a free market society. Paradoxically, establishing a “free” market society regularly requires coercion on a massive scale because most people cling fiercely to their cultural traditions.17 Polanyi’s classic study, The Great Transformation makes the point concisely: Establishing a free market society “must disjoint man’s relationships and threaten his natural habitat with annihilation.”18 Also paradoxically, established “free” market societies require the continuing presence of powerful control systems. Carefully engineered management, advertising, taxation, and mass media techniques keep people buying, selling, working, borrowing, lending, and consuming at optimal rates, deliberately undermining the countervailing influences of new social structures that spontaneously arise in modern families, offices, factories, etc.19 Thus, opportunities to reestablish new forms of psychosocial integration are suppressed. Although various forms of capitalism have existed throughout history, free market society first achieved full strength in early modern England. Well before the English Revolution of 1640, free market advocates were able to draw theological justification from English Protestantism, legal support from Parliament, and coercive power from the crown. By a series of increments, England achieved a full-blown free market society by the early 19th century. This was in part achieved through a massive, forced eviction of the rural poor from their farms, commons, and villages and the absorption of

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some of them into urban slums and a brutal, export-oriented manufacturing system. Those who resisted these new realities too strenuously were further dislocated from their families and communities, by forced apprenticeship of their children, destruction of their unions and other associations of working people, elimination of local charity to the “undeserving poor,” and by confinement in “houses of correction” where they were encouraged to accept their new responsibilities with whips and branding irons.20 Forced dislocation spread from England to the rest of the British Isles, e.g., the “clearances” of the clan society of the Scottish highlands, and to English colonies abroad, e.g., the settlement of Australia by “transportation” of convict labour. The dislocated British immigrants reproduced their own condition by dislocating aboriginal peoples wherever they landed, with the support and encouragement of the Imperial Government. The necessary connection between the free market economy and dislocation in early 19thcentury England was recognized as much by Whigs who supported free market capitalism, like William Townsend and Herbert Spencer, as by those who opposed it, like Robert Owen and Karl Marx. Marx and Engels devoted some of the most powerful rhetoric in their Communist Manifesto to describing the dislocation that free markets produced in Europe.21 In contemporary times as well, the devastating effects of free markets on traditional society have been amply documented, both by scholars who support the globalization of free markets and by those who oppose it.22 The most enthusiastic advocates of free market society often justify mass dislocation by emphasizing the fact that free market institutions are sometimes voluntarily chosen and bring wealth to some of those who join them, apparently forgetting that free markets are more often established by force and bring poverty to most of those who survive the dislocation. The highlands of Northwestern Scotland provide an example of the dislocating effects of free markets on traditional society. Until the second half of the 18th century, highlands society was little touched by free markets. The local

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economy was a network of traditional obligations among people living in stable families and occupying well-defined social strata: chiefs, tacksmen, subtenants, and cotters. English was a foreign language; people spoke Gaelic. Each highlander belonged to a clan, and all members were expected to support their clan chief both with the produce from their farms and their valour on the battle field. In return, the clan chief was expected to preserve his people’s rights to their tiny farms in perpetuity. Interclan battles were bloody enough, but also ritualised with the flash of competing tartans, the call of bagpipes, and the legacy of warrior heros. There was little export or import and little use for money. Although highland society suffered from famine in poor years, it offered psychosocial integration to even the very poorest, and emigration was uncommon.23 After the last major armed uprising against British rule was defeated at the Battle of Culloden in 1746, the British government began the systematic destruction of highland society. The traditional bearing of arms was prohibited, as was traditional dress, including plaid, tartan, and kilt. The hereditary powers of the chiefs were abrogated and some of their lands were confiscated. Chiefs who retained land were admitted into English society, but only if they transformed themselves from Gaelic-speaking chiefs to English-speaking landlords. The free market completed the work of cultural destruction that military conquest had begun. In an era of war and population explosion, England needed more meat and wool than it could produce and new landlords of the spacious highlands had the opportunity to sell these commodities to a huge free market. At the same time that the newly minted landlords were losing their traditional rank in society, they were being tantalized with the rewards that the export market could bring: homes in London, city wives with worldly repartée and a cultivated taste for clothes and jewlery, English peerages, continental food, and art. The highlands had traditionally produced cattle and grain, mostly for local consumption. However, it was quickly discovered that the landlord’s wealth could be multiplied by

replacing the cattle with new breeds of hardy sheep and reducing the human population from many subsistence farmers to a few shepherds. For the most part the clansmen, now looked upon as peasants subject to the dictates of the agricultural market, remained a warrior race in their own minds and would have nothing to do with running sheep, especially on the lands of evicted comrades and kinsmen. Either the free market was to be thwarted by tradition, or the highlanders had to be evicted. The evictions that ensued were so extensive that they came to be known as “clearances.” Legal eviction notices procured by clan chiefs or English landlords who had bought the formerly inalienable land in the free market, usually allowed highland families a few months to voluntarily leave and pull down their houses. Most refused and were burnt out by the sheriff. In lieu of their ancestral land, the families were sometimes offered barely habitable land on the coast and the opportunity to join the herring fishery (by building their own boats) or to work as miners. Sometimes their only option was to emigrate in disease-ridden boats for Canada or other destinations at their own expense. Sporadic rebellions against the clearances by disarmed highlanders were quelled by regular troops from Scottish regiments, dispatched by the English king, at the request of local chiefs or English landlords. The legality of this military coercion was upheld in court on free market principles. Extensive justifications for the clearances that were written for public consumption stressed that: the productivity of the land was improved, which was true; that the cotters under the traditional system were extremely poor, which was true enough; and that the evicted people were happy with the situation, which was an outrageous lie. Because England successfully dominated the 19th-century world, English free market economics, with its intrinsic destruction of traditional culture, spread across the map of western Europe.24 Because free market society now dominates the world, the destruction of traditional culture has become ubiquitous. In an ultimate irony, tens of thousands of Latin American peasants, some of whom grew coca

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on their tiny farms, are currently being dislocated in the interest of preventing addiction through the War on Drugs.25 Dislocation in free market societies is not confined to poor people or poor countries. At the end of the 20th century, for rich and poor alike, jobs disappear on short notice; communities are weak and unstable; people routinely change lovers, families, occupations, co-workers, technical skills, languages, nationalities, priests, therapists, spiritual beliefs, and ideologies as their lives progress. Prices and incomes are no more stable than social life. Even the continued viability of crucial ecological systems is in question. For rich and poor alike, dislocation plays havoc with delicate ties between people, society, the physical world, and spiritual values that sustain psychosocial integration. Again, Polanyi made the complex point concisely: the most obvious effect of the new institutional system was the destruction of the traditional character of settled populations and their transmutation into a new type of people, migratory, nomadic, lacking in self-respect and discipline— crude, callous beings of whom both labourer and capitalist were an example.26

One index of dislocation among the rich is the spreading social problems of the U.S. middle class, arguably the pinnacle of success in the free market world. The pressures of ever-increasing competitiveness, productivity, flexibility, overwork, downsizing, restructuring, etc., on the two working parents in American middle class families, often cut off from their extended families, are such that the children are deprived of essential time and support, even if adequate daycare fills their needs during the working day. Psychologist Richard DeGrandpre has called this a “culture of neglect” and a “trickle-down theory of child rearing.” He identifies this dislocation from traditional family supports as a direct cause of the rapid spread of “Attention Deficit Hyperactivity Disorder” and the consequent prescription of the stimulant Ritalin to school age children, about 15% of whom are now on Ritalin.27 Americans consistently score the highest, relative to

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all other developed countries, on a plethora of other indications of dislocation, including divorce, single parenthood, children in poverty, economic disparity, and excessive television viewing.28 Canada’s middle-class plight is not as extreme as the U.S., but the trends are the same. Other signs of dislocation of the rich include the growing discontent, stress, and workplace violence among corporate “management.” Current management literature abounds with discussions about how the army of dysfunctional managers should themselves be managed. As sociologist John Gray puts it, “Businesses have shed many of the responsibilities that made the world of work humanly tolerable in the past.”29 There have been pauses in the advance of free market society. For example, it was slowed during the depression of the 1930s when the Roosevelt government in the U.S. and a sizeable group of American economic thinkers warned that it would be necessary to seriously curtail free market fundamentalism if capitalism was to survive. Free market ideology was not prominent in Canada or the U.S. between 1940 and 1970, even though these countries were citadels of capitalism during the “Cold War.” These were the years in which popular wisdom celebrated Keynesian economics, the welfare state, and regulations on the flow of international capital.30 But times have changed. Free market fundamentalism has accelerated dislocation everywhere, as the ideological threat of a successful Soviet economy disappeared and as worldwide competition has seemed to require frenzied productivity. This is equally the case in countries with “mature” economies, including Canada; in “developing” countries under the aegis of the International Monetary Fund and the World Bank; and in China, which has gradually been moving towards a free market economy at an accelerating pace since the 1980s. The World Trade Organization, the International Chamber of Commerce, and other powerful transnational bodies urge dramatically expanding the scope of free markets in areas, such as education and medicine, where their role was previously limited.31

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The hegemony of free market principles is extending beyond limits that have long seemed prudent. For example, Adam Smith warned in The Wealth of Nations that national governments must resist the power of manufacturers to “become formidable to the government, and . . . intimidate the legislature” (p. 415). Smith also feared excessive profits (pp. 109–110) and considered “private luxury and extravagance” to be “ruinous taxes” (p. 72). Futurists predict—and sometimes celebrate— more increases in dislocation as the Internet further replaces local ties.32 Ultimately, people are expected to even give up their identity as human beings—the ultimate dislocation. Italian futurist, Valerio Evangelisti described it this way: Traditional capitalism only needed to advertise. But the new capitalism goes into people’s imagination, dreams, and most intimate visions of the world. The growth of communication has permitted it to go there, imposing lifestyles, creating needs that did not exist before, deliberately increasing people’s thirst for approval. It is impossible to understand contemporary society without taking the rapid colonialization of the imagination that has been accomplished in recent years into account . . . There is a deliberate attempt to rob people of their identity.33

DISLOCATION AS THE PRECURSOR OF ADDICTION Only people who are chronically and severely dislocated are vulnerable to addiction, although some of them manage to avoid it. Some eventually find ways to achieve enough psychosocial integration and some who do not achieve psychosocial integration enter into lifestyles that cannot be called “addiction” without stretching the word too thin. They may, for example, become eccentric, physically ill, depressed, hypochondriacal, violent, or suicidal instead. The historical correlation between severe dislocation and addiction is strong. Although alcohol consumption and drunkenness on festive occasions was widespread in Europe during the middle ages, and although a few people became “inebriates” or “drunkards,” mass alcoholism was not a problem. However,

alcoholism gradually spread with the beginnings of free markets after 1500, and eventually became a raging epidemic with the dominance of free market society after 1800.34 From Charles Dickens onward, social historians often identified dislocation (along with poverty) as a major cause of alcoholism.35 Eric Hobsbawm wrote as follows about the “labouring poor” in the early 19th century: faced with a social catastrophe they did not understand, impoverished, exploited, herded into slums that combined bleakness and squalor, or into the expanding complexes of small-scale industrial villages, [most of the labouring poor] sank into demoralization. Deprived of the traditional institutions and guides to behaviour, how could many fail to sink into an abyss of hand-to-mouth expedients, where families pawned their blankets each week until pay-day and where alcohol was “the quickest way out of Manchester” (or Lille or the Borinage). Mass alcoholism, an almost invariable companion of headlong and uncontrolled industrialization and urbanization, spread “a pestilence of hard liquor” across Europe.36

Opium use, which had been common and unproblematic in England for centuries, first became perceived as a widespread addiction problem in the 19th century.37 Other kinds of addiction spread too, leading to a profusion of newly recognized problems from aspirin addiction to workaholism and to a huge number of treatment and self-help programs. But was it really dislocation per se, that caused the spread of addiction? Could it not also have been poverty, disease, physical pain, the availability of new drugs, or a new Puritanism? The ideal test would be a historical situation where dislocation was extreme, but was unaccompanied by the other possible causes. Because Vancouver only partially fits these requirements, I have selected two Canadian examples that approach this ideal type more closely, and an apparent counterexample.

Native Canadians Extensive anthropological evidence shows that prior to their devastation by Europeans, the diverse native cultures in Canada all provided

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a level of psychosocial integration that is unknown to modern people. Most native people lived communally and shared their resources within a matrix of expectations and responsibilities that grew from their family, clan, village, and religion as well as their individual talents and inheritance of particular prerogatives. They clung to their cultures with courageous resolution—although they valued European trading goods, they found European ways repellant. On the other hand, Canadian natives had a long tradition of warfare, cruel torture of prisoners, and slavery38 like the Europeans. Although murder, adultery, and insanity sometimes occurred within Canadian aboriginal culture,39 I have as yet found no mention by anthropologists of anything that could reasonably be called addiction, despite the fact that activities were available that have proven addictive to many people in free market societies, such as eating, sex, gambling, psychedelic mushrooms, etc. Canadian natives did not have access to alcohol, but natives in what is now Mexico and the American Southwest did. Where alcohol was readily available, it was used moderately, often ceremonially rather than addictively.40 The history of Canadian aboriginals is different from the more famous “Indian wars,” enslavement, and mass slaughter that occurred in the U.S. and in Latin America. Centuries before Vancouver was founded, both British and French trading companies in Canada established formal and mutually beneficial furtrading relationships with many native tribes, primarily in eastern and central Canada. Few European settlers then sought to settle in the inhospitable Canadian climate, so there was little need to displace the natives. Later, the English colonial government formed indispensable military alliances with various aboriginal nations in several wars, particularly against the U.S.41 After these crucial wars ended, it would have been unseemly for the Crown, as it began to covet the vast native lands, to slaughter former allies who had fought loyally and sometimes decisively. Instead, the British and later Canadian governments quietly pursued a policy, later called “assimilation,” intended to move

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aboriginal lands into the real estate market and aboriginal people into the labour market as quietly as possible. This policy was explicitly intended to strip the natives of their culture and lands. One notorious instrument of this policy was a network of “residential schools” where children, often forcibly taken from their parents, were forcefully taught to despise their own language and customs, which sometimes alienated them from their own families as well. An 1847 report of the colonial Canadian government contained this comment: Their education must consist not merely of the training of the mind, but of a weaning from the habits and feelings of their ancestors, and the acquirements of the language, arts, and customs of civilised life.42

Although assimilation policy very nearly succeeded in eliminating native languages and spiritual practices, it failed to integrate the natives into free market society, thus leaving them utterly dislocated.43 As wards of the federal government, however, they generally had food, housing, and some protection. Although some Canadian natives developed a taste for riotous drunkenness from the time that Europeans first introduced alcohol, many individuals and tribes either abstained, drank only moderately, or drank only as part of tribal rituals for extended periods.44 It was only during assimilation that alcoholism emerged as a pervasive, crippling problem for native people, along with suicide, domestic violence, sexual abuse, and so forth. Although some eastern tribes were ravaged by drunkenness and alcoholism centuries before assimilation was established as a policy, the causal principle appears to be the same. For example, the Hurons of eastern Canada, who were “civilized” by the devotion of courageous French missionaries backed by the firepower of the French Army early in the 17th century, were famous for their drunken violence.45 “Civilization,” as it came to these natives, was administered by militant Jesuits in a century of fanatical religious zeal. This meant destruction of the robust Huron religion and, hence, Huron culture itself, with dislocation as the consequence. Eventually

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every tribal culture in Canada was engulfed by the overpowering European culture, and every tribe succumbed to the ravages of dislocation, including epidemic alcoholism. Massive dislocation produced massive addiction. The Vancouver area had a relatively minor history of fur trade and no history of military alliance with the Crown. The natives were dispossessed of their lands without great violence,46 enslavement, or impoverishment, but deliberate destruction of whatever remained of their culture began immediately and, with it, rampant alcoholism.47 Throughout the period of assimilation up to the present, Canadian natives have had an astronomical rate of alcoholism, although the statistics may understate the problem. Although a few reserves have only minor problems with alcoholism, alcoholism in many reserves is nearly 100% (including people in stages of recovery). Alcoholism was only one consequence of this mass-produced dislocation. Other consequences include drug addictions, depression, domestic violence, and suicide.48 There is a more popular explanation for the widespread alcoholism of Canadian natives. They are often said to have a racial inability to control alcohol. However, this is unlikely, since alcoholism was not a ruinous problem among natives until assimilation subjected them to extreme dislocation. Moreover, if natives were handicapped by the “gene for alcoholism,” the same must be said of the Europeans, since those subjected to conditions of extreme dislocation also fell into it, almost universally.

Orcadians in Canada The history of the Hudson’s Bay Company, the “oldest continuous capitalist corporation still in existence,”49 provides an example where, at least for some of its employees, maximum dislocation was little confounded by other distress. The Hudson’s Bay Company was chartered by Charles II of England, in 1670. Until 1987, a span of more than three centuries, it maintained forts and fur trading outposts on the shores of Hudson’s bay and throughout the Canadian north. Some of the company’s traders were volunteers from London and some

were from the Orkney Islands at the Northern extreme of Scotland, where the ships from London stopped en route to Hudson’s Bay to provision and to augment their complement. Preferred as employees because they were already accustomed to extreme northern latitudes and life at sea, and because of their characteristic sobriety and obedience, the Orkney volunteers were mostly poor lads who volunteered for adventure and escape from the confines of traditional Orkney society. Whereas they did gain some of what they sought, they severed their ties to a close, traditional system based on both common land and cotter labour which persisted in the Orkneys until the middle of the 19th century,50 long after it had been cleared from the highlands. As “Bay men,” their only contact with home came once a year from a single ship that brought mail, supplies, and English sailors, and took out the pelts. When the annual ship disappeared, the men were alone again. Although fed and treated as well as the era and circumstances permitted, their lives provide evidence of the long-term effects of dislocation: With some exceptions, the Bay men became internal exiles in both their homelands, original and adopted. Never part of any society outside the fur trade, they gradually pruned their ancestral roots, becoming bitterly aware of the true nature of any voluntary emigration: that one is exiled from and never to, and that disinheritance and marginality are all too often the price of freedom. More than one loyal HBC trader faced the end of his days with few close friends or blood relatives he wished to acknowledge and so bequeathed whatever worldly goods he had gathered to the only family he had: the Company.51

One unmistakable aspect of the lives of the Bay men was intemperance. Alcoholism appears to have been rampant: The Company quickly realized that liquor was a greater enemy than the climate to its trade on the bay, no matter how many prohibitions it proclaimed and no matter how often it paid off informers to halt the smuggling of brandy cases on outgoing ships, the booze flowed steadily

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across the Atlantic. Exceptional was the Company [employee] who failed to organize surreptitious caches of several gallons or so of brandy for his private stock.52

The alcohol-related problems suggest widespread alcoholism, although this word had not yet been invented. The following was written about an outpost on Hudson’s Bay named “Moose Factory”: Many of the work accidents at Moose were alcohol-related. One man consumed so much “bumbo”—that fur-trade mixture of rum, water, sugar, and nutmeg—that he fell off the sloop and promptly drowned. With some regret and much haste, his mates lost no time in auctioning off the contents of his chest. The chief factors were always afraid that the men on watch, who were too often drunk, would spitefully or accidentally set fire to the buildings. The courage to commit suicide could also be found in the bottle. “Brandydeath” was common.53

But could the men already have been alcoholic before they encountered the supreme dislocation of Hudson’s Bay? Or could the extremes of northern life have made them alcoholic? These explanations could work for the Londoners, but not the Orcadians. The Orcadians were preferred employees of the Bay because of their natural sobriety and because they were accustomed to life at extreme northern latitudes. Dislocation transformed them. Local preachers in the Orkneys spoke of the returning Bay men and those who had served long stints in the English fishing fleets in similar terms: the Rev. Francis Liddell, minister of Orphir, launched into an impassioned diatribe against those who abandoned wives, children, and parents to enter the service of the Company, eventually returning home with enough money to out-bid honest farmers; they brought home none of the virtues of the savage, but all the vices— indolence, dissipation, and irreligion; “My God!” he declaimed, “shall man, formed in the image of his Creator, desert the human species and, for the paltry sum of six pounds a-year, assume the manners and habits of the brutes that perish?54

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Counterexample: “Instantaneous Addiction” If dislocation is the necessary precursor to addiction, then there could be no instances in which addiction occurs unless preceded by dislocation. Yet, popular wisdom teems with apparent counterexamples. For example, between 1986 and 1992 the American media reported a catastrophic epidemic of addiction to crack cocaine among American youth. Far from being limited to dislocated people, crack addiction reportedly afflicted all those who used the drug even once. Respected mainstream American news media reported that addiction was spreading inexorably because smoking crack caused “instantaneous addiction,” qualifying it as “the most addictive drug known to man.” The resulting “epidemic” was “as pervasive and dangerous in its way as the plagues of medieval times,” and “all but universal.”55 Neurobiological researchers of the day devised brilliant explanations for the irresistible addictiveness of crack that was being claimed, without seriously testing the validity of the claim itself.56 Had the proclaimed addictiveness of crack been true, it would have proven that dislocation is not the necessary precursor of addiction. However, it was false. Numerous large scale studies have now shown conclusively that only a small fraction of crack cocaine users become addicts. Those who do become addicted are concentrated among the visibly dislocated segments of the population, and their reasons for continuing crack cocaine use are easily understandable as responses to dislocation.57 Severely dislocated people are likely to become addicted if they try crack, but they are equally vulnerable to many other addictions as well. Anthropologist Philippe Bourgois has described the adaptive function of the “crack economy” of young blacks and Hispanics in New York City. Economically and socially dislocated in the ghetto, young men “struggle for survival, and for meaning” (p. 61). Even a dangerous life of addiction and petty crime at least avoids doing degrading work for pathetic wages. The most successful drug users rise through the hierarchies of drug society and

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achieve a kind of substitute psychosocial integration with the larger community: The feelings of self-actualization and self-respect that the dealer’s lifestyle offers cannot be underestimated. A former manager of a coke-shooting gallery who had employed a network of a halfdozen sellers, lookouts, and security guards and who had grossed $7000–13,000 per week for over a year before being jailed explained to me that the best memories of his drug-dealing days were of the respect he received from people on the street. He described how, when he drove up in one of his cars to pick up the day’s receipts, a bevy of attentive men and women would run to open the door for him and engage him in polite small talk, not unlike what happens in many licit businesses when the boss arrives. Others would offer to clean his car. He said that even the children hanging out in the street who were too young to understand what his dealings involved looked up to him in awe.58

Crack addiction, like any addiction, can have horrible consequences, but the demonic ability of “crack” to cause addiction, as much in psychosocially integrated people as in dislocated people, is a total fabrication.59 Crack is not, in any important sense, the cause of crack addiction, but dislocation is. Unfortunately, the media, politicians, and even some addiction professionals have not publicized the fact that the irresistibly addictive demon crack is a fabrication, and, therefore, many members of the general public and even addiction professionals still believe it to be true. The coils of propaganda that support the “war on drugs” are strong and resilient, like those that support wars in general.60 There is no space in this short chapter to evaluate the possibility that drugs other than crack induce addiction in non-dislocated people, although the claim was widely believed for alcohol in the 19th century, heroin at the turn of the century, and marijuana in the 1920s. No credible evidence for any of these claims has materialized. In each case, the great majority of users take the drug in moderation, do not become addicted, and feel they gain more from their drug use than they lose.61 No matter what drug they use, drug addicts who can be

carefully studied turn out to have been severely dislocated before their addiction ensued.

CONCLUSION: GETTING AT THE ROOTS OF ADDICTION Every society must cherish its defining beliefs. Therefore, it is only polite to overlook connections between free markets, dislocation, and addiction. Print and electronic media foster this distraction, celebrating the free market’s achievements with blinding fireworks and deafening fanfare. As well, they endlessly publicize new medical explanations for the puzzling spread of addictions and new hopeful solutions for the “drug problem” But we can no longer afford this much politeness, because interventions that ignore the connection between free markets, dislocation, and addiction have proven little better than Band-Aids applied to the gaping wound that addiction inflicts upon free market society. This is not to say that prevention, treatment, harm reduction, and police intervention are useless, only that these four pillars of intervention cannot reduce addiction faster than free market society mass-produces it. Under these conditions, civil inattention to root causes is unaffordable. There have been decades of futile debate about whether addiction is a “criminal” problem or a “medical” problem. The hard fact is that it is neither. In free market society, the spread of addiction is primarily a political, social, and economic problem. If the political process does not find contemporary wellsprings of psychosocial integration, society—with its ever freer markets—will manifest ever more dislocation and addiction. Careful coordination of prevention, treatment, harm reduction, and policing (the “four pillars”) can ameliorate drug addiction, but cannot even address the larger problem of addiction or its root causes. Political action is necessary.

CHANGING THE DEBATE One form of political action is changing the terms of the debate on addiction. A realistic discussion must recognize that addiction is

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mass-produced in free market society, and that, therefore, society as well as individuals must change. To define addiction as either a “drug problem” or a “disease” of aberrant individuals, is to prolong a wild goose chase. Addiction is a harmful lifestyle, which may or may not involve drugs, which more and more people in free market society are adopting as a desperate measure to prevent themselves from being crushed by severe, prolonged dislocation. Changing the terms of this debate is a huge task, since the current manner of speaking of addiction as an individual drug-using disease is maintained by a media army that has been launching this message for decades. People endure this barrage of disinformation partly because it complements a deeply rooted North American “temperance mentality,” which makes it seem natural to blame social problems on drugs and alcohol62 and partly because it profits many institutions and professions that treat, police, prevent, and “harm reduce” the putative disease. Those who launch the public information barrage prosper because the “War on Drugs,” which has drawn its justification from it,63 serves vital commercial and geopolitical purposes for vested interests with very deep pockets.64 Professionals in the field of addiction could take the lead in changing the terms of the debate. Rather than endlessly competing for funds by overstating their own achievements, those who support each of the four pillars should apprise society of the limited extent of their accomplishments, thereby showing that even the four pillars together cannot save the day. Some policemen have bravely spoken out on the limited impact of police intervention, leading some jurisdictions away from excessive drug law enforcement.65 Similar forthrightness from prevention, treatment, and harm reduction professionals would help a lot. Prevention professionals know that their success in dissuading people from drug use over the long term is low. Treatment professionals know that no matter how much treatment is available, most addicts will not accept it voluntarily, that most of those who do accept it will not overcome their addiction in a lasting way, and that imposing it involuntarily is even worse. Harm

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reduction professionals know that most addicts on methadone maintenance programs continue to inject, and most addicts with access to needle exchange programs continue to share needles on frequent occasions. . . . society cannot “prevent,” “treat,” or “harm reduce” its way out of addiction any more than it can “police” its way out of it. This does not mean that professional intervention should be eliminated, only that more fundamental steps are essential.

CLARIFYING DIRECTIONS FOR POLITICAL CHANGE Authoritative voices around the world are raising a mighty chorus of warnings against the psychological devastation engendered by the free market society (in addition to the more visible ecological and social devastation).66 According to Globe and Mail journalist, P. McKenna: “It is absolutely essential for states and individuals to locate that delicate balance between . . . a world of high-tech, instantaneous communication, idolatry of markets and investment and ‘Darwinian brutality’ . . . and . . . a world with a heartfelt sense of belonging, rootedness, community and identity.”67 Sociologist John Gray: “It is true that restraints on global free trade will not enhance productivity; but maximum productivity achieved at the cost of social desolation and human misery is an anomalous and dangerous idea.”68 People knowledgeable about addiction can add a new counterpoint to this chorus, because understanding the relationships between free markets, dislocation, and addiction provides a fresh take on some old themes. The complex problem of dislocation and addiction is not exactly the same as more familiar issues, like “eliminating poverty” or “achieving social justice.” Although poverty and injustice are abhorrent, both are frequently borne without addiction.69 It is poverty of the spirit, which is called “dislocation” in this chapter, that is the core precursor of addiction. The key to controlling addiction is maintaining a society in which psychosocial integration is attainable by the great majority of people. People need to belong within their society, not just trade in its markets.

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For example, in an era when corporations and capital can hopscotch continents in pursuit of cheap labour, it is a matter of social justice that working people ought to have the same rights of mobility as those who would exploit them. However, the free movement of labour is not the best solution to this problem, since immigration usually entails extreme dislocation, which adds greatly to the hardships of workers who immigrate, even if they do achieve better pay. This is perhaps less apparent in Canada than in other countries, since Canada still affords room for population growth, allowing many immigrants to Canada to find permanent homes that are far better than those they left. But the dislocation that results from immigration is hard to bear even under the best conditions, and it is exacerbated in most countries by corruption, violence, betrayal, and ultimately deportation when a temporary labour need ends.70 Instead of mass migration, a better solution to the problem of exploitation of labour is imposing fair labour standards on a global level and preventing transnational corporations from inducing local governments to rescind local labour, health, safety, and environmental protections. Current concerns with the outrageous bias of international free market institutions (WTO, World Bank, etc.) towards the economic interests of rich countries and with criminal corruption in large corporations might also be understood somewhat differently in light of the globalization of addiction. Bias and corruption are huge problems,71 but neither of them is intrinsic to the free market. Rather, they are manifestations of contemporary excesses that might be correctable through political pressure. On the other hand, continuing, ever-increasing dislocation of people from human culture in order to create free markets is intrinsic to free market society— addiction would be endemic in the purest form of free market society. At this time in history, it is premature to automatically attribute a well-developed approach to the problem of addiction to the political “left,” although the left is the historical opponent of punitive treatment of drug addicts. Rapid expansion of free market society is currently accepted—either enthusiastically, grudgingly, or unconsciously—by many of those

who wear the label “left,” “radical,” “labour,” “intellectual,” or “liberal” on the political spectrum,72 as well as those labeled “right.” The left needs to provide a fuller analysis of the devastating psychological impact of free markets, in addition to their devastating ecological, social, and political impacts.

SOCIAL CHANGE Confronting the globalization of addiction requires more than words. There need to be concrete changes in social policy. As an example, consider the huge amounts of money now spent in British Columbia on low-flying helicopters that search for marijuana plantations. The quest is futile, because the province is immense and because marijuana can be grown indoors. Moreover, the great majority of marijuana users suffer no addiction or other discernible ill-effects. The side-effect of this futile policing is the transformation of resourceful and prosperous growers who might be mainstays of rural communities into criminals.73 Community-busting proceeds further when the RCMP arrives in a community, announces a meeting, and enlists the aid of local people to inform on their neighbours who might be growers, thus sowing further suspicion and division. At the same time, the provincial government cannot find enough money to support the local schools and hospitals in many of these same remote communities, displacing children and medical patients into adjacent districts, far from families and friends. The police frequently cannot find money to control petty crime, undermining the family security. There are not enough social workers to carefully investigate suspected cases of child abuse. As a consequence some children are destroyed by abuse and others are apprehended when their natural families could be restored to peacefulness with a little support or supervision. All of the money now being spent vainly and disruptively attacking marijuana cultivation could be far better spent in the same communities to prevent the dislocation of the children, the sick, and the vulnerable. Reducing dislocation would reduce present and future addiction and other forms of self-destruction.

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The social changes that need to be made on provincial and federal levels run counter to the trends of recent years. Federal and provincial governments have cut social housing, denying thousands the step towards psychosocial integration that decent, stable housing provides. They have cut unemployment insurance and welfare, forcing people to move to where jobs are more plentiful, abandoning their home communities. Overall, public spending has been in decline for much of the 1990s, undermining our ability to care for one another and to provide decent employment in socially useful fields. Solutions to the rising tide of addiction and other consequences of dislocation flow naturally from attention to root causes. We need to restore social spending. We need to enhance our ability to care for one another. We need to invest in social housing. We need to reform our public services, so they become more nurturing. We need to rebuild programs like welfare and UI that give people choices and allow them to stay in their home communities. We need to place full employment once again at the top of the public policy agenda. On a global level, substantially reducing the addiction problem requires nothing less than exercising sensible, humane controls over markets, corporations, environments, public institutions, and international agencies to reduce dislocation. This cannot be achieved without conflict, because it will inevitably impede the pursuit of ever-increasing wealth and ever-freer markets. Of course it would be naive to hope for a return to any real or imagined golden age. However, it is at least as naive to suppose that society can continue to hurtle forward, ideologically blinded to the crushing problems that free markets create. Solving the problem of dislocation is not the least of the tests that the new, global society must pass, if it is to endure and flourish.

3. 4. 5. 6.

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NOTES 1. For example, “anomie,” “identity diffusion,” “alienation,” “les désarrois de l’individusujet.” 2. The premises in this paragraph were given their clearest formulation and theoretical development in Erik Erikson’s work (1963; 1968; 1982). The theory of this chapter follows Erikson throughout. It could also be stated in the language of

8. 9. 10. 11.

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postmodernist psychoanalysis (Dufour 2001), but this seems unnecessarily complex. The premises in this paragraph were given their classical statement in Polanyi’s The Great Transformation (1944). Alexander, 1990, chap. 8; Erikson, 1968, p. 88. Reviewed by Orford, 1985; Alexander, 1990; Alexander & Schweighofer, 1988. It is conventional among addiction professionals to think of addiction as having multiple precursors, often called “risk factors,” that correlate positively with the incidence of addiction. The thesis of this report is that the single underlying cause or precursor of addiction is a person who can find no better way of coping with a state of sustained, severe dislocation than to adopt an addictive lifestyle. Various risk factors correlate with addiction because they raise the risk of dislocation or because they put drugs or other common objects of addiction close to hand. Thus, childhood abuse is a risk factor because it produces emotional wounds that raise the likelihood of dislocation as the child matures. I have developed this theory at length elsewhere (e.g., Alexander, 1990; 1994). Marx and Engels devoted some of the most powerful rhetoric in the Communist Manifesto to the destructive relationship between bourgeois capitalism and traditional social bonds (Marx & Engels, 1848/1948). Ultimately, however, they expressed no expectation that a Communist society would restore traditional social relationships, and, in fact, distanced themselves from “utopian” socialists and communists who believed in their restoration (pp. 39–42). In an often-quoted paragraph, Marx and Engels appear to endorse the bourgeois faith that the “real conditions of life” come to the fore when traditional social ties are broken (Marx & Engels, 1848/1948, p. 12) The Soviet Union’s practice of destroying traditional society in the interest of economic development is well known in the case of collective farms and well-documented in many other instances (see Gray, 1998, chap. 6; Ginisty, 1999). The Chinese communist government of Mao Tse Tung went to great lengths to preserve most aspects of traditional rural social structure and had no major problems with opium addiction or alcoholism, despite the widespread availability of good, cheap beer. However, massive dislocation of the Chinese rural population increased substantially during and after the reign of Deng Xiao Peng and much more is expected with the entry of China into the WTO (Cernetig, 1999; Lew, 2000; Mangin, 2000). If the theory of addiction that this report posits is correct, China will experience massive increases in addiction (although not necessarily drug addiction) in the next few years. Newman, 1959; Slater, 1980; Newman, 1991, chap. 17; Barlow & Winter, 1997, chap. 1. Bula & Ward, 2000. Hill-Tout, 1978, e.g., p. 45; Pethick 1984. Pethick, 1984

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12. McDonald & Barman, 1986. 13. Juristat: Canadian Centre for Justice Statistics, 1999; Murphy, 1922/1973. Although B.C. is Canada’s most drug addicted province, it is surpassed in this regard by its arctic territories, i.e., the Yukon and the Northwest Territories. This too fits easily into the theoretical structure of this report. 14. Alexander & Schweighofer, 1988. 15. Alexander, 1990; 1994. 16. The term “free market” is used here in its conventional sense, meaning a system in which, in all spheres of activity, people and corporations have the maximum freedom of choice in shopping, hiring, firing, and investing. The term is often contested because although “free market” economics maximize certain important freedoms, they curtail the freedom of citizens to safeguard social cohesion and the physical environment by regulating markets and corporations (Chossudovsky, 1997). 17. Polanyi, 1944; Agar, 1936/1999; Hill, 1958, chap. 7; Gray, 1998; McFeat, 1966; McMurtry, 1998, pp. 259–296. 18. 1944, p. 42. An expanded, but still concise statement of Polanyi’s essential analysis can be found on pp. 40–42. 19. Beniger, 1986; Bourdieu, 1998; Beaud & Pialoux, 2000. 20. Hill, 1958, chap. 7; Neeson, 1993; Polanyi, 1944. 21. Marx & Engels, 1848/1948, p. 11. 22. Scholars who recognize the devastating effect of free market society on traditional culture but nonetheless support it include Hayek (1944), Beniger (1986, pp. 434–435), Giddens, (1999), and Friedman, (2000, pp. 11–12). Scholars who condemn the devastating effect of free markets on traditional society include Polanyi (1944), Hobsbawm (1994, p. 16), Chossudovsky (1997), Gray (1998), Sassen (2000). 23. Prebble, 1963. 24. Polanyi, 1944, p. 173. 25. Lemoine, 2001. 26. Polanyi, 1944, p. 128, italics added. 27. DeGrandpre, 1999, p. 18. 28. Bronfenbrenner, et al., 1996. 29. 1998, p. 72. 30. Agar & Tate, 1936/1999; Giddens, 1998; Hobsbawm, 1994; Polanyi, 1944. 31. Chossudovsky, 1997; George, 1999; Lew, 2000; Mangin, 2000; McQuaig, 1998. 32. Harvey, 1998, p. 25. 33. Evangelisti, 2000, p. 29, my translation. 34. Austin (1985) contrasted drinking in medieval and eighteenth-century Europe as follows: Although chronic inebriety was a sin (in medieval Europe), occasional inebriety was accepted as a natural aspect of life. One of the few examples of legislation against drunkenness was a decree by Archbishop Theodore of Canterbury in the seventh century ordering that anyone who drank to excess must do penance for fifteen days. Because of the importance of beer and wine to the diet,

drink controls largely focused on protecting the drinker from unscrupulous sellers, maintaining a good supply and a fair price, and reducing the adverse consequences (such as public disorders) of too much drinking. As in antiquity, inebriety was largely associated with occasional festivities and with a few specific populations (nobles, students, and clerics) who had the wealth, free time, or access to supplies that enabled more regular indulgence. . . . In the eighteenth century, concerns again rose as inebriety became more regular among more people, reaching unprecedented heights. The upper classes and the towns continued to lead the way, but chronic inebriety was no longer primarily the prerogative of the upper-classes. The major development of the century was the expansion of drinking among the lower classes and into rural villages. Its was most prevalent in England, but everywhere complaints about inebriety multiplied. (pp. xviii, xx) 35. Charles Dickens, 1835/1994; Hughes, 1987. 36. Hobsbawm, 1962, p. 202. 37. Berridge and Edwards (1981) argue that this was more a matter of class persecution and professional ambition than of a major increase in addiction. They also report, however, a substantial increase of opium use in 19th-century England and indications of at least moderately increased addiction as well. 38. Jewitt, 1824/1988; MacAndrew & Edgerton, 1969, pp. 137–139; McFeat, 1966. 39. Oberg, 1934, p. 193. 40. McAndrew & Edgerton, 1969, p. 109. 41. Allen, 1992; Newman, 1985. 42. Quoted by Haig-Brown, 1988, p. 25. 43. Chrisjohn, Young, & Maraun, 1997; Haig-Brown, 1988. 44. McAndrew & Edgerton, 1969, chap. 6. 45. McAndrew & Edgerton, 1969, pp. 124–126 46. Of course British authorities always had the lash, the gallows, and the artillery of the royal navy close at hand, and these were called into service at the slightest indication of organized resistance (Arnett, 1999). It is impossible to know whether the natives were persuaded to give up their cultures by being hopelessly outnumbered, by the magical attraction of British trade goods, or by occasional demonstrations that resistance would always encounter irresistible force. 47. Kew, 1990; Matas, 2000. 48. Some indirect evidence for this assertion comes from research on the relationship between youthful suicide and cultural integrity in native groups (Chandler & Lalonde, 1998). 49. Newman, 1985, p. 3. 50. Thompson, 1987, p. 222. 51. Newman, 1985, p. 9. 52. Newman, 1985, pp. 160–161. 53. Pannekoek, 1979, p. 5. 54. Thompson, 1987, p. 220.

THE ROOTS OF ADDICTION 55. Quotes collected by Reinarman and Levine, 1997, chap. 1. 56. Wise & Bozarth, 1987. 57. Erickson et al., 1994; Matthews et al., 1994; Cheung & Erickson, 1997; Morgan & Zimmer, 1997; Reinarman & Levine, 1997; Peele & DeGrandpre, 1998. 58. Bourgois, 1997, p. 71. 59. Trebach, 1987; Erickson & Alexander, 1989; Alexander, 1990, chap. 5; Erickson et al., 1994; WHO/ UNICRI, 1995; Reinarman & Levine, 1997; Peele & DeGrandpre, 1998. 60. Alexander, 1990; Hermann & Chomsky, 1988; DeBray, 1999. 61. See Alexander (1990; 1994) for a review of the relevant literature. The validity of the generalization made in this paragraph is not as obvious for heroin as it is for alcohol and marijuana. Although there are large numbers of non-addicted recreational users of heroin (Trebach, 1987), there may not be enough to justify the generalization. However, heroin is virtually identical pharmacologically with a large number of other “opiates” or “opioids,” e.g., morphine, dilaudid, and Demerol whose preponderant use is nonaddictive. 62. Levine, 1992; Alexander et al., 1998. 63. Alexander, 1990, chap. 8. 64. The best documented beneficiary of the drug war is the U.S., which uses the label of “drug traffickers” as a justification for suppressing anti-capitalist uprisings in Latin America and of imposing discipline on disobedient foreign governments. Drug companies, which use the drug war to eliminate the illegal competition for the psychoactive drugs they sell are also major beneficiaries (Chomsky, 1992, chap. 4; Lemoine, 2000; 2001; Buchanan & Wallack, 1998). 65. An outstanding Canadian example is the late Gil Puder, of the Vancouver Police Department (Puder, 1998). 66. e.g., Bourdieu, 1998; Dufour, 2001. 67. McKenna, 1999. 68. Gray, 1998, p. 83. 69. For example, describing the lowest and largest stratum of highland traditional society, Prebble (1963) wrote: The cotter was from birth a servant. Tradition and customary right gave him a little grazing for a cow on the township pasture, a kail-yard and a potato-patch by his round-stone hut, and for these he paid a lifetime of service to the sub-tenant. . . . The servant of the servant is worse than the devil. Bad is the tenancy, but the evil of the Evil One is in the sub-tenancy. His escape could come in his dreams, or in the sharing of glory with the chief when the Bard sang or the Piper played. He could escape further into the King’s red coat, and die at Ticondaroga or Havana with the slogan of his clan on his lips. Yet the life was something which he and the sub-tenants were themselves unwilling to change. Their attachment to the land was deep

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and strong. They had peopled it with talking stones, snow-giants, and mythical warriors of mountain granite. Their culture was virile and immediate, their verse flowered on the rich mulching of their history. (p. 15) 70. Fennell, 2000; Morice, 2000. 71. Bulard, 2000; De Brie, 2000; Quéau, 2000; VidalBeneyto, 2000; Viveret, 2000. 72. Giddens, 1998; Goytisolo & Grass, 1999; Dixon, 2000. 73. Poole, 1998.

REFERENCES Agar, H. (1936/1999). Introduction. In H. Agar & A. Tate (Eds.), Who owns America: A new declaration of independence. Wilmington, Delaware: ISI Books. Alexander, B.K. (1990). Peaceful measures: Canada’s way out of the “War on Drugs.” Toronto: University of Toronto Press. Alexander, B.K. (1994). L’héroïne et la cocaïne provoquent-elles la dépendance? Au carrefour de la science et des dogmes établis. In P. Brisson (Ed.), L’usage des drogues et la toxicomanie. Montreal: Gaëtan Morin. Alexander, B.K., Dawes, G.A., van de Wijngaart, G.F., Ossebard, H.C., Y Maraun, M.D. (1998). The “temperance mentality”: A comparison of university students in seven countries. Journal of Drug Issues, 28, 265–282. Alexander, B.K. & Schweighofer, A.R.F. (1988). Defining “addiction.” Canadian Psychology, 29, 151–162. Allen, R.S. (1992). His Majesty’s Indian allies: British Indian policy in the defense of Canada, 1774–1815. Toronto: Dundern. Arnett, C. (1999). The terror of the coast: Land alienation and colonial war on Vancouver Island and the Gulf Islands, 1849–1863. Vancouver, BC, Canada: Talonbooks, 1999. Austin, G.A. (1985). Alcohol in western society from Antiquity to 1800: A chronological history. Santa Barbara, California: ABC-Clio Information Services. Barlow, M. & Winter, J. (1997). The big black book: The essential views of Conrad and Barbara Amiel Black. Toronto: Stoddard. Beaud, S. & Pialoux, M. (2000, January). Cette casse délibérée des solidarités militante: Des ouvriers sans classe. Le Monde diplomatique, pp. 10–11.

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Beniger, J.R. (1986). The control revolution: Technical and economic origins of the information society. Cambridge, Massachusetts: Harvard University Press. Berridge, V. & Edwards, G. (1981). Opium and the people: Opiate use in nineteenth century England. London: Allan Lane. Bourdieu, P. (1998, March). L’essence du néolibéralisme. Le Monde Diplomatique, p. 3. Bourgois, P. (1997). In search of Horatio Alger: Culture and ideology in the crack economy. In C. Reinarman and H.G. Levine (Eds.), Crack in America: Demon drugs and social justice. Berkeley: University of California Press, pp. 57–76. Bronfenbrenner, U., McClelland, P., Wethington, E., Moen, P., and Ceci, S.J. (1996). The state of Americans: This generation and the next. New York: Free Press. Buchanan, D.R. & Wallack, L. (1998). This is the Partnership for Drug Free America: Any questions? Journal of Drug Issues, 28, 329–356. Bula, F. & Ward, D. (2000, 3 March). Vancouver envy: Why the world is beating a path here to learn how to fix its broken cities. The Vancouver Sun, p A1, A8–9. Bulard, M. (2000, January). La firmes pharmaceutique organisent làpartheid sanitaire. Le monde diplomatique, pp. 8–9. Cernetig, M. (1999, 23 June). China’s painful blast from the past: Outlawed for decades the rickshaw is back, as are porn, prostitutes, and even opium. ‘Mao would not be happy.’ Globe and Mail, pp. A1, A11. Chandler, M.J. & Lalonde, C. (1998). Cultural continuity as a hedge against suicide in Canada’s First Nations. Transcultural Psychiatry, 35, 191–219. Cheung, Y.W. & Erickson, P.G. (1997). Crack use in Canada: A distant American cousin. In Reinarman, C. & Levine, H.G. (Eds.), Crack in America: Demon drugs and social justice. Berkeley: University of California Press. Chomsky, N. (1992). Deterring democracy. New York: Hill and Wang. Chossudovsky, M. (1997) The globalization of poverty: Impacts of IMF and World Bank reforms. London: Zed Books. Chrisjohn, R, & Young, S., with Maraun, M. (1997). The circle game: Shadows and

substance in the Indian residential school experience in Canada. Penticton, British Columbia: Theytus Books. De Brie (2000, April). Etats, mafias et transnationales comme larrons en foire. Le monde diplomatique, pp. 4–5. DeBray, R. (1999, June). Une machine de guerre. Le monde diplomatique. pp. 8–9. DeGrandpre, R. (1999). Ritalin nation: Rapidfire consciousness and the transformation of human consciousness. New York: Norton. Dickens, C. (1835/1994). Gin shops. Republished in, The Dent uniform edition of Dickens’ journalism, sketches by Boz and other early papers, 1833–1835. London: J.M. Dent. Dixon, K. (2000, January). Dans les soutes du : La trosiéme voie, version britannique. Le monde diplomatique. p. 3 Dufour, D.-R. (2001, February). Les désarrois de l’individu-sujet. Le Monde Diplomatique, pp. 16–17. Erickson, P.G., Adlaf, E.M., Smart, R.G., & Murray, G.F. (Eds.) (1994). The steel drug: Cocaine and crack in perspective (2nd ed.). New York: Lexington Books. Erickson, P.G. & Alexander, B.K. (1989). Cocaine and addictive liability. Social Pharmacology, 3, 249–270. Erikson, E.H. (1963). Childhood and society (2nd ed.). New York: Norton. Erikson, E.H. (1968). Identity, youth and crisis. New York: Norton. Erikson, E.H. (1982). The life cycle completed. New York: Norton. Evangelisti, V. (2000, Août). La science-fiction en prise avec le monde réel: Une littéerature des . Le monde diplomatique, p. 29. Fennell, T. (2000, 11 December). The smuggler’s slaves. Maclean’s, pp. 14–19. Friedman, T. (2000). The lexus and the olive tree., rev. ed., New York: Farrar, Strauss, & Giroux. George, S. (1999, July). A l’OMC, trois ans pour achever la mondialisation. Le monde diplomatique, pp. 8–9. Giddens, A. (1998). The third way. Cambridge, England: Polity Press. Ginisty, B. (1999, December). La spiritualité au risque des idoles. Le monde diplomatique, p. 32.

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Goytisolo, J. & Grass, G. (1999, November). Que peut la littérature? Le monde diplomatique, pp. 28–29. Gray, J. (1998). False dawn: The delusions of global capitalism. London: Granta Publications. Haig-Brown, C. (1988). Resistance and renewal: Surviving the Indian residential school. Vancouver, BC, Canada: Tillacum. Harvey, P.-L. (1998, June). Réseaux et appartenances: Le développement d’identités extraterritoriales. Options Politiques, 19(5), 25–29. Hayek, F.A. (1944). The road to serfdom. Chicago: University of Chicago Press. Hermann, E. & Chomsky, N. (1988). Manufacturing consent: The political economy of the mass media. New York: Pantheon. Hill, C. (1958). Puritanism and revolution: The English revolution of the 17th century. New York: Schocken. Hill-Tout, C. (1978). The salish people: The local contribution of Charles Hill-Tout. Volume III: The Mainland Halkomelem. Vancouver, Talonbooks. Hobsbawm, E.J. (1962). The age of revolution: 1789–1848. Cleveland: World Publishing Co. Hobsbawm, E.J. (1994). Age of extremes: The short twentieth century, 1914–1991. London: Michael Joseph. Hughes, R. (1987). The fatal shore: The epic of Australia’s founding. New York: Knopf. Jewitt, J. (1824/1988). A journal kept at Nootka Sound. Fairfield, Washington: Ye Galleon Press. Juristat: Canadian Centre for Justice Statistics (1999). Illicit drugs and crime. Statistics Canada 85–002-XPE, vol. 19. no 1. Kew, J.E.M. (1990). History of coastal British Columbia since 1846. In W. Suttles (Ed.), Northwest Coast. Washington, D.C.: Smithsonian Institution. (Volume 7 of Handbook of North American Indians, W.C. Sturtevant, general editor, pp. 159–169). Lemoine, M. (2000, May). En Colombie, une nation, deux etats. Le monde diplomatique, 18–19. Lemoine, M. (2001, January). Culture illicites, narcotrafic, and guerre on Colombie. Le monde diplomatique, 18–19. Levine, H.G. (1992). Temperance cultures: Concern about alcohol problems in Nordic and English-speaking cultures. In G. Edwards,

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M. Lader, & C. Drummond, (Eds.), The nature of alcohol and drug related problems. London: Oxford University Press. Lew, R. (2000, December). L’empire du Milieu dans la tanière du tigre: Quand la Chine courtise l’OMC. Le monde diplomatique, pp. 16–17. Mangin, M. (2000, December) Inquiétante vague de chômage. Le monde diplomatique, pp. 16–17. Marx, K. & Engels, F. (1848/1948). Manifesto of the Communist Party: Authorized English translation. New York: International Publishers. Matas, R. (2000, 25 July). Squamish support land-claims settlement: $92.5-million deal ends Kitsilano Point claim. Globe and Mail, pp. A1, A5. Matthews, L.C.B., Dawes, G.A., Nadeau, B.G., Wong, L.S. and Alexander, B.K. (1994). The British Columbia Key Informant Study. Report to the World Health Organization, Geneva, Switzerland, 52 pp. McAndrew, C. & Edgerton, R.B. (1969). Drunken comportment: A social explanation. Chicago: Aldine. McDonald, R.A.J. & Barman, J. (1986). Vancouver past: Essays in social history. Vancouver: University of British Columbia Press. McFeat, T. (1966). Indians of the North Pacific Coast. Ottawa: Carleton University Press. McKenna, P. (1999, 26 June). Life in the “fast world.” Globe and Mail, p. D12. McMurtry, J. (1998). Unequal freedoms. Toronto: Garamond Press. McQuaig, L. (1998). The cult of impotence: Selling the myth of powerlessness in the global economy. Toronto: Viking. Morgan, J.P. and Zimmer, L. (1997). Animal self-administration of cocaine: Misinterpretation, misrepresentation, and invalid extrapolation to humans. In Erickson, P.G., Riley, D.M., Cheung, Y.W. and O’Hare, P.A. (Eds.), Harm reduction: A new direction for drug policies and programs. Toronto: University of Toronto Press. Morice, A. (2000, November) De l’ aux quotas. Le monde diplomatique, pp. 6–7. Murphy, E. (1922/1973). The black candle. Toronto: Coles. Neeson, J.M. (1993). Commoners: Common right, enclosure and social change in England,

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1700–1820. Cambridge: Cambridge University Press. Newman, P.C. (1959). Flame of power: Intimate profiles of Canada’s greatest businessmen. Don Mills Ontario: Longman Canada. Newman, P.C. (1985). Company of adventurers, vol. I. Markham, Ontario: Penguin Viking. Newman, P.C. (1991). Merchant princes: Company of adventurers, vol. III. Toronto, Ontario: Penguin Viking. Oberg, K. (1934). Crime and punishment in Tlingit society. American Anthropologist, 36, 145–156. Reprinted in McFeat (1966). Pannekoek, F. (1979). Corruption at moose. The Beaver, Spring, 4–11. Peele, S., & DeGrandpre, R.J. (1998). Cocaine and the concept of addiction: Environmental factors in drug compulsions. Addiction Research, 6, 235–263. Pethick, D. (1984). Vancouver, the pioneer years 1774–1886. Langley, BC, Canada, Sunfire Publications. Polanyi, K. (1944). The great transformation: The political and economic origins of our times. Boston: Beacon. Poole, M. (1998). Romancing Mary Jane: Confessions of a failed marijuana grower. Vancouver: Douglas and McIntyre Prebble, J. (1963). The highland clearances. London: Penguin Books.

Puder, G. (1998, 21 April). Recovering our honour: Why policing must reject the “War on Drugs”. Presented to “Sensible Solutions to the Urban Drug Problem,” a conference of The Fraser Institute, Vancouver, B.C. Quéau, P. (2000, January). A qui appartiennent les connaissances? Le monde diplomatique, pp. 6–7. Reinarman, C. & Levine, H.G. (1997). Crack in America: Demon drugs and social justice. Berkeley: University of California Press. Sassen, S. (2000, November). Mais pouquoi émigrent-ils? Le monde diplomatique, pp. 4–5. Slater, P. (1980). Wealth addiction. New York: Dutton. Thompson, W.P.L. (1987). History of Orkney. Edinburgh: Mercat. Trebach, A.S. (1987). The great drug war. New York: Macmillan. Vidal-Beneyto, J. (2000, April). Pourquoi la droite triomphe en Espagne: Almodovar, le franquisme et la démocratie. Le monde diplomatique, p. 10. Viveret, P. (2000, February). Un humanisme à refonder: Qu’allons faire de notre espèce? Le monde diplomatique, pp. 26–27. WHO/UNICRI (1995). Cocaine project. Geneva: World Health Organization. Wise, R.A. & Bozarth, M.A. (1987) A psychomotor stimulant theory of addiction. Psychological Review, 94, 469–492.

CHAPTER 10

The Extraordinary Science of Addictive Junk Food Michael Moss

On the evening of April 8, 1999, a long line of Town Cars and taxis pulled up to the Minneapolis headquarters of Pillsbury and discharged 11 men who controlled America’s largest food companies. Nestlé was in attendance, as were Kraft and Nabisco, General Mills and Procter & Gamble, Coca-Cola and Mars. Rivals any other day, the C.E.O.s and company presidents had come together for a rare, private meeting. On the agenda was one item: the emerging obesity epidemic and how to deal with it. While the atmosphere was cordial, the men assembled were hardly friends. Their stature was defined by their skill in fighting one another for what they called “stomach share”—the amount of digestive space that any one company’s brand can grab from the competition. James Behnke, a 55-year-old executive at Pillsbury, greeted the men as they arrived. He was anxious but also hopeful about the plan that he and a few other food-company executives had devised to engage the C.E.O.s on America’s growing weight problem. “We were very concerned, and rightfully so, that obesity was becoming a major issue,” Behnke recalled. “People were starting to talk about sugar taxes, and there was a lot of pressure on food companies.” Getting the company chiefs in the same room to talk about anything, much less a sensitive issue like this, was a tricky business, so Behnke and his fellow organizers had scripted the meeting carefully, honing the message to its barest essentials. “C.E.O.’s in the food industry are typically not technical guys, and they’re uncomfortable going to meetings where technical people talk in technical terms about

technical things,” Behnke said. “They don’t want to be embarrassed. They don’t want to make commitments. They want to maintain their aloofness and autonomy.” A chemist by training with a doctoral degree in food science, Behnke became Pillsbury’s chief technical officer in 1979 and was instrumental in creating a long line of hit products, including microwaveable popcorn. He deeply admired Pillsbury but in recent years had grown troubled by pictures of obese children suffering from diabetes and the earliest signs of hypertension and heart disease. In the months leading up to the C.E.O. meeting, he was engaged in conversation with a group of food-science experts who were painting an increasingly grim picture of the public’s ability to cope with the industry’s formulations—from the body’s fragile controls on overeating to the hidden power of some processed foods to make people feel hungrier still. It was time, he and a handful of others felt, to warn the C.E.O.’s that their companies may have gone too far in creating and marketing products that posed the greatest health concerns. The discussion took place in Pillsbury’s auditorium. The first speaker was a vice president of Kraft named Michael Mudd. “I very much appreciate this opportunity to talk to you about childhood obesity and the growing challenge it presents for us all,” Mudd began. “Let me say right at the start, this is not an easy subject. There are no easy answers—for what the public health community must do to bring this problem under control or for what the industry should do as others seek to hold

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it accountable for what has happened. But this much is clear: For those of us who’ve looked hard at this issue, whether they’re public health professionals or staff specialists in your own companies, we feel sure that the one thing we shouldn’t do is nothing.” As he spoke, Mudd clicked through a deck of slides—114 in all—projected on a large screen behind him. The figures were staggering. More than half of American adults were now considered overweight, with nearly onequarter of the adult population—40 million people—clinically defined as obese. Among children, the rates had more than doubled since 1980, and the number of kids considered obese had shot past 12 million. (This was still only 1999; the nation’s obesity rates would climb much higher.) Food manufacturers were now being blamed for the problem from all sides— academia, the Centers for Disease Control and Prevention, the American Heart Association, and the American Cancer Society. The secretary of agriculture, over whom the industry had long held sway, had recently called obesity a “national epidemic.” Mudd then did the unthinkable. He drew a connection to the last thing in the world the C.E.O.’s wanted linked to their products: cigarettes. First came a quote from a Yale University professor of psychology and public health, Kelly Brownell, who was an especially vocal proponent of the view that the processedfood industry should be seen as a public health menace: “As a culture, we’ve become upset by the tobacco companies advertising to children, but we sit idly by while the food companies do the very same thing. And we could make a claim that the toll taken on the public health by a poor diet rivals that taken by tobacco.” “If anyone in the food industry ever doubted there was a slippery slope out there,” Mudd said, “I imagine they are beginning to experience a distinct sliding sensation right about now.” Mudd then presented the plan he and others had devised to address the obesity problem. Merely getting the executives to acknowledge some culpability was an important first step, he knew, so his plan would start off with a small but crucial move: the industry should use the expertise of scientists—its own and others—to

gain a deeper understanding of what was driving Americans to overeat. Once this was achieved, the effort could unfold on several fronts. To be sure, there would be no getting around the role that packaged foods and drinks play in overconsumption. They would have to pull back on their use of salt, sugar, and fat, perhaps by imposing industrywide limits. But it wasn’t just a matter of these three ingredients; the schemes they used to advertise and market their products were critical, too. Mudd proposed creating a “code to guide the nutritional aspects of food marketing, especially to children.” “We are saying that the industry should make a sincere effort to be part of the solution,” Mudd concluded. “And that by doing so, we can help to defuse the criticism that’s building against us.” What happened next was not written down. But according to three participants, when Mudd stopped talking, the one C.E.O. whose recent exploits in the grocery store had awed the rest of the industry stood up to speak. His name was Stephen Sanger, and he was also the person—as head of General Mills—who had the most to lose when it came to dealing with obesity. Under his leadership, General Mills had overtaken not just the cereal aisle but other sections of the grocery store. The company’s Yoplait brand had transformed traditional unsweetened breakfast yogurt into a veritable dessert. It now had twice as much sugar per serving as General Mills’ marshmallow cereal Lucky Charms. And yet, because of yogurt’s well-tended image as a wholesome snack, sales of Yoplait were soaring, with annual revenue topping $500 million. Emboldened by the success, the company’s development wing pushed even harder, inventing a Yoplait variation that came in a squeezable tube—perfect for kids. They called it Go-Gurt and rolled it out nationally in the weeks before the C.E.O. meeting. (By year’s end, it would hit $100 million in sales.) According to the sources I spoke with, Sanger began by reminding the group that consumers were “fickle.” (Sanger declined to be interviewed.) Sometimes they worried about sugar, other times fat. General Mills, he said, acted

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responsibly to both the public and shareholders by offering products to satisfy dieters and other concerned shoppers, from low sugar to added whole grains. But most often, he said, people bought what they liked, and they liked what tasted good. “Don’t talk to me about nutrition,” he reportedly said, taking on the voice of the typical consumer. “Talk to me about taste, and if this stuff tastes better, don’t run around trying to sell stuff that doesn’t taste good.” To react to the critics, Sanger said, would jeopardize the sanctity of the recipes that had made his products so successful. General Mills would not pull back. He would push his people onward, and he urged his peers to do the same. Sanger’s response effectively ended the meeting. “What can I say?” James Behnke told me years later. “It didn’t work. These guys weren’t as receptive as we thought they would be.” Behnke chose his words deliberately. He wanted to be fair. “Sanger was trying to say, ‘Look, we’re not going to screw around with the company jewels here and change the formulations because a bunch of guys in white coats are worried about obesity.’” The meeting was remarkable, first, for the insider admissions of guilt. But I was also struck by how prescient the organizers of the sit-down had been. Today, one in three adults is considered clinically obese, along with one in five kids, and 24 million Americans are afflicted by type 2 diabetes, often caused by poor diet, with another 79 million people having prediabetes. Even gout, a painful form of arthritis once known as “the rich man’s disease” for its associations with gluttony, now afflicts eight million Americans. The public and the food companies have known for decades now—or at the very least since this meeting—that sugary, salty, fatty foods are not good for us in the quantities that we consume them. So why are the diabetes and obesity and hypertension numbers still spiraling out of control? It’s not just a matter of poor willpower on the part of the consumer and a give-the-people-what-they-want attitude on the part of the food manufacturers. What I found, over four years of research and reporting, was a conscious effort—taking place in

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labs and marketing meetings and grocery-store aisles—to get people hooked on foods that are convenient and inexpensive. I talked to more than 300 people in or formerly employed by the processed-food industry, from scientists to marketers to C.E.O.s. Some were willing whistle-blowers, while others spoke reluctantly when presented with some of the thousands of pages of secret memos that I obtained from inside the food industry’s operations. What follows is a series of small case studies of a handful of characters whose work then, and perspective now, sheds light on how the foods are created and sold to people who, while not powerless, are extremely vulnerable to the intensity of these companies’ industrial formulations and selling campaigns.

“IN THIS FIELD, I’M A GAME CHANGER” John Lennon couldn’t find it in England, so he had cases of it shipped from New York to fuel the “Imagine” sessions. The Beach Boys, ZZ Top, and Cher all stipulated in their contract riders that it be put in their dressing rooms when they toured. Hillary Clinton asked for it when she traveled as first lady, and ever after her hotel suites were dutifully stocked. What they all wanted was Dr Pepper, which until 2001 occupied a comfortable third-place spot in the soda aisle behind Coca-Cola and Pepsi. But then a flood of spinoffs from the two soda giants showed up on the shelves—lemons and limes, vanillas and coffees, raspberries and oranges, whites and blues and clears—what in food-industry lingo are known as “line extensions,” and Dr Pepper started to lose its market share. Responding to this pressure, Cadbury Schweppes created its first spinoff, other than a diet version, in the soda’s 115-year history, a bright red soda with a very un-Dr Pepper name: Red Fusion. “If we are to re-establish Dr Pepper back to its historic growth rates, we have to add more excitement,” the company’s president, Jack Kilduff, said. One particularly promising market, Kilduff pointed out, was the “rapidly growing Hispanic and AfricanAmerican communities.”

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But consumers hated Red Fusion. “Dr Pepper is my all-time favorite drink, so I was curious about the Red Fusion,” a California mother of three wrote on a blog to warn other Peppers away. “It’s disgusting. Gagging. Never again.” Stung by the rejection, Cadbury Schweppes in 2004 turned to a food-industry legend named Howard Moskowitz. Moskowitz, who studied mathematics and holds a Ph.D. in experimental psychology from Harvard, runs a consulting firm in White Plains, where for more than three decades he has “optimized” a variety of products for Campbell Soup, General Foods, Kraft, and PepsiCo. “I’ve optimized soups,” Moskowitz told me. “I’ve optimized pizzas. I’ve optimized salad dressings and pickles. In this field, I’m a game changer.” In the process of product optimization, food engineers alter a litany of variables with the sole intent of finding the most perfect version (or versions) of a product. Ordinary consumers are paid to spend hours sitting in rooms where they touch, feel, sip, smell, swirl, and taste whatever product is in question. Their opinions are dumped into a computer, and the data are sifted and sorted through a statistical method called conjoint analysis, which determines what features will be most attractive to consumers. Moskowitz likes to imagine that his computer is divided into silos, in which each of the attributes is stacked. But it’s not simply a matter of comparing Color 23 with Color 24. In the most complicated projects, Color 23 must be combined with Syrup 11 and Packaging 6, and on and on, in seemingly infinite combinations. Even for jobs in which the only concern is taste and the variables are limited to the ingredients, endless charts and graphs will come spewing out of Moskowitz’s computer. “The mathematical model maps out the ingredients to the sensory perceptions these ingredients create,” he told me, “so I can just dial a new product. This is the engineering approach.” Moskowitz’s work on Prego spaghetti sauce was memorialized in a 2004 presentation by the author Malcolm Gladwell at the TED conference in Monterey, Calif.: “After . . . months and months, he had a mountain of data about how the American people feel about spaghetti sauce. . . . And sure enough, if you sit down

and you analyze all this data on spaghetti sauce, you realize that all Americans fall into one of three groups. There are people who like their spaghetti sauce plain. There are people who like their spaghetti sauce spicy. And there are people who like it extra-chunky. And of those three facts, the third one was the most significant, because at the time, in the early 1980s, if you went to a supermarket, you would not find extra-chunky spaghetti sauce. And Prego turned to Howard, and they said, ‘Are you telling me that one-third of Americans crave extra-chunky spaghetti sauce, and yet no one is servicing their needs?’ And he said, ‘Yes.’ And Prego then went back and completely reformulated their spaghetti sauce and came out with a line of extra-chunky that immediately and completely took over the spaghetti-sauce business in this country. . . . That is Howard’s gift to the American people. . . . He fundamentally changed the way the food industry thinks about making you happy.” Well, yes and no. One thing Gladwell didn’t mention is that the food industry already knew some things about making people happy— and it started with sugar. Many of the Prego sauces—whether cheesy, chunky, or light—have one feature in common: The largest ingredient, after tomatoes, is sugar. A mere half-cup of Prego Traditional, for instance, has the equivalent of more than two teaspoons of sugar, as much as two-plus Oreo cookies. It also delivers one-third of the sodium recommended for a majority of American adults for an entire day. In making these sauces, Campbell supplied the ingredients, including the salt, sugar, and, for some versions, fat, while Moskowitz supplied the optimization. “More is not necessarily better,” Moskowitz wrote in his own account of the Prego project. “As the sensory intensity (say, of sweetness) increases, consumers first say that they like the product more, but eventually, with a middle level of sweetness, consumers like the product the most (this is their optimum, or ‘bliss,’ point).” I first met Moskowitz on a crisp day in the spring of 2010 at the Harvard Club in Midtown Manhattan. As we talked, he made clear that while he has worked on numerous projects aimed at creating more healthful foods and

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insists the industry could be doing far more to curb obesity, he had no qualms about his own pioneering work on discovering what industry insiders now regularly refer to as “the bliss point” or any of the other systems that helped food companies create the greatest amount of crave. “There’s no moral issue for me,” he said. “I did the best science I could. I was struggling to survive and didn’t have the luxury of being a moral creature. As a researcher, I was ahead of my time.” Moskowitz’s path to mastering the bliss point began in earnest not at Harvard but a few months after graduation, 16 miles from Cambridge, in the town of Natick, where the U.S. Army hired him to work in its research labs. The military has long been in a peculiar bind when it comes to food: How to get soldiers to eat more rations when they are in the field. They know that over time, soldiers would gradually find their meals-ready-to-eat so boring that they would toss them away, halfeaten, and not get all the calories they needed. But what was causing this M.R.E.-fatigue was a mystery. “So I started asking soldiers how frequently they would like to eat this or that, trying to figure out which products they would find boring,” Moskowitz said. The answers he got were inconsistent. “They liked flavorful foods like turkey tetrazzini, but only at first; they quickly grew tired of them. On the other hand, mundane foods like white bread would never get them too excited, but they could eat lots and lots of it without feeling they’d had enough.” This contradiction is known as “sensoryspecific satiety.” In lay terms, it is the tendency for big, distinct flavors to overwhelm the brain, which responds by depressing your desire to have more. Sensory-specific satiety also became a guiding principle for the processed-food industry. The biggest hits—be they Coca-Cola or Doritos—owe their success to complex formulas that pique the taste buds enough to be alluring but don’t have a distinct, overriding single flavor that tells the brain to stop eating. Thirty-two years after he began experimenting with the bliss point, Moskowitz got the call from Cadbury Schweppes asking him to create a good line extension for Dr Pepper. I spent an

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afternoon in his White Plains offices as he and his vice president for research, Michele Reisner, walked me through the Dr Pepper campaign. Cadbury wanted its new flavor to have cherry and vanilla on top of the basic Dr Pepper taste. Thus, there were three main components to play with. A sweet cherry flavoring, a sweet vanilla flavoring and a sweet syrup known as “Dr Pepper flavoring.” Finding the bliss point required the preparation of 61 subtly distinct formulas—31 for the regular version and 30 for diet. The formulas were then subjected to 3,904 tastings organized in Los Angeles, Dallas, Chicago, and Philadelphia. The Dr Pepper tasters began working through their samples, resting 5 minutes between each sip to restore their taste buds. After each sample, they gave numerically ranked answers to a set of questions: How much did they like it overall? How strong is the taste? How do they feel about the taste? How would they describe the quality of this product? How likely would they be to purchase this product? Moskowitz’s data—compiled in a 135-page report for the soda maker—is tremendously fine-grained, showing how different people and groups of people feel about a strong vanilla taste versus weak, various aspects of aroma and the powerful sensory force that food scientists call “mouth feel.” This is the way a product interacts with the mouth, as defined more specifically by a host of related sensations, from dryness to gumminess to moisture release. These are terms more familiar to sommeliers, but the mouth feel of soda and many other food items, especially those high in fat, is second only to the bliss point in its ability to predict how much craving a product will induce. In addition to taste, the consumers were also tested on their response to color, which proved to be highly sensitive. “When we increased the level of the Dr Pepper flavoring, it gets darker and liking goes off,” Reisner said. These preferences can also be cross-referenced by age, sex, and race. On Page 83 of the report, a thin blue line represents the amount of Dr Pepper flavoring needed to generate maximum appeal. The line

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is shaped like an upside-down U, just like the bliss-point curve that Moskowitz studied 30 years earlier in his Army lab. And at the top of the arc, there is not a single sweet spot but instead a sweet range, within which “bliss” was achievable. This meant that Cadbury could edge back on its key ingredient, the sugary Dr Pepper syrup, without falling out of the range and losing the bliss. Instead of using 2 milliliters of the flavoring, for instance, they could use 1.69 milliliters and achieve the same effect. The potential savings is merely a few percentage points, and it won’t mean much to individual consumers who are counting calories or grams of sugar. But for Dr Pepper, it adds up to colossal savings. “That looks like nothing,” Reisner said. “But it’s a lot of money. A lot of money. Millions.” The soda that emerged from all of Moskowitz’s variations became known as Cherry Vanilla Dr Pepper, and it proved successful beyond anything Cadbury imagined. In 2008, Cadbury split off its soft-drinks business, which included Snapple and 7-Up. The Dr Pepper Snapple Group has since been valued in excess of $11 billion.

“LUNCHTIME IS ALL YOURS” Sometimes innovations within the food industry happen in the lab, with scientists dialing in specific ingredients to achieve the greatest allure. And sometimes, as in the case of Oscar Mayer’s bologna crisis, the innovation involves putting old products in new packages. The 1980s were tough times for Oscar Mayer. Red-meat consumption fell more than 10 percent as fat became synonymous with cholesterol, clogged arteries, heart attacks, and strokes. Anxiety set in at the company’s headquarters in Madison, Wisconsin, where executives worried about their future and the pressure they faced from their new bosses at Philip Morris. Bob Drane was the company’s vice president for new business strategy and development when Oscar Mayer tapped him to try to find some way to reposition bologna and other troubled meats that were declining in popularity and sales. I met Drane at his home in

Madison and went through the records he had kept on the birth of what would become much more than his solution to the company’s meat problem. In 1985, when Drane began working on the project, his orders were to “figure out how to contemporize what we’ve got.” Drane’s first move was to try to zero in not on what Americans felt about processed meat but on what Americans felt about lunch. He organized focus-group sessions with the people most responsible for buying bologna— mothers—and as they talked, he realized the most pressing issue for them was time. Working moms strove to provide healthful food, of course, but they spoke with real passion and at length about the morning crush, that nightmarish dash to get breakfast on the table and lunch packed and kids out the door. He summed up their remarks for me like this: “It’s awful. I am scrambling around. My kids are asking me for stuff. I’m trying to get myself ready to go to the office. I go to pack these lunches, and I don’t know what I’ve got.” What the moms revealed to him, Drane said, was “a gold mine of disappointments and problems.” He assembled a team of about 15 people with varied skills, from design to food science to advertising, to create something completely new—a convenient prepackaged lunch that would have as its main building block the company’s sliced bologna and ham. They wanted to add bread, naturally, because who ate bologna without it? But this presented a problem: There was no way bread could stay fresh for the two months their product needed to sit in warehouses or in grocery coolers. Crackers, however, could—so they added a handful of cracker rounds to the package. Using cheese was the next obvious move, given its increased presence in processed foods. But what kind of cheese would work? Natural Cheddar, which they started off with, crumbled and didn’t slice very well, so they moved on to processed varieties, which could bend and be sliced and would last forever, or they could knock another two cents off per unit by using an even lesser product called “cheese food,” which had lower scores than processed cheese in taste tests. The cost dilemma was solved when Oscar Mayer merged with Kraft in 1989 and the company

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didn’t have to shop for cheese anymore; it got all the processed cheese it wanted from its new sister company, and at cost. Drane’s team moved into a nearby hotel, where they set out to find the right mix of components and container. They gathered around tables where bagfuls of meat, cheese, crackers and all sorts of wrapping material had been dumped, and they let their imaginations run. After snipping and taping their way through a host of failures, the model they fell back on was the American TV dinner—and after some brainstorming about names (Lunch Kits? GoPacks? Fun Mealz?), Lunchables were born. The trays flew off the grocery-store shelves. Sales hit a phenomenal $218 million in the first 12 months, more than anyone was prepared for. This only brought Drane his next crisis. The production costs were so high that they were losing money with each tray they produced. So Drane flew to New York, where he met with Philip Morris officials who promised to give him the money he needed to keep it going. “The hard thing is to figure out something that will sell,” he was told. “You’ll figure out how to get the cost right.” Projected to lose $6 million in 1991, the trays instead broke even; the next year, they earned $8 million. With production costs trimmed and profits coming in, the next question was how to expand the franchise, which they did by turning to one of the cardinal rules in processed food: When in doubt, add sugar. “Lunchables With Dessert is a logical extension,” an Oscar Mayer official reported to Philip Morris executives in early 1991. The “target” remained the same as it was for regular Lunchables—“busy mothers” and “working women,” ages 25 to 49—and the “enhanced taste” would attract shoppers who had grown bored with the current trays. A year later, the dessert Lunchable morphed into the Fun Pack, which would come with a Snickers bar, a package of M&M’s or a Reese’s Peanut Butter Cup, as well as a sugary drink. The Lunchables team started by using Kool-Aid and cola and then Capri Sun after Philip Morris added that drink to its stable of brands. Eventually, a line of the trays, appropriately called Maxed Out, was released that had as

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many as nine grams of saturated fat, or nearly an entire day’s recommended maximum for kids, with up to two-thirds of the max for sodium and 13 teaspoons of sugar. When I asked Geoffrey Bible, former C.E.O. of Philip Morris, about this shift toward more salt, sugar, and fat in meals for kids, he smiled and noted that even in its earliest incarnation, Lunchables was held up for criticism. “One article said something like, ‘If you take Lunchables apart, the most healthy item in it is the napkin.’” Well, they did have a good bit of fat, I offered. “You bet,” he said. “Plus cookies.” The prevailing attitude among the company’s food managers—through the 1990s, at least, before obesity became a more pressing concern—was one of supply and demand. “People could point to these things and say, ‘They’ve got too much sugar, they’ve got too much salt,’” Bible said. “Well, that’s what the consumer wants, and we’re not putting a gun to their head to eat it. That’s what they want. If we give them less, they’ll buy less, and the competitor will get our market. So you’re sort of trapped.” (Bible would later press Kraft to reconsider its reliance on salt, sugar, and fat.) When it came to Lunchables, they did try to add more healthful ingredients. Back at the start, Drane experimented with fresh carrots but quickly gave up on that, since fresh components didn’t work within the constraints of the processed-food system, which typically required weeks or months of transport and storage before the food arrived at the grocery store. Later, a low-fat version of the trays was developed, using meats and cheese and crackers that were formulated with less fat, but it tasted inferior, sold poorly, and was quickly scrapped. When I met with Kraft officials in 2011 to discuss their products and policies on nutrition, they had dropped the Maxed Out line and were trying to improve the nutritional profile of Lunchables through smaller, incremental changes that were less noticeable to consumers. Across the Lunchables line, they said they had reduced the salt, sugar, and fat by about 10 percent, and new versions, featuring mandarin-orange and pineapple slices, were in development. These would be promoted as

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more healthful versions, with “fresh fruit,” but their list of ingredients—containing upward of 70 items, with sucrose, corn syrup, highfructose corn syrup, and fruit concentrate all in the same tray—have been met with intense criticism from outside the industry. One of the company’s responses to criticism is that kids don’t eat the Lunchables every day—on top of which, when it came to trying to feed them more healthful foods, kids themselves were unreliable. When their parents packed fresh carrots, apples, and water, they couldn’t be trusted to eat them. Once in school, they often trashed the healthful stuff in their brown bags to get right to the sweets. This idea—that kids are in control—would become a key concept in the evolving marketing campaigns for the trays. In what would prove to be their greatest achievement of all, the Lunchables team would delve into adolescent psychology to discover that it wasn’t the food in the trays that excited the kids; it was the feeling of power it brought to their lives. As Bob Eckert, then the C.E.O. of Kraft, put it in 1999: “Lunchables aren’t about lunch. It’s about kids being able to put together what they want to eat, anytime, anywhere.” Kraft’s early Lunchables campaign targeted mothers. They might be too distracted by work to make a lunch, but they loved their kids enough to offer them this prepackaged gift. But as the focus swung toward kids, Saturdaymorning cartoons started carrying an ad that offered a different message: “All day, you gotta do what they say,” the ads said. “But lunchtime is all yours.” With this marketing strategy in place and pizza Lunchables—the crust in one compartment, the cheese, pepperoni, and sauce in others—proving to be a runaway success, the entire world of fast food suddenly opened up for Kraft to pursue. They came out with a Mexican-themed Lunchables called Beef Taco Wraps; a Mini Burgers Lunchables; a Mini Hot Dog Lunchable, which also happened to provide a way for Oscar Mayer to sell its wieners. By 1999, pancakes—which included syrup, icing, Lifesavers candy, and Tang, for a whopping 76 grams of sugar—and waffles were, for a time, part of the Lunchables franchise as well.

Annual sales kept climbing, past $500 million, past $800 million; at last count, including sales in Britain, they were approaching the $1 billion mark. Lunchables was more than a hit; it was now its own category. Eventually, more than 60 varieties of Lunchables and other brands of trays would show up in the grocery stores. In 2007, Kraft even tried a Lunchables Jr. for 3- to 5-year-olds. In the trove of records that document the rise of the Lunchables and the sweeping change it brought to lunchtime habits, I came across a photograph of Bob Drane’s daughter, which he had slipped into the Lunchables presentation he showed to food developers. The picture was taken on Monica Drane’s wedding day in 1989, and she was standing outside the family’s home in Madison, a beautiful bride in a white wedding dress, holding one of the brand-new yellow trays. During the course of reporting, I finally had a chance to ask her about it. Was she really that much of a fan? “There must have been some in the fridge,” she told me. “I probably just took one out before we went to the church. My mom had joked that it was really like their fourth child, my dad invested so much time and energy on it.” Monica Drane had three of her own children by the time we spoke, ages 10, 14, and 17. “I don’t think my kids have ever eaten a Lunchable,” she told me. “They know they exist and that Grandpa Bob invented them. But we eat very healthfully.” Drane himself paused only briefly when I asked him if, looking back, he was proud of creating the trays. “Lots of things are tradeoffs,” he said. “And I do believe it’s easy to rationalize anything. In the end, I wish that the nutritional profile of the thing could have been better, but I don’t view the entire project as anything but a positive contribution to people’s lives.” Today Bob Drane is still talking to kids about what they like to eat, but his approach has changed. He volunteers with a nonprofit organization that seeks to build better communications between school kids and their parents, and right in the mix of their problems, alongside the academic struggles, is childhood

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obesity. Drane has also prepared a précis on the food industry that he used with medical students at the University of Wisconsin. And while he does not name his Lunchables in this document, and cites numerous causes for the obesity epidemic, he holds the entire industry accountable. “What do University of Wisconsin M.B.A.’s learn about how to succeed in marketing?” his presentation to the med students asks. “Discover what consumers want to buy and give it to them with both barrels. Sell more, keep your job! How do marketers often translate these ‘rules’ into action on food? Our limbic brains love sugar, fat, salt . . . So formulate products to deliver these. Perhaps add low-cost ingredients to boost profit margins. Then ‘supersize’ to sell more. . . . And advertise/ promote to lock in ‘heavy users.’ Plenty of guilt to go around here!”

“IT’S CALLED VANISHING CALORIC DENSITY” At a symposium for nutrition scientists in Los Angeles on February 15, 1985, a professor of pharmacology from Helsinki named Heikki Karppanen told the remarkable story of Finland’s effort to address its salt habit. In the late 1970s, the Finns were consuming huge amounts of sodium, eating on average more than two teaspoons of salt a day. As a result, the country had developed significant issues with high blood pressure, and men in the eastern part of Finland had the highest rate of fatal cardiovascular disease in the world. Research showed that this plague was not just a quirk of genetics or a result of a sedentary lifestyle—it was also owing to processed foods. So when Finnish authorities moved to address the problem, they went right after the manufacturers. (The Finnish response worked. Every grocery item that was heavy in salt would come to be marked prominently with the warning “High Salt Content.” By 2007, Finland’s per capita consumption of salt had dropped by a third, and this shift— along with improved medical care—was accompanied by a 75 percent to 80 percent decline in the number of deaths from strokes and heart disease.)

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Karppanen’s presentation was met with applause, but one man in the crowd seemed particularly intrigued by the presentation, and as Karppanen left the stage, the man intercepted him and asked if they could talk more over dinner. Their conversation later that night was not at all what Karppanen was expecting. His host did indeed have an interest in salt, but from quite a different vantage point: The man’s name was Robert I-San Lin, and from 1974 to 1982, he worked as the chief scientist for FritoLay, the nearly $3-billion-a-year manufacturer of Lay’s, Doritos, Cheetos, and Fritos. Lin’s time at Frito-Lay coincided with the first attacks by nutrition advocates on salty foods and the first calls for federal regulators to reclassify salt as a “risky” food additive, which could have subjected it to severe controls. No company took this threat more seriously—or more personally—than Frito-Lay, Lin explained to Karppanen over their dinner. Three years after he left Frito-Lay, he was still anguished over his inability to effectively change the company’s recipes and practices. By chance, I ran across a letter that Lin sent to Karppanen three weeks after that dinner, buried in some files to which I had gained access. Attached to the letter was a memo written when Lin was at Frito-Lay, which detailed some of the company’s efforts in defending salt. I tracked Lin down in Irvine, California, where we spent several days going through the internal company memos, strategy papers, and handwritten notes he had kept. The documents were evidence of the concern that Lin had for consumers and of the company’s intent on using science not to address the health concerns but to thwart them. While at Frito-Lay, Lin and other company scientists spoke openly about the country’s excessive consumption of sodium and the fact that, as Lin said to me on more than one occasion, “people get addicted to salt.” Not much had changed by 1986, except Frito-Lay found itself on a rare cold streak. The company had introduced a series of highprofile products that failed miserably. Toppels, a cracker with cheese topping; Stuffers, a shell with a variety of fillings; Rumbles, a bite-size granola snack—they all came and went in a

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blink, and the company took a $52 million hit. Around that time, the marketing team was joined by Dwight Riskey, an expert on cravings who had been a fellow at the Monell Chemical Senses Center in Philadelphia, where he was part of a team of scientists that found that people could beat their salt habits simply by refraining from salty foods long enough for their taste buds to return to a normal level of sensitivity. He had also done work on the bliss point, showing how a product’s allure is contextual, shaped partly by the other foods a person is eating, and that it changes as people age. This seemed to help explain why FritoLay was having so much trouble selling new snacks. The largest single block of customers, the baby boomers, had begun hitting middle age. According to the research, this suggested that their liking for salty snacks—both in the concentration of salt and how much they ate— would be tapering off. Along with the rest of the snack-food industry, Frito-Lay anticipated lower sales because of an aging population, and marketing plans were adjusted to focus even more intently on younger consumers. Except that snack sales didn’t decline as everyone had projected, Frito-Lay’s doomed product launches notwithstanding. Poring over data one day in his home office, trying to understand just who was consuming all the snack food, Riskey realized that he and his colleagues had been misreading things all along. They had been measuring the snacking habits of different age groups and were seeing what they expected to see, that older consumers ate less than those in their 20s. But what they weren’t measuring, Riskey realized, is how those snacking habits of the boomers compared to themselves when they were in their 20s. When he called up a new set of sales data and performed what’s called a cohort study, following a single group over time, a far more encouraging picture—for Frito-Lay, anyway—emerged. The baby boomers were not eating fewer salty snacks as they aged. “In fact, as those people aged, their consumption of all those segments—the cookies, the crackers, the candy, the chips—was going up,” Riskey said. “They were not only eating what they ate when they were younger, they were eating more of it.” In fact, everyone in

the country, on average, was eating more salty snacks than they used to. The rate of consumption was edging up about one-third of a pound every year, with the average intake of snacks like chips and cheese crackers pushing past 12 pounds a year. Riskey had a theory about what caused this surge: Eating real meals had become a thing of the past. Baby boomers, especially, seemed to have greatly cut down on regular meals. They were skipping breakfast when they had early-morning meetings. They skipped lunch when they then needed to catch up on work because of those meetings. They skipped dinner when their kids stayed out late or grew up and moved out of the house. And when they skipped these meals, they replaced them with snacks. “We looked at this behavior, and said, ‘Oh, my gosh, people were skipping meals right and left,’” Riskey told me. “It was amazing.” This led to the next realization, that baby boomers did not represent “a category that is mature, with no growth. This is a category that has huge growth potential.” The food technicians stopped worrying about inventing new products and instead embraced the industry’s most reliable method for getting consumers to buy more: the line extension. The classic Lay’s potato chips were joined by Salt & Vinegar, Salt & Pepper, and Cheddar & Sour Cream. They put out Chili-Cheese-flavored Fritos, and Cheetos were transformed into 21 varieties. Frito-Lay had a formidable research complex near Dallas, where nearly 500 chemists, psychologists, and technicians conducted research that cost up to $30 million a year, and the science corps focused intense amounts of resources on questions of crunch, mouth feel, and aroma for each of these items. Their tools included a $40,000 device that simulated a chewing mouth to test and perfect the chips, discovering things like the perfect break point: people like a chip that snaps with about four pounds of pressure per square inch. To get a better feel for their work, I called on Steven Witherly, a food scientist who wrote a fascinating guide for industry insiders titled, “Why Humans Like Junk Food.” I brought him two shopping bags filled with a variety of chips to taste. He zeroed right in on the Cheetos.

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“This,” Witherly said, “is one of the most marvelously constructed foods on the planet, in terms of pure pleasure.” He ticked off a dozen attributes of the Cheetos that make the brain say more. But the one he focused on most was the puff’s uncanny ability to melt in the mouth. “It’s called vanishing caloric density,” Witherly said. “If something melts down quickly, your brain thinks that there’s no calories in it . . . you can just keep eating it forever.” As for their marketing troubles, in a March 2010 meeting, Frito-Lay executives hastened to tell their Wall Street investors that the 1.4 billion boomers worldwide weren’t being neglected; they were redoubling their efforts to understand exactly what it was that boomers most wanted in a snack chip. Which was basically everything: great taste, maximum bliss but minimal guilt about health and more maturity than puffs. “They snack a lot,” FritoLay’s chief marketing officer, Ann Mukherjee, told the investors. “But what they’re looking for is very different. They’re looking for new experiences, real food experiences.” Frito-Lay acquired Stacy’s Pita Chip Company, which was started by a Massachusetts couple who made food-cart sandwiches and started serving pita chips to their customers in the mid-1990s. In Frito-Lay’s hands, the pita chips averaged 270 milligrams of sodium—nearly one-fifth a whole day’s recommended maximum for most American adults—and were a huge hit among boomers. The Frito-Lay executives also spoke of the company’s ongoing pursuit of a “designer sodium,” which they hoped, in the near future, would take their sodium loads down by 40 percent. No need to worry about lost sales there, the company’s C.E.O., Al Carey, assured their investors. The boomers would see less salt as the green light to snack like never before. There’s a paradox at work here. On the one hand, reduction of sodium in snack foods is commendable. On the other, these changes may well result in consumers eating more. “The big thing that will happen here is removing the barriers for boomers and giving them permission to snack,” Carey said. The prospects for lower salt snacks were so amazing, he added, that the company had set its sights

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on using the designer salt to conquer the toughest market of all for snacks: schools. He cited, for example, the school-food initiative championed by Bill Clinton and the American Heart Association, which is seeking to improve the nutrition of school food by limiting its load of salt, sugar and fat. “Imagine this,” Carey said. “A potato chip that tastes great and qualifies for the Clinton-A.H.A. alliance for schools. . . . We think we have ways to do all of this on a potato chip, and imagine getting that product into schools, where children can have this product and grow up with it and feel good about eating it.” Carey’s quote reminded me of something I read in the early stages of my reporting, a 24-page report prepared for Frito-Lay in 1957 by a psychologist named Ernest Dichter. The company’s chips, he wrote, were not selling as well as they could for one simple reason: “While people like and enjoy potato chips, they feel guilty about liking them. . . . Unconsciously, people expect to be punished for ‘letting themselves go’ and enjoying them.” Dichter listed seven “fears and resistances” to the chips: “You can’t stop eating them; they’re fattening; they’re not good for you; they’re greasy and messy to eat; they’re too expensive; it’s hard to store the leftovers; and they’re bad for children.” He spent the rest of his memo laying out his prescriptions, which in time would become widely used not just by FritoLay but also by the entire industry. Dichter suggested that Frito-Lay avoid using the word “fried” in referring to its chips and adopt instead the more healthful-sounding term “toasted.” To counteract the “fear of letting oneself go,” he suggested repacking the chips into smaller bags. “The more-anxious consumers, the ones who have the deepest fears about their capacity to control their appetite, will tend to sense the function of the new pack and select it,” he said. Dichter advised Frito-Lay to move its chips out of the realm of between-meals snacking and turn them into an ever-present item in the American diet. “The increased use of potato chips and other Lay’s products as a part of the regular fare served by restaurants and sandwich bars should be encouraged in a concentrated

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way,” Dichter said, citing a string of examples: “potato chips with soup, with fruit or vegetable juice appetizers; potato chips served as a vegetable on the main dish; potato chips with salad; potato chips with egg dishes for breakfast; potato chips with sandwich orders.” In 2011, The New England Journal of Medicine published a study that shed new light on America’s weight gain. The subjects—120,877 women and men—were all professionals in the health field, and were likely to be more conscious about nutrition, so the findings might well understate the overall trend. Using data back to 1986, the researchers monitored everything the participants ate, as well as their physical activity and smoking. They found that every four years, the participants exercised less, watched TV more, and gained an average of 3.35 pounds. The researchers parsed the data by the caloric content of the foods being eaten, and found the top contributors to weight gain included red meat and processed meats, sugar-sweetened beverages, and potatoes, including mashed and French fries. But the largest weight-inducing food was the potato chip. The coating of salt, the fat content that rewards the brain with instant feelings of pleasure, the sugar that exists not as an additive but in the starch of the potato itself—all of this combines to make it the perfect addictive food. “The starch is readily absorbed,” Eric Rimm, an associate professor of epidemiology and nutrition at the Harvard School of Public Health and one of the study’s authors, told me. “More quickly even than a similar amount of sugar. The starch, in turn, causes the glucose levels in the blood to spike”—which can result in a craving for more. If Americans snacked only occasionally, and in small amounts, this would not present the enormous problem that it does. But because so much money and effort has been invested over decades in engineering and then relentlessly selling these products, the effects are seemingly impossible to unwind. More than 30 years have passed since Robert Lin first tangled with FritoLay on the imperative of the company to deal with the formulation of its snacks, but as we sat at his dining-room table, sifting through his records, the feelings of regret still played on his

face. In his view, three decades had been lost, time that he and a lot of other smart scientists could have spent searching for ways to ease the addiction to salt, sugar, and fat. “I couldn’t do much about it,” he told me. “I feel so sorry for the public.”

“THESE PEOPLE NEED A LOT OF THINGS, BUT THEY DON’T NEED A COKE” The growing attention Americans are paying to what they put into their mouths has touched off a new scramble by the processed-food companies to address health concerns. Pressed by the Obama administration and consumers, Kraft, Nestlé, Pepsi, Campbell, and General Mills, among others, have begun to trim the loads of salt, sugar, and fat in many products. And with consumer advocates pushing for more government intervention, Coca-Cola made headlines in January by releasing ads that promoted its bottled water and low-calorie drinks as a way to counter obesity. Predictably, the ads drew a new volley of scorn from critics who pointed to the company’s continuing drive to sell sugary Coke. One of the other executives I spoke with at length was Jeffrey Dunn, who, in 2001, at age 44, was directing more than half of Coca-Cola’s $20 billion in annual sales as president and chief operating officer in both North and South America. In an effort to control as much market share as possible, Coke extended its aggressive marketing to especially poor or vulnerable areas of the U.S., like New Orleans—where people were drinking twice as much Coke as the national average—or Rome, Ga., where the per capita intake was nearly three Cokes a day. In Coke’s headquarters in Atlanta, the biggest consumers were referred to as “heavy users.” “The other model we use was called ‘drinks and drinkers,’” Dunn said. “How many drinkers do I have? And how many drinks do they drink? If you lost one of those heavy users, if somebody just decided to stop drinking Coke, how many drinkers would you have to get, at low velocity, to make up for that heavy user? The answer is a lot. It’s more efficient to get my existing users to drink more.”

THE SCIENCE OF ADDICTIVE JUNK FOOD

One of Dunn’s lieutenants, Todd Putman, who worked at Coca-Cola from 1997 to 2001, said the goal became much larger than merely beating the rival brands; Coca-Cola strove to outsell every other thing people drank, including milk and water. The marketing division’s efforts boiled down to one question, Putman said: “How can we drive more ounces into more bodies more often?” (In response to Putman’s remarks, Coke said its goals have changed and that it now focuses on providing consumers with more low- or no-calorie products.) In his capacity, Dunn was making frequent trips to Brazil, where the company had recently begun a push to increase consumption of Coke among the many Brazilians living in favelas. The company’s strategy was to repackage Coke into smaller, more affordable 6.7-ounce bottles, just 20 cents each. Coke was not alone in seeing Brazil as a potential boon; Nestlé began deploying battalions of women to travel poor neighborhoods, hawking American-style processed foods door to door. But Coke was Dunn’s concern, and on one trip, as he walked through one of the impoverished areas, he had an epiphany. “A voice in my head says, ‘These people need a lot of things, but they don’t need a Coke.’ I almost threw up.” Dunn returned to Atlanta, determined to make some changes. He didn’t want to abandon the soda business, but he did want to try to steer the company into a more healthful mode, and one of the things he pushed for was to stop marketing Coke in public schools. The independent companies that bottled Coke viewed his plans as reactionary. A director of one bottler wrote a letter to Coke’s chief executive and board asking for Dunn’s head. “He said what I had done was the worst thing he had seen in 50 years in the business,” Dunn said. “Just to placate these crazy leftist school districts who were trying to keep people from having their Coke. He said I was an embarrassment to the company, and I should be fired.” In February 2004, he was. Dunn told me that talking about Coke’s business today was by no means easy and, because he continues to work in the food business, not without risk. “You really don’t want them mad at you,” he said. “And I don’t mean that, like,

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I’m going to end up at the bottom of the bay. But they don’t have a sense of humor when it comes to this stuff. They’re a very, very aggressive company.” When I met with Dunn, he told me not just about his years at Coke but also about his new marketing venture. In April 2010, he met with three executives from Madison Dearborn Partners, a private-equity firm based in Chicago with a wide-ranging portfolio of investments. They recently hired Dunn to run one of their newest acquisitions—a food producer in the San Joaquin Valley. As they sat in the hotel’s meeting room, the men listened to Dunn’s marketing pitch. He talked about giving the product a personality that was bold and irreverent, conveying the idea that this was the ultimate snack food. He went into detail on how he would target a special segment of the 146 million Americans who are regular snackers—mothers, children, young professionals—people, he said, who “keep their snacking ritual fresh by trying a new food product when it catches their attention.” He explained how he would deploy strategic storytelling in the ad campaign for this snack, using a key phrase that had been developed with much calculation: “Eat ’Em Like Junk Food.” After 45 minutes, Dunn clicked off the last slide and thanked the men for coming. Madison’s portfolio contained the largest Burger King franchise in the world, the Ruth’s Chris Steak House chain, and a processed-food maker called AdvancePierre whose lineup includes the Jamwich, a peanut-butter-and-jelly contrivance that comes frozen, crustless, and embedded with four kinds of sugars. The snack that Dunn was proposing to sell: carrots. Plain, fresh carrots. No added sugar. No creamy sauce or dips. No salt. Just baby carrots, washed, bagged, then sold into the deadly dull produce aisle. “We act like a snack, not a vegetable,” he told the investors. “We exploit the rules of junk food to fuel the baby-carrot conversation. We are pro-junk-food behavior but anti-junk-food establishment.” The investors were thinking only about sales. They had already bought one of the two biggest

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farm producers of baby carrots in the country, and they’d hired Dunn to run the whole operation. Now, after his pitch, they were relieved. Dunn had figured out that using the industry’s own marketing ploys would work better than anything else. He drew from the bag of tricks that he mastered in his 20 years at Coca-Cola,

where he learned one of the most critical rules in processed food: The selling of food matters as much as the food itself. Later, describing his new line of work, Dunn told me he was doing penance for his CocaCola years. “I’m paying my karmic debt,” he said.

PART III

Treating Addiction

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CHAPTER 11

Financing and Ideology in Alcohol Treatment* Constance Weisner and Robin Room

The way U.S. society has handled its alcohol and mental health problems has changed radically since the 1950s. Sociologists have characterized these changes as “the medicalization of deviance” or “the rise of the welfare state.” In fact, the changes have been so complex that they defy such simple characterization. Some believe that the power of the medical profession over alcohol and mental health problems has declined (Bunce et al., 1981:159). On the other hand, while there were certainly shifts in professional ideology and changes in bellwether treatment institutions in the late 1940s and 1950s, mental health services did not change drastically until the late 1960s and early 1970s, and alcohol services until after 1970. The expansion of both services coincided with the beginning of a period of conservative politics and fiscal crisis. As a result the federal government tried to pass the cost of these changes on to the state governments. While these changes increased the availability and responsiveness of services, they also included a strong element of social control (Morgan, 1981b:243). The timing of the changes also affected the way the new services were financed, and their relation to the bureaucratic organization of government and to their clients. Where these services were traditionally provided by civil servants, most of the new services were provided by non-government agencies operating on contract. There are two main forms of such contractual financing of services. First, services can be provided on behalf of, and paid for by, the government under a master contract for a specific period of time. These are

called “contract agencies.” Second, services can be provided and paid for on a case-by-case basis under an insurance or other third-party coverage stimulated by, or subsidized by, the government. These are called “private treatment agencies.” The shifts in the scope, structure, and financing of alcohol services emerged in response to changes both in the specific field of alcohol treatment and in the larger society. For example, the rise of contractual relations in human services reflects a variety of motivations, including moves by government to cut costs, the rise of an ideology of accountability in the provision of professional services, the emergence of alternative services, and the movement of entrepreneurial and investment groups into the human services “industries.” But the shifts in scope, structure, and financing have in turn deeply affected the ideology and functioning of the services. This paper is a case study of changes in alcohol services in California since 1970. First, we review the history of the modern alcohol treatment system. Second, we discuss the nature of, and reasons for, the major changes in the scope, funding, and delivery of alcohol services that have taken place in the public sector since 1970. Third, we describe how private treatment agencies have rapidly developed as third-party payments have grown. Fourth, we analyze how these changes have transformed the social ecology and functions of the alcohol treatment system. Finally, we discuss the implications of the changes for treatment ideology and practice and for the characteristics of the client population.

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DEVELOPMENT OF THE MODERN ALCOHOL TREATMENT SYSTEM After the Second World War, state governments shouldered most of the responsibility for providing treatment for mental health and alcohol problems in the U.S. These services were concentrated in large public mental hospitals. Beginning in the 1950s, in California as well as in other states, a variety of smaller, communitybased therapeutic institutions slowly grew up alongside the traditional state system. These included halfway houses and community outpatient clinics. While many of these institutions were originally supported by charities or churches, a few were funded by state or local governments. Right from the start, the community-based programs differentiated between alcohol problems and mental health problems, and established separate institutions for both. Even the literature on halfway houses in the mental health field (Rausch with Rausch, 1968) and in the alcohol field (Cahn, 1970; Martinson, 1964) remained quite separate. The separation reflected the influence of the nascent alcoholism movement, with its view of alcohol problems as a disease and its perception that alcoholics were not well served in mental health institutions (Roizen and Weisner, 1979:77; Wiener, 1981). In 1954, somewhat later than in many other U.S. states, California established a state commission to deal with alcoholism. In 1957, these alcohol functions were transferred to California’s Department of Public Health (Reynolds, 1973:76). Thereafter, responsibility for alcoholism remained separate from California’s Department of Mental Hygiene. By the early 1960s the state was supporting a few pilot alcoholism clinics in communities (Morgan, 1980:131), including a few halfway houses (Martinson, 1964:432). By the mid-1960s, the federal government had committed itself to a policy of encouraging the treatment of alcohol and mental problems at the community level. It began providing what was originally seen as “start-up” money for community mental health centers, with alcoholism treatment as an optional service. In 1967, federal legislation setting up the Social and Rehabilitation Services

agency offered an opportunity—quickly seized by California—for states to secure federal funds which would match state funds on a percentage basis for the rehabilitation of alcoholics (Reynolds, 1973:101). In the early 1970s, with the separation of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) from the National Institute of Mental Health, substantial federal funds became available to community alcoholism programs from mental health treatment—a policy already established in California. In the meantime, in the early 1970s California stopped treating alcoholics in state psychiatric hospitals. Between 1950 and 1972, alcoholic first admissions to these hospitals dropped from 34.9 to 13.9 per 100,000 persons aged 20 and older. During the same period, alcoholic involuntary commitments dropped from 37.3 to 0.4. Alcoholic admissions disappeared entirely in the following years (Cameron, 1982:132). This change was part of a general trend at both the national and state levels in the late 1960s and 1970s to use community-based agencies rather than large state hospitals for dealing with mental health problems (Lerman, 1981:77). By 1975, the number of residents in state mental hospitals was one-third of what it had been in 1955 (President’s Commission on Mental Health, 1978:9). But whereas in the U.S. as a whole alcoholic admissions to mental health hospitals fell less than other admissions, in California the change was much more sharply focused on alcoholic admissions. By the early 1970s, the phasing out of alcohol treatment services in California public psychiatric hospitals was so complete that information on them was no longer collected and published (Cameron, 1982:132). At all levels of government—federal, state, and local—the largest growth in government support specifically for alcoholism treatment came during the 1970s. Yet many of the parameters for that expansion were set in the previous decades. In 1957, California passed legislation establishing programs to treat alcoholism not through a state-operated civil service agency, but rather through “contract and cooperat(ion) with local governmental agencies and voluntary nonprofit organizations” (quoted in Reynolds,

FINANCING/IDEOLOGY IN ALCOHOL TREATMENT

1973:76). The advent of federal project grants for alcoholism treatment reinforced this move to establish services in both local government and nonprofit organizations. Meanwhile, federal health and social programs began providing subventions to individuals thereby supporting and transforming local treatment agencies. Federal social security and disability insurance payments had originally not been available to institutionalized individuals. But in the 1960s these restrictions were relaxed (Lerman, 1981:77). At the same time, the federal government established new health and social programs such as Medicare, Medicaid, and food stamps. These indirect subventions were available whether treatment was offered by local government, by a nonprofit agency, or by a forprofit firm. However, it was not until the federal government encouraged the extension of health insurance to cover alcoholism treatment in the late 1970s that private, for-profit agencies penetrated the alcohol service industry.

THE PUBLIC ALCOHOL TREATMENT SYSTEM SINCE 1980 There were a wide range of public treatment programs available in most counties in California in the first half of the 1980s. In most metropolitan communities, publicly funded services consisted of social model (non-medical) detoxification units with medical back-up, halfway houses, information and referral services, drop-in centers, outpatient counseling services, occupational program consultants, prevention/ education services, and drunk driving programs. There were as many as 25 different agencies providing these services in counties with populations ranging from 500,000 to one million. Most of these services were also available in rural counties, though some were combined in a much smaller number of agencies, or shared between counties. Room (1980) suggests that the U.S. population in treatment for alcoholism increased at least 20-fold between 1942 and 1976. Attempts to document changes in the number of individuals treated for alcohol problems in California since 1950 have proved difficult, due to changes in institutional responsibility and changing definitions of alcoholism,

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as well as poor and unsystematic record-keeping within and across agencies. Funding for the public alcohol treatment system increased rapidly over a relatively short time span. In California in 1980, the total stateadministered budget for alcohol programs was over $70 million; of this total, $6 million was from federal subventions, $8 million from county funds, $37 million from state funds, and $19 million from client fees and insurance reimbursements (California, Department of Alcohol and Drug Programs, 1980:43). Direct federal grants (outside the state budget) added about another $10 million. This represents a substantial growth from the total 1972–73 budget of slightly over $26 million (California, Human Relations Agency 1972:37). When money for alcohol treatment in California first became available in the 1960s, most of the services were initially provided through the counties by civil service agencies, often county hospitals. With the sudden injection of funding from NIAAA and the state in the early 1970s, many California counties began to contract out many of their services rather than to include them under their civil service systems. This phenomenon was not unique to the alcohol field. Terrell and Kramer (1982:1), in their study of contracting for human services in nine northern California counties, note that “indeed, while governmental responsibilities for ensuring public welfare have enlarged tremendously in the years since 1965, the scale of public provision has been increasingly checked by the development of new instruments like vouchers, tax incentives, and contracting.” All of the counties studied were contracting out for mental health services. Terrell and Kramer found “in three agency areas (aging, community action, mental health) over 70 percent of all expenditures are made via nonprofit social agencies. In two other areas (social services, general revenue sharing), over one-fifth and one-third of the funds, respectively, are contracted out” (1982:20). They describe the origins of contracting: Contracting for social welfare first became a major option for service delivery in the 1960s within

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a context of rapidly expanding federal spending and the inability of many public agencies to handle increased responsibilities. Major changes in the political culture of the 1970s contributed to the expanded use of nonprofit organizations as the disenchantment with bureaucracies and the backlash against taxes and spending made nongovernmental arrangements appealing. In addition, the emergence of public policy themes such as decentralization, deinstitutionalization, privatization, and ‘social targeting’ all gave further impetus to voluntary community-based services. (1982:2)

Terrell and Kramer were unable to document the shift from county-run to contracted programs.1 Our attempts to document this change across California were likewise unsuccessful.2 This is partly due to the many changes in jurisdiction in the state government. During the 1960s, the responsibility for alcohol services shifted between three different departments. Even after 1970, when state and federal legislation called for a single state agency, there were changes in the way the agency related to the state departments of mental health, drug abuse, and public health in 1973, 1974, 1976, and 1978. These institutional changes were

reflected at the county level as well, with the result that records of funding arrangements are scattered through different departments and do not always specifically mention alcohol services. This same situation has made it difficult to document other areas of the history of alcohol services financing as well, such as the amounts of money spent by third party payments for alcoholism treatment. Since statistics were not available for California as a whole, we collected information from the County Alcohol Program Administrations of the seven counties which receive the bulk of federal and state funds (90 percent of the residential services budget, 65 percent of the detox budget, and 60 percent of the halfway house budget) (California, Department of Alcohol and Drug Programs, 1983). Table 11.1 shows the shift from county to contract programs from the middle 1970s to 1982–83. The data do not reflect the full extent of the shift, as most counties did not have specific statistics for their alcohol programs until the years indicated in the table. One county, Contra Costa, reported that in 1974–75 it spent 100 percent of its funds on county-operated programs. Staff from other counties said that county-operated

Table 11.1 Funds Allocated to County-Operated Programs and to Programs Run by Private Contractors1 Mid 1970s2

1982–83

County

Percent County-run Programs

Percent Contracted Programs

Percent County-run Programs

Percent Contracted Programs

Alameda Contra Costa Los Angeles Orange Santa Clara San Diego San Francisco

873 92 34 624 63 38 39

13 8 66 38 37 62 61

163 20 19 374 26 0 26

84 80 81 63 74 100 74

Notes: 1. These amounts represent the counties’ total alcohol funds from federal, state, and local sources. Percentages are rounded off. 2. Because of jurisdictional changes in location of alcohol programming and inconsistent availability of alcoholspecific budget figures for the 1970s from county to county, the same baseline years are not presented: Orange was 1975–76; Alameda 1976–77; Santa Clara, San Diego and San Francisco 1977–78; and Los Angeles 1978–79. 3. Includes funds spent for central program administration. 4. Includes some client fees.

FINANCING/IDEOLOGY IN ALCOHOL TREATMENT

programs received higher percentages prior to the years for which they had records. The counties decided to contract out alcohol services for a number of reasons, including the sudden arrival of money and the immediate need to provide services; a more responsive labor force; the lower cost of providing services outside of local government; and the freedom to hire employees outside the civil service system. The shift can also be seen as an extension of how funds were being channeled from one level of government to another. Each level of government appeared to be contracting with the one below it. In addition, with a mandate to construct a comprehensive system, local alcohol treatment administrators first disbursed money to existing programs, many of them in the private or voluntary sectors; in some cases they funded the entire program, and in other cases only certain service components. A limited number of new programs were then started to fill some of the remaining gaps. Many alcohol treatment administrators said they felt it made sense to give the new treatment funds to organizations that had a proven record. Moreover, by at least partially funding a wide variety of alcohol treatment institutions, the administrators were able to maintain control over—and claim credit for—many more programs. As Salamon and Abramson (1982:37) note, the tradition of government “partnership” with non-profit entities such as the alcohol treatment contract agencies actually has deep roots in U.S. history. But the 1960s and early 1970s saw an increase in the federal government’s use of contract relationships for social and health services. In some cases, such as the neighborhood health centers legislation and the Amended Food Stamp Act of 1977, the federal government actually forced nonprofit rather than local government governance by disqualifying programs run by local government from participation (National Association of State Alcohol and Drug Abuse Directors, 1984; Sardell, 1983:488). Federal subventions, both contractual funding and subventions through individual entitlements, have indeed transformed the financial base of the nonprofit sector. Salamon and Abramson (1982:44) estimate that in 1980, for the U.S. as a whole,

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58 percent of the revenues of social service agencies and 36 percent of the revenues of health care agencies came from federal programs. They also estimate that 20 percent of federal funding for nonprofit agencies came in direct contracts, 27 percent through state or local governments, and 53 percent through individual-level subventions (1982:45). California’s state alcohol problems agency, the Department of Alcohol and Drug Programs, was authorized from its inception to contract either with local governments or with nonprofit agencies. Since the early 1970s, the state has contracted exclusively with the counties. But California set a precedent for contracting with nonprofit agencies by providing subventions to some halfway houses in 1961; by the Late 1960s this practice was widely imitated in other states. Cahn (1970:150) refers to “quasipublic halfway houses”: These are organized under voluntary auspices but with public funds, most often provided by the state alcoholism authority for meeting deficits. . . . In some states the state alcoholism authority also helps finance the original capital investments. . . . Several quasi-public institutions are in states whose mental hospitals do not accept alcoholics for treatment; they offer some of the programs normally available in the specialized wards of state mental institutions.

This suggests that in the late 1960s subventions for halfway houses were a special case; the primary state relationship for other treatment agencies was with local governments. In contrast, Aiken and Williams’ (1982) review of “state and local programs on alcoholism” gives prominent billing to “private non-profit providers” for all kinds of services, in discussing intergovernment relations as well as relationships between government and the private sector (1982:338). Government subvention of nonprofit halfway houses carried over to the county level in California, but has progressively expanded to include most other treatment modalities and agencies. This enthusiasm for contracting with private agencies was even extended in the 1970s to contracts with for-profit firms to

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manage the county general hospital (Shonick and Roemer, 1982:188).

THE GROWTH OF PRIVATE FOR-PROFIT AGENCIES The use of private hospitals and sanitaria for the treatment of alcohol problems in the U.S. extends back to the “inebriate asylums” of the late 19th-century (Corwin and Cunningham, 1944:9). Through the 1920s and 1930s such hospitals were the only institutions available for treating alcoholism. The lack of other treatment alternatives played an important role in the birth of Alcoholics Anonymous (AA) (Blumberg, 1977).3 Until the 1980s, however, there were relatively few private hospitals, and they served primarily an affluent clientele. Since the mid 1970s, state and federal government action transformed the arena of private, for-profit treatment facilities for alcohol problems. Quite early in its existence, NIAAA decided that health insurance for alcoholism was the best way to assure a stable funding base for alcoholism treatment. Rodwin (1982) has detailed the steps NIAAA took to bring this about. State alcoholism agencies joined this effort; by September 1981, 33 of 50 states had passed legislation requiring group health insurance providers to offer optional coverage for alcohol treatment. Rodwin points out a number of factors responsible for the increase in health insurance for alcohol treatment services, including an environment of concern about alcoholism (partly due to NIAAA’s campaign and pressure by the alcoholism movement); the federal Health Maintenance Organization Act of 1973, which required all Health Maintenance Organizations to provide alcoholism services in order to qualify for federal subsidies; and the growth of employee-assistance programs in industry, which made management interested in health insurance for such services. The growth of hospital-based facilities was also encouraged by the existence of substantial excess capacity in many hospitals, after a period of federally-financed overbuilding. In 1979, the National Drug and Alcoholism Treatment Utilization Survey indicated that 32 percent of all funding for alcohol treatment centers came

from third party health insurance—both public and private. Private health insurance alone contributed 18 percent of all funding. Although this is still significantly lower than the share of private health insurance for other medical services (almost 30 percent) . . . it would seem reasonable to pronounce NIAAA’s campaign to promote health insurance an “admirable success” in reaching its goals. (Rodwin, 1982:17)

These government initiatives resulted in a phenomenal growth of private, hospital-based alcoholism programs. These programs were most often for inpatients and lasted about four weeks. They emphasized therapy based on the disease concept, education about the medical effects of alcoholism, and attendance at AA meetings. Attempts to document the growth in private programs in California through state and county records were frustrating, since hospital beds for alcoholism treatment were listed under categories such as medical surgery, acute psychiatry, and, most recently, chemical dependency. Another reason the growth has not been charted is that it has been difficult for researchers to gain access to information from these facilities (Rodwin, 1982). In 1983 there were at least 96 private residential alcohol programs in California (Alcoholism: The National Magazine, 1983; Moore, 1981). The California State Health Planning Department has had such a large number of requests for licenses for chemical dependency rehabilitation hospitals since that classification was legislated by the state in 1983 that they have asked the regional Health Service Administration offices to do assessments of need. On the national level, a 1982 survey by the National Institute on Alcohol Abuse and Alcoholism found that most alcoholism treatment units in the U.S. were privately owned, that third party payment dollars had increased since 1979, and “that much of the overall increase in the private sector was accounted for by a steady growth in the number of units owned by profit-making organizations.” Private sector treatment was found to have increased 48.2 percent between 1979 and 1982 (U.S. National Institute on Alcohol Abuse and Alcoholism, 1984:46).4

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This growth brought problems in its wake. The excess capacity in general hospitals and the preference of health insurance carriers for hospital-based programs meant that the treatment offered by these programs was often very expensive. Profitable corporations emerged which leased empty wards of hospitals and installed chains of alcohol treatment centers. For example, in 1982 American Medical International, a corporation owning a large number of health facilities and listed on the New York and London stock exchanges, purchased 24 Raleigh Hills alcoholism treatment facilities (U.S. Journal of Drug and Alcohol Dependence, 1982). In 1983, Comprehensive Care Corporation (Comp Care), one of the major California private groups, began reorganizing due to “rapid growth into more than a $400 million company. The company has posted record earnings each year since its formation in 1972, earning $10.8 million on revenues of $89.4 million in the fiscal year ending last May 31, and $3.3 million on revenues of $25.8 million for the first quarter of this fiscal year” (Lewis, 1983:7). In 1982, the National Council on Alcoholism (NCA), the leading voluntary organization in the field, set up a group to examine “treatment financing issues,” noting that “the proprietary treatment sector which flourished in the past several years is coming under increased scrutiny by the media, public and private insurers, and by public officials at both the state and national levels, in a manner which is not unlike that for the nursing home industry several years ago” (National Council on Alcoholism, 1982:1). The NCA chairman’s letter which announced the study listed several reasons for conducting it, including: 1.

2.

3.

The explosive growth of hospital-based alcoholism treatment programs in response to the liberalization of insurance coverage, and under-utilization of acute care hospital beds. Growing disillusionment among insurors with the high cost of hospital-based rehabilitation programs, where it is not unusual for treatment to cost between $6,000 and $10,000. Adverse publicity for one of the largest proprietary treatment chains, Raleigh Hills

4.

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hospitals, which has focused on allegations of profiteering under Medicare, deficient patient care, misleading advertisements, and a controversial form of treatment. Lack of agreement among professionals in the field as to what is the most effective treatment for alcoholism (National Council on Alcoholism, 1982:1).

The growing alcohol treatment industry has formed its own organization to protect its interests and has hired many veterans of the alcoholism movement to project a favorable image. Industry representatives reacted strongly to questioning by the administration of the Alcohol, Drug and Mental Health Administration about the high cost of alcoholism treatment by stressing that treatment must be hospital-based to be reimbursable (Lewis, 1982:5).

CHANGING FUNCTIONS AND CHARACTERISTICS OF ALCOHOL TREATMENT By 1974, Harold Hughes, the sponsor of the Comprehensive Act of 1970, was becoming distressed at the rapid growth in the size and power of the public and private establishment for the treatment of alcoholism. He described it as “a new civilian army that has now become institutionalized. The alcohol and drug industrial complex is not as powerful as its military-industrial counterparts, but nevertheless there are some striking similarities” (Hughes quoted in Wiener, 1981:3). In retrospect, however, we can see that the system has grown and changed even more radically since Hughes spoke; yet there has been little explicit discussion of these changes and of their relationship to the ideology of the treatment enterprise itself. The combined effect of the growth of the contract agency system and of the private hospital-based treatment chains and services has been an enormous growth in treatment capacity for alcoholism. In the course of this growth, requests for a demonstration of need for services have been readily met by recourse to the concept of the hidden alcoholic and to

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surveys which suggest that the number of alcoholics in the population is 10 times the number in treatment. The problems involved in using survey data to estimate need have been discussed by alcohol researchers (Cahalan, 1976; Room, 1980). Most of those identified in surveys as having alcohol-related problems are not inclined to volunteer for treatment. Yet the beds and treatment slots must be filled. The old state mental hospital system, with its civil-servants and continuing budget, could take years to respond to changes in the patient load. But public, contract-based services and private programs must respond to such changes in days. The private hospitalbased treatment services are reimbursed under health insurance contracts for each service performed for each client, and a lack of clients immediately makes revenues fall. The contract agencies must account to the county or other government funding agencies for the services they provide. As government fiscal crises tighten budgets, the contract agencies are also under pressure to make up shortfalls by taking on clients who can pay for treatment.5 Although in theory the public and private programs do not compete for the same clients, in practice this does happen. At meetings between agencies—for example, county level Alcohol Advisory Board meetings and regional Health Service Administration planning meetings—private hospitals appeal to public programs to refer clients who can afford to pay, since public programs are intended for those who are unable to pay. Public programs respond that they also need paying clients. Thus, treatment agencies must show considerable entrepreneurship in dealing with agencies, institutions treating other social and health problems, and potential individual clients. The administrators of public contract agencies have become adept at recognizing and profiting from new opportunities. In the counties we studied, when Boards of Supervisors were pushed to provide generalized services for disfranchised groups, such as ethnic groups or women, they often called on contract agencies in the alcohol treatment system, even though the request for help had not specifically mentioned alcohol (Roizen and Weisner,

1979; Weisner, 1981). If the political process demanded special services for a new special population—ethnic minorities, women, gays, the disabled—an alcohol counselor from that population was found and a new service added to the county’s list of alcohol services. If stiffened drunk driving laws funneled a new stream of clients into treatment, agencies responded almost overnight by changing their functions. At the level of the individual case, staff learned strategies in intervention and confrontation to widen the agency’s outreach. The public alcohol treatment system is affected by many of the same needs and resources, conflicts and contradictions, and historical, political, and economic pulls as other institutions within the larger welfare system. But it has some characteristics which make it particularly flexible in meeting broader social and political needs. First, the tremendous growth of the treatment system has created an unusual need for a sufficiently large clientele to warrant continued and even increased funding (Room, 1980). Second, the drive for a legitimate place within the social service bureaucracy has fostered a desire for an articulate, nonmarginal clientele, in contrast to the more disreputable public drunk (Kurtz and Regier, 1975). Third, the potential to draw funds from a variety of sources has often rested on an ability to expand the types of problems defined as alcohol-related, and thus within the treatment system (Roizen and Weisner, 1979:82; Wiener, 1981:157). Fourth, as the treatment system has expanded, it has continued to strive for respectability, often by cementing relations with other institutions (Weisner, 1981:127). The history of both the public and private alcohol treatment systems has made them vulnerable to pressures to redefine service populations and functions, and, in general, to accommodate other institutions. Expanding definitions of domestic violence has been just one example of these pressures: Strategies for handling domestic violence have emerged which emphasize alcohol problems, though the research literature is skeptical of a causal link (Morgan, 1981a). But the program administrators knew that funds were more likely to be available for alcohol treatment than for family

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counselling (Weisner, 1981). The impact of extending alcohol funding to other problem areas has been twofold: it has assisted individual agencies in coping with fiscal problems, and it has propagated a broader definition of alcohol-related problems (Morgan, 1981a). Providing services on a contractual basis has facilitated such rapid shifts in the public system. The funding of such agencies is not as secure; they must reapply annually. Their employees do not have the security of employment that civil service employees have. They are the ones most likely to be asked to make changes when a new service is needed, since the county run programs are more entrenched and difficult to change. Alcohol treatment agencies have had to be increasingly competitive and have had to redefine their functions and services in accordance with politically determined priorities. For instance, one county we studied had a contract program to provide information and referral and short-term counseling for alcoholism in 1982. The following year its program shifted to coordinating drunk driving referrals between the courts and other treatment agencies, and developing a prevention program using volunteers. Contract services that have survived in an environment of competition for resources have developed local political connections as a selfprotective device, but they remain exposed to political shifts at several levels of government. At the very least, they are obligated to stay on good terms with the county, rather than with their own boards of directors. As a result, they often face intractable dilemmas. While they must respond to their boards, they are frequently issued contradictory directives. In one county, many agencies responded by trying to secure their funding sources, often at the expense of their community constituencies and even their boards of directors. The boards in some cases ceased functioning, or existed in name only (Roizen and Weisner, 1979).

SHIFTS IN ALCOHOLISM TREATMENT The changes we have described in both public and private agencies have transformed the way alcoholism is combined with other problems

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in the counties we have studied. In an unstable environment, there is a premium on arranging a stable supply of clients. It is a major coup for a halfway house to sign a contract to provide services for a labor union. Personnel departments of large corporations are besieged by offers to contract for employee assistance programs. Public service advertising by hospital-based alcoholism treatment units, aimed more at the family than at the individual alcoholic, are now a regular part of television in California. In the public system, the search for new and more stable sources of clients has led to the courts. An increasing number of clients in alcohol treatment come from the criminal justice system; in some cases the courts are the main source (Boscarino, 1980:403; Clarke, 1975:220; Dunham and Mauss, 1982:7; Morrissey, 1981; Speiglman and Weisner, 1982:10; U.S. National Institute on Alcohol Abuse and Alcoholism 1982:3; Weisner, 1981, 1983). Perhaps no other social agency is as well situated to provide a steady flow of clients as the criminal courts. The coercion of the courts ensures that the referred case arrives, and often can be used to induce the client to pay for treatment. We found that by 1981 the trickle of cases from the courts to alcoholism treatment in California had increased to a flood. Clients were referred not only for public drunkenness and drunk driving, but also for wife battery, child abuse, robbery, forgery, and assault. Nevertheless, by the middle of 1982, because of tough, new drunk driving laws, drunk drivers began to be one of the dominant treatment groups throughout California. There are many mechanisms of referral, from formal diversion procedures to conditions of probation, sentencing, and parole. Defense attorneys often advise their clients to volunteer for treatment in the hope of a shorter sentence (Speiglman and Weisner, 1982:5). While social action groups such as Mothers Against Drunk Driving have been influential on tougher legislation regarding drunk driving, the public alcohol treatment system has lobbied for penalties including treatment as well as traditional sanctions. The private alcohol treatment system has grown more in response to the need to fill hospital beds rather than to a line of people

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waiting to be treated. Here too, coercion— albeit sometimes more subtle than in the public system—has become a prominent marketing strategy. One coercive strategy focuses on the family of persons with alcohol problems. The family is helped to confront the alcoholic with the seriousness of the problem and persuade him or her to seek treatment (Melody, 1980). The rationale for this strategy is that, when faced with evidence and an ultimatum from the family, the individual will stop denying the problem and agree to seek treatment. Often the individual’s employer is involved. The rapid spread of employee assistance programs with their strategy of constructive confrontation has coincided with the growth of private programs and increased health insurance coverage. Private programs have documented the cost of alcoholism to industry and actively market their programs there. While it seems illogical to the outsider that persons who remain sufficiently stable to have retained their jobs should be in hospitals rather than outpatient programs, many industries and unions contract exclusively with hospital programs. As we have seen, both public and private treatment systems are under pressure to find clients who can pay fees. As a result, coercion is increasingly intrinsic to the client-gathering process. These changes have brought striking shifts in treatment.

Changes in the Process and Ideology of Treatment The flood of clients referred from the courts has been accompanied by changes in treatment philosophy. The original ideology of Alcoholics Anonymous (AA) and the alcoholism movement was highly oriented toward the client’s motivation and voluntary treatment. AA waited for people to come in the door. Being properly motivated and receptive to the recovery process was considered crucial to recovery. Within the space of a few years, however, the barrier between voluntary and involuntary clients dissolved. The movement’s rhetoric shifted to accommodate the realities of gathering clients. Programs became expert in “breaking through denial”; indeed, the whole rhetoric

of intervention revolves around the concept of denial. Public programs use the threat of jail as a therapeutic tool (Weisner, 1981:51). The same change in attitude is found in private programs, which intervene to precipitate a crisis: the alcoholic thus hits bottom sooner, breaks through denial more easily, and becomes more receptive to treatment (Roman and Trice, 1967). The people who provide treatment do not appear to have stopped to consider the implications of the new rhetoric—though some of the originators of the ideas have (Roman, 1980). There is certainly little self-consciousness about it. The 1982 annual California Alcohol Conference, sponsored by statewide treatment organizations, had as its theme “Breaking Down Barriers” with an emphasis on “networking and developing productive coalitions among alcohol programs and allied human service and law enforcement agencies for greater impact on individual and community denial” (California State Alcohol Treatment Conference, 1982:1). Workshops in intervention are some of the most popular and available training courses for those working in alcohol treatment (Faulkner Training Institute, 1983; Johnson Institute Seminars, 1983; Scripps Memorial Hospital, 1984). Treatment goals have also changed. In one county, agencies under contract with the county alcohol administration stated in their contracts with the county that they would attempt to keep two-thirds of their clients out of the criminal justice system for at least six months (Speiglman and Weisner, 1982:23). The mixture of coerced and voluntary clients also has affected the treatment atmosphere. When some members of a therapy group bring attendance cards to be signed for their probation officers or employers, it changes the atmosphere of the group as a whole. Currently in California counties, alcohol treatment providers do not have the prerogative of screening out drunk driver clients entering court-mandated programs. However, where the provider does have the power to screen cases, as with other coerced clients seeking treatment to avoid jail, there are ethical dilemmas. The agencies have no control over the context in which treatment is presented to the clients, nor

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over what other alternatives are offered. This may greatly influence how clients present themselves and what attitude they take to therapy. Traditionally, providers have not hesitated to terminate their relationship with clients who were not successfully participating in treatment. However, with the need to keep the new treatment slots filled, programs often feel pressured to retain clients who are not appropriate or who are not committed. Providers must also consider that clients may lose their jobs or go to jail if treatment is terminated. Even discharging clients for reasons which are based solely on medical or clinical grounds can have potentially dire consequences. However, with other clients, a reverse problem exists. In some programs, such as drunk driving, where the treatment system is taking over a whole category of clients with which the court has long been frustrated, judges really do not want individuals returned to them unless they fail drastically. The courts thus make it very difficult for agencies to get rid of these clients.

Role Conflicts for Therapists In both the public and private programs, in the counties we have studied, the changing environment of treatment has created ambiguities about responsibility. Who is the provider responsible to—the alcoholic, the family, the employer, the judge, or the probation officer? In the public sector, at treatment conferences and meetings of administrators, agency directors consistently mention the reality of the pressure to be responsible to the criminal justice system or to groups which are powerful in deciding where the handling of clients such as drunk drivers should take place (California Senate Committee on Health and Welfare, 1981; California State Alcohol Treatment Conference, 1982; Northern California Conference on Drunk Driving, 1982). Agency officials speak without apparent defensiveness of the need to convince judges and Mothers Against Drunk Driving that they are punishing as well as treating criminal justice clients. Indeed, during interviews for a pilot study in one county most of these clients described their agency

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experience as “doing time.” Counselors show little compunction in forcing clients to attend sessions and abstain from drinking by threatening to return them to the courts. Our fieldwork has found that as public programs have become dependent on the criminal justice system for clients, they become threatened by potential policy changes—such as shortening the programs—which would change the existing arrangements. While counselors often play an empathic role during therapy, publicly they define their clients as dangerous and in need of longer-term programs. Agency staff are thus caught in a dual role: They must gain their clients’ confidence while also presenting an unsympathetic view of clients to demonstrate the seriousness of the problem. In response to a recent court ruling (People v. Municipal Court, 1983) that treatment could not be a substitute for jail, treatment providers stressed how tightly structured their programs were and suggested that the judge increase the length of stay in the program to make it as long or longer than a jail sentence. The situation within private agencies is not much different. As long as agencies have to market their programs and compete in courting referrals from employee assistance programs, their main alliances will be with the employers and unions rather than with individual clients. In both private and public agencies, the staff are caught in the uneasy compromise between a therapeutic model and a model of social control and punishment.

Compromises of Confidentiality Alcoholism treatment has traditionally placed great emphasis on confidentiality and anonymity. The very name of Alcoholics Anonymous reflects a concern, and indeed an imperative, to maintain confidentiality (Beauchamp, 1980:50). Yet the new environment of treatment agencies compromises client confidentiality in the counties we have studied. In public programs, some counselors regularly discuss clients with probation officers. Others give only minimal information through written reports (Speiglman and Weisner, 1982). In private programs and in those public programs with contracts

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with employers, information on clients who have been referred by employers must be given. Similarly, counselors must report to the courts on the client’s compliance or progress. In such cases, treatment is no longer a private matter between therapist and client. In both public and private programs, court-referred clients must sign release-of-information consent forms. Aiken and Weiner (1974) suggest that such clients may actually have less legal protection than they would in a conventional criminal justice setting.

Shift in Clientele The new entrepreneurial environment has brought changes in economic and class characteristics of clients in the counties we have studied. Medicaid, which formerly supported some hospital-based care for very low income individuals, no longer covers costs, and clients having only Medicaid are therefore not accepted in private programs. These programs are populated by individuals who have private health insurance, whose employer will pay for their treatment, or whose family is sufficiently affluent to pay for the treatment. There have also been changes in the class composition of the clientele within public agencies. The public drunk, for whom the alcohol treatment system was first created (Kurtz and Regier, 1975), has been gradually pushed out the door. While the public alcohol treatment system in some counties is required by law, to make services available to indigents, just how seriously this charge must be taken has never been clarified. At the same time, agencies are under pressure from county administrations to collect fees. Examination of state management information statistics has shown that indigent clients are found in agencies which emphasize custody rather than treatment or cure and offer only short term services (Speiglman and Weisner, 1982:33; Weisner, 1983). The most common treatment locations for indigents are drop-in centers and social model detoxification units, which are in effect one-to-three day, non-medical, drying-out stations. An obvious way in which referrals from criminal justice have resulted in class bias is

that treatment programs often only accept clients who can pay. If defendants cannot pay, their attorneys are less likely to request treatment and judges are more hesitant to refer (Speiglman and Weisner, 1982; Weisner, 1981; see also Fagan and Fagan, 1982). In the counties we have studied, drunk driving programs are often structured in such a way that only those who can pay are referred to them, while other offenders receive jail sentences or have their driver’s licenses suspended. Many of the clients referred by the courts and employee programs are thus closer to the profile of problem drinkers in the general population than to the traditional alcoholic (Room, 1977:81). While historically the treatment field has only concerned itself with alcoholism, its ideology has always allowed for a definition of those with alcohol problems as early-stage alcoholics. But, increasingly, the field is extending its jurisdiction beyond alcoholism to include also alcohol problems. In the public system, agencies have quite explicitly enlarged the scope of their responsibility to alcoholism and alcohol problems. Both public and private programs have incorporated into their conceptual understanding of alcoholism, and into their treatment population, the idea of co-alcoholism. The coalcoholic is anyone who is affected by someone else’s alcoholism. It originally referred to family members.6 However, it is now frequently heard in reference to friends, employers, and even the community. While mental health and alcohol therapists have long advocated family participation in treatment, only alcohol treatment has carried the concept to the point of giving it a name and labeling it as a disease— we do not hear of co-schizophrenics or co-drug addicts. In an environment of flexible adaptation to changing definitions of problems—and thus to new populations—it has not been difficult to make a case for the need to treat this population. Agencies are interested in this group because they are attractive clients compared with the chronic alcoholic (Weisner, 1981:23). More importantly, co-alcoholics represent a whole new group for treatment—one that may be as large as the alcoholic population itself.

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CONCLUSION Those who treat alcohol problems fall into two very different groups. One group talks of “recovering alcoholics” and espouse the Alcoholics Anonymous philosophy, related self-help strategies, and nonprofessionalized treatment agencies. A second group, made up of medical and psychiatric personnel in hospital and clinical settings, has a more traditional psychotherapeutic approach. Despite their differences, these groups have traditionally agreed that it is futile to help people who do not voluntarily seek help and acknowledge their alcoholism. Thus, in the past, clients were not accepted for treatment unless they admitted they were alcoholics (Roizen and Weisner, 1979; Sterne and Pittman, 1965). Itinerant alcoholics knew they had to make this admission if they wished to receive services—even if only food and lodging— from alcohol-oriented agencies (Bibby and Mauss, 1974; Wiseman, 1970:239). This ideology and rhetoric have undergone dramatic change. Treatment providers now emphasize aggressive outreach and intervention; they talk of confrontation and constructive coercion as tools of a tough love that will overcome denial. The providers themselves have not changed, only the rhetoric. Some would suggest that this shift is related to a drift toward a more punitive approach to alcohol problems in U.S. society (Mäkelä et al., 1981:107, 111). However, as our research indicates, the shift reflects radical changes in the size, structure, and financing of the alcohol treatment system itself.

NOTES *

A summary of an earlier version of this paper was presented at the 10th World Congress of the International Sociological Association, Mexico City, August 16–21, 1982. Preparation of this paper was supported by a National Alcohol Research Center grant (AA-05595) from the U.S. National Institute on Alcohol Abuse and Alcoholism. The authors thank the many alcohol program administrators and treatment providers who cooperated in the fieldwork. 1. Paul Terrell, February 6, 1984: personal communication. 2. At numerous times in the past we have attempted to find these statistics from various departments

3.

4.

5.

6.

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in the state and local governments, including the California State Department of Health Services, the California Department of Alcohol and Drug Programs, and the Contra Costa-Alameda County Health Services Administration. We have also had personal communication with the directors and some staff members of the alcohol administrations of the seven counties receiving approximately 75 percent of the state administered budget. Alcoholics Anonymous was founded by Bill W. in 1935. (Consistent with principles of anonymity in the organization, the literature does not use his last name). One of the strains that influenced the formation of AA was dissatisfaction with mental hospital treatment for alcoholism. The survey also found that while alcohol treatment in outpatient services decreased (community health centers by 8 percent and free-standing outpatient centers by 17.7 percent) since 1979, there was an increase in hospital-based alcoholism treatment units reporting. “Units in mental and psychiatric hospitals increased by 13 percent, and units in other specialized hospitals as well as general hospitals (including Veterans Administration hospitals) increased by 10 percent”; (U.S. National Institute of Alcoholism and Alcohol Abuse, 1984:45). This is a reflection of the increase of third party payment fees for hospital-based care. The county-run and county-contracted programs charge fees on a sliding scale from being free to $16.00 per hour for outpatient services. Some of them charge no fees or accept General Assistance payments for residential services; the most expensive programs charge $750 per month. The term “co-alcoholic” appears to have emerged in the early 1970s in the therapeutic self-help literature directed at relatives—particularly wives—of alcoholics. The term does not appear in the 1982 edition of the Dictionary of Words About Alcohol (Keller et al., 1982) and is apparently not used in the literatures of Al Anon, family therapy, and transactional analysis. While some early usages in the self-help literature avoid imputing responsibility to the “co-alcoholic” for the “alcoholic’s” behavior, or regarding “coalcoholism” as a disease (Coudert, 1972:173), the term has increasingly taken on these attributes (Fajardo, 1976).

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Aiken, Robert and Sheldon Weiner 1974 “The interface of mental health and judicial systems: Early impressions of an ASAP-related treatment effort.” Pp. 292–301 in Morris Chafetz (ed.), Proceedings of the Third Annual Alcoholism Conference of the National Institute on Alcohol Abuse and Alcoholism. Washington, DC: Department of Health, Education and Welfare. Alcoholism: The National Magazine 1983 “National Alcoholism Treatment Center Directory, 1983–1984,” 3(March/April):1–38. Beauchamp, Dan 1980 Beyond Alcoholism. Philadelphia, PA: Temple University Press. Bibby, Reginald and Armand Mauss 1974 “Skidders and their servants: Variable goals and functions of the skid row rescue mission.” Journal for the Scientific Study of Religion 13(4):421–436. Blumberg, Leonard 1977 “The ideology of a therapeutic social movement: Alcoholics Anonymous.” Journal of Studies on Alcohol 38(11):2122–2143. Boscarino, Joseph 1980 “A national survey of alcoholism treatment centers in the United States: A preliminary report.” American Journal of Drug and Alcohol Abuse 7(3,4):403–413. Bunce, Richard, Tracy Cameron, Patricia Morgan, James Mosher, and Robin Room 1981 “California’s alcohol experience: Stable patterns and shifting responses.” Pp. 159–199 in Eric Single, Patricia Morgan, and Jan de Lint (eds.), Alcohol, Society and the State: 2. The Social History of Control Policies in Seven Countries. Toronto: Addiction Research Foundation. Cahalan, Don 1976 “Some background considerations in estimating needs for states’ services dealing with alcohol-related problems.” Unpublished paper for National Center for Health Statistics. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism (July 27). Cahn, Sidney 1970 The Treatment of Alcoholics: An Evaluative Study. New York: Oxford University Press. California, Department of Alcohol and Drug Programs 1980 California Alcohol Program: Plan FY 1980–1981. Sacramento: Department of Alcohol and Drug Programs. California, Department of Alcohol and Drug Programs 1983 California Alcohol Program: Plan FY 1983–1984. Sacramento: Department of Alcohol and Drug Programs.

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Second Edition. New Brunswick, NJ: Rutgers Center of Alcohol Studies. Kurtz, Norman and Marilyn Regier 1975 “The uniform alcoholism and intoxication treatment act.” Journal of Studies on Alcohol 36(11):1421–1440. Lerman, Paul 1981 Deinstitutionalization: A Cross-Problem Analysis. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Lewis, Jay 1982 Alcoholism Report 10(June 30):1–6. Minneapolis, MN: Johnson Institute. Lewis, Jay 1983 Alcoholism Report 12(December 16):1–8. Minneapolis, MN: Johnson Institute. Mäkelä, Klaus, Robin Room, Eric Single, Pekka Sulkunen and Brendan Walsh 1981 Alcohol, Society and the State: Vol. 1. A Comparative Study of Alcohol Control. Toronto: Addiction Research Foundation. Martinson, Robert 1964 “The California Recovery House: A sanctuary for alcoholics.” Mental Hygiene 48(3):432–438. Melody, Moya 1980 “Care Units: Making money from the disease concept of alcoholism.” Unpublished Master’s thesis, Department of Journalism, University of California, Berkeley. Moore, Jean (ed.) 1981 Directory of alcoholism treatment centers. Western edition, plus supplement. Sharton, CT: ATD Publications. Morgan, Patricia 1980 “The state as mediator: Alcohol problem management in the postwar period.” Contemporary Drug Problems 9(1):107–140. Morgan, Patricia 1981a “From battered wife to program client: The impact of the state in the shaping of a social problem.” Kapitalistate Issue 9:1–16. Morgan, Patricia 1981b “Systems in crisis: Social welfare and the state’s management of alcohol problems.” Contemporary Drug Problems 10(Summer):243–261. Morrissey, Elizabeth 1981 “The role of life changes in the development of alcohol-related problems.” Seminar presented to the Social Research Group Seminar, Berkeley, California, January 13. (University of Washington, Seattle; Alcoholism and Drug Abuse Institute). National Association of State Alcohol and Drug Abuse Directors 1984 “1983 Year in Review.” Alcohol and Drug Abuse Report, December 1983 and January 1984:1–36.

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National Council on Alcoholism 1982 Letter of appointment of an ad hoc working group on alcoholism treatment issues, May 7, New York: National Council on Alcoholism. Northern California Conference on Drunk Driving 1982 Program statement of the Northern California Conference on Drunk-Driving, sponsored by the Bay Area Coalition on Alcohol Problems, San Mateo, CA. People v. Municipal Court (Hinton), Cal. App.3d, 1983. President’s Commission on Mental Health 1978 “Report of the task panel on the nature and scope of the problem.” Pp. 1–138 in Task Panel Reports, Volume 2, Appendix. Washington, DC: U.S. Government Printing Office. Raush, Harold with Charlotte Raush 1968 The Halfway House Movement. New York: Appleton Century Crofts. Reynolds, Lynn 1973 “The California Office of Alcohol Program Management: A development in the formal control of a social problem.” Unpublished Ph.D. dissertation, School of Public Health, University of California, Berkeley. Rodwin, Victor 1982 “Health insurance and alcohol treatment services: A strategy for change or a buttress for the status quo?” Working paper, Berkeley, CA: Alcohol Research Group. Roizen, Ron and Constance Weisner 1979 Fragmentation in Alcoholism Treatment Services: An Exploratory Analysis. Report C-24, Berkeley, CA: Social Research Group. Roman, Paul 1980 “Medicalization and social control in the workplace: Prospects for the 1980s.” Journal of Applied Behavioral Science 16(3):407–422. Roman, Paul and Harrison Trice 1967 “Alcoholism and problem drinking as social roles: The effects of constructive coercion.” Paper presented at the annual meetings of the Society for the Study of Social Problems, San Francisco, August 26. Room, Robin 1977 “Measurement and distribution of drinking patterns and problems in general populations.” Pp. 61–87 in Griffith Edwards, Mark Keller, James Mosher and Robin Room (eds.), Alcohol-Related Disabilities. Offset Publication 32. Geneva: World Health Organization. Room, Robin 1980 “Treatment-seeking populations and larger realities.” Pp. 205–224 in Griffith Edwards and Marcus Grant (eds.),

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Alcoholism Treatment in Transition. London: Croom Helm. Room, Robin 1983 “Sociological aspects of the disease concept of alcoholism.” Pp. 47–91 in Reginald Smart, Fredrick Glaser, Yedy Israel, Harold Galant, Robert Popham, and Wolfgang Schmidt (eds.), Research Advances in Alcohol and Drug Problems, Volume 7. New York and London: Plenum Press. Sardell, Alice 1983 “Neighborhood health centers and community-based care: Federal policy from 1965 to 1982.” Journal of Public Health Policy 4(4):484–504. Scripps Memorial Hospital 1984 “Intervention.” Brochure for a training workshop for alcohol treatment professionals. La Jolla, CA: Scripps Memorial Hospital. Shonick, William and Ruth Roemer 1982 “Private management of public hospitals: The California experience.” Journal of Public Health Policy 3(2):182–205. Speiglman, Richard and Constance Weisner 1982 “Accommodation to coercion: Changes in alcoholism treatment paradigms.” Paper presented at the annual meetings of the Society for the Study of Social Problems, San Francisco, September 3–6. Sterne, Muriel and David Pittman 1965 “The concept of motivation: A source of institutional and professional blockage in the treatment of alcoholics.” Quarterly Journal of Studies on Alcohol 26(1):41–57. Terrell, Paul and Ralph Kramer 1982 “Degovernmentalizing public services: The use of

voluntary social agencies by local government.” Paper presented at the Seminar on Local Government Organization and Economy, Sigtuna Sweden, May. U.S. Journal of Drug and Alcohol Dependence 1982 “AMI purchases Raleigh Hills.” U.S. Journal of Drug and Alcohol Dependence, 6(12):1 U.S. National Institute on Alcohol Abuse and Alcoholism 1982 Statistical Report: National Institute on Alcohol Abuse and Alcoholism Funded Treatment Programs, Calendar Year 1980, Volume 4. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. U.S. National Institute on Alcohol Abuse and Alcoholism 1984 “Epidemiological Bulletin 2: Changes in Alcoholism Treatment Services, 1979–1982.” Alcohol Health and Research World, Winter 1983/84 8(2):44–47. Weisner, Constance 1981 Community Response to Alcohol-Related Problems: A Study of Treatment Providers’ Perceptions. Report C30, Berkeley, CA: Social Research Group. Weisner, Constance 1983 “The alcohol treatment system and social control: A study in institutional change.” Journal of Drug Issues 13(1):117–134. Wiener, Carolyn 1981 The Politics of Alcoholism: Building an Arena Around a Social Problem. New Brunswick, NJ: Transaction Books. Wiseman, Jacqueline 1970 Stations of the Lost: The Treatment of Skid Row Alcoholics. Englewood Cliffs, NJ: Prentice-Hall.

CHAPTER 12

Ideological Implications of Addiction Theories and Treatment Kathryn J. Fox

Political ideologies lie beneath debates over such apparently objective, scientific claims as theories of disease causality. Tesh (1988) called these ideologies or values “hidden arguments” that direct science and policy toward a particular configuration of facts. Interventions and treatments are, thus, predicated on unconscious assumptions about the nature of individuals and certain populations (Patton 1990). As such, sub rosa ideological assumptions about those addicted to substances infuse common treatment modalities.1 In other words, drug and alcohol treatment approaches imply particular characteristics of their treatment populations. In this article, I consider the direction that the discourse concerning addiction etiology and treatment has taken. Specifically, I focus on the consequences of “disease” theories of addiction to opiates and alcohol.2 Two different approaches toward the treatment of these “addictions” are reviewed: Alcoholics Anonymous and methadone maintenance treatment. I argue that the specific designs for treatment reflect the attendant orientations of the targeted populations of users. Sharing a similar theory of addiction, alcohol treatment and methadone maintenance have had diverse histories that may reflect the class composition of their consumers. An analysis of the mechanics of the treatment models reveals that each method contains a set of hidden arguments in the form of class-based assumptions about the populations served. [...]

THE DISEASE CONCEPT A rather incessant debate has lingered among interested experts regarding the etiology of addiction. The dominant paradigms locate the source of addiction in either psychological predisposition or metabolic disease. Clearly, both analyses tend to disregard structural or predominantly social influences. In both models, though, an addicted individual is viewed as having some condition prior to substance use that made addiction almost inevitable. Not surprisingly, the psychological and psychiatric professions make a strong case for individual personality as the culprit and thus advocate therapy as an appropriate treatment (Peele 1984). The medical profession, on the other hand, regards substance addiction as a disease or metabolic defect requiring medical intervention, but for which there is no known cure. In both examples, rational choice in a given situation is rarely assumed; rather, both schools of thought imply the presence of some variety of defect. However, they tend to view the sometimes distasteful behavior accompanying addiction somewhat differently. The relevant question is which came first—the behavior or the addiction? As methadone’s pioneers stated, “It is important to distinguish the causes from the consequences of addiction” (Dole and Nyswander 1967:21). There are serious implications in accepting either view. For example, a medical model that insists that certain individuals are bound to become addicts has the consequence of

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releasing the addict from liability. Perhaps this partially explains the widespread popularity of this view among laypeople (Conrad 1975).3 On the other hand, embracing a social-psychological model establishes addiction within the domain of mental health, thus offering a treatment alternative that may be ironically more stigmatizing and punitive. Although public opinion probably amounts to a combination of these two theories, treatment paradigms reflect the undeniable and growing primacy of the disease model.4 Both Alcoholics Anonymous (AA) and methadone maintenance treatment embrace the metabolic disease theory. AA conceives of alcoholism as an inbred “allergy” to alcohol.5 Methadone maintenance was designed to stabilize clients and return them to productive lives by staving off the perpetual craving for heroin. Although the dominant treatment models for addiction to both substances reflect this theoretical position, the disease approach manifests itself differently for each. Examining each treatment model with regard to contextual differences provides the groundwork for discovering the hidden arguments that lie in wait.

TREATMENT IN CONTEXT The disease concept has taken dissimilar forms in methadone maintenance and AA. I compare four of the issues that influence the shape of their modalities: (a) historical backgrounds, (b) the conception of personal responsibility, (c) the role of professionals, and (d) treatment financing. Finally, I consider the ideological implications of the divergence discovered regarding these issues.

HISTORICAL CONTEXT The unique histories of both AA and methadone maintenance provide insight into the forms their respective treatment modalities took. Frustrated by the contribution of “drying-out” hospitals to the effort of sustaining sobriety, two middle-class men (one physician) created AA in 1935 as a quasi-religious support group for fellow alcoholics. Anonymity was

crucial in destigmatizing the alcoholic identity and motivating people to submit to the fellowship offered. In addition, group support by alcoholic peers was considered a sensible solution to the vexing problem of perpetual temptation. Two important propositions are central to AA’s philosophy: that alcoholics are unable to control their drinking and that support can help them to abstain permanently (Peele 1989:43–44). The cornerstone of the treatment is the idea that a certain portion of the population is born alcoholic even before the individuals take their first drink; these people will become powerless over alcohol when they eventually drink. Although this provides a clear demonstration of a medical concept, the treatment that AA advanced initially was self-help in a nonprofessionalized setting (Weisner and Room 1984:180). Several writers have documented the history of methadone maintenance as a public policy initiative (Epstein 1977; Musto 1973; Nelkin 1973). During the 1950s, the New York State Medical Society and the American Bar Association joined forces in calling for investigatory research on substitution therapy (Senay 1985). The American public was concerned about the presumed connection between heroin addiction and street and property crime. Later, during the Nixon administration, the motivation for pursuing maintenance as a treatment protocol was the reduction of crime statistics. From these initial ventures, the confluence of medical and law enforcement paradigms is apparent. By 1973, political strategists secured funding for 450 methadone programs after only a few years of research into its effectiveness (Epstein 1977). Treatment and evaluation research was conducted by Dole and Nyswander in 1964. Their goal was not necessarily to make addicts drug free, but to make participants socially productive (Dole and Nyswander 1967:22).6 They interpreted the crimes committed by addicts as consequences of “drug hunger.” Maintaining addicts on methadone would successfully eliminate the need to commit theft for drug money by providing a licit substitute that blocked heroin craving.7

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In this brief examination of the different motivations and actors behind the creation of these treatment models, a perceptible difference immediately comes to the fore regarding the element of social control. The fact that AA was created by self-proclaimed alcoholics as a means of self-help stands in stark contrast to methadone maintenance’s inception as a means of controlling criminal impulses.8 This control was mediated by professionals and embraced by an administration arguably motivated more by reelection than humanitarianism. Yet in both models of treatment, we see reductionist tendencies regarding the problem and the “cure.” AA perceives alcoholism as incurable; total abstinence offers the only escape from its clutches. Abstinence includes all substances to which alcoholics may be prone to addiction.9 Methadone maintenance proponents confine the problematic features of heroin addiction to the interminable hunger for heroin and the fear of painful withdrawal symptoms. Consequently, the rationale for maintenance is that if addicts’ constant hunger for heroin can be “cured” or blocked, then the other problems associated with addiction will dissolve.

PERSONAL RESPONSIBILITY A “disease” approach relieves drug-dependent persons of responsibility for their condition. However, the illegal context in which heroin addiction exists significantly changes the nature of responsibility. Although in 1962 the Supreme Court decided that addiction itself is a disease rather than a crime, the purchase, sale, and consumption of heroin is nonetheless illegal (Musto 1973). Consequently, the disease model is somewhat differentially applied to opiate addiction in that the penalty regarding the drug of choice is more punitive. In other words, heroin addiction is managed in a quasimedical, quasi-criminal arrangement. As Nelkin (1973:40) stated, “The legality of methadone is its major advantage over heroin.” Although the U.S. has a long history of ambivalence toward alcohol use, its prohibition has been repealed almost as long as opiates have been illegal. The

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situation is quite distinct for alcohol abusers: Their addiction breaks no law. In addition, treatment for alcohol addiction has benefited from an increasingly positive image. In fact, the identity of a “recovering” alcoholic is almost special, as more and more public figures and movie stars proclaim their triumphs over booze (Peele 1989). Meanwhile, methadone maintenance clients try to hide their “dirty little secret” (Murphy and Irwin 1992). Their status is remarkably more marginal. Concomitant with the themes of marginality and responsibility is stigmatization. Trice and Roman (1970) make the case that alcoholics have more success in the “delabeling” process than either addicts or the mentally ill. Through their organization, alcoholics managed to replace the deviant label of alcoholic with a socially acceptable label. Alcoholics’ ability to successfully subvert the stereotype associated with them is due to the fact that the stereotype is directly connected to drinking behavior. In other words, the deviance vanishes when drinking ceases (Trice and Roman 1970). In contrast, prevalent stereotypes of mental illness and illicit drug addiction are more ambiguous, and perhaps more extreme. Consequently, the disappearance of the deviance is less obvious; delabeling is less convincing. Furthermore, observing “normal” drinking behavior is common, whereas “normal” drug use is less visible (Trice and Roman 1970:541). A collective cultural impression of what constitutes normal use is more readily available with a legal, ubiquitous drug such as alcohol than with an illicit drug such as heroin. The issue of responsibility has two aspects: responsibility for the cause of addiction and responsibility for the consequences. Alcoholics have been more successful in transforming the meaning of recovery, which indicates their enthusiasm for focusing on their personal responsibility for abstinence rather than on the primary addiction. The disparate images of an abstinent alcoholic, on the one hand, and a maintained addict, on the other, demonstrates the association of varying degrees of personal responsibility for addicts and alcoholics. In addition, the polarized images reflect the relative status of abstinence treatment.

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Although the notion of multimodalities has become more acceptable, for many years the alcohol treatment industry had nothing but contempt for drug-replacement therapy (Zweben and Sorensen 1988). As methadone does not constitute a cure for heroin addiction as was originally pronounced, and as AA insists that addiction is progressive and irreversible, then abstinence is deemed the only legitimate treatment. Because “just saying no” is a popular dictum, abstinence resonates with a cultural theme of personal responsibility as well.

THE ROLE OF PROFESSIONALS Returning for a moment to the traditions of AA and methadone maintenance, an analysis of each treatment model reveals the differential power of professionals involved. In AA, professional presence is virtually nonexistent. In fact, AA has no formally hierarchical structure. Although meetings are facilitated by a veteran recovering alcoholic or counselor, no members are accorded more authority than the others. In general, the 12-step model is central to alcohol treatment in the U.S. Medical treatment tends to be ancillary to AA. After initial detoxification, chemical dependency wards in hospitals use 12-step meetings as the fulcrum of their treatments.10 Even within professional treatment settings, counselors are paraprofessionals with personal histories of alcohol abuse (Peele 1989). Traditionally, and by design, AA has relied on support groups organized in an egalitarian fashion. Dole and Nyswander (1967) purposefully did not feature psychotherapy or psychological support as components of their methadone maintenance program. They did not believe that addicts needed counseling as their problems were not psychological in nature. The “antisocial activities” in which addicts engaged were consequences rather than precursors of drug addiction (p. 20). Because they considered heroin addiction to be a condition similar to diabetes, indefinite maintenance provided the only viable treatment. Therefore, retention in the program was fundamental. Group support, on the other hand, is a more appropriate strategy for programs that insist on total abstinence.

Methadone maintenance requires the use of medical technology and trained personnel because treatment literally involves the dispensation of a drug. However, the structure of methadone clinics is such that staff members have significant power over clients, even in outpatient clinics. For example, often clients are not privy to information about their own dosage and rarely participate in dosage decisions. Dosage and detoxification are matters of staff discretion (Rosenbaum and Murphy 1984). In addition, clients must submit to regular drug screening; most clinics use “dirty urine specimens” as grounds for termination from a program (Murphy and Rosenbaum 1988:402fn). The discrepancy between models regarding personal autonomy and the goal of self-empowerment is evident by the presence or absence of sanctions. Whereas AA acknowledges that most participants will suffer from relapse (as the disease itself is considered persistent), methadone clinics exercise punitive discretion and set the terms for treatment.

TREATMENT FINANCING Both alcohol and opiate treatment have become part of what is disparagingly referred to as the “drug abuse industrial complex” (Senay 1983:57). In the U.S., private and public treatment combined generate $2 billion annually (Peele 1989). Whereas methadone clinics have always required a steady stream of clients to justify continued government funding, the landscape of alcohol treatment has changed dramatically. AA is a nonprofit organization that has been assimilated into for-profit ventures. As mentioned previously, the 12-step approach is integral to treatment, even in private hospitals. AA was premised on the essentiality of voluntary participation and individual motivation. However, as the need to fill client slots grew, treatment facilities adopted aggressive intervention tactics to broaden their market. The late 1970s witnessed an emergence of for-profit alcohol treatment facilities as health insurance plans began to cover treatment costs. In addition, counties received new funds to contract

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for services. By 1982, the majority of treatment agencies were privately owned and operated (Weisner and Room 1984).11 The consequence of these developments has been that the ideology associated with treatment was transformed. Structured conditions affected the theoretical frames implemented in treatment. For instance, noncompliant potential clients were judged as suffering from denial, which contradicted the AA standard regarding who was suitable for help. Professional expertise was invoked in persuading individuals and the public of the widespread, and unrecognized, problem of alcoholism. AA has been swept into the maelstrom of the ever-expanding meaning of alcoholism and potential recruits for treatment. As private hospitals attempted to drum up business, they adopted a “coercive marketing strategy” (Weisner and Room 1984:177) and tailored their functions to the wider population of consumers. The rhetoric has changed in that the disease label has been applied to a host of personal problems from being an adult child of an alcoholic to a “woman who loves too much.” Consequently, the U.S. has witnessed an enormous boom in 12-step programs and programs designed to treat a vast array of problems, including compulsive gambling, codependency, and sex addiction. Agencies that attend to other social problems, such as battered women’s shelters, are pressured to expand the definition of the problem to consider it “alcohol related” in order to receive certain funds. Thus, one implication of the recent financing structure and boon of available alcohol resources is that the complexity and political aspects of spouse abuse, as one example, are reduced to merely effects of alcohol (Morgan 1981:34). Additionally, agencies are able to shore up their funding bases by responding to trends in treatment for social problems. Meanwhile, private treatment centers benefit from a regular flow of clients referred by the criminal courts. Diversion into treatment rather than jail is an option offered to drunk drivers, wife abusers, and child abusers, as well as some heroin addicts (Weisner and Room 1984). This option, however, is often available only to those who can afford private treatment

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(i.e., those who have health insurance); those who cannot may suffer legal consequences or settle for county out-patient facilities (Weisner and Room 1984:179–80). Knowledge systems must be reconfigured to support the material demands of treatment. As such, the ideology behind treatment rhetoric has been refurbished to fit the needs of the industry. In other words, alcoholism is still a disease, but the numbers afflicted by the disease in some transmuted form have skyrocketed. And although individuals’ personal recognition of their own disease is essential in AA, treatment itself aids in the process of awareness. Peele (1989) discovered that those targeted for treatment (perhaps by employers or family) who refuse to acknowledge the existence of their problem are summarily assumed by professionals to be in denial. Likewise, those who recover successfully without treatment are dismissed as never having had a real problem at all (Peele 1989). Furthermore, therapists routinely refer clients to 12-step–style support groups for “codependents” of alcoholics in which an AA model for treatment is used for people who may never have had an alcoholic drink in their lives! The lure of funding and legitimating the need for services has motivated the alcohol treatment industry to widen its net. AA has established its sovereignty to such an extent that its ideology has invaded the popular discourse on social problems. Although medical concepts are now bandied about by laypersons regarding various conditions for which there is no “medical” evidence, Weisner and Room (1984:180) argued that the dramatic innovation in treatment financing accounts for the change in structure, ideology, and language. Originally funded as a social experiment, methadone maintenance treatment was supported by the city of New York (Etzioni and Remp 1973). In the 1960s and 1970s, methadone programs were expanded and funded at the federal level only to be cut drastically in the 1980s.12 Counties granted drug abuse treatment funds became motivated to create turnover in their client population as they amassed waiting lists of prospective clients (Murphy and Rosenbaum 1988). As a result of budget cuts,

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some counties instituted a “two-year rule” that dictated that after two years of maintenance, clients could either begin paying for their treatment or detoxify from methadone (Knight et al. 1996). Murphy and Rosenbaum found that a majority of clients have difficulty meeting the fee requirements. In essence, the rule forces many clients to wean themselves off of the program. However, methadone was conceived by its originators (and later determined to be effective primarily) as a long-term solution; most clients who detoxify from methadone eventually revert to heroin usage (Rosenbaum and Murphy 1984). County programs were afforded a certain percentage of discretionary funds for those clients whom clinic staff deemed less able to detoxify or who would be adversely affected by the fee requirements. Such discretion has created tensions between clinic staff and clients, amplifying the punitive power of programs over participants (Murphy and Rosenbaum 1988:399). Kidorf et al. (1995) examined the incentive systems provided by treatment programs that allow clients to earn privileges, such as taking doses home. In this sense, staff discretion in rewarding appropriate behavior symbolizes the power differential between staff and clients in drug abuse treatment programs. Methadone treatment has not experienced the expansion of its presence as AA has. It is less likely that the term addict could be applied as liberally as alcoholic as alcohol consumption is legal and socially acceptable. Certainly alcohol consumption is more visible. Moreover, the unique financing situation of alcohol treatment prompted marketing innovations that had some success in making the alcoholic label more tolerable, or at least more pervasive, than the addict label. The ebb and flow of financing and the privatization of treatment influenced methadone treatment admission as well, albeit to a lesser extent. In the 1970s, when funds were flowing and programs proliferated, clinics were less stringent in their admission requirements as they were induced to meet the supply of their services. For example, early programs insisted on strict criteria for determining that potential clients had indeed been heroin addicts for

an extended period of time and that they had repeatedly failed to detoxify themselves (Etzioni and Remp 1973). In addition, it was imperative in the early programs’ designs that participation be voluntary. However, these requisites were subject to maneuver, and eventually the courts played a role in feeding a steady stream of clients into methadone clinics, often in an effort to relieve the burden on the courts and prisons. Both fiscal crises and expanded funding shape program eligibility, and thus program design and attendant ideological representations of clients. Desires to increase supply and the need to justify the supply influence the rhetoric as well as official program guidelines. In the case of methadone maintenance, funding constraints significantly altered the programs’ objectives; in alcohol treatment, swelling resources amended the targeted population. The fact that private alcohol treatment facilities have proliferated while methadone has suffered from county and state fiscal crises indicates the class composition of their markets.

HIDDEN CLASS ARGUMENTS IN TREATMENT GOALS The fact that financial conditions have had distinct consequences for both approaches to treatment is not merely circumstantial. Behind the unique histories and models are hidden assumptions about the characteristics of their clientele. The divergent role of professionals, as well as the different interests and vantage points of the programs’ creators, reproduce the relative position and power of their target populations. Methadone is used primarily as a maintenance drug, but only rarely used solely as a detoxifying tool. However, the equivalent technological or medical solution for alcohol, a substance called Antabuse, is specifically used for detoxification and very rarely used for maintenance (Etzioni and Remp 1973:179). Again, the dominant medical opinion regards both heroin and alcohol addiction as metabolic conditions; both are considered incurable diseases. Yet, the primary treatment goals differ remarkably with regard to expectations about

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successful abstinence. I argue that unconscious assumptions about client competencies inform the varying ways that treatment technologies are used.13 Abstinence requires self-control and willpower. A model such as AA assumes that individuals can resist the temptation to drink, even though it may be difficult. The model is based on renewing self-restraint “one day at a time.” Methadone maintenance, on the other hand, is a model that tacitly implies that addicts cannot commit to abstinence. In other words, for addicts to resist heroin, they must be given another addictive substance as a substitute. The allegedly more benign drug stabilizes addicts so that they will not commit socially unacceptable acts. American folk wisdom insists that narcotic addicts rob and steal for drug money to maintain their habits, whereas alcoholics do not. Although it is difficult to make comparisons given the distinctive legal statuses of the substances, the legend of an inherent and simplistic connection between drugs and crime has persisted for decades (Johnson et al. 1985; Nurco et al. 1985). In these cases, we see quite distinct repercussions of the disease model application. Addicts ostensibly need medical intervention administered in a professional setting, whereas alcoholics can treat their own disease. Expectations regarding competency seem apparent and can be related to social class background. Middle-class values of self-control, willpower, a work ethic, and deferment of gratification are ingredients of a drug-free abstinence model. Success in AA requires hard work every day to remain sober. Individual will and suppression of desire are essential components. In contrast, although being maintained on methadone is also hard work of a sort, methadone suppresses desire for the addicts, presumably because they are deemed incapable without assistance. In addition, maintenance programs insist that participants submit to rules and regulations as well as discretionary punitive measures. Because drug addiction is no longer criminal and treatment is designed for treating addiction only, a viable explanation for the difference in stances toward addicts and alcoholics is “who

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they are.” A majority of heroin addicts in treatment are from the lower and working classes (Rosenbaum 1991).14 Conrad and Schneider (1980) argued that as behaviors are observed creeping into the middle class, the likelihood that the behavior will become medicalized is greater (see also Rosecrance 1985). Yet although both addictions have been medicalized in theory, the mark that medicalization has left in each case illustrates the incredible variance by class that a standard disease model can have. The medicalization of heroin addiction entailed intervention by scientists purposefully attempting to control illegitimate behaviors and to manage crime. As such, the social control function of methadone is explicit. Medical treatment as a form of therapy rests on the hope that behavior can be changed through knowledge and technology. Consequently, technological solutions are desirable and possible in marginal populations. Issues of social control are obscured, though, by the presumed benefits to society and the mandate of government officials to control the problem. The presumed benevolence of medical professionals further conceals the controlling function of methadone. In alcohol treatment, medical intervention occurs only to the extent that safety is ensured in the detoxification process. The fulcrum of the remedy for alcohol abuse is the unsupervised, unsanctioned choice to abstain with group support. The potential for social control is far less conspicuous; medical intervention is less threatening.

HIDDEN ARGUMENTS IN THE STRUCTURE OF TREATMENT AA meetings have been likened to a “Methodist class meeting” (Whitley 1977). It is important to note the strong parallel in design of traditional religion and the format that AA has adopted. Peele (1984:1338) has remarked that AA resembles nineteenth-century temperance movements and that its focus on salvation through God can be traced to southern and mid-western evangelical Protestantism. Though AA has attempted to dissociate itself from any one conception of God, a significant step for

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every alcoholic in AA is to surrender oneself to “a higher power.” Concomitant with the prominence of God, AA incorporates a restructuring component that enables alcoholics to make their past lives comprehensible (Thune 1977). AA meetings socialize members toward a life and identity as an alcoholic; acceptance of the new identity is tantamount to success (Denzin 1993). The resemblance between a religious conversion process and indoctrination into AA’s canon have been widely noted (Peele 1984; Thune 1977; Trice and Roman 1970; Whitley 1977). The conversion process involves public confession, remorse, and ultimate redemption. Self-castigation and imposed humility are crucial elements in the conversion process. The likeness to traditional Christianity is startling. Purging one’s soul of the sins of alcoholism indeed recalls the temperance movements of the past, which have been associated typically with the middle class. Life histories, the “idiom” of AA, encompass accounts of the downward spiral into alcoholism (Thune 1977:80). Thune found that little mention is made of any individual’s past life except as it relates to and dramatizes the deleterious impact of alcohol. In addition, “denial” is invoked if new members in AA (or inpatient treatment) do not properly convey the misery and havoc created by alcohol. Members learn through the process of AA participation to fashion their tales according to the patterns represented in the meetings. In this way, participants master the style and format of an appropriate alcoholic history and, thus, reinterpret their past lives and mold them into more acceptable and conforming ones. Thune (1977) charged that the life story format is more akin to monologues than group therapy. Whitley (1977) and Peele (1984) discovered that many of the life stories were “big fish” stories; members embellish their descent into hell each time their stories are told. The technique rehearsed by members is to remind themselves continually of the hell to which they have been and from which they have risen. The significance of these redemption tales is the degree to which their resonance is class related. Trice and Roman (1970) argued that

middle-class alcoholics find greater relief in AA than do lower and working-class participants. They argued that the “repentant role” (p. 543) taps into middle-class American values and religious imagery. Americans are fond of redemptive characters and are moved by folk tales that illustrate precisely how low sinners can go and the magnificent distance between their depths and survival. A dominant theme in AA is the “downward spiral” or “hitting rock bottom” (p. 543). In meetings, the life story formula focuses on lurid descriptions of life at rock bottom and concludes with praise for the miraculous redemptive powers of AA. Trice and Roman (1970) argued that for middle-class participants, the victory in rising again seems much greater than for lower class members; for lower class participants, the distance between rock bottom and their zenith of triumph is not as impressive. Middle-class members, thus, can feel more victorious, more successful. The model for fruitful participation in AA, therefore, is a classic American folk tale of the self-made individual, prevailing over adversity through sheer determination. AA provides a better fit for middle-class members because of the subterranean theme of achievement. The emphasis on the daily struggle to maintain abstinence, the litany of accounts of self-willed conquests over alcohol with the help of AA, and the model of introspection that insists on self-diagnosis reflect middle-class attitudes and values. In addition, the work ethic and willpower involved in denying the body of pleasure expose remnants of Calvinism. Public confessions and a focus on interpersonal communication in a quasi-therapeutic environment reflect an orientation that better corresponds to middle-class than lower class experience and capacity (Trice and Roman 1970). In addition, as Reinarman (1995:91) pointed out, the proliferation of 12-step groups makes sense in the context of a postmodern era because of the ways in which they provide “identity, community, and cosmology.” These may be luxuries that only the middle class can afford. Middle-class methadone maintenance clients report feeling unidentified with the lifestyle of typical clients in their programs (Rosenbaum 1991). Because they do not assume the total

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identity of either heroin addicts or methadone addicts, middle-class addicts in treatment have greater ease reentering a conventional lifestyle. In addition, they have more resources to draw on that provide incentive for leaving both heroin and methadone behind. Because the majority of heroin addicts come from the lower classes, the orientation of their programs is distinct from that of a 12-step model. Proponents of methadone have encountered criticism regarding the inherently addictive properties of methadone. Epstein (1977) found that their responses in defense of maintenance uncover hidden arguments for the continued operation of the programs. For example, one counterargument offered is that continued maintenance is like “chemical parole,” insofar as it forces addicts to report to and interact with a rehabilitation agenda. Medical professionals as well as social scientists envisioned methadone’s greatest benefit as a form of bait to entice addicts into a regimented program wherein “true rehabilitation” could take place (Epstein 1977:286). However, the true rehabilitation comprised a law enforcement objective of deterrence rather than a social psychological model of counseling. Although maintenance designers envisioned the goal of treatment in relation to a strictly metabolic theory of causality, clearly assumptions about the etiology of addiction were confounded even within the treatment organizations and their advocates. In addition, Dole and Nyswander (1965, 1966, 1967) had no intention of methadone’s being used in a coercive manner. However, a significant portion of those involved in creating methadone programs as a policy were dubious about its logic and rationale. Although its purpose has been misappropriated to use methadone as a means of social control, criticism has also been launched at its pioneers regarding the repercussions of indefinite maintenance. Ausubel (1983:851) argued that methadone maintenance “constitutes and perpetuates an immature coping mechanism” by using chemicals to protect addicts from the unpleasant task of adjusting to reality. In other words, maintaining addicts on licit drugs does not insist that addicts “work hard” like grownups to stay clean; in essence, their recovery should be more

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painful. Additionally, great efforts are made to adjust the dosage level to ensure that addicts cannot experience euphoria while on methadone. Methadone programs attempt to treat pharmacologically the tendency for addicts to seek pleasure, whereas adversaries of maintenance insist that addicts should experience the harsh and punishing consequences of addiction and recovery. These arguments echoing punitive sentiments indicate a continued ambivalence in American sentiment as to whether or not addiction is more appropriately treated criminally or medically. The preoccupation with reducing addicts’ levels of pleasure and increasing their adherence to values associated with the middle class illuminate Lindesmith’s (1940:919) statement “Addicts, to a greater or lesser extent, always have been a pariah class which has not been in a position to refute any charges levelled against it.” Assumptions about the hedonistic proclivities of addicts and their lack of self-restraint permeate theories and program designs in drug treatment. For instance, Ausubel (1983:856) questioned, “Would drug-induced euphoria be equally attractive and satisfying, for example, to a motivationally mature individual with strong long-term drives for achievement?” It is difficult to imagine such a characterization being levelled at middle-class alcoholics. The relative value of abstinence over maintenance is evidenced by the current concern that addicts have difficulty in fruitfully detoxifying from methadone. The middle-class values of self-control and inner strength infuse treatment ideology. That alcoholics in AA are able to abstain while addicts must be maintained both reflects the class orientation of the consumer populations and perpetuates the unconscious assumptions about the cultural distinctions between the groups of users.

CONCLUSION Zola (1966) noted cultural distinctions between ethnic groups regarding their responses to and experiences of particular illness symptoms. He argued that rather than cultural differences causing variance in actual symptoms and illness, sociocultural differences determine the definition

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and response to similar situations. With regard to addiction, social class played a unique role in the responses available to the afflicted, even though their metabolic conditions have been deemed virtually identical. The collective response of the middle class has been to fashion for themselves a nonhierarchical arrangement that stresses personal communication, values associated with hard work, and self-diagnosis and treatment. Their relative power vis-á-vis drug addicts enables the development of such a treatment design (Patton 1990). In addition to the disparate contexts in which alcohol and opiate treatment exist, an analysis of the structure of each model uncovers political ideologies in the foundation. For example, medical theory and rhetoric dominate the bulk of substance abuse treatment ideology. However, the repercussion of this dominance is, as Starr (1982:19) explained, that “once people began to regard science as a superior and legitimately complex way of explaining and controlling reality, they wanted physicians’ interpretations of experience regardless of whether the doctor had remedies to offer.” The remedies provided by the medical profession to middle-class alcoholics are legitimacy and clemency. Although the quasi-religious component of AA offers reconciliation and redemption through the process of purging, the medical model insists that the disease was inevitable. Thus, the alcoholic can claim credit for the victory of will through recovery without accepting responsibility for the original sin. In addition, medical sovereignty joined forces with the political arm of alcoholism’s public relations and education campaigns (Schneider 1978). Studies that report success in re-socializing alcoholics toward moderate drinking have occasionally been squelched and vehemently discounted by the treatment industry and the National Council on Alcoholism (Peele 1984:1340). Despite a relative dearth of evidence to support the claim that alcoholism is a disease, the hegemony of the theory and the 12-step model persist, in part, because of support from medical authorities. However, medical dominance has had varying ramifications for those under the profession’s jurisdiction. As Berlant (1975:252) argued, “Not

all groups which comprise society have benefited from the monopolization of medical services, and this very condition helps explain better why monopolization has occurred.” In other words, the professional ideologies and interests of medical practitioners coincide with those of the more powerful classes. Therefore, the profession’s assessments and provisions assist particular, more powerful groups better than others. For example, methadone maintenance has experienced a rough ride in terms of public relations. Methadone programs have been the territory of a specialized group of professionals and have been administered by unevenly trained paraprofessionals. Actual treatment outcomes have had little visibility in mainstream medicine (Senay 1983). In addition, a substantial proportion of methadone advocates’ energies have been spent defending their programs from attack. Had maintenance benefited from the widespread sanction of medical authorities and their vast public relations resources, perhaps its history would tell a different tale. However, the remedy that medical professionals have provided heroin addicts has been in the form of a technological shortcut (Etzioni and Remp 1973; Nelkin 1973). The reliance of addicts on medical personnel for treatment has the effect of reducing treatment to simple drug dispensation, client management, and the possibility of social control rather than empowerment. Whereas alcoholics gain from the positive connotation of a disease model, heroin addicts maintained on methadone do not experience the same destigmatization. In fact, the status of being a methadone addict is often more marginal than being a heroin addict.15 Public perception of the evils of various drugs and the kinds of people assumed to use them factor into the ensuing treatment designs, as well as assumptions about what addicts need and the degree to which they are capable of performing according to a middle-class standard of competence.

NOTES 1. I use the term addiction with caution and reluctance. However, both AA and methadone maintenance are intended to treat what they term addictions. Thus, for lack of a better term, I use it.

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2. 3.

4.

5.

6. 7. 8.

9. 10.

However, I am not presuming to judge what constitutes addiction or how best, if at all, to “treat” the condition. Many of the texts referred to here were written in the 1960s and 1970s when the subject was a popular one for debate. A Gallup poll conducted in 1987 reported that almost 90 percent of the population believe that alcoholism is a disease (Peele 1989:46). However, some would argue that this reflects the effectiveness of the public relations campaigns of the National Council on Alcoholism and the alcohol treatment industry’s advertising rather than true public opinion. Trice and Roman (1970:541) argued that the public does not actually accept the metabolic disease concept but rather believes that addiction is a moral or psychological sickness. The disease model was widely promoted by Jellinek’s (1960) book on the topic. The role of metabolic disease theory in opiate addiction was advanced largely by Dole and Nyswander (1965, 1966, 1967). It is not the aim of this article to analyze the theories of addiction causality, or to decide which model is correct. Much has been written that is critical of both models. For a critique of the disease model, see Fingarette (1988), Peele (1984, 1989), and Szasz (1992). For opposing views, see Vaillant (1983), Dole and Nyswander (1967), and Jellinek (1960). The 12-step model has also been incorporated into opiate addiction treatment insofar as there is a Narcotics Anonymous that functions as an abstinence model like AA (see also Nurco et al. 1990–91). However, Narcotics Anonymous is not as prevalent as AA. Here I use the two as polar ideal-types of treatment models for the sake of clarity. For an evaluation of the effects and benefits of long-term methadone treatment, see Goldstein and Herrera (1995). However, Kleinman and Lukoff (1977) found that maintenance was less successful than anticipated in reducing crime. Nurco et al. (1990–91) have conducted research on the infusion of a self-help abstinence model in methadone maintenance clinics. However, although Narcotics Anonymous may be advocated by the clinic staff, self-help is not constitutive of a maintenance design. However, AA meetings are notorious for the impressive quantities of coffee and cigarettes consumed during the meetings. Although alcohol treatment is dominated by the 12-step model, the influence of the medical profession must not be underestimated. AA privileges the personal experience of alcoholics over medical authority and has purposefully retained control of the interpretation of experience in the hands of laypeople. In fact, many have argued that its premises are religious rather than scientific, because members are more interested in horror stories than evidence of biochemical predispositions (Peele 1989; Thune 1977; Whitley 1977). However, the disease

11. 12.

13.

14. 15.

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model of alcohol addiction on which AA is based is a product of the sovereignty of medical knowledge and the supremacy of its explanatory powers (see Starr 1982). In addition, the medical model of alcohol addiction received more credence after the American Medical Association endorsed it in 1956 (Peele 1984; see also Schneider 1978). For an evaluation of the effectiveness of private treatment programs, see McLellan et al. (1993). Presently, methadone maintenance is largely funded by counties and states augmented by federal grants; however, some private agencies exist and hospitals admit heroin addicts into their chemical dependency wards. Clearly, the fact that heroin is illegal and its users are often driven to commit crimes to support their habits partially explains the differences between AA and methadone maintenance. However, I would argue that the illegality of heroin further bolsters my supposition that class differences between populations of users determine the forms that treatment takes. One could make the case that class and (perhaps even more important, race) determine in large part which substances are criminalized (Duster 1970; Musto 1973; Reinarman and Levine 1995). It is beyond the scope of this article to attempt an explanation for the variance in class composition of heroin addicts and alcoholics. On the basis of my fieldwork experience, heroin addicts generally have disdain for the methadone maintained because they view them as addicts who do not even get high.

REFERENCES Ausubel, David P. 1983. “Methadone Treatment: The Other Side of the Coin.” The International Journal of the Addictions 18:851–62. Berlant, Jeffrey L. 1975. Profession and Monopoly: A Study of Medicine in the United States and Great Britain. Berkeley: University of California Press. Conrad, Peter. 1975. “The Discovery of Hyperkinesis: Notes on the Medicalization of Deviant Behavior.” Social Problems 23:12–21. Conrad, Peter and Joseph Schneider. 1980. Deviance and Medicalization: From Badness to Sickness. St Louis, MO: C. V. Mosby. Denzin, Norman K. 1993. The Alcoholic Society: Addiction and Recovery of Self. New Brunswick, NJ: Transact ion Books. Dole, Vincent P. and Marie E. Nyswander. 1965. “A Medical Treatment for Diacetylmorphine (Heroin) Addiction: A Clinical Trial with Methadone Hydrochloride.” Journal of the American Medical Association 193:646–50.

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———. 1966. “Rehabilitation of Heroin Addicts After Blockade with Methadone.” New York State Journal of Medicine 66:2011–17. ———. 1967. “Heroin Addiction—A Metabolic Disease.” Archives of Internal Medicine 120:19–24. Epstein, Edward Jay. 1977. Agency of Fear: Opiates and Political Power in America. New York: G. P. Putnam’s Sons. Etzioni, Amitai and Richard Remp. 1973. Technological Shortcuts to Social Change. New York: Russell Sage Foundation. Fingarette, Henry. 1988. Heavy Drinking: The Myth of Alcoholism as a Disease. Berkeley: University of California Press. Goldstein, Avram and James Herrera. 1995. “Heroin Addicts and Methadone Treatment in Albuquerque: A Twenty-Two Year Follow-Up.” Drug and Alcohol Dependence 40:139–50. Jellinek, E. M. 1960. The Disease Concept of Alcoholism. Highland Park, NJ: Hillhouse Press. Johnson, Bruce D., Paul J. Goldstein, Edward Preble, James Schmeidler, Douglas S. Lipton, Barry Spunt, and Thomas Miller. 1985. Taking Care of Business: The Economics of Crime by Heroin Abusers. Lexington, MA: Lexington Books. Kidorf, Michael, Maxine L. Stitzer, and Roland R. Griffith. 1995. “Evaluating the Reinforcement Value of Clinic-Based Privileges Through a Multiple-Choice Procedure.” Drug and Alcohol Dependence 39:167–72. Kleinman, Paula Holzman and Irving F. Lukoff. 1977. “The Magic Fix: A Critical Analysis of Methadone Maintenance Treatment.” Social Problems 25:208–14. Knight, Kelly Ray, Marsha Rosenbaum, Mary S. Kelley, Jeanette Irwin, Allyson Washburn, and Lynn Wenger. 1996. “Defending the Poor: The Impact of Lost Access to Subsidized Methadone Maintenance Treatment on Women Injection Drug Users.” Journal of Drug Issues 26:923–42. Lindesmith, Alfred. 1940. “The Drug Addict as a Psychopath.” American Sociological Review 5:914–20. McLellan, A. Thomas, Grant R. Grissom, Peter Brill, Jack Durell, David S. Metzger, and Charles P. O’Brien. 1993. “Private Substance Abuse Treatment: Are Some Programs More Effective Than Others?” Journal of Substance Abuse Treatment 10:243–54.

Morgan, Patricia. 1981. “From Battered Wife to Program Client: The State’s Shaping of Social Problems.” Kapitalistate 9:17–39. Murphy, Sheigla and Jeanette Irwin. 1992. “Living with the Dirty Secret: Problems of Disclosure for the Methadone Maintained.” Journal of Psychoactive Drugs 24:257–64. Murphy, Sheigla and Marsha Rosenbaum. 1988. “Money for Methadone II: Unintended Consequences of Limited-Duration Methadone Maintenance.” Journal of Psychoactive Drugs 20:397–402. Musto, David. 1973. The American Disease: Origins of Narcotic Control. New Haven, CT: Yale University Press. Nelkin, Dorothy. 1973. Methadone Maintenance: A Technological Fix. New York: George Braziller. Nurco, David N., John C. Ball, John W. Shaffer, and Thomas E. Hanlon. 1985. “The Criminality of Narcotic Addicts.” Journal of Nervous and Mental Disease 173:94–102. Nurco, David N., Phillip E. Stephenson, and Thomas E. Hanlon. 1990–91. “Aftercare/ Relapse Prevention and the Self-Help Movement.” International Journal of the Addictions 25:1170–1200. Patton, Cindy. 1990. Inventing AIDS. New York: Routledge. Peele, Stanton. 1984. “The Cultural Context of Psychological Approaches to Alcoholism: Can We Control the Effects off Alcohol?” American Psychologist 39:1337–51. ———. 1989. The Diseasing of America: Addiction Treatment Out of Control. Boston: Houghton Mifflin. Reinarman, Craig. 1995. “The Twelve-Step Movement and Advanced Capitalist Culture: The Politics of Self-Control in Postmodernity.” pp. 90–109 in Cultural Politics and Social Movements, edited by Marcy Darnovsky, Barbara Epstein, and Richard Flacks. Philadelphia, PA: Temple University Press. Reinarman, Craig and Harry G. Levine. 1995. “The Crack Attack: America’s Latest Drug Scare, 1986–1992.” Pp. 147–186 in Images of Issues: Typifying Contemporary Social Problems, 2nd ed., edited by Joel Best. Hawthorne, NY: Aldine de Gruyter. Rosecrance, John. 1985. “Compulsive Gambling and the Medicalization of Deviance.” Social Problems 32:275–84.

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Rosenbaum, Marsha. 1991. “Staying Off Methadone Maintenance.” Journal of Psychoactive Drugs 23:251–60. Rosenbaum, Marsha and Sheigla Murphy. 1984. “Always a Junkie? The Arduous Task of Getting Off Methadone.” Journal of Drug Issues 14:527–52. Schneider, Joseph. 1978. “Deviant Drinking as Disease: Alcoholism as a Social Accomplishment.” Social Problems 25:361–72. Senay, Edward C. 1983. “Methadone Maintenance: An Update.” DHHS Publication Number (ADM) 83–1264. Washington, DC: U.S. Government Printing Office. ———. 1985. “Methadone Maintenance Treatment.” International Journal of the Addictions 20:803–21. Starr, Paul. 1982. The Social Transformation of American Medicine. New York: Basic Books. Szasz, Thomas S. 1992. Our Right to Drugs: The Case for a Free Market. New York: Praeger. Tesh, Sylvia Noble. 1988. Hidden Arguments: Political Ideology and Disease Prevention. New Brunswick, NJ: Rutgers University Press.

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Thune, Carl E. 1977. “Alcoholism and the Archetypal Past: A Phenomenological Perspective on Alcoholics Anonymous.” Journal of Studies on Alcohol 38:75–88. Trice, Harrison M. and Paul Michael Roman. 1970. “Delabeling, Relabeling, and Alcoholics Anonymous.” Social Problems 17:538–46. Vaillant, George E. 1983. The Natural History of Alcoholism. Cambridge, MA: Harvard University Press. Weisner, Constance and Robin Room. 1984. “Financing and Ideology in Alcohol Treatment.” Social Problems 32:167–83. Whitley, Oliver R. 1977. “Life with Alcoholics Anonymous: The Methodist Class Meeting as a Paradigm.” Journal of Studies in Alcohol 38:831–48. Zola, Irving Kenneth. 1966. “Culture and Symptoms—An Analysis of Patients’ Presenting Complaints.” American Sociological Review 31:615–30. Zweben, Joan Ellen and James L. Sorensen. 1988. “Misunderstandings about Methadone.” Journal of Psychoactive Drugs 20:275–81.

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CHAPTER 13

Disciplining Addictions The Bio-Politics of Methadone and Heroin in the U.S. Philippe Bourgois BIOPOWER, POWER/KNOWLEDGE, AND THE SPECIFIC INTELLECTUAL This paper draws on Michel Foucault to argue that methadone maintenance, the largest biomedically organized and federally controlled drug treatment modality in the U.S., affecting approximately 115,000 heroin addicts, represents the state’s attempt to inculcate moral discipline into the hearts, minds, and bodies of deviants who reject sobriety and economic productivity. Surprisingly, Foucault has relatively rarely been applied to studying illegal psychoactive drugs or to critiquing the social science and biomedical literatures on the subject (for some exceptions see Bourgois, Lettiere, and Quesada 1997; Friedman and Alicea 1995; Moore and Wenger 1995; O’Malley and Mugford 1992; Smart 1984). Foucault’s concepts of (1) biopower, (2) the disciplinary power/ knowledge nexus, and (3) the political utility of the specific intellectual offer a means for critiquing the moral imperatives that drive most drug policy under the rubric of quantitative evidence-based science and health promotion. To summarize briefly, Foucault’s term biopower refers to the ways historically entrenched institutionalized forms of social control discipline bodies. The bio-politics of substance abuse include a wide range of laws, medical interventions, social institutions, ideologies, and even structures of feeling (Ong 1995; Caputo and Yount 1993; Foucault 1982: 208–226; Williams 1977; Rabinow (ed.) 1984: 258–272). The definition of methadone maintenance as “drug treatment” is a particularly concrete example of biopower at

work. The state and medical authorities have created distinctions between heroin and methadone that revolve primarily around moral categories concerned with controlling pleasure and productivity: legal versus illegal; medicine versus drug. The contrast between methadone and heroin illustrates how the medical and criminal justice systems discipline the uses of pleasure, declaring some psychoactive drugs to be legal medicine and others to be illegal poisons. Ultimately, it can be argued that the most important pharmacological difference between the two drugs that might explain their diametrically opposed legal and medical statuses is that one (heroin) is more pleasurable than the other (methadone). By interweaving fieldwork descriptions and street conversations of inner city-based heroin addicts this paper offers an ethnographic critique of methadone treatment programs in the U.S. More importantly, it links the on-the-ground flesh-and-blood contradictions of methadone versus heroin addiction to the academic, medical, and social service discourses that constitute what Foucault would identify as the power/knowledge nexus of the science of substance abuse treatment. In Foucault’s framework, power and knowledge constitute one another, and in that process they set the parameters for disciplining social life. He argues that academic, medical, and juridical fields of study and practice emerged historically as central components of social control through the construction of epistemological frameworks defined as legitimate science and health (Foucault 1981). Concretely, in the case of methadone, competing scientific, political, and populist discourses mobilize an avalanche

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of objective, technical, and rigorously quantified data that render them oblivious to their embroilment in a Calvinist-Puritanical project (Weber 1958) of managing immoral pursuits of pleasure and of promoting personal self-control in a manner that is consonant with economic productivity and social conformity. A theoretically informed ethnographic approach, in contrast, can offer specific practical insights into the slippery and often contradictory ways power operates in the health sciences. In this vein, in an attempt to take Foucault out of a theoretical realm that often paralyzes political or even practical engagement, I will render him “specifically applied” by addressing the relative pharmacological merits of heroin versus methadone from the perspective of harm/ risk reduction, despite the conundrum of falling into the power/knowledge trap of drug treatment debates that camouflage moral judgements behind medical objectivity. I hope to contribute, however humbly, to Foucault’s political challenge of developing technically useful, applicable “specific knowledges” around the controlling micro-practices and discourses that engulf our everyday lives and desires (Rabinow (ed.) 1984: 67–75). At the same time, it is important to be aware that the role of what Foucault calls the “specific intellectual” who engages “real, material everyday struggles” and poses concrete alternatives through technical positioning can be treacherous (ibid.: 68). In an attempt to reduce structurally imposed social suffering by applying one’s knowledge to promote one particular drug treatment modality or public policy over another, the specific intellectual risks merely tinkering with the efficiency of biopower and missing the more complicated picture of the multi-faceted ways power operates. Even the best of intentions to help or to serve the socially vulnerable can also simultaneously perpetuate— or even exacerbate—oppression, humiliation, and dependency of one kind or another. Nevertheless, in this paper I raise the politically taboo possibility that heroin may be less harmful than methadone. In fact, contrary to the standard biomedical definition of the two drugs as incompatible pharmacologically, they may actually be complementary to one another in the context of treatment.

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FROM “DOPE” TO “MEDICATION” Both heroin and methadone addicts are physiologically addicted to a drug that alters their metabolisms and their states of consciousness. A heroin addict however, is defined—and often acts—as a self-destructive, irresponsible criminal. A long-term methadone addict, in contrast, is defined—and often acts—as a worthy, well-disciplined citizen/patient who is dutifully on the road to recovery from substance abuse. Methadone addicts are referred to as “patients,” “clients,” and even “consumers.” In contrast heroin addicts are “criminals,” “sociopaths,” “deviants,” or at best “sick.” An ethnographer who watched the introduction of methadone maintenance as the primary treatment modality in New York City from 1973 to 1975 astutely noted: “The ‘dope’ became ‘medication,’ the ‘addict’ became a ‘patient,’ ‘addiction’ became ‘treatment’” (Agar 1977: 176; see also Agar and Stephens 1975). This dramatic metamorphosis was made possible in the U.S. by the biomedical theories of two doctors in the late 1960s. They redefined heroin addiction as an objective, identifiable “metabolic disease.” It became a physiological imbalance at the level of the brain’s synapses requiring medical stabilization through pharmacological intervention (Dole and Nyswander 1967). Like heroin and cocaine, which were originally hailed as cures for morphine addiction in the 1800s when they were first synthesized, methadone in the Post-World War II era is considered to be a cure for heroin addiction. The specific biomedical term for the way methadone intervenes pharmacologically in the brain’s synapses is as an “opiate agonist.” It blocks both the pleasure and the pain that heroin produces by generating alternative sensations of its own at the “µ” opioid receptor sites in the brain’s synapses. According to the biomedical paradigm: Methadone is a slow-onset, long-acting, mu opiate receptor agonist that reduces the craving for heroin and largely prevents the reward or euphoria if the patient slips and takes a dose of an opiate. (O’Brien 1997)

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In other words methadone is a biomedical technology that facilitates a moral block to pleasure. Ironically, methadone’s effectiveness at blocking opiate-driven euphoria is predicated upon methadone being more highly physically addictive than heroin or morphine. Most methadone addicts develop such a rapid physical tolerance to the drug that they are no longer able to feel significant pleasurable effects from its consumption after only a few weeks of daily consumption. By stimulating the neurotransmitters in the brain synapses so intensively that they cannot process the electromagnetic signals for feeling the euphoria that heroin consumption triggers, methadone is supposed to enable addicts to reorganize their lives productively and healthfully. They can no longer nod away their days in unemployed bliss (or agony); they are no longer constrained to engage in risky injection practices (Ball et al. 1988), or to pursue illegal income-generating strategies. Indeed, for a significant minority of heroin addicts methadone maintenance stabilizes their lives and enables them to withdraw completely from street-based substance abuse. For the majority, however, the effects of methadone maintenance are much more mixed, and for some they are virulently counter-productive.

ETHNOGRAPHIC DISSONANCE Long-term participant-observation ethnographic fieldwork among middle-aged homeless addicts in San Francisco and among younger heroin addicts in East Harlem and Montreal demonstrates that the official biomedical discourse on methadone makes little sense pharmacologically or socially—at least for the majority of opiate addicts one encounters on the street. My decade-long archive of fieldwork notes on street drugs contains dozens of matter-of-fact references to methadone addicts and users “nodding out,” “throwing up from overdoses,” and aggressively and gleefully consuming cocaine, wine, prescription pills, and even heroin to augment the euphoria of their opiate agonist: East Harlem, 1989: Stumbling like a drunk; slurring his words; drooling and nodding, Tito almost in tears

begged me to give him $10 to buy some powder cocaine, “Para arreglarme [to straighten myself out].” As a street dealer Tito has a big heroin habit. He claims that it is over $60 a day. Today was Tito’s first day of methadone maintenance, and the 35 mg initial dose that they gave him was knocking him off his feet. I felt sorry for him because he reports to work [selling heroin on 124th St.] at 3:00 p.m. He will be fired—or worse—if he arrives stumbling, slurring, and nodding. A fieldwork note in a very different setting at a Montreal methadone clinic describes my concern when an HIV-positive transgender heroin addict threw up all over my feet. Once again methadone’s interference with the addict’s capability to perform his/her job emerges as the primary concern and justifies a craving for cocaine. Montréal, March 1997: Annie’s body simply could not tolerate the 35 mg initial dosage the clinic doctors had prescribed. She could barely stand up, but it was past the clinic’s closing time and she had to leave. When we stepped outside, slipping and sliding on the ice and snow on our way to the prostitute stroll where she was looking for work well after midnight in below-zero weather I offered to pay for a hotel room for her. She replied with a sigh, “No thanks, what I really need is a shot of coke to straighten me out. I have to get back to work.” Biomedical treatment experts would explain away these ethnographic vignettes as portraying the initiation phase of methadone treatment prior to dosage stabilization. Their explanations certainly sound biomedically convincing. Nevertheless, on dozens of occasions I watched Primo, the former crack dealer now working as a building porter, nod blissfully after sniffing a small $10 packet of heroin even after his methadone clinic had increased his daily dose to the maximum allowable level of 120 mgs per day. East Harlem, July 1996: I read Papit (Primo’s 12-year-old son), the passages in my book where his father talks of not having money to buy him a birthday present. Primo nodded out in the middle of my reading and even dropped his slice of pizza; his mouth drooped open drooling ever-so slightly.

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Later Primo insisted that he had not consumed any extra heroin that day. He claims that the nodding was strictly due to the methadone. His wife confided to me disgustedly, however, that Primo has “been sniffing dope on the sneak-tip.” His son Papito, who is not supposed to know anything about his father’s methadone addiction, looks profoundly depressed to me. Primo’s wife might not be right because 3 months later Primo apologized to me for not being able to comment on the manuscripts I had given him, claiming that he always nods out whenever he starts to read. “I can only just barely even watch television . . . I hate methadone!” As Primo’s addiction illustrates, methadone maintenance treatment is often experienced as a hostile and/or arbitrary forum for social control and enforced dependency among street addicts. It seeps into the fabric of one’s most intimate relationships, distorting (in Primo’s case) respectful interaction with children, wives, intellectual friends. Methadone addiction elicits a panoply of practices ranging from resistance, anger, and depression, to compliance and relief as the following notes from another telephone conversation with Primo document: East Harlem, April 1997: Primo told me that not a day passes without him thinking about his mother who died of AIDS over a year ago. He was laid off from his porter job and has not been called back in over 2 months—his longest hiatus of unemployment yet. To make matters worse the New York City Housing Authority has set a court date to evict him from his mother’s apartment where he has lived all his life and where she died. Primo has a past felony record and Public Housing now has a “one-strike-you-are-out” ruling. To top it off last week his methadone clinic raised him another 10 milligrams because of dirty urine. One of Primo’s sisters offered to allow him to live with her in New Jersey, where he can work with a cousin who is a contractor. Primo cannot move in with his sister, however, because New Jersey does not give methadone to New York emigrants.

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Primo is too embarrassed to tell his sister about his methadone addiction, as a result his sister and everyone are convinced he is being a flake who does not want to work or turn his life around. Last week Primo’s counselor threatened to discontinue him because he has not obtained an updated tuberculosis test. He also owes $1,000 to the program in lapsed monthly payments. For some reason, however, the dispenser did not “write him up” and he has been “getting dosed” despite non-payment. Once again, we see how profoundly methadone articulates in Primo’s case with his structurally exacerbated depression to affect intimate definitions of self-respect. The political economic constraints limiting Primo’s life chances (i.e., unemployment, felony record, medical bills, housing market, etc.) are already overwhelming, and methadone’s rigid institutional regulations further curtail his options for autonomous change. They even isolate him from his kin-based social support network at a time of personal despair when threatened by homelessness. The ethnographic literature on methadone confirms widespread resentment as well as a passive self-deprecating obedience on the part of structurally vulnerable methadone addicts (cf. Rosenbaum and Murphy 1984). One study quotes addicts as referring to their relationship to methadone as “a ball and chain” (Johnson and Friedman 1993: 37); other researchers cite methadone addicts as complaining of “feeling like automatons,” and of “becoming robotic” (Uchtenhagen 1997; Koester et al. 1999). In Denver street addicts had nicknamed methadone “methadeath” (Koester et al. 1999).

FEDERAL BIOMEDICAL VERSUS POPULIST PROHIBITIONIST AND ABSTINENCE DISCOURSES ON METHADONE The biomedical discourse of addiction as a disease is promoted at the federal level through the National Institutes of Health (NIH), which officially declared methadone maintenance to be the most effective modality for treating

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heroin addiction in the 1980s and 1990s. Their conference titles and publications invariably display the aggressive/defensive slogan “Treatment Works,” for the benefit of congressional budget committees and a tax paying public which prefers to punish criminals than to treat them. Methadone is especially appealing to treatment scientists because the biomedical world is dedicated to solving complex social ills by developing laboratory-based, high-tech potions that promise quick-fixes and easily replicable efficient outcomes. Methadone is understood to be the technocratic magic bullet that can resolve social, economic, and human existential quandaries by intervening almost surgically at the level of the brain’s synapses. Indeed methadone has become the model for all drug treatment: short-circuiting pleasure sensations within the brain’s synapses. Hundreds of millions of dollars have been spent on laboratory research to develop similar magic bullets to combat addiction to other street drugs (cf. Balter 1996). The federal U.S. commitment to methadone was formally reconfirmed in 1998 by a NIH National Consensus Development Panel (NCDP), entitled “Effective Medical Treatment of Opiate Addiction.” The biggest opponent to the NIH biomedical discourse celebrating methadone treatment comes from the “Just-SayNo-To-Drugs” moral abstinence discourse (see critique by Rosenbaum 1995) that dominates the U.S. Congress, law enforcement, popular culture, churches, 12-step recovery programs, and the health fad movements (from aerobics and cholesterol monitoring to new-age holism). The Just-Say-No camp is oblivious or else hostile to the “addiction is a metabolic disease” discourse of doctors who prescribe methadone and attempt to control and rehabilitate bodies through pharmacological therapeutics. Instead they exhort citizens to personal abstinence based on individual willpower and spirituality. The healthist/abstinence discourse (Crawford 1984) complements a third influential position that criminalizes drugs. The criminal emphasis is so hegemonic in the U.S. that the biomedical disease model can only resist it passively. Indeed one of the self-proclaimed yardsticks for the success of methadone treatment is that it reduces crime. There is room for a “good-cop/bad-cop”

complementarity between the biomedical and the criminal discourses since criminals can be both punished and rehabilitated.1 The healthist vision, on the other hand, tolerates no pharmacological tampering whatsoever with addicted brains. Methadone patients, for example, are not usually welcome at 12-step Narcotics Anonymous meetings. The 1998 National Consensus Development Panel document promoting methadone was primarily concerned with arguing against the prohibitionist criminalizing discourse of the drug warriors who dominate Congress and the U.S. criminal justice apparatus. To gain credibility, despite being federally convened and funded, the authors introduced themselves as “a non-advocate, non-federal panel of experts.” They directed their most pointed criticism at “unnecessary federal regulation,” which they considered “a major barrier to providing methadone maintenance treatment” (NCDP 1998; CESAR Fax 1997). Using the 20th-century language and values of biopower, the consensus panel’s arguments in favor of methadone emphasize its impact on health, mortality, productivity, and morality. Their summary presents methadone as being “effective in reducing illicit opiate drug use, reducing crime, enhancing social productivity and reducing the spread of viral diseases such as acquired immunodeficiency syndrome (AIDS) and hepatitis” (NCDP 1998: 1937). The consensus document specifically notes that the death rate of heroin addicts is “more than 3 times greater than that experienced by those engaged in MMT [methadone maintenance treatment]” (NCDP 1998: 1939). In a special section entitled “Joblessness” the report assures readers that methadone addicts have superior citizenship qualities as measured according to the most objective index available in the late 20th century: “Persons dependent on opiates who are in MMT earn more than twice as much money annually as those not in treatment” (NCDP 1998: 1939). It is disconcerting to contrast the statistical certainties of the NIH consensus statement to the ways Primo, Tito, and Annie in the preceding ethnographic vignettes explain their lived experiences on the street of the interface between methadone and employment/income generation.

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LOCAL DISCOURSES ON METHADONE: NEW YORK VERSUS SAN FRANCISCO The tension between the medical, the prohibitionist, and the abstinence discourses play themselves out in the all-American terrain of states’ rights. In eight states methadone treatment is illegal. Even where it is legal, however, dramatically different local cultures of treatment have emerged depending upon local constellations of forces between the medical and criminal justice establishments, the size of the street addict population, and the cultural politics of the region. In New York City (and in general along the Eastern Seaboard) the biomedical model of substance abuse as a metabolic disease requiring pharmacological intervention dominates. Long-term methadone maintenance is relatively easy to obtain. Methadone treatment is a multi-million dollar treatment and research for-profit industry located at dozens of accessible, usually federally subsidized clinics and research hospitals. In contrast, San Francisco is dominated by an almost New Age (but profoundly Puritanical) celebration of healthy, drug-free bodies. There is even a cultural nationalist, identity politics conspiracy theory discourse that equates methadone to genocide against people of color. Methadone, in short, is morally suspect and access to long-term maintenance clinics is extremely limited (see critique by Rosenbaum 1995). Methadone maintenance is provided preferentially to heroin addicts with terminal or dangerously contagious diseases like tuberculosis and HIV who need to be carefully monitored and controlled. As a compromise for the long lines of addicts seeking any kind of treatment whatsoever, a panoply of badly organized for-profit and sometimes corrupt 21-day detox venues have emerged (National Alliance of Methadone Advocates 1997). They prescribe methadone on a temporary basis at low doses that do not exceed 40 mgs per day despite the fact that biomedical researchers insist that 60 to 80 mgs is the minimum effective dose to block the brain’s synapses. In fact, some epidemiological studies conclude that the minimum effective dosage is as high as

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80–120 mgs (Caplehorn et al. 1993; Cooper 1989; D’Aunno and Vaughn 1992; Dole and Nyswander 1982). The San Francisco treatment community’s pure body discourse can be read between the lines of the handout published by the City’s Public Health Service listing the rules governing access to methadone treatment clinics: Maintenance Program 1 . . . No Waitlist. Languages: English, Egyptian, and Norwegian. Requirements: to be eligible you need to have one failed detox attempt and at least one year of heroin addiction (that you can prove—from a medical record, police record, etc.) You will also need a TB test, a Syphilis test, and a general physical. MediCal accepted. Maintenance Program 2 . . . Waitlist varies depending on your health. Preference is given to people who are seriously ill. Requirements: letter of diagnoses of HIV positive or active TB (not just skin-test positive). If you are not ill you may need to detox several times. (7-day wait to get back on detox). Maintenance Program 3 . . . Requires several years of heroin addiction and previous failed detox attempts . . . If you have recently been in another methadone detox you must wait: 7 days for a $225 slot; 28 days for a $100 slot . . . Bring proof of income . . . and a MONEY ORDER for the price of the detox. (no cash or personal checks accepted) [Original emphasis]

This handout sheet full of byzantine rules that counselors, community-based health outreach workers, and harm reduction activists are supposed to use to facilitate street addicts into recovery is a good example of multiple discourses (puritanical, healthiest, and culturally correct) run amok in a for-profit medical economy with a decaying public health sector (see Crawford 1984; Rosenbaum and Murphy 1987a; Murphy and Rosenbaum 1988). The primary fear of treatment centers which promote a healthist abstinence discourse is that individuals who are not truly heroin addicts will wheedle their way into methadone addiction—or worse yet, that individuals who actually enjoy methadone may become addicted to methadone for its latent euphorigenic

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properties (Spunt et al. 1986). The front-line service providers who treat street addicts, consequently, focus their energy on hair-splitting triages between healthy and unhealthy bodies (i.e., being positive for the TB skin test vs. having active TB; or between accepting money orders instead of MediCal cards and cash). At the same time in tune with Californian identity politics they even strive to stretch cultural categories (Egyptian and Norwegian!) to promote diversity goals.

THE BIRTH OF THE METHADONE CLINIC Despite the federal government’s solid commitment through the NIH to the biomedical disease model of addiction, the public health establishment at the federal level bows to pressure from more prohibitionist criminalizing discourses on addiction spearheaded by Republicans in Congress and law enforcement agencies. Promoters of methadone, consequently, defensively focus much of their energy to ensure that legal methadone destined for treatment is not diverted illegally to thrill seekers. They also have to monitor that methadone is not supplemented with other illegal drugs that intensify its latent or frustrating euphorigenic qualities. The result is a panoply of repressive federal, state, and local regulations on methadone treatment at specially licensed methadone clinics like the ones documented in the outreach handouts cited earlier and in the videotaped conversation just above. Psychosocial treatment is subordinated to repression of criminal behavior at most methadone clinics. To prevent patients from re-selling their doses on the street, addicts are forced to come to their clinic in person every day (hence Primo’s problem with tardiness at work when his clinic changed locations) to receive their liquid dose of methadone, which they are then forced to swallow under the watchful eye of a dispenser. This requirement of daily attendance is probably the single most resented regulation of methadone treatment, and according to one study significantly interferes with treatment retention rates (Rhoades et al. 1998). Exceptionally compliant addicts are rewarded

for good behavior with the privilege of “takehome doses.” Run-of-the-mill addicts only receive eminently re-saleable “take-homes” on Sundays. Despite all these micro-logistical precautions, doses of liquid methadone smuggled out of clinics in throats and cheeks or as privileged take-homes can be purchased on the blocks surrounding large methadone clinics in most large cities. The complicated micrologistics for overseeing the consumption of methadone in order to prevent illegal methadone ingestion and to discourage ongoing poly-substance abuse by recovering addicts has given birth to a culture of the methadone clinic. Most of the approximately 115,000 addicts on methadone maintenance in the U.S. during the 1990s were granted only limited “take-home” privileges. Consequently virtually every day they are forced to converge on methadone clinics to drink their medication in a supervised setting. One of the explicit therapeutic goals of methadone maintenance treatment is to sever an opiate addict’s social relationship to the criminal economy and to the street-based substance abuse community. Ironically, however, for most patients, it accomplishes much the reverse. The ethnographic literature on methadone clinics from the 1970s confirms how the multi-million dollar, federally subsidized institution of methadone clinics in the cities that initiated large maintenance programs created an active culture of “broken down, toothless garbage heads” (as Primo refers to his colleagues at the clinic he attends). The intense policing and disciplining of methadone combined with its frustrating euphorigenic qualities render it a drug of last resort for tired, elderly heroin addicts no longer capable (or willing) to generate sufficient income in the underground economy. Symbolic interactionists, ethnomethodologists, and other empirically descriptive ethnographers consistently document methadone addicts as being at the bottom of the status hierarchy of street-based drug abusers (Goldsmith et al. 1984; Hunt et al. 1985; Preble and Miller 1977; Agar 1977). Institutionally autonomous street-based addicts contrast themselves to “those lame methadone winos” (Preble and Miller 1977). Hence the

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term “righteous dope fiends” to identify heroin addicts who are determined to die as outlaws with their boots on (Sutter 1966; see also Finestone 1957; Preble and Casey 1969).

BIOPOWER IN ACTION The repressive micro-logistics of methadone administration at clinics offers a graphic image of Foucault’s concept of biopower unfolding in a very concrete setting: On any given day throughout the U.S. dispensers are cursing recalcitrant addicts, ordering them to open their mouths and move their tongues to make sure they have swallowed all of their “medication.” As we experienced in the videotaped conversation outside the San Francisco methadone clinic security guards regularly patrol the block in front of clinics to chase away loiterers who might be reselling or buying smuggled methadone, or who might be selling methadone-enhancing substances. In short, there is a very intense policing, medical disciplining, and social dividing of bodies at the methadone clinic. Methadone clinics, like most out-patient drug treatment programs, are required to submit their clients to random urine tests to verify poly-psychoactive substance consumption and continued illegal opiate use. Indeed, studies measuring continued consumption of illegal substances by methadone addicts offer figures that range from 16% to 60% (Caplehorn et al. 1993; GAO 1990). By strategically varying, supplementing, or destabilizing the effects of their dose with poly-drug consumption, methadone addicts can augment the otherwise marginal or only ambiguously pleasurable effects of methadone. Ethnographers working in the early years of methadone maintenance noted that a significant number of addicts actually managed to enjoy the methadone high (Agar and Stephens 1975; Stephens and Weppner 1973). As noted in the fieldwork vignettes from East Harlem and Montreal, street addicts report that cocaine mixes well with methadone, especially at high doses (Hunt et al. 1984; Hunt et al. 1986; Rhoades et al. 1998; Strug 1985). Cocaine, in its smokeable base form known as crack, can be cheaply combined with methadone to approximate

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the recherché speedball effect: a contradictory roller-coaster high where the sedative effects of the opiate interact with the stimulating effects of cocaine (see Bourgois 1998). Valium is also said to enhance the otherwise often frustrating or subtle euphorigenic sedative effects of methadone. The most common substance abused by methadone addicts, however, continues to be fortified wine (Preble and Miller 1977; Valentine 1978). The appeal of combining cocaine, alcohol, and benzodiazepines with methadone can be particularly noxious for pregnant heroin addicts who are mandated into treatment, as poly-drug consumption is usually more detrimental to fetal development than heroin alone (Chavkin and Breitmart 1997). An intense struggle unfolds inside methadone clinics over the dosage levels provided to addicts. Many addicts like Max in San Francisco want higher doses in order to “stay well”—or more surreptitiously in order to feel more strongly the usually frustratingly mild euphoric effects of a stable dose of methadone. Other addicts like Primo in New York want lower doses in the hope of becoming “drug free”—or more surreptitiously in order to be able to feel the euphoria of an occasional illegal supplementary consumption of a bag of street heroin. Dosage levels are further complicated by the pharmacological fact that methadone is dangerous. Even heroin addicts with large addictions can be overdosed and killed when first prescribed methadone. By law they have to be started at low levels. Their dosages are then raised by 10 or 5 milligram increments depending upon the evolution of their “tolerance levels.” Furthermore, individual metabolisms vary considerably, allowing patients to achieve different balances of forbidden euphorigenic feelings as Primo’s case illustrates. He continues to “nod out” despite having been maintained at high dosages for several years. Similarly both Annie, the transvestite from Canada, and Tito, the street dealer in East Harlem, stumbled about the streets throwing up after taking only relatively low doses of methadone yet having high tolerances to heroin. The most common scenario around dosage levels in maintenance clinics is the experience of Primo, whose dosage was raised every time he gave a “dirty

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urine” sample until, against his will, he was brought up to 120 milligrams, which is such a high level of dosage that his clinic must request special federal/state authorization. As the conversation and events videotaped outside the San Francisco methadone clinic demonstrate, it only takes a few minutes inside (or outside) a methadone clinic to realize that what the scientific biomedical treatment community refers to as “effective methadone dosage” level has little to do with technocratic pharmacological logics and much more to do with naked power relations. Dosage is determined by a struggle over pleasure, pain, and compliant social control. For example: (1) Max, who was suffering from methadone withdrawal symptoms, had been on a blind dose since inadvertently becoming addicted to methadone in the hospital; he begged for a higher dosage, but was unwilling to pay for it and instead was rapidly detoxed; in response he spent what money he had on street heroin. (2) Sid failed his alcohol breathalyzer test and was refused his 40 milligram dose (after paying for it). (3) Harry, at 80 milligrams, had his dose lowered for a week for failing to follow the clinic’s rules limiting alcohol consumption. Given Harry’s high dosage addiction it is not coincidental that he was the only person who at least partially defended the clinic’s administrative computerized tracking system. (“Well it must go to a main terminal.”) He was also embarrassed for the sake of the clinic when we filmed our flight from the aggressive security guard. (“I hope you can edit all that out.”) Six months later when Harry died, grotesquely bloated from liver disease, his heroin addict friends (Sid, Max, etc.) were convinced that the rapidity and the painfulness of his decay was caused by the high daily dose of methadone he had been consuming over the last 2 years.

DISCIPLINING THE DOSAGE: BIOMEDICINE’S POWER/KNOWLEDGE NEXUS Just as the birth of the methadone clinic offers a graphic example of bio-politics in action around the state-mediated struggle to create

disciplined and addicted—but heroin-free— subjects, so too the literatures on methadone in the field of substance abuse treatment and research offer a classic case study of Foucault’s understanding of the disciplinary impact of the power/knowledge nexus. Relative dosage levels emerge as the central focus of the biomedical scientific debate on methadone’s effectiveness. Indeed, much of the discussion is reduced to a technocratic concern with finding the adequate dosage level. Large, epidemiological surveys of methadone treatment clinics consistently produce anomalistic data that one would think might question the scientific coherence of methadone treatment. The disconcerting empirical outcomes of methadone treatment, however, are successfully explained away as caused by “inadequate dosages” (GAO 1990; D’Aunno and Vaughn 1992; Dole 1989; Dole and Nyswander 1982). The literature describes dosage level as a purely pharmacologically determined objective variable. It is oblivious to the fact that recalcitrant addicts like Max, Sid, and Harry in San Francisco or Primo in New York are violently physically disciplined—if not fully controlled—at the capillary brain synapse level by manipulations in their dosage levels. As our ethnographic vignettes document, methadone addicts who fail to obey clinic rules (i.e., stay sober, make payments, arrive on time, etc.) are purposely sent either into paroxysms of debilitating whole body pain (i.e., Max, Harry, and Sid), or else into drooling oblivion (i.e., Primo) by punitive decreases or increases in their dosage levels. Instead, the power/knowledge logic of biomedicine frames these conflicts strictly in terms of a technocratic search for the correct dosage. In the literature no mention is ever made of the types of concerns and rages expressed on video as we fled from the San Francisco methadone clinic. The technocratic search for determining the appropriate dosage level obscures the repressive fact that addicts like Max, Sid, and Harry are terrified of being thrown into violent withdrawal symptoms by a sudden decision of the clinic doctor or the nurse dispenser. Similarly, the dosage debate erases any scientific documentation of the humiliation experienced

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by Primo and his 12-year-old son when Primo, who had been raised against his will to 120 milligrams, nodded and drooled into his pizza in the midst of an intensely personal conversation with his son. Not surprisingly, in epidemiological studies the single most significantly correlated variable for compliance among methadone addicts is a high dose level (D’Aunno and Vaughn 1992). The literature, however, avoids the obvious explanation for why there should be such a strong correlation between high dosage level and patient compliance. It is just accepted as a pharmacological fact, which is as neutral and as precise as might be the correct dose of antibiotics for a blood infection (cf. Maremanni et al. 1994). Researchers are so uncritically immersed in the disciplining parameters of their biomedical framework that they fail to recognize that it is the painfully physiologically addictive properties of methadone that reduce even the most oppositional outlaw street addicts (like Primo in East Harlem or more broken-down Harry in San Francisco) into stable patients once their bodies have built up a large enough physical dependence on methadone to make it too physically painful for them to misbehave. Some of the most revealing large-scale studies of dosage levels at methadone clinics have been conducted by a social worker at the University of Chicago, who receives multimillion dollar federal grants to distribute a relatively simple, self-descriptive questionnaire to random national samples of hundreds of different methadone clinics. The responses demonstrate that average dosage levels fluctuate wildly across the nation. In other words the statistics reveal that there is no biologically coherent rhyme or reason to the way methadone is prescribed across the U.S. Most clinics administer an average dose that is considerably lower than the dose that is considered by treatment researchers to be the minimum necessary dosage for effectively maintaining clients in compliant treatment (i.e., under 60 milligrams). A full 25% of the clinics surveyed set an upper maximum dose limit 10 milligrams below the 60 milligram minimum (D’Aunno and Vaughn 1992: 256).

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The apparent biomedical dosage inadequacy of most methadone maintenance treatment clinics is, once again, an expression of the competition of contradictory discourses: the criminalizing and healthist versions of biopower that dominate in law enforcement, and popular culture, versus the “addiction-is-adisease” model that prevails in the biomedical establishment and emphasizes the pharmacological control of bodies. This contradiction is reflected in the imposition by the legislature of repressive legal regulations that discourage high dosage prescriptions of methadone despite the emphatic consensus of federally funded drug researchers that the biggest problem with most methadone clinics is the inadequately low doses they administer. Federal law requires clinic doctors to obtain special permission to prescribe more than 100 milligrams of methadone and further limits the rights of addicts with 100 milligram habits from having access to “take home” doses (Dole and Nyswander 1982; Newman 1987). High doses, of course, are especially susceptible to profitable diversionary resale since most individuals consuming methadone for the first time only need 20 milligrams to experience euphoria—complete with stumbling, nodding, and drooling as the cases of Annie, the Canadian transvestite, and Tito, the East Harlem heroin seller, illustrate. At the same time because of federal pressure for “adequate doses” to produce compliant (i.e., thoroughly addicted) patients, more clinics are increasing dosage levels to the maximum level allowed (D’Aunno et al. 1992). Dissatisfaction by doctors over average low dosage levels at clinics across the country is confirmed repeatedly in the most prestigious medical journals. They regularly run editorials calling for less federal regulation to enable more accurate and higher dosage levels (cf. Cooper 1989; D’Aunno and Vaughn 1992; Dole 1989; Dole and Nyswander 1982). In contrast, federal publications such as a 1990 report by the Government Accounting Office call for greater central government supervision, but also ironically in the name of ensuring more accurate, higher doses—precisely what the doctors who protest federal regulations also want (GAO 1990).

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These convoluted political and moral tensions, anxieties, and internal inconsistencies over dosage levels often manifest themselves at the clinic level with clients being denied access to information on their dosage level. In fact, clients are at best politely ignored when they report dramatically negative physical symptoms in response to dosage changes—hence, Max’s description of his withdrawal experience outside the San Francisco clinic. Treatment scientists assert that patients should not “have a consultative influence on the determination of their dosage” (D’Aunno and Vaughn 1992). Detoxification clinics which tend to be more moralistic and healthist usually prescribe the lowest average dose levels and they are the least likely to allow addicts to know their dosage for fear of being manipulated into prescribing excessively high doses that might produce euphoria or might provide opportunities for smuggling out underground economy doses in cheeks or jowls. Significantly, these pro-abstinence clinics are “the least influenced by government regulation” (D’Aunno and Vaughn 1992: 257).2 Federal regulation, although heavily concerned with criminalizing substance abuse, promotes control and compliance through the biomedical venue of prescribing high doses for long—even unlimited—periods of time (Maremmani et al. 1994). In addition to the dramatic statistics on ineffective dosage levels at clinics all across the U.S. (D’Aunno and Vaughn 1992; GAO 1990), the epidemiological and survey literature also confronts the medical illogic of the surprisingly unpleasant side effects of methadone consumption. For example, one study reveals that 80% of a random sample of 246 addicts complained of a wide range of some dozen different types of complications caused by methadone ingestion. The primary ones were “sexual dysfunction,” “constipation,” and “muscle and bone aches.” A considerable number of patients suffered from “psychological distress,” “impotence,” and “libido abnormalities;” others experienced more routine “nausea,” “vomiting,” and “appetite abnormalities” (see review by Goldsmith et al. 1984; and see discussion by Rosenbaum and Murphy 1987b). Significantly, once again, studies documenting the negative side effects of methadone almost inevitably conclude that the

long list of complaints made by the majority of addicted methadone consumers is “related to dosage acclimatization” problems. Once again the power/knowledge nexus manages to focus the problematic dimensions of methadone as a treatment modality onto the technical question of adequate dosage level. Most importantly, addicts are held responsible for causing these dosage inconsistencies by continuing surreptitiously to consume other euphorigenic drugs that exacerbate methadone’s unpleasant range of side effects.

THE MEDICAL PRESCRIPTION OF HEROIN IN SWITZERLAND Given that the side effects of methadone are dramatically more unpleasant than those of heroin (Uchtenhagen 1997) one wonders why methadone “cures” while heroin “sickens.” Foucault’s insights into the ways illegalities shape delinquency and his documentation of how the modern prison has failed to curb crime since the first day of its inception sheds insight into how it has been possible for methadone to have such a mediocre clinical treatment record for so many years yet continues to be considered the most effective treatment modality available for heroin. Foucault argues that prisons were not meant to eliminate criminal behavior, otherwise they would have long since disappeared since they produce recidivism and criminal subcultures. Instead prisons, like methadone clinics, distinguish, divide, and distribute illegalities, thereby differentiating them in various manageable forms (Foucault 1979; Rabinow 1998). Oblivious to Foucault’s critiques of statesponsored medicalized control, Swiss substance abuse prevention researchers dedicated themselves very pragmatically to studying the internationally taboo question of whether heroin works better than methadone as a treatment modality. They launched a large pilot program for the medical prescription of heroin to stabilize chronic heroin addicts. Fully subscribing to the positivist natural science model of evidence-based epidemiological clinical trials that measure objective health outcomes, the Swiss conducted a large double-blind study

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involving 1,146 randomly selected heroin addicts whom they alternately treated with heroin, methadone, and morphine, both intravenously and orally (Uchtenhagen 1997). The side effects of methadone were so much worse than those of morphine and heroin that the biggest administrative problem of the study was the high attrition rates of the control subjects who were prescribed methadone instead of heroin or morphine (Uchtenhagen 1997). The research documented statistically that addicts who were medically prescribed heroin became more socially functional according to the classic biomedical and criminological indexes that measure health status as well as social compliance: mortality, hospitalization, psychological distress, criminal activity, legal employment, abstinence from the consumption of illegal drugs, etc. (Uchtenhagen 1997). Compared to the addicts placed on methadone or morphine maintenance, those who consumed medically prescribed heroin were healthier, “less depressed,” “less anxious,” and “less prone to delirium.” They were also “better housed,” “more employed,” used “less welfare,” and “decreased their street contacts more” as well as their “sensations of automatism.” Those prescribed heroin also used less illegal heroin and cocaine. Most dramatically, medically stabilized heroin addicts decreased their participation in crime sevenfold. The Swiss document concludes matter-offactly that medically prescribed heroin is a better treatment modality than methadone or morphine. Their research design includes no qualitative component and is exclusively composed of rigorously quantified statistical correlations. The findings not only contradict the legal and moral discourses of the U.S. medical establishment and law enforcement institutions but also contradict the very core of the U.S. biomedical understanding of the pharmacological mechanism that defines methadone as an agonist block to heroininduced pleasure sensations inside the brain’s synapses. The Swiss addicts were allowed to complement their treatment medication with other psychoactive drugs and Table 6 of the final report documents that methadone (by a factor of 257%!) was the drug that was most

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frequently voluntarily combined with intravenous heroin by study participants in the clinic. Even when participants had the choice of augmenting their base prescription of intravenous heroin with unlimited quantities of heroin, morphine, cocaine, or methadone in either injectable, oral, or smokeable form, a plurality chose oral methadone as a supplement to heroin. Most significantly those addicts who achieved stable employment were the ones who most frequently requested a supplement of oral methadone to complement their stable prescription of heroin in order to limit the number of times per day they had to interrupt their work schedule to inject. This offers a dramatic contrast to the U.S. biomedical treatment model’s understanding of methadone that asserts that it is pharmacologically incompatible with heroin, and that most problems with methadone treatment can be attributed to inadequate dosage levels. The homologous biomedical Swiss model comes to precisely the opposite conclusion: Low doses of methadone in combination with heroin are the most effective way to rehabilitate formerly hard-core, anti-social addicts.

ENGAGING FOUCAULT WITH HARM/RISK REDUCTION In 1997 the Swiss government conducted a referendum in which well over 60% of the population voted to legalize the medical prescription of heroin. It is ironic that Switzerland, historically the cradle of Calvinism, should be the first country in the industrialized world officially to abandon the criminal repression of heroin. Does this contradict the interpretation that a Calvinist-Puritanical morality that identifies pleasure with sinfulness and idleness (Weber 1958) motivates government drug policy to criminalize the pursuit of pleasure? Or is the Swiss championing of the medical prescription of heroin the ultimate expression of an efficient and highly technified biopower in pragmatic practice? Indeed, the medical prescription of heroin can be understood as an extraordinarily effective method of social control—far more efficient than the prescription of methadone. It is easier to integrate stabilized, mildly euphoric

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heroin addicts into the lowest tiers of the legal labor force than it is to bully frustrated, depressed, oppositional methadone addicts into social compliance. Within the biomedical paradigm of finding technological magic-bullet solutions to complicated chronic social problems, the pharmacology of heroin allows for greater social engineering at a much cheaper cost. It is precisely the unambiguously euphoric effects of heroin, combined with its relative lack of negative side effects, that makes heroin such an effective agent of biopower once it is directly administered by the state through medical treatment clinics. In this practical vein, the risk/harm reduction paradigm represents an interstice between the state and the medical apparatuses where specific Foucaultian critiques of drug policy can become concrete. The first step is to suggest that according to a wide range of quantifiable measurements heroin appears to be a less harmful and more socially useful drug than methadone. More precisely, the drug combination that the Swiss study stumbled upon—i.e., low doses of methadone supplemented by strategic injections of pharmaceutically pure heroin—can be identified as an especially effective magicbullet-like potion for stabilizing heroin addicts who want to enter the labor market. Ironically, once again, this directly contradicts the U.S. biomedical establishment’s understanding for why methadone is effective in drug treatment as an opiate agonist which by its pharmacological definition is supposed to be incompatible with heroin consumption. More important, however, than arguing over the relative effectiveness of the precise balance of milligrams of one opiate versus another is the political and intellectual urgency of debunking the power/knowledge dead-end that has confined discussions of drug treatment effectiveness to technical debates over dosage titrations. The bio-politics of methadone revolve around a political economy of human dignity that is both cultural and economic. It is no coincidence that virtually every single ethnographic description or conversation cited in this text articulates methadone consumption with the central problem of employment and income generation.

From a less economically oriented political economy perspective, the search for cultural respect emerges as another central facet complicating methadone’s acceptability on the street. Indeed, virtually all the ethnographic accounts from the first decades of methadone studies identify the drug’s unsatisfactory location in street-based status hierarchies. More intimately, the research from the 1980s cites the unpleasant physical and emotional effects and context of methadone consumption at user-unfriendly clinics. In this polarized context, medicalized heroin, precisely because of the pleasure it provides to its consumers, offers the opportunity of metamorphosing a larger percentage of depressed self-destructive, oftenviolent street-relegated outlaws into relatively reliable, low wage laborers—or at worst into harmless, complacent, inexpensive beneficiaries of public sector largess. We need to de-exoticize how we think about drugs. The dramatic social transformation of heroin from drug to medicine in the Swiss experiments was accomplished merely by the juridical act of legalizing—or at least medicalizing—heroin-cum-methadone addiction. Perhaps, more important from a humanitarian risk reduction perspective, medicalized heroin would also certainly result in dramatic reductions in HIV, hepatitis, abscesses, tuberculosis, and other new epidemics of self-administered social suffering that plague inner cities. The most significant effect would be a massive reduction in the numbers of incarcerated inner-city youth—the most dramatic outcome of U.S. drug and social welfare policy at the close of the 20th century.

NOTES 1. See Smart 1984 for a discussion of the interface between British medical and criminal discourses on drugs. 2. The more morally repressive, low-dose, “ineffective” clinics also treat the highest proportions of African American addicts. Surprisingly, this correlation is not explored empirically or theoretically in the epidemiological literature despite the proxy measurement it provides on differential access to biomedical facilities by race due to government regulation.

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REFERENCES Agar, M. 1977 Going Through the Changes: Methadone in New York City. Human Organization 36(3): 291–295. Agar, M. and R.C. Stephens 1975 The Methadone Street Scene. Psychiatry 38: 381–387. Ball, J., C. Lange, P. Myers, and S.R. Friedman 1988 Reducing the Risk of AIDS Through Methadone Maintenance Treatment. Journal of Health and Social Behavior 29: 214–226. Balter, M. 1996 New Clues to Brain Dopamine Control, Cocaine Addiction. Science 271(5251): 909. Bourgois, P. 1998 Just Another Night in a Shooting Gallery. Theory, Culture, and Society 15(2). Bourgois, P., M. Lettiere, and J. Quesada 1997 Social Misery and the Sanctions of Substance Abuse: Confronting HIV Risk Among Homeless Heroin Addicts in San Francisco. Social Problems 44(2): 155–173. Caplehorn, J., J. Bell, D. Kleinbaum and V. Gebski 1993 Methadone Dose and Heroin Use During Maintenance Treatment. Addiction 88: 119–124. Caputo, J. and M. Yount 1993 Institutions Normalization and Power. In Foucault and the Critique of Institutions. J. Caputo and M. Yount, eds., pp. 3–26. University Park PA: The Pennsylvania State University Press. CESAR Fax 1997 NIH-Sponsored Independent Consensus Panel Calls for Increased Availability of Methadone Treatment with Less Government Regulation. December 1, 1997, 6(47). Chavkin, W. and V. Breitbart 1997 Substance Abuse and Maternity: The United States as a Case Study. Addiction 92(9): 1201–1205. Cooper, J. 1989 Methadone Treatment and Acquired Immunodeficiency Syndrome. Journal of the American Medical Association 262(12): 1664–1668. Crawford, R. 1984 A Cultural Account of ‘Health’: Control, Release, and the Social Body. In Issues in the Political Economy of Health Care. John McKinley, ed., pp. 60–103. New York: Tavistock Publications. D’Aunno, T. and T. Vaughn 1992 Variations in Methadone Treatment Practices. Journal of the American Medical Association 267 (2): 253–258.

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Dole, V. 1989 Methadone Treatment and the Acquired Immunodeficiency Syndrome Epidemic. Journal of the American Medical Association 262(12): 1681–1682. Dole, V.P. and M.E. Nyswander 1967 Heroin Addiction: A Metabolic Disease. Archives of Internal Medicine 120: 19–24. Dole, V.P. and M.E. Nyswander 1982 Performance-Based Rating of Methadone Maintenance Programs. New England Journal of Medicine 306(3): 169–172. Finestone, H. 1957 Cats, Kicks, and Color. Social Problems 5(1): 3–13. Foucault, M. 1979 Discipline and Punish: The Birth of the Prism. New York: Vintage Books. Foucault, M. 1981 Power/Knowledge: Selected Interviews and Other Writings, 1972–1977. Colin Gordon, ed., New York: Pantheon/Random House. Foucault, M. 1982 The Subject and Power. In Michel Foucault: Beyond Structuralism and Hermeneutics. Hubert L. Dreyfus and Paul Rabinow, eds., pp. 208–226. Chicago IL: University of Chicago Press. Friedman, J. and M. Alicea 1995 Women and Heroin: The Path of Resistance and Its Consequences. Gender and Society 9(4): 432–449. General Accounting Office 1990 Methadone Maintenance: Some Treatment Programs Are Not Effective; Greater Federal Oversight Needed. Report to the Chairman, Select Committee on Narcotics Abuse and Control, House of Representatives. Goldsmith, D., D. Hunt, D. Lipton and D. Strug 1984 Methadone Folklore: Beliefs About SideEffects and Their Impact Upon Treatment. Human Organization 43: 330–340. Hunt, D. and D. Lipton 1985 It Takes Your Heart: The Image of Methadone Among Street Addicts and Its Effect on Recruitment and Methadone Treatment. International Journal of the Addictions 20(11&12): 1751–1771. Hunt, D. and D. Lipton 1986 The Costly Bonus: Cocaine Related Crime Among Methadone Treatment Clients. Advances in Alcohol and Substance Abuse 6(2): 107–122. Hunt, D., D. Strug, D. Goldsmith, D. Lipton, B. Spunt, L. Truitt and K. Robertson 1984 An Instant Shot of “Aah”: Cocaine Use Among Methadone Clients. Journal of Psychoactive Drugs 16(3): 217–227.

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Johnson, P. and J. Friedman 1993 Social Versus Physiological Motives in the Drug Careers of Methadone Clinic Clients. Deviant Behavior 14: 23–42. Koester, S., K. Anderson, and L. Hoffer 1999 Active Heroin Injectors’ Perceptions and Use of Methadone Maintenance Treatment. Substance Use and Misuse 34(14): 2135–2153. Maremmani, I., R. Roberto Nardini, O. Zolesi, and P. Castrogiovanni 1994 Methadone Dosages and Therapeutic Compliance During a Methadone Maintenance Program. Drug and Alcohol Dependence 34: 163–166. Moore, L. and L. Wenger 1995 The Social Context of Needle Exchange and User Self-Organization in San Francisco: Possibilities and Pitfalls. Journal of Drug Issues 25(3): 583–598. Murphy, S. and M. Rosenbaum 1988 Money for Methadone 2: Unintended Consequences of Limited Duration Methadone Maintenance. Journal of Psychoactive Drugs 20(4): 397–402. National Alliance of Methadone Advocates 1997 California Methadone Clinics Target of Fraud Probe; Clinic Reveals Patient Records to DEA, Patients Arrested. www.ndsn.org/AUGUST97/ FRAUD.html National Consensus Development Panel 1998 Effective Medical Treatment of Opiate Addiction. Journal of the American Medical Association 280(22): 1936–1943. Newman, R. 1987 Methadone Treatment: Defining and Evaluating Success. New England Journal of Medicine 317(7): 447–450. O’Brien, C. 1997 A Range of Research-Based Pharmacotherapies for Addiction. Science 278: 66–70. O’Malley, P. and S. Mugford 1992 Moral Technology: The Political Agenda of Random Drug Testing. Social Justice 18: 122–146. Ong, A. 1995 Making the Biopolitical Subject: Cambodian Immigrants, Refugee Medicine, and Cultural Citizenship in California. Social Science and Medicine 40(9): 1243–1257. Preble, E. and J. Casey, Jr. 1969 Taking Care of Business—The Heroin User’s Life on the Street. The International Journal of the Addictions 4(1): 1–24. Preble, E. and T. Miller 1977 Methadone, Wine and Welfare. In Street Ethnography. R.S. Weppner, ed., Los Angeles: Sage. Rabinow, P. 1998 Discussant’s comments on the panel “Foucault in the Social Sciences,” at the

69th Annual Meetings of the Pacific Sociological Association. San Francisco, April 16. Rabinow, P., ed. 1984 The Foucault Reader. New York: Pantheon Books. Rhoades, H., D. Creson, R. Elk, J. Schmitz, and J. Grabowski 1998 Retention, HIV Risk, and Illicit Drug Use During Treatment: Methadone Dose and Visit Frequency. American Journal of Public Health 88(1): 34–39. Rosenbaum, M. 1995 The Demedicalization of Methadone Maintenance. Journal of Psychoactive Drugs 27(2): 145–149. Rosenbaum, M. and S. Murphy 1984 Always a Junkie?: The Arduous Task of Getting Off Methadone. Journal of Drug Issues 16(4): 527–552. Rosenbaum, M. and S. Murphy 1987a Money for Methadone: Preliminary Findings from a Study of Alameda County’s New Maintenance Policy. Journal of Psychoactive Drugs 19(1): 13–19. Rosenbaum, M. and S. Murphy 1987b Not the Picture of Health: Women on Methadone. Journal of Psychoactive Drugs 19(2): 217–226. Smart, C. 1984 Social Policy and Drug Addiction: A Critical Study of Policy Development. British Journal of Addiction 79: 31–39. Spunt, B., D. Hunt, D. Lipton, and D. Goldsmith 1986 Methadone Diversion: A New Look. Journal of Drug Issues 16(4): 569–583. Stephens, R. and R. Weppner 1973 Legal and Illegal Use of Methadone: One Year Later. American Journal of Psychiatry 130: 1391–1394. Strug, D. 1985 Patterns of Cocaine Use Among Methadone Clients. International Journal of the Addictions 20(8): 1163–1175. Sutter, A.G. 1966 The World of the Righteous Dope Fiend. Issues in Criminology 2(2): 177–222. Uchtenhagen, A. 1997 Rapport de Synthese PROVE. Zurich: Institut fur Suchtforschung in Verbindung and Institut fur Sozial-Und Praventivmedizin, Universitat Zurich. Valentine, B. 1978 Hustling and Other Hard Work: Lifestyles in the Ghetto. New York: The Free Press. Weber, Max. 1958 The Protestant Ethic and the Spirit of Capitalism. Upper Saddle River, NJ: [1905] Prentice-Hall. Williams, R. 1977 Marxism and Literature. Oxford: Oxford University Press.

CHAPTER 14

Drug Courts and the Logic of Coerced Treatment Rebecca Tiger

BACKGROUND The increasing criminalization of drug use over the past 30 years, as evidenced by lengthy mandatory sentences for drug convictions and dramatic increases in federal funding for the War on Drugs, has had a significant impact on the number of people incarcerated in the U.S., which now exceeds 2.3 million (Bureau of Justice Statistics [BJS], 2008). Of the 5 million additional people under criminal justice supervision, the majority are regularly drug tested and must remain drug free as a condition of their probation or parole (BJS, 2007). During this same time, research into the etiology of the “disease” of addiction has received considerable attention by the scientific and medical community and funding from the federal government (Conrad and Schneider, 1992; May, 2001). The concept of addiction as a compulsive behavior amenable to treatment underlies most medical and behavioral theories of addiction, even though these theories are often in conflict about the nature of addiction. The therapeutic and criminalized perspectives are seemingly contradictory approaches to the “problem” of substance use, with one calling for treatment and the other punishment. Despite these contradictions, these perspectives merge with the use of coerced drug treatment as a punishment for drug-related offenses.

COERCED TREATMENT The U.S. government experimented throughout the twentieth century with different policy approaches to drug use, but concerted efforts

to coerce drug users into treatment as a criminal justice strategy only began in earnest in the early 1960s. California’s Civil Addict program, implemented in 1961 and run by the Department of Corrections, permitted the state to involuntarily commit people for several years of inpatient drug treatment and followup. In 1966, the federal government passed the Narcotic Addict Rehabilitation Act, which permitted all states to implement coerced treatment programs (Musto, 1999). In most states, treatment services were provided in prison settings yet funds from this Act helped establish a system of drug treatment programs that was virtually nonexistent before this time. Treatment Alternatives to Street Crime (TASC), developed in the 1970s, and still in existence, was the first major coerced treatment program that took drug offenders out of the criminal adjudication process and placed them in drug treatment facilities not run by the criminal justice system (Nolan, 2001). Defendants were returned to the court system when they had completed treatment but had little interaction with judges during treatment. Despite the lengthy history of the relationship between the criminal justice and drug treatment systems, this connection had been sporadic and efforts were stymied by the increasing use of incarceration to punish drug offenders and a decline in rehabilitative ideology in the criminal justice system (Garland, 2001; Mauer, 2001). In the 1970s, states began implementing highly punitive approaches to drug use. For example, in 1973, New York passed the Rockefeller Drug Laws, which called for a 15-year prison sentence for anyone convicted of selling two

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ounces or possessing four ounces of narcotics. The federal Anti-Drug Abuse Acts of 1986 and 1988, part of Ronald Reagan’s War on Drugs, imposed harsh mandatory sentences for drug possession. The result was a doubling of arrests for drug offenses (Mauer, 2001). An important factor underlying these trends was determinate sentencing requirements, which allowed judges little to no discretion in the sentencing process (Tonry, 1996).

DRUG COURTS Formed partly in response to the overcrowding of jails and prisons that has stemmed from punitive drug policies (Olson et al., 2001; Spohn et al., 2001), drug courts seek to address the underlying addiction that many in criminal justice believe is the impetus for drug-related crimes, while still retaining the coercion traditionally associated with criminal justice. As the U.S. Department of Justice’s Drug Courts Program Office explains, “drug courts leverage the coercive power of the criminal justice system to achieve abstinence and alter criminal behavior through the combination of judicial supervision, treatment, drug testing, incentives, sanctions and case management” (Drug Courts Program Office, 2000). Unlike previous attempts at coerced treatment, sanctions “of increasing severity”—including incarceration—imposed by the judge are considered “instrumental” in drug court operation (Snavely, 2000). Drug court judges retain considerable power over the treatment process, meet regularly in the courtroom with defendants, and routinely monitor their progress, using urine testing and reports from treatment programs to assess compliance with treatment protocols (Burns and Peyrot, 2003; Fox and Huddleston, 2003; Kassebaum and Okamoto, 2001; Nolan, 2001, 2002). The structure of drug courts differs across jurisdictions, but they all share three main common features. First, they use “legal and external pressure” through the power of the judge to mandate people to drug treatment. Second, the defendant’s progress in drug treatment is heavily monitored by the drug court judge through mechanisms such as reports from treatment providers and mandatory drug

testing. Drug testing is considered a key feature of drug courts and a way that abstinence from drugs can be “objectively” and “reliably” monitored (DCPO, 1997). Third, drug courts use a variety of sanctions to punish noncompliance and incentives to reward progress. Sanctions offer a “swift and coordinated response to noncompliance” that is “immediate, of increasing severity and predictable” (NDCI, 2000). Sanctions can include public warnings in the courtroom, increased frequency of drug testing, fines, jail, and, finally, termination from the program (and a certain prison sentence). Rewards can include public praise from the judge, ceremonies marking advancement to the next treatment phase, a decrease in the frequency of required court appearances, and graduation from the program. Since their first appearance in Dade County, Florida in 1989, drug courts have expanded to every state, with more than 2,100 drug courts now in operation (Huddleston et al., 2008). Drug court activities expand the boundaries of dominant criminal justice practice by defining drug use as a criminal and medical and behavioral problem amenable to courtmonitored therapeutic interventions and traditional criminal justice sanctions. Drug courts accomplish this by combining medicalized theories of persistent substance use—a type of biopsychological determinism—with classical criminological arguments about the importance of sanctions to shape behavior that is, according to this model, within the individual’s control.

METHODS My research draws on the sociology of knowledge to examine the theories drug court advocates use to legitimate their activities and how they articulate a role for the courts in solving the complex problem of addiction. To articulate these theories, I have relied on two primary data sources: (1) documents generated by the advocacy organizations, governmental agencies, and research centers concerned with drug courts and their expansion and (2) interviews with 12 key members of these organizations who are actively involved in

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articulating the drug court field. To supplement the document analysis, I have conducted 12 interviews with key drug court representatives to understand these individuals’ perspectives on the goals, practice, and consequences of drug courts and how they came to view drug use as a problem best served by coerced treatment. I have analyzed the drug court documents and interviews with an eye toward how they construct broad theories of addiction and the problem-solving role of the criminal justice system to argue for expanded coerced drug treatment. Drawing on David Garland’s work on punishment, I have analyzed the “discursive tropes” that constitutes “the institutionalized culture of control” (Garland, 2001:xii). Through this process, I also link the interview and document data on drug courts back to the “extra-textual factors” (Hook, 2001)—the historical precedents and social processes—that support the arguments about addiction and the court’s role in solving social problems that drug court advocates make.

THEORIES OF ADDICTION AND RECOVERY Drug courts advocates draw on medicalized interpretations of addiction to argue for increased judicial control over defendants (Burns and Peyrot, 2003). Importantly, it is these advocates’ theories of recovery from addiction that are crucial to understanding drug court practice. Drug court advocates call their work “enlightened coercion” (Satel, 2000), enlightened because they’re drawing on what proponents call the “psychopharmacological science” or, alternatively, the “neuroscience of addiction.” As one advocate explained: “Neuroscience has come so far in the last ten years that unless you’re a Neanderthal” you’ll understand “what the science tells you about the hijacked brain . . . the effects that [these] drugs have on the pleasure centers of the brain.” Drug court advocates use the science about the effects of drugs on the brain to articulate a disease model of addiction that focuses more broadly on its treatment. As one advocate pointed out, “drug courts would be

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unimaginable without this growing assumption that . . . addiction is a disease and it can be treated.” It is a condition in which “relapse is inevitable” and whose ultimate cure requires “long-term, intensive assistance.” It is also a disease that, because it affects the pleasure centers, people do not want to necessarily be cured from. So, what drug courts offer, in the words of one proponent, is “the coercive power to get people into treatment who don’t want it. And to keep people there who don’t want to stay there.” Importantly, then, drug courts “teach . . . people to learn to manage their ambivalence towards recovery.” Drug courts are concerned, principally, with “abstinence from drugs” (DCPO, 1997), but their challenge is how to foster this abstinence and its long-term maintenance. As one advocate explained: “it’s not good to just to get somebody clean and sober. We might as well have done nothing if that’s all we’ve done.” Drug courts are interested, then, in affecting a constellation of behaviors believed to contribute to drug use and its outgrowth, criminal activity. It is at the level of the goals of drug courts that moral and medical considerations merge quite clearly. As an advocate explained: “For an addict, we’re asking them to change everything—their friendships, how they see themselves in the world, their family dynamic, their hangouts, down to the music they listen to and how they dress.” Another proponent explained: We’ve got to make sure they can work, that they’re educated, that they can get a job, that they can keep a job, that they have skills, that they . . . learn how to get up in the morning and go to work. That they learn that when their boss pisses them off they don’t slug them. That they learn behavior they’ve never learned before. How do you get a house, how do you raise your kids . . . if you don’t have a kind of holistic view of this person’s recovery, you’re setting these people up for failure.

Rather than punishing a specific criminal act that has happened in the past, a traditional role for courts, drug courts are focused on curing a specific condition, that of addiction, and affecting future action. Their theories of what it takes to facilitate recovery—what aspects of

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the defendants’/clients’/participants’ lives (drug courts advocates use all three labels) need to be in place for recovery to take hold—are quite broad. The court, then, becomes concerned with behaviors that are not necessarily illegal but that courts stake their claim over in the name of recovery. The National Association of Drug Court Professionals, the sole drug court advocacy organization, in a document outlining the “Key Components of Drug Courts” (DCPO, 1997), argues that a drug court program’s effectiveness should be measured according to the following outcomes: reduced recidivism rates, abstinence from drugs and alcohol, changes in jobs skills and employment, changes in literacy and educational attainment, changes in physical and mental health, changes in the status of family relationships, increased use of healthcare and other social services, and increased economic productivity of drug court participants. It is these factors that determine whether a particular court has been effective and against which drug court performance should be measured. Karen Freeman-Wilson (2004), a retired drug court judge and former CEO of the National Association of Drug Court Professionals, has argued to the U.S. Congress that traditional measures of court success such as recidivism rates are insufficient to measure the transformations drug courts are seeking. Rather, Judge Freeman-Wilson argued, drug court participants, in order to be considered successful, should be “required to engage in community service, actively search for a job, comply . . . with ancillary services they may have been sent to, AND tak[e] prescribed medication for cooccurring disorders.” Further, she explained, the courts should examine the drug court defendant’s relationship with family members and ask: “Is this person developing new, healthy relationships?” Follow-up measures of success should examine the participant’s “prosocial participation in the community. How do they give back?” The Center for Court Innovation—an organization based in New York City that has funded and evaluated drug courts in New York State and has made substantial contributions

to the national discussion about problemsolving courts generally (see, e.g., Berman et al., 2004)—argues for the importance of “extending the judge’s authority,” writing that “perhaps some of the basic elements of aftercare—looking for a job, getting an education, coming up with a plan for housing, family reunification—should” be part of the last phase of court supervision. If this were the case, they argue, “[j]udges could then bring the coercive power of the court to this aspect of recovery, pushing clients towards a firm hold on a stable life and withholding graduation until at least some basics are in place” (Berman and Anderson, 1999). The broad goals of drug courts necessarily extend the court’s traditional jurisdiction. As one advocate explained: The court in the drug court model uses its coercive power to . . . move participants successfully through their recovery . . . Courts traditionally are focused on process . . . problem-solving courts are about the exact opposite. . . . Their ultimate goal is to change the future behavior of litigants.

A key way they justify this expansion is through references to the health of not just individuals but of communities. An introductory reader on problem-solving courts explains that these courts “extend the role of the legal system beyond fact-finding and the imposition of sanctions. They use the authority of the court to maintain the social health of the community” (Butts, 2001:121). Further, “[p]roblem-solving courts are moving the legal system away from the bureaucratic, statecentered perspective and toward a framework that sees each court embedded in the community from which it draws its clientele” (Butts, 2001:123). Because of this focus on the community, “[p]roblem-solving courts tend not to confine their reformist energies to the four walls of the courthouse . . . [but] also seek to achieve broader goals in the community at large, using their prestige to affect change outside the courtroom without comprising [sic] the integrity of the judicial process within the courtroom”

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(Berman and Feinblatt, 2002:5). One book explains the drug court’s role this way: Another issue is the question of where treatment begins and ends. Drug courts have expanded the concept of treatment beyond its traditional definition. With drug courts the goal is not simply to get participants sober, as it might be in a straight-up treatment program, because then you just end up with a sober criminal. The idea is to work on the behavior that is problematic to the community. So for drug courts the goals is not just sobriety but also law-abiding behavior. (Fox and Berman, 2002:9)

Drug courts broaden the scope of activities the court monitors, in the name of helping people, and draw on prevailing theories of addiction and recovery to justify their expanded jurisdiction. As one advocate explained: Drug courts become very personal. Drug court judges become very involved with these people. The clinical people do. The defense does. The prosecutors do. They care about these people. And when you care about people, you want to do more and more and more for them.

In making their case for coercion, drug courts emphasize the role that coercion plays in the therapeutic setting. It is at the level of cure—at the level of treatment—where drug courts make an intervention and they make coercion the main feature of that intervention. Drug court advocates argue that “force is the best medicine.” An “evidence-based” approach, they claim, shows us that addicts need coercion. Further, they argue, “the empirical data on drug treatment programs unequivocally . . . support . . . this proposition”—that coercion is the key to rehabilitation—and that “voluntary treatment is wildly less successful than coerced treatment.” As one advocate explained: “an addict . . . they need to be coerced, they need carrots, they need sticks, in order to stay about new behaviors.” While, according to this model, addicts are sick, they are also in control of their disease and this control can be enhanced through sanctions and incentives imposed by the court. Drug court advocates actively construct a solution to the problem of addiction that clearly

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articulates, with coercion as the centerpiece, an expanded role for the courts, and judges specifically, in the recovery process. When asked to talk about what problem drug courts are responding to, advocates uniformly point to institutional failures—specifically, the criminal justice system’s inability to effectively address the needs of drug-involved offenders. The advocates I spoke with refer to the “revolving door nature of justice” for drug offenders and the inappropriateness of incarcerating addicts, but use this critique not to argue for transforming the laws around drug-related offenses but to reform how the justice system responds to these offenses. They are actively involved in reorienting the criminal justice system’s understanding of the underlying motivations for these offenses. By arguing strenuously for the importance of the judge and articulating such a clear and preferred role for criminal justice personnel in overseeing the treatment process, advocates are also simultaneously reorienting broad assumptions about treatment. They construct a model where the judge is the central figure in the recovery process. As one advocate explained: “Who is more powerful in the criminal justice system than the judge? And the judge when enlightened and when trained and when willing to lead . . . it’s unstoppable.” Another advocate explained drug court success this way: “If you ask [participants] what mattered most in their succeeding, they’ll say the judge. And, they become vested in the judge’s approval, in an authority figure caring about them. They love their judges.” According to another advocate: There’s that parental relationship . . . that occurs[s] with some defendants in court. Where a defendant or participant in drug court really doesn’t want to let that judge down . . . there’s something parental that goes on. And there’s some kind of transference that goes on there. Where somebody truly an authority and truly is respected in the community is rooting for that participant.

A key way the judge enacts this power is through sanctions—“the hammer”—that are used to shape behavior. According to advocates, sanctions, “where the rubber hits the road,” work largely because the judge, as the

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parental figure, enacts them on the defendants, whose addiction has rendered them childlike. One advocate attributed drug court success to “the immediacy of sanctions,” explaining: it’s like kids. You don’t punish a child for something they did six months ago . . . You will learn consequential thinking. Addicts go through their lives, through their addicted lives, thinking their drug use will have no consequences . . . Because they don’t think consequentially. . . . And so, the frequent interaction with the judge and the immediacy of the response, you didn’t go to treatment yesterday, the judge gets notified, you’re brought in, you have a consequence. So, your bad behavior will have consequences . . . and hopefully the participant starts to learn, then, a sense of accountability.

Despite the fact that drug court advocates describe addiction as a “brain disorder” and a “brain disease”—and actively work to retrain people in the criminal justice system to view drug-using offenders as sick—their work is focused largely on advancing a punishment model that relies on, and greatly enhances, judicial, rather than medical, oversight of drug offenders. One advocate explained, of the broad appeal of drug courts: [Drug courts are] rehabilitation for a new generation. So it’s not a rehabilitation that’s a get out of jail card or that’s, we’re sorry because there’s root causes of crime and we’re going to explain away your behavior and absolve you of your individual responsibility. It’s an approach that combines punishment and health that . . . contains elements of a classic punitive model but also classic rehabilitative model.

DISCUSSION The sociologist Carl May has argued that that the medicalization of addiction has been only partially successful and that “clinical constructions of addiction still engage a set of moral questions” (2001:386). This is the case, May argues, because addiction can be known only through symptoms and while medical theories may be able to explain susceptibility—how one becomes an addict or the effects of drugs when

one takes them—these theories do not have much to offer to help explain how to cure an addict. Drug courts emerge in an environment where scientific theories about the effects of drugs on the brain predominate but in which addiction’s manifestation is seen through behaviors considered to be associated with, or the outgrowth of, drug use. This model, then, is really a behavioral approach to addiction rather than a medicalized approach and leaves open ample opportunity for the criminal justice system, with its focus on behavior, to assert a role for itself in recovery. Drug court advocates expand the boundaries of traditional criminal justice practice, overseeing an increasing number of aspects of defendants’ lives in the name of curing, or at least managing, defendants’ addiction. They rely on the disease model to argue for enhanced judicial control of drug addicts and stake their claims on their supposed influence on the future behavior of defendants. The sociologists Conrad and Schneider (1992) have argued that one of the “ideological benefits” to conceptualizing behavior in medical terms is that it can help decriminalize a behavior. When medical social control is exerted over the problem, punitive sanctions are decreased because the person exhibiting the deviant behavior is now defined as “sick” instead of “bad.” Importantly, however, Conrad (1992) furthered this argument, explaining that the medicalization process, while dominant in contemporary society, is never complete and exists in stages. The first level, conceptual medicalization, involves defining a problem in medical terms but does not require a physician to be involved in diagnosis or treatment. The second and third levels—institutional and interactional— entail an increased role for physicians as either legitimating experts or direct providers of the specific intervention. Drug courts are an important example of conceptual medicalization where medical terminology is used but medical professionals have little or no involvement. Advocates of coerced treatment see drug courts as an important part of both the “war on addiction” and of institutional reform within the criminal justice system. Drug court advocates are motivated both by the desire

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to keep addicts out of prison but also by the desire to keep them under the supervision of the courts and have argued, in journal articles and editorials, strenuously against criminal justice reforms that seek to minimize the criminal justice system’s control over illicit drug users and/or permit people to access treatment without judicial monitoring and oversight (Lieupo and Weinstein, 2004; Marlowe et al., 2004). As one advocate explained, “drug court is as close to decriminalization as we’ve gotten . . . with decriminalization, we lose a very, very valuable ally in the war against addiction . . . and that is the coercive power of the justice system.” The goals of this coercion remain quite vague. The broad goals of drug courts, from abstinence to improved family relations to job stability, and their increased oversight of defendants lead to two consequences that are a direct outgrowth of a model that explicitly fuses rehabilitation and punishment. First, drug courts expand the scope of activities the court monitors, in the name of helping people, and draw on prevailing theories of addiction and recovery to justify their expanded jurisdiction. Second, drug courts are helping transform prevailing notions about addiction by making their case for coercion and arguing that coercion is the key to getting people to stay in treatment long enough for it to be effective. Both these consequences are a direct outgrowth of the logic of caring that guides drug court practitioners’ activities combined with their attempt to reform both how courts operate and the public’s perception of courts as legitimate community-oriented institutions. . . . In this call to inject a healing function in the criminal justice system, drug courts greatly resemble the “court-based regime[s] of social governance” (Willrich, 2003:243) of the Progressive Era in the U.S. Armed with new theories about what causes crime and how to fix the individual criminal, Progressive Era reformers, in the early twentieth century, argued for more humane ways to punish transgressors. The courts became an important arena in which this new approach to punishment was enacted; the medical model of deviant behavior was a key tool reformers used to justify court expansion and the individualized punishment/

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rehablitation the courts enacted. Like these earlier courts, drug courts draw on outside disciplinary perspectives to articulate an enhanced role for the court as an institution that uses its punitive power to coerce rehabilitation in the name of “helping” people. The disease designation, in its attempt to illuminate the complexities of and differentiate among the individuals under criminal justice supervision, actually obscures their racial homogeneity. By ascribing a disease state to defendants, drug courts erase considerations of race from discussions of criminal justice processing. An important part of the uniformity of the way drug court advocates spoke about coerced treatment and the criminal justice system was the virtual absence of race from our discussions. The advocates I interviewed spoke about the “revolving door” of drug offenders, the explosion of drug-related arrests in the 1980s, and the jail and prison overcrowding that compelled them to seek alternative sanctions to prison for addicts. In a criminal justice system defined almost exclusively in terms of racial inequality, where African Americans and Latinos are vastly overrepresented and far more likely than their white drug-using counterparts to be arrested (King, 2008), the absence of a discussion of race is notable. According to this disease logic, the state of addiction renders individuals vulnerable to criminal justice involvement, not bias in policing, arrest, charging, conviction, and sentencing that lead some drug users directly into long-term oversight by the criminal justice system (Tonry, 1995). In the end, medical designations mask the racial and class control drug court and similar strategies are engaged in by deeming defendants sick, thus de-politicizing their supervision at the hands of judges, lawyers, doctors, and social workers. In doing so, advocates of these courts reform how the criminal justice system understands and responds to drug-related offenses while firmly cementing control of addiction in the hands of this same system. By removing consideration of race and class, drug courts continue with, rather than depart from, the historically persistent efforts to define deviance in ways that are compatible with an implicit logic of inequality; and to define deviance in ways

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that complement rather than counter the concentrated institutional context of prison. Drug courts, then, present an alternative to incarceration that keeps the War on Drugs firmly intact and does little to address the biases that this war perpetuates.

REFERENCES Berman, Greg, Aubrey Fox, and Robert V. Wolf (eds.). 2004. A Problem-Solving Revolution: Making Change Happen in State Courts. New York: Center for Court Innovation. Berman, Greg, and David Anderson. 1999. Drugs, Courts and Neighborhoods. New York: Center for Court Innovation. Berman, Greg, and John Feinblatt. 2002. Judges and Problem-Solving Courts. New York: Center for Court Innovation. BJS. 2007. Probation and Parole in the United States 2007. Washington, DC: Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice. BJS. 2008. Correctional Population in the United States, Annual Prisoners in 2008. Washington, DC: Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice. Burns, Stacy Lee, and Mark Peyrot. 2003. “Tough Love: Nurturing and Coercing Responsibility and Recovery in California Drug Courts,” Social Problems 50: 416–438. Butts, Jeffrey A. 2001. “Introduction: ProblemSolving Courts,” Law & Policy 23: 121–124. Conrad, Peter. 1992. “Medicalization and Social Control,” Annual Review of Sociology 18: 209–232. Conrad, Peter, and Joseph W. Schneider. 1992. Deviance and Medicalization: From Badness to Sickness. Philadelphia, PA: Temple University Press. DCPO. 1997. Defining Drug Courts: The Key Components. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Drug Courts Program Office. Drug Courts Program Office. 2000. About the Drug Courts Program Office: Fact Sheet. Washington, DC: U.S. Department of Justice, Office of Justice Programs. Fox, Aubrey, and Greg Berman. 2002. “Going to Scale: A Conversation About the Future of Drug Courts,” Court Review 39(3): 4–13.

Fox, Carson, and C. West Huddleston. 2003. “Drug Courts in the U.S.,” Issues of Democracy 8. Freeman-Wilson, Karen. 2004. “Testimony of the National Association of Drug Court Professional’s National Drug Court Institute,” in Oversight Hearing: “Measuring the Effectiveness of Drug Addiction Treatment.” Washington, DC: U.S. House of Representatives, Committee on Government Reform, Subcommittee on Criminal Justice, Drug Policy and Human Resources. Garland, David. 2001. The Culture of Control: Crime and Social Order in Contemporary Society. Chicago, IL: University of Chicago Press. Hook, Derek. 2001. “Discourse, Knowledge, Materiality, History: Foucault and Discourse Analysis,” Theory & Psychology 11: 521–547. Huddleston, C. West, Douglas Marlowe, and Rachel Casebolt. 2008. Painting the Current Picture: A National Report Card on Drug Courts and Other Problem-Solving Court Programs in the United States. Washington, DC: Bureau of Justice Assistance, Office of Justice Programs, U.S. Department of Justice. Kassebaum, G., and D. K. Okamoto. 2001. “The Drug Court as a Sentencing Model,” Journal of Contemporary Criminal Justice 17: 89–104. King, Ryan. 2008. Disparity by Geography: The War on Drugs in America’s Cities. Washington, DC: Sentencing Project. Lieupo, Kelly, and Susan P. Weinstein. 2004. “Ballot Initiatives: Wolves in Sheep’s Clothing,” Drug Court Review IV: 51–66. Marlowe, D. B., D. S. Festinger, and P. A. Lee. 2004. “The Judge is a Key Component of Drug Court,” National Drug Court Institute Review 4: 1–34. Mauer, Marc. 2001. “The Causes and Consequences of Prison Growth in the United States,” in David Garland (ed.), Mass Imprisonment: Social Causes and Consequences: pp. 4–14. Thousand Oaks, CA: Sage. May, Carl. 2001. “Pathology, Identity and the Social Construction of Alcohol Dependence,” Sociology 35: 385–401. Musto, David. 1999. The American Disease: Origins of Narcotic Control. New York: Oxford. NDCI. 2000. “The Critical Need for Jail as a Sanction in the Drug Court Model,” Drug Court Practitioner Fact Sheet II. Alexandria, VA: National Drug Court Institute.

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Nolan, J. 2001. Reinventing Justice: The American Drug Court Movement. Princeton, NJ: Princeton University Press. Nolan, J. 2002. “Therapeutic Adjudication,” Society 39: 29–39. Olson, David E., Arthur J. Lurigio, and Stephanie Albertson. 2001. “Implementing the Key Components of Specialized Treatment Courts: Practice and Policy Considerations,” Law & Policy 23: 171–196. Satel, Sally L. 2000. “Drug Treatment: The Case for Coercion,” National Drug Court Institute Review 3: 1–23. Snavely, Kathleen R. 2000. “The Critical Need for Jail as a Sanction in the Drug Court Model,”

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in Drug Court Practitioner Fact Sheet. Alexandria: National Drug Court Institute. Spohn, C., R. K. Piper, T. Martin, and E. D. Frenzel. 2001. “Drug Courts and Recidivism: The Results of an Evaluation Using Two Comparison Groups and Multiple Indicators of Recidivism,” Journal of Drug Issues 31: 149–176. Tonry, Michael. 1995. Malign Neglect: Race, Crime and Punishment in America. New York: Oxford University Press. Tonry, Michael. 1996. Sentencing Matters. New York: Oxford. Willrich, Michael. 2003. City of Courts: Socializing Justice in Progressive Era Chicago. New York: Cambridge University Press.

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CHAPTER 15

Social Capital and Natural Recovery Overcoming Addiction Without Treatment Robert Granfield and William Cloud INTRODUCTION There exists compelling evidence supporting the proposition that recovery from alcohol and drug misuse without treatment is a common occurrence. Resolution of alcohol- and drug-use related problems without treatment has been referred to as “natural recovery” (1,2), maturing out (3,4), autoremission (5), spontaneous remission (6,7), and spontaneous recovery (8). Although a number of different terms are prevalent in the literature, they all subscribe to the basic principle that people overcome substance–misuse associated problems without recourse to treatment. These differences in terminology notwithstanding, as Lewis (9) has assertively argued, “there can be no doubt that spontaneous remission occurs” [emphasis added]. In their report on the effectiveness of addiction treatment, researchers at Harvard Medical School presented findings indicating that 80% of all alcohol-dependent persons who recover for a year or more do so on their own, many after being unsuccessfully treated (10). (It should be pointed out that, perhaps with the exception of methadone, there are no specific treatment paradigms or approaches for users of specific substances. The same approaches are used across substances as well as across temporal and spatial proximity.) Similarly, in a series of studies conducted in Canada to determine the prevalence of recovery without treatment, researchers found an impressive incidence of “natural recovery” (11). In these studies, data from two general population surveys were

analyzed. Both surveys found that over 77% of individuals who had overcome an alcohol use problem did so without treatment. In an earlier study the Sobell’s and their colleagues reported that a sizable majority of “heavy” alcohol users, 82%, recovered on their own. Vaillant (12), in his classic study on the natural history of alcoholism, similarly reported that an impressive number of those he followed over an extensive period of time overcame their alcohol use problems without recourse to treatment or 12-step programs. The prevalence of untreated recovery among drug-dependent persons appears to be no less significant than for those with alcohol use problems. In their study of 106 problem cocaine users who quit, Waldorf and his colleagues (13) found that just over 71% stopped using without treatment. Interestingly, a greater number of these untreated quitters than treated ones in their study were able to successfully stop on their initial attempt. Among those who are more heavily involved in a criminal subculture, however, such untreated success may occur less often. One study of 343 male inmates in a medium-security prison found that only 25% of incarcerated offenders with a drug use problem stopped using drugs on their own before reaching prison (14). Although the rate of untreated recovery within this group is lower than in the previously cited study, Walters nonetheless maintains that the natural remission of substance misuse occurred twice as often among the prisoners he studied than did treatment-based remission. While the drug users in each of these studies reported extensive

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involvement with drugs, the lower rate among the incarcerated may suggest that the life circumstances that led them into prison posed greater barriers to effective self-change. As several researchers have demonstrated, the process of untreated recovery is often precipitated by a combination of “avoidance-oriented” and “approach-oriented” conditions present in a person’s life (8). Avoidance initiated recovery occurs when individuals experience negative consequences as a result of their substance misuse that consequently lead them to discontinue their habit. For instance, “hitting bottom” experiences, such as those described in 12-step literature, have been commonly considered a necessary precondition for recovery. Among untreated cocaine quitters studied by Waldorf and his colleagues, between 23% and 46% experienced work, financial, or health problems (13). Similarly, in a comparative study of treated and untreated alcoholics, Linda Sobell and her colleagues found negative consequences to be a common theme among both groups (15). Each group reported high levels of physical, social, legal, work, and financial problems. A number of drug-dependent individuals, however, including those who experience untreated recovery, report approach-oriented reasons for discontinuing their use. For instance, some heroin addicts have discontinued use as a result of the “pulls” of the good life exemplified by the dominant value system of work and stable living rather than from the “pushes” associated with hitting bottom (1). Many of these addicts “drift out” of misuse in order to salvage and enhance their stake in conventional life as experienced through jobs, families, and friends (13). In some cases, approach-oriented explanations of change such as an increasing sense of responsibility, the preservation of social relationships, experiencing a religious conversion, having a child (5), getting married (6), establishing new relationships, and forging new identities (2) outnumber avoidance-oriented reasons for cessation (8). In general, the extant research on untreated recovery supports both avenues of cessation. This is particularly true among untreated remitters who engage in ongoing cognitive evaluations of these negative “pushes” and positive

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“pulls” associated with recovery. As previous researchers have pointed out, self-change is strongly associated with the ability to reflect on the costs and benefits of continued use (16). One study, for instance, found that cognitive appraisals had powerful transformative effects. For almost half of the people in that study of alcohol dependent persons who discontinued use without treatment, “the very notion or idea of consuming an alcoholic beverage automatically and instantaneously evoked powerful negative thoughts or feelings such as disgust, embarrassment, physical discomfort, or even nausea” (16). Where reflected appraisals of use occur, both avoidance-oriented and approachoriented strategies seem to be equally effective pathways out of drug use problems. In fact, one pair of researchers proposed a three-stage model of spontaneous remission that combined both the avoidance and approach orientations (7). The initial stage in their model involves finding the resolve to terminate the use of substances. In most cases these researchers found that such resolve was precipitated by avoidance experiences such as assorted medical, financial, and work-related problems, as well as “bottom-hitting” events. The second stage consisted of making a public pronouncement to quit that demonstrates one’s resolve. Finally, their third or maintenance stage involves the development of approach-oriented assets such as social support, new relationships, increasing self-confidence, identity changes, and increased involvement in institutions like the family, religion, and education. While this literature has illuminated many of the individual factors correlated with natural recovery, there has been less attention directed at theorizing about the broader social context within which an individual is embedded and its relation to the process of “natural recovery.” Many researchers have identified the importance of social context in the experience of recovery from addiction, both with and without treatment. Overcoming addictive behaviors strongly correlates to the social context and the resources that adhere to a person’s social position (17,18). In a recent paper, Bloomqvist (19) argues that “the way in which resources and life opportunities are allocated in the population

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are likely to influence peoples’ overall options for stable recovery as well as the specific paths this process may take.” Similarly, Murphy and Rosenbaum (20) note that while virtually anyone can experience problems with alcohol and drugs, “individuals with life options or have a stake in conventional life tend to have a greater capacity for controlling their drug use or for getting out of trouble if they don’t.” While the concept of social context and related resources that cohere to an individual’s position within society has been viewed as relevant in recovery from drug use problems, a structural perspective on natural recovery remains under-developed. Up to now, the literature on natural recovery has tended to identify the correlates associated with overcoming substance misuse without developing general theoretical principles related to the social context within which natural recovery occurs. This may be the result of the fact that much “natural recovery” research has focused on the termination of substance misuse as the primary outcome, rather than examining the broader social context within which this change occurs. Like the earlier research on natural recovery, this paper focuses on the alteration of use patterns among self-remitters, but places greater attention on theorizing about the context of change. This paper seeks to broaden the literature on “natural recovery” through an examination of the role that “social capital” plays in self-recovery from alcohol- and drug-use associated problems. Social scientists have increasingly used the term “social capital” as a way of denoting the various types of resources appropriable from the interpersonal relationships within which a person is embedded (21). Social capital is, as Bourdieu (22) postulates, “the sum of the resources, actual or virtual, that accrue to an individual or a group by virtue of possessing a durable network of more or less institutionalized relationships of mutual acquaintance and recognition.” As Portes (23) has explained, social capital can provide sources of social control, family support, and extra-familial benefits. This paper draws upon the analytical insight attendant to the concept of social capital through an exploration of how social relations helped facilitate “natural recovery” from

alcohol and drug addiction. We begin with a general exploration of how social capital theory can provide a useful framework to understand the process of “natural recovery.” Next we examine the various types of social capital present in the lives of our respondents that assisted them with their “natural recovery” efforts. Finally, we conclude with a discussion of the implications a social capital paradigm has for addiction treatment and drug policy.

METHOD Data for this study were collected in the mid1990s through audio-recorded, in-depth, semi-structured interviews with 46 formerly alcohol- and drug-dependent individuals who overcame their patterns of substance misuse without treatment or participation in self-help groups. Each interview was transcribed and analyzed using standard qualitative techniques including framing and forming hypotheses out of the emerging inductive data, manual coding, and re-coding of data in order to categorize and compile an organized data base, brief memos and elaborations of emerging themes, patterns and theoretical insights, and, diagramming the association between emergent variables and creating analytical typologies (24). Twenty-five individuals participating in this study reported having had alcohol-use related problems while the remaining 21 individuals had experienced problems from the use of illicit substances, most notably powder cocaine, “crack” cocaine, methamphetamines, and heroin. A minority of respondents had experienced problems with varied combinations of these substances. While many individuals revealed that they also used cigarettes, with many indicating they discontinued their cigarette use along with the use of other substances, there was no systematic attempt to collect data pertaining to nicotine use and cessation. Subsequently, no reliable findings can be reported with regard to nicotine use or its cessation. The mean age of our respondents at the time of the interviews was 38.4 years and, as indicated in Table 15.1, the mean number of years addicted was 10.9 years while the mean length of cessation of addiction was 6.5 years.

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Table 15.1 Reported Years of Addiction and Years since Addiction Years of Addiction

1–2 3–5 6–8 9–11 12–15 16–20 21+ Total Average

Years Since Addiction

Alcohol

Drug

Total

0 5 1 4 4 4 7 25 14.7

3 8 6 1 3 0 0 21 5.9

3 13 7 5 7 4 7 46 10.9

We used three criteria for untreated recovery in selecting our respondents. First, they had to have been drug- or alcohol-dependent for a period of at least one year. Determination of “dependency” was made only after careful consideration; each had to have experienced frequent “cravings,” extended periods of daily use, and serious consequences resulting from use. Second, to be eligible, individuals had to have resolved their “dependency” for a period of at least one continuous year. The final selection criterion we used was that individuals had received no treatment at all, including participation in 12-step groups, or participated only minimally in treatment and did not attribute recovery to their treatment. In actuality, about 90% of our subjects fit into the first category of never having experienced treatment at all. The remaining 10% had very limited contact with treatment but unequivocally maintained that they did not recover because of this experience. We employed a snowball sampling technique to select these individuals. Our initial step was to use referral chains that were developed through a chance meeting of an untreated remitter by one of the authors. About half of the individuals we interviewed were contacted through this method. Upon concluding an interview with the respondent each was asked if they knew someone like themselves who had overcome substance misuse without treatment. If the respondent indicated they did know of

1–2 3–5 6–8 9–11 12–15 16–20 21+

Alcohol

Drug

Total

3 10 3 4 3 2 0 25 6.8

2 9 7 1 0 2 0 21 5.9

5 19 10 5 3 4 0 46 6.5

other individuals with similar experiences we asked them to contact that individual and have them call us. In order to solicit additional interviews, we placed advertisements in local newspapers. The advertisement, placed in two major city newspapers for a period of one week, extended invitations to individuals who had overcome alcohol- and drug-use associated problems without treatment to discuss their experiences. All respondents were informed about the nature of the research, assured confidentiality, and informed that their participation was voluntary and that they could choose not answer any questions we posed. The interview process involved: (1) explaining the research, (2) gaining the respondent’s informed consent, (3) collecting face sheet information pertaining to the substances used, related problems, length of time notaddicted, as well as general demographic data including gender, ethnicity, occupational background, educational credentials, age, and marital status, and (4) exploring the experience of natural recovery. As Table 15.2 indicates, the vast majority of the individuals we interviewed had completed high school. Most possessed college experience and several respondents held graduate degrees. Most were employed in professional occupations, including law, engineering, and health care, held managerial positions, or operated

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Table 15.2 Age, Education, Gender, and Occupation of Sample

Age 20–29 30–39 40–49 50+ Education Less than 12 High School Some College College Postgraduate Gender Male Female Occupation Professional Business Laborer Service Employee No Occupation (student, homemaker, retired)

their own businesses. The respondents participating in this study are socially advantaged, a factor that will become particularly important in our analysis. With the exception of two individuals, all respondents were white. At the time of the interview, all were actively engaged in a variety of pursuits associated with religion, education, community life, and health among others. While all presently resided in a large Western city in the U.S., they came from diverse geographical backgrounds. While some spent most of their lives in other large urban areas, others grew up in small towns in the U.S. The primary source of income presently for these respondents was work associated with their profession or career. While some were previously involved in the selling of illicit drugs during their period of active use, most did not participate in the drug trade. Three-fifths of the group were male (25) and two-fifths were female (18).

Number

Percent

7 13 18 8

15 28 39 17

2 11 14 13 6

4 24 30 28 13

28 18

60 40

12 13 8 2 11

26 28 17 4 24

SOCIAL CONTEXT, ADDICTION, AND RECOVERY Emancipation from personal problems like addiction is not equally distributed within society. One’s social structural position and associated social relations mediate the ability to experience self-change. Giddens (26) recognizes the importance of one’s structural location in affecting personal change by asserting that “access to means of self-actualization becomes itself one of the dominant focuses of class division and the distribution of inequalities more generally.” Indeed, while dependency and recovery are not reducible to social class alone, these experiences are certainly related to it (25). Although the current stage of social development may contribute to a range of personal problems and available solutions, these problems and possible solutions are not equality

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distributed within society. Rather, opportunities to develop alcohol- and drug-use associated problems as well as opportunities to transform oneself are unevenly distributed. Individuals who possess life options and resources because of their social position tend to have a greater capacity for getting out of trouble with drugs (13,20). According to social psychologist, Jill Kiecolt, even the chances of developing selfefficacy are affected by social position. As she writes, “location in social structure sorts persons into ‘contexts of action’ which afford different amounts of resources and opportunities for engaging in efficacious action and building self-esteem” (27). Developing the self-efficacy to change oneself is significantly influenced by social structural conditions present or absent in an individual’s life. Thus, men may pursue self-change differently than women, whites may have different strategies than non-whites, and the middle-class may possess resources for change that are unavailable or in limited supply to those who are economically disadvantaged. As one moves up the social hierarchy, opportunities for developing efficacy leading to change increases, while those located near the bottom experience limited opportunities in the form of attributes and resources functional for self-change (28). Consequently, the process of becoming “alcohol” or “drug-dependent” and the strategies for change are not merely contained within an individual, but are greatly affected by one’s more general position within the larger social structure. One way of operationalizing this unequal distribution of emancipatory opportunities is through the concept of “social capital.” The concept of social capital is broadly defined by Coleman (29) as: a variety of different entities having two characteristics in common: They all consist of some aspect of a social structure, and they facilitate certain action of individuals within the structure. Like other forms of capital, social capital is productive, making possible the achievement of certain ends that would not be attainable in its absence. . . . Social capital inheres in the structure of relations between persons and among persons.

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The resources that adhere to these social relations can operate at the broader levels of social organization as in the formation of civic groups and business norms pertaining to trust and cooperation or they can inhere more locally to individuals within particular social settings (30,31). In most cases, however, social capital is unequally distributed within society. As Granovetter and Tilly (32) conclude: “since personal relations are typically homogeneous by class, ethnicity, and region, this mode of allocation can effectively produce existing inequalities.” While the concept of social capital has been used to explain occupational mobility (33,34), the extent of civic culture (30,35) as well as business transactions and economic behavior more generally (29,31), the concept has utility for understanding personal problems such as those associated with addictions and efforts to overcome these problems. Like the above examples, personal problems and their solutions are embedded within a larger structure of social relations and networks. Just as drug use is mediated by the structured relations within which one is embedded, so too are the opportunities for personal change. The opportunities for self-change among crack users in inner-city barrios are undoubtedly different from those in the middle-class who not only have better access to treatment, but also possess greater amounts of social capital that can facilitate change (20). Ultimately, higher status confers more resources, access to social relations, and greater opportunities for self-change (27,28). The following section examines how the structural location of our respondents and their associated social capital are related to their ability to recover from their addictions without treatment.

SOCIAL CAPITAL AND “NATURAL RECOVERY” Substance use and misuse generally occurs within a larger social context within which individuals are socialized into use, develop the rationales associated with use, and derive meanings of their substance-use related experiences. The networks within which these respondents

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were embedded contributed to their use and misuse of substances. Many discussed how their networks afforded them access to substances as well as to a supportive community of users. However, while these networks contributed to the use and misuse of substances, the networks of our respondents were not characterized by a life primarily associated with consuming intoxicating substances. Rather, while our respondents participated in drug using networks, they nonetheless possessed a degree of social stability in their lives that limited their personal deterioration. Most respondents, despite their patterns of “heavy” consumption, maintained fairly regular work lives and were, for the most part, able to avoid lengthy involvement in the criminal justice system. In a sense, these respondents might be categorized as living a double life with one foot in the conventional world and one foot in the deviant world of drug addiction—“twoworlders.” As such, the social capital possessed by our respondents contributed not only to their particular patterns of misuse, but also, and perhaps most importantly, mitigated the potential problems associated with their misuse. Like the experience of substance use and misuse, individuals who overcome alcohol and drug dependencies do so within a context of social relations and the resources adherent to those relations. Each of our respondents reengaged in institutional life, such as work, school, religion, and family, as well as developed or re-established meaningful social relationships, often within the institutions to which they had been connected. However, while these emerging institutional commitments and social relations proved beneficial to those we interviewed, they did not occur independent of each individual’s embeddedness within a structured set of relations. In other words, peoples’ ability to become immersed in conventional life and develop meaningful social relations is influenced by the pre-existing social capital they bring with them into their addiction as well as the amount of social capital they are able to retain through these dependencies. For the most part, because these respondents led relatively stable middle-class lives prior to and during their dependencies, the quality and quantity of social capital they possessed

significantly aided them in their ability to transform their lives. As illustrated below, although our respondents believed that they had overcome their dependencies on their own, their “natural recovery” actually occurred within a structured context of social relations. The social capital that adhered to these relations offered these respondents access to information, normative expectations, relationships, institutions, and other opportunities that provided useful resources for their personal transformations, resources that might otherwise be unavailable in different social contexts.

STABILITY There were a variety of factors in these respondent’s lives that assisted in their creation and maintenance of social capital. One such factor was the degree of stability they brought with them into their dependent use and the amount of stability they maintained during their dependencies. None of our respondents assumed the role of “street addict” or “skid row” alcoholic, nor were any incarcerated for a significant length of time. None had engaged in the sort of street crime, prostitution, or violence that is commonly portrayed in the media. This fact alone assisted these respondents in their ability to maintain a degree of stability. However, the stability of these respondents went beyond these dimensions. Contrary to the popular image of alcoholics and drug addicts, most held steady jobs prior to their dependent use and many remained employed during their dependencies, even though they experienced a host of problems. In the words of an accountant who had experienced a 10-year addiction to cocaine: I really started using heavily and having problems. But through it all, I worked. I was an office manager for an insurance firm for about 5 years. . . . Then in 1985 I decided to commit myself to something, although I was still using heavily. I second mortgaged my house and pulled out $30,000 and bought a tax practice that had 2000 customers.

Having a stable employment history also provided these respondents with the opportunity

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to witness the consequences of their excessive use. Many of those interviewed worked in jobs where they feared that their excessive use would be exposed. One 48-year-old architectural engineer explained that he was worried about what his colleagues would think of his crack use: I was pretty much in control of my life, in my profession. I moved here for job advancement, though I was having problems with alcohol and crack. Professionally I was doing good. I was pushing the edge. Then the crashing down became tremendously worrisome. I was using a lot and became concerned that I would lose my job and the respect of my associates.

Another respondent, a case manager at a social service center, similarly became concerned about potentially losing his job. This respondent explained: Here I was all the way through college. I had a pretty good job and a family and a real bad addiction. . . . If they [colleagues] found out that I was doing (using cocaine and heroin) this I would get fired. And now with drug testing, I would never get another job if I’m not able to pass a drug test.

Even when these respondents experienced problems on the job, most were nonetheless able to keep them. In part, this is because most of these respondents were employed in primary labor market jobs that feature “well-defined paths for advancement and the protection of rules of due process” (36). Unlike low-skilled secondary labor market jobs, employment in the primary labor market typically includes higher salaries, job security, and until recently, generous health benefits (37). Where a person falls within this segmented labor market has significant implications for the level of stability they experience (38). Very often, respondents were protected by the normative prescriptions and legal rights associated with primary labor market employment. For instance, one respondent was having problems at the trucking company where he worked. As a result of his “excessive tardiness and absenteeism,” he was eventually fired. However, with the help of his college-professor

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father who retained legal assistance, Dennis “fought it [the decision] in court and eventually won and got reinstated.” In his words, “I knew how to use the system to my advantage. I just used it the way it was written. The union hacked me all the way and the arbitration rules were in my favor.” Although Dennis continued his use of substances for a short period after this incident, the stability he experienced assisted him in his natural recovery efforts. Among these respondents, the possession of stable employment not only afforded them access to non-substance using colleagues whose opinions they respected, but also provided them with an institutional investment that made it easy for them to eventually quit their own use. In addition, this stability, even while respondents were actively using, gave them financial security that mitigated the need to engage in criminal activities in order to secure drugs. Whether respondents such as Dennis would have pursued criminal activities without such stability is not known. The demographics of these respondents would suggest that they would be unlikely candidates for such activities given their previous levels of stability and socialization. However, what is clear from these individuals is that their economic stability before, during, and after their periods of dependency had a profound impact on their ability to overcome substance misuse and addiction without planned professional treatment or mutual-help programs such as AA, NA, or therapeutic communities. Thus, the greater the level of stability, the greater the likelihood that an individual is able to recover without treatment.

IDEOLOGY Another type of social capital possessed by these respondents that mediated their untreated recovery was ideologically based. Coleman (29) points out that, “[a]n ideology can create social capital by imposing on an individual who holds it the demand that he act in the interests of something or someone other than himself.” As Coleman argues, the development of such ideologies depends, in large part, on the structural connections between an individual and others. The

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possession of social capital can facilitate action by generating a sense of obligation and expectation to act in normatively conventional ways (39). The ideologies held by our respondents, formed through their relations with others, helped facilitate their eventual “natural recovery.” While most of these respondents attributed their self-healing abilities to their own personal resilience and motivations, it is clear that such attributes emerged not from their internal qualities alone, but rather through their association with others. For instance, many developed a strong desire to terminate their dependencies because of their obligation to others. As Coleman (29) points out, this sense of obligation to others is a type of social capital: “[i]ndividuals in social structure with high levels of obligations outstanding at any time, whatever the source of those obligations, have greater social capital on which they can draw.” This suggests that individuals with obligations to others possess increased motivation to act in particular ways. Those who do not possess or fail to recognize their obligation to others are free to violate personal trust, while those holding an ideology of obligation are somewhat more constrained in their actions (31). Many of our respondents possessed such obligations to others. This ideology, forged out of their own biographical experiences, provided them with powerful incentives to change. For instance, a retired military officer with an extensive history of alcohol dependency, describes how his obligation to himself and others served as a catalyst to change: What it finally came down to, I just stopped. I gotta take a look at my life and what the fuck was going on. I’d seen other guys die. That didn’t scare me because I’ve never been afraid of death. But what did scare the shit out of me was that I wasn’t doing a damn thing with my life. I was brought up to be more than an alcoholic.

Another respondent, a 42 year-old business owner, possessed a strong sense of purpose that grew out of his early experiences growing up on the East Coast. As he explained: “I’ve always believed that I had a sense of purpose in my life and a certain amount of strength to accomplish things. I had seen my father accomplish

a lot and he taught me that there’s nothing I can’t do if I try.” Another respondent who was a manager in a local business, while attributing his self-healing to “intestinal fortitude,” nonetheless spoke of his obligation to others. As he commented: “A lot of people have stuck by me during all my problems and I’ll be damned if I’m going to let them down.” This ideology of obligation also manifested itself in the desire to avoid being exposed to non-using friends. This fear of exposure is a type of social capital in that it represents a pre-existing social relation that is capable of influencing behavior. In some cases, this fear prevented the escalation of use. One respondent who had been dependent on heroin and cocaine explained: I stopped shooting up, but I continued using for a long time. I had no marks and I wanted to stop before I had any marks. That was my biggest fear was that I would be discovered and the shame that would be surrounding it. It’s OK, it’s socially acceptable to snort, but not to inject.

Although, like the earlier respondent, this individual attributed his eventual self-healing to his “sheer willpower,” his “will” to stop, like his determination to avoid needle tracks, was related to his involvement in social relations. Similarly, another respondent, who when she was trying to stop, stayed with a non-using friend in Texas and indicated how her connection to this friend influenced her use: One of the things that happened [when I was trying to stop] was that I went down to Texas to stay with a friend. However, I took some stuff with me in case I got the urge. And I remember thinking that I was staying with this girlfriend of mine and her two kids and I remember thinking that she would kill me if she knew that I brought drugs into her house. And she had been my best friend and we did some together years before, but she would kill to protect her kids.

She continued by discussing how this relationship ultimately helped her to discontinue her drug use: “I knew I couldn’t tell Lisa. I came to realize that my life had nothing to do with the people that I really cared about.

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They never would expect that I would get so wrapped up with drugs.” Rather than individual choice alone, respondents’ access to social relations and the related social capital associated with these relations provided much of the incentive for change.

MAINTAINING RELATIONSHIPS Respondents also maintained a degree of social capital that facilitated their recovery by not “burning their bridges” with non-using family members and friends. Although these respondents frequently discussed relational turmoil, in many cases, this turmoil was not sufficient to extinguish relationships. Respondents repeatedly spoke of the importance that family and friends played in their processes of self-healing. This sympathetic investment on the part of others was critical to the personal transformations experienced by these respondents. Very often, respondents claimed that without the help and support of family and friends, they might still be using. As David Karp (40) points out in his work on depression, the potential problems in managing relationships with troubled people can be daunting. As in the case of depression, alcoholand drug-dependent people test the limits of friends’ and family members’ patience. In many cases, people who are dependent on these substances breach what Candace Clark (41) refers to as the “emotional economy.” According to Clark, there are sympathy boundaries within all relationships that are constantly being managed. The margin of sympathy is determined by how much each has given and received in the past. Drawing upon this general concept, Karp (40) likens this emotional economy to a bank. He writes: each of us expects to get approximately what we give and an individual who makes great sympathy demands without re-payment may run out of credit altogether. Should a person become ‘bankrupt’ in a particular relationship, he or she will have to draw on sympathy accounts that remain “open” in other relationships.

While the “emotional economy” of the family and friends of the depressed individuals

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studied by Karp were often tested, he found that intimates sought to honor their perceived commitments to the depressed individual. He concluded that such commitments among family members and friends were essential in relieving the profound emotional pain associated with depression. The commitments that other people feel toward an individual are a type of social capital that is beneficial to those suffering with depression or dependency. In a sense and as suggested by the term emotional economy, this commitment is a form of capital that troubled individuals may draw upon, provided they have not exceeded their sympathy credit. For most of these respondents, the sympathy boundaries associated with the implied emotional economy, while strained, had not been breached. Because of this, respondents were able to benefit from the relational investment of others. In other words, respondents could use the resources that family members and friends possessed to aid in their self-healing. As demonstrated below, access to these resources proved to be extremely beneficial. Friends and family often provided respondents with the emotional support they needed to overcome their dependencies. Very often, respondents talked about how they gained emotional strength from the support of others. Jane, a 26-year-old assistant manager with a long time dependency on cocaine, discussed the importance of her friends: My [non-using] friends were very important to me. I had some dear friends that were supportive and it helped me to take a look internally as far as pulling up my own willpower and making the decision to quit.

Another respondent, a case manager in an alcohol- and drug-user treatment clinic, expressed similar sentiments over the importance of having good friends. Asked what strategies she used to discontinue her drug use, she responded: I think through support of my friends and talking about the frustration and what I was going through. . . . I was living with one friend and another lived in the same apartment complex.

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There were many times I knocked on his door and cried, bawled my head off and he would sit there and listen. I would cry about the fear because I would get the urge to use and it would be overwhelming. That was the only place I could turn. . . . I have known this guy since 3rd grade. We are great friends. I always tell him that he saved my life. I really respect his opinion. If it had not been for him, I probably wouldn’t have been able to do it.

In cases such as these, intimates played the role of a counselor in helping individuals struggle with the emotional demands associated with overcoming their dependencies. However, these intimates frequently provided something much more important than a sympathetic ear and good advice. They offered individuals a sense of belonging. In the words of one respondent, a 36-year-old former heroin addict: “they [my friends] were just there and they made me feel like there was a place for me. I think a lot of drug addicts feel like you don’t matter, no one cares what happens to you.” Knowing that her friends still cared provided the reassurance and strength to overcome her addiction to heroin. Not only were respondents able to draw upon the emotional investments of others, they were also able to directly benefit from the more tangible resources and connections of family and friends. These resources often were made available to respondents at a critical juncture in their dependent careers. Such resources frequently corresponded to the turning points these respondents experienced. In some cases, the resources possessed by friends facilitated employment. These respondents’ economical and occupational stability were buttressed by their social relations with friends who provided them with the “ties” and connections necessary for acquiring good jobs. Sally, who during her excessive use of cocaine and “crank” worked full-time as an environmental activist and attended school, discussed the importance of having stable friends in the labor market. She eventually left her job and the “drug scene” by going to Texas to stay with an old friend. Upon returning to Colorado and in need of employment, Sally explained the ease she had in acquiring another environmental job: “I came back and I made a phone call to a friend and I had a job.” As she continued, “It was a

good feeling, being able to do that kind of thing after all I was through, knowing that I can still get a good job.” Similarly, another respondent reflects on how a friend led to her developing a new life that began with acquiring a job: I had a very strong connection to this friend and she opened the right doors at a time that I needed it. She got me involved with (a civic organization). They were embarking on their . . . program that was a three-year alcohol awareness type program that was implemented nationally. I signed up to be on a committee and I ended up chairing it. I went to Washington for some large conference. It was really neat for me to do. I was only a short way into my sobriety when all this happened. The doors just opened for me. I have really good friends.

Being embedded within a structure of social relationships that were capable of providing resources such as access to meaningful employment was critical to respondents’ eventual recoveries. Not only were they relieved of any financial burdens that might promote the desire to use, but also, their networks facilitated their re-commitment to the conventional world of work. They each had renewed their “stake in conventional life” through the social capital they possessed (13). This re-commitment to institutions also occurred in arenas other than work. For instance, many of these respondents experienced religious conversions. These conversions did not occur independent of the context of social relations. Rather, respondents used the social capital of their friends to connect them to religious institutions. One respondent, for instance, while believing that change must “come from within,” nonetheless experienced his spiritual awakening by utilizing the resources of a friend. He explained: “I got involved in a Buddhist religion through a friend. I knew that she practiced. She got me involved in it and I felt that some type of spiritual faith might help me. I think it has because I continue to practice.” Another explained how his “Buddha buddies” got him involved in Buddhism. For him, that became his main support group.

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The resources of parents also proved beneficial to many younger respondents. An extended analysis of two cases illustrates this point. Andy, another heroin addict who, at the time of the interview, worked in the film industry, discussed how he was able to use the resources made available by his parents. Andy dropped out of high school after completing his sophomore year. Life grew increasingly ugly for Andy as he became involved in stealing cars to support his habit. As things began to deteriorate around him, he made the decision to “get out of that environment.” With some financial assistance from his parents, Andy moved to Hawaii to stay with some relatives in order to “clean up his act.” Although Andy was able to finish his high school education while in Hawaii, he nonetheless returned to his intravenous use of heroin. After three years of living Hawaii, Andy decided to move back to Arizona where his parents lived. At this point Andy’s parents provided him with the finances to attend college where he finally was able to stop his heroin use. As he explained: My family helped out with my schooling and then once I was in this academic environment, I really look advantage of it. I made dean’s list each semester. I graduated with a 3.7 GPA. . . . Once I graduated I started applying my degree in broadcast journalism. I decided to start a business and wanted to go to a big city to do it, like Denver. I wanted to go out West but a journalist friend of mine was moving to Denver. So, I acquired a loan, with the help of my parents, bought a bunch of video equipment and moved here.

Andy owes a great deal to his parents who continued their emotional investment in their son, even through the hard times. Their preserved emotional investment in their son allowed him to utilize the resources they and other relatives were able to make available. Had Andy breached the sympathy boundaries of his parents by “burning his bridges,” he might never have been capable of building the kind of institutional re-commitments and social relations necessary to break his heroin addiction without treatment. Through his parent’s resources, Andy has been able to acquire a good education, grow a successful video production

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business, and become actively involved in community life through dance and theater. Ironically, even his involvement in dance, in part, stemmed from social capital established while living in Hawaii. Andy met and studied with his present dance teacher while she was visiting Hawaii several years earlier. Daria, a 25-year-old college student with a 5-year dependency on heroin, provides a similar account of supportive parents. Daria contacted us after hearing about the study from a student who had attended a lecture given by one of the authors. She, like other respondents, was anxious to tell her story. Daria began injecting heroin at age 17 while she was working as a teenage fashion model. Her use escalated rapidly so that within a year she was, in her words, “really addicted.” “We just did it and did it and did it,” she explained. “Eventually I was at the point of waking up and thinking about it because the first thing I did before going to pee was shoot up.” After experiencing several overdoses, she made the decision to stop. Rather than going to a detox clinic or worse, however, Daria was afforded the comfort of a mountain “getaway” to quit cold turkey. As she explains: My husband and I set up a plan. I was going to go up to a secluded house in the mountains owned by my dad. When I went up there I was really sick from detoxing. We did it but I was really miserable but I wasn’t using. I think we were there about 45 days.

After finally getting off heroin, Daria sought to re-establish her relationship with her parents. Although their relationship had been strained over the years of her heroin addiction, they nonetheless were able to reconcile their differences. In fact, Daria’s parents provided additional support for her determination to remain drug-free. When asked about her relationship with her parents, Daria commented: My mom is trying to make a relationship now when I’m 25. . . . I don’t want to put her through more than she needs. I’m working on building trust with my parents now. She still doesn’t trust me when she gives me money for school to pay my tuition [at an expensive private school] but I know they’re really proud of me now that I’m clean.

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As in the case of Andy, Daria’s termination of heroin use after several years of addiction was facilitated, in large part, by the unyielding support of her parents who provided her with valuable resources. Not only was she afforded the opportunity to remain isolated from a subculture of drug addicts by withdrawing in the comfort of the peaceful Rocky Mountain environment, but she also had her education at an expensive private college subsidized by her parents. Being a member of the upper-middle class and having access to financial and other resources meant that Daria’s recovery from heroin addiction was extremely different from that of a street “junkie.” Unlike “street junkies” who often have little to look forward to after they stop using, Daria had access to resources that encouraged her to develop a renewed stake in conventional life. She was surrounded by a supportive “safety net” that eased her transition into a drug-free lifestyle. Like Andy, Daria was finally able to walk away and stay away from heroin because she did not have to work hard to become re-integrated into the conventional world. Because Daria’s physical, emotional, and financial needs were taken care of, when she finally made the decision to change her life, she was able to move forward towards her own self-actualization without treatment.

DISCUSSION AND IMPLICATIONS As suggested by this study, social capital is differentially distributed among alcohol- and drug-dependent individuals and those who are able to overcome their drug dependencies without formal planned or mutual-help treatment, as a group, may possess more of this capital than those who are involved in treatment. This is not to suggest that members of the middleclass are immune to addiction problems. Rather, the crucial point is that those who possess larger amounts of social capital, perhaps even independent of the intensity of use, will be likely candidates for less intrusive forms of treatment such as those associated with brief intervention and “natural recovery” (42). A focus on enhancing social capital, as well as other forms of capital, is consistent with a

harm-reduction approach that concentrates on integrating alcoholics and addicts into their “natural communities” as opposed to isolating them from these available resources (43). Indeed, the practice of terminating employees with drug-use associated problems or imprisoning users directly contradict the successful experiences of our respondents. As Patricia Erikson (44) has recently pointed out, the concept of social capital offers a new direction for policy-makers, particularly in the general area of harm reduction. As she writes, “the importance of community social capital, referring to the structure of resource generating social relations in the community, as conditioned by socio-economic conditions, employment opportunities, basic infrastructure, and social welfare services, in determining the size of the population that is most vulnerable. The building of social capital to bring about the improvement of the most fundamental living conditions of the population is a vital aspect of harm reduction.” A harm-reduction approach to recovery would seek to increase the capacity of individuals to overcome their addiction. This approach would suggest that one avenue to recovery would be to work at the environmental level to build the social capital of individuals and of the communities where they reside. In this regard, treatment may be more effective if it is directed at enhancing the available social capital of drug addicts and alcoholics as opposed to focusing on a dependent person’s use independent of the social context that surrounds that person. As Stanton Peele (4) writes, “addicts improve when their relationships to work, family, and other aspects of their environment improve.” Individuals who recover from their addictions without treatment illustrate the importance that social capital has in their lives, prior to their addiction, during it, and as they attempt to change. A focus on the social context of addiction and recovery may lead to a reevaluation of the disease-oriented proposition which posits that individuals are powerless over the drugs which they consume. This social capital/ recovery relationship is the principal rationale for suggesting to practitioners who are not already doing so to view treatment on a

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continuum from least intrusive to most intrusive and which can be usefully considered in terms of professional-planned-mutual-help and self-help. While recovery without treatment is clearly the least intrusive of all possible options and holds numerous advantages, particularly for those possessing a good supply of social capital, brief intervention comports well with the concept of “natural recovery” and should be considered by treatment professionals as a viable option for many who are struggling with addiction. Research that investigates further the social capital/recovery relationship could yield important results. For instance, what are the social capital attributes possessed by individuals that reside in communities with little social capital that either prevents them from experiencing substance-use related problems or allows them to overcome them. Such a focus could help identify the actual or potential resiliencies in people’s lives that help them overcome assorted problems, including problems associated with the misuse of substances. In addition, quantitative studies that are able to draw a correlation between measurements of social capital and recovery could be useful in generalizing the importance of social capital variables to a wider audience. Finding general patterns of association between social capital and recovery would raise important policy considerations. Our analysis has implications for how others react to various types and patterns of substance addiction as well. Generally, more attention is directed at the substance to which a person is addicted than to the circumstances within which a person is embedded. For instance, proponents of concepts such as “tough love” might see the kind of support and assistance given to our respondents as enabling their disease. Perhaps it is understandable that parents and friends who, because of several failed attempts or simply because it is an excuse for the lack of real intimacy, wish to terminate all interaction with “substance abusing” individuals. However, the individuals we interviewed suggest that having caring and nurturing friends and family members, who did not condone their behavior but were there to provide support, was critical to their “natural recovery.”

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If our respondents offer any guide, the maintenance of intimacy is essential to the ability to overcome dependencies. True intimacy does not mean condoning any and all behavior, including behavior associated with alcohol and drug misuse. Nor does it mean, however, that one should make love and nurturance contingent on authoritarian demands. As Giddens (46) writes, “intimacy is not being absorbed by the other, but knowing his or her characteristics and making available one’s own.” While establishing personal boundaries is a part of any healthy relationship based upon intimacy, it does not necessarily imply the retraction of affective ties. Rather, and in the case of troubled individuals, it may involve “loving detachment,” or “the emerging capacity to sustain care for the other without shouldering the burden of his or her addiction” (41). Unfortunately, concepts such as “tough love” may end up holding the dependent individual hostage to the insecurity or inability of family members and friends. As our respondents demonstrate, intimacy is not only important for the emotional benefits associated with being accepted by others, but, perhaps more importantly, because it provides continued access to the social capital of others who can provide resources and networks. The destruction of social capital prevents a person in need from utilizing the capital of others. This impediment to the “capital” of others can often exacerbate personal problems. Though we live in a society that glorifies a meritocratic ideology of “pulling oneself up by the bootstraps,” it is largely a cultural myth. Few people accomplish much in this world, whether in their chosen occupation or in overcoming life’s many challenges, without the assistance of others. Whether through the direct action of “networking” or through an accident of circumstance, we are both aided and restricted by the structured set of social relations within which we are embedded. It is in this sense then that “natural recovery” is indeed natural. The experiences of our respondents, while subscribing to an individualistic ideology of recovery, actually attest to the importance of existing social relations that surround and envelop them. The “natural” communities of friends,

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family members, and relatives, and the social capital available through these connections, contributed significantly to the personal transformations of our respondents.

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12. Vaillant, G. The Natural History of Alcoholism. Harvard University Press: Cambridge, MA, 1983. 13. Waldorf, D.; Reinarman, C.; Murphy, S. Cocaine Changes: The Experience of Using and Quitting. Temple University Press: Philadelphia, PA, 1991. 14. Walters, G. The Natural History of Substance Abuse in an Incarcerated Criminal Population. J. Drug Issues 1996, 26(Fall), 943–959. 15. Sobell, L.; Sobell, M.; Toneatto, T. Recovery from alcohol problems with treatment. In Self-Control and the Addictive Behaviors; Heather, N., Miller, W.R., Greeley, J., Eds.; Maxwell Macmillan: New York, 1992. 16. Ludwig, A. Cognitive Processes Associated with Spontaneous Recovery from Alcoholism. J. Studies Alcohol. 1985, 46, 53–58. 17. Tucker, J.; Vuchinich, R.E.; Gladsjo, J.A. Environmental influences on relapse in Substance Use Disorders. Int. J. Addictions 1990/91, 25, 1017–1050. 18. Tucker, J. Environmental Contexts Surrounding Resolution Among Problem Drinkers with Different Help-Seeking Experiences. Paper presented at the International Conference on Natural History of Addictions: Recovery from Alcohol, Tobacco, and Other Drug Problems without Treatment. Les Diablerets, Switzerland, 7–12 March, 1999. 19. Bloomqvist, J. Recovery With and Without Treatment: A Comparison of Resolutions of Alcohol and Drug Problems. Paper presented at the International Conference on Natural History of Addictions: Recovery from Alcohol, Tobacco, and Other Drug Problems without Treatment. Les Diablerets, Switzerland, 7–12 March, 1999. 20. Murphy, S.; Rosenbaum. M. Two Women Who Used Cocaine Too Much: Class, Race, Gender, Crack, and Coke. In Crack In Context: Demon Drugs and Social Justice: Reinarman, C.; Levine. H.; Eds.; University of California Press: Berkeley, CA, 1997. 21. Sandefur, R.; Laumann, E. A Paradigm for Social Capital. Relationality and Society. 1998, 10, 481–501. 22. Bourdieu, P.; Wacquant, L.J.D. An Invitation to Reflexive Sociology. University of Chicago Press: Chicago, 1992.

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PART IV

Expanding Addiction

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CHAPTER 16

A Disease of One’s Own Life Stories, Identity, and the Emergence of Co-Dependency John S. Rice Since the mid-1980s, co-dependency1 has become an increasingly significant sociocultural phenomenon, attracting perhaps millions of adherents and accounting for millions of dollars in book sales. Consider the following: •

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During the summer of 1989, the first National Conference on Co-Dependency was held at the Wyndham Paradise Valley Resort in Scottsdale, Arizona. Although conference planners anticipated perhaps 800, the event “sold out at 1,800 registrants [and] many people were turned away for lack of space.” Indeed, the “resort had to set up impromptu food booths all over the hotel” (Krier 1989, p. 21). As of July 1990, Co-Dependents Anonymous (CoDA) meetings numbered 2,088 weekly throughout the U.S. and 64 international meetings were registered with the CoDA International Service Office. Melody Beattie’s Codependent No More (1987)2 was the 10th best-selling trade paperback in the nation on the Publishers Weekly 18 October 1991 list. It has been on that list 154 weeks.

John Bradshaw—a co-dependency theorist, management consultant, family systems therapist, and lecturer—has also been remarkably prolific and successful. In 1989, Bradshaw On: The Family (1988) and Healing the Shame That Binds You (1989) were selling a combined total of about 40,000 copies per month. His most recent book, Homecoming: Reclaiming and Championing Your Inner Child (1990)

was the eighth best-selling nonfiction hardcover in the nation on the Publishers Weekly 9 September 1991 list. It has been on the list 51 weeks. This partial catalogue underscores co-dependency’s rapid incorporation into contemporary American culture. Yet, for both the theorists and their critics (e.g., Kaminer 1990; Krier 1989; Kristol 1990; Streitfeld 1990), defining what, exactly, “co-dependency” is proves elusive. Only since the First National Conference have theorists agreed upon a single definition, and even that—as critics quickly and, often, condescendingly note—remains extremely unspecific: “a pattern of painful dependence on compulsive behaviors and on approval from others in an attempt to find safety, self-worth and identity” (Krier 1989, p. 1). Rather than use co-dependency theory as foil for yet another display of critical and theoretical acumen, this study treats co-dependency as a life story people select as a narrative of their lives to acquire a new and more satisfying sense of identity (see, e.g., Bruner 1987; Denzin 1989, 1990a, 1990b; Plummer 1983, 1990a, 1990b). Although co-dependent life stories clearly draw upon both psychotherapeutic and addictive “canons” (Denzin 1990a), each approach has different rules for what constitutes a true statement; each “creates” and requires different kinds of individuals. This suggests that such groups as CoDA, Alcoholics Anonymous (AA), Adult Children of Alcoholics (ACoA), and the like should be understood as “discursive formations” (Foucault 1972, also 1980a, 1980b, 1984a, 1984b, 1984c, 1984d).

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This analysis comprises two stages. First I examine the major canon-forming works in the discourse to isolate the rules that distinguish CoDA life stories from those of adaptational/ addictive and liberation psychotherapy discourses. The primary, but not only, texts used are by Beattie (1987), Bradshaw (1988), Schaef (1986), and Subby (1987). This combined archaeology and genealogy yields a clearer portrait of what it means to “become co-dependent” (cf., Becker 1963; Matza 1969; Rudy 1986). Second I consider the role of power in life story construction and selection.

BACKGROUND: OF THERAPY AND ADDICTION Co-dependency is clearly part, and an increasingly important part, of contemporary efforts to find alternatives to “traditional” forms of identity, such as those the nuclear family, denominational and church-based religion, and the demands of a normative community yield. The past three decades have seen an explosion of such alternative life stories, particularly those psychotherapy and addiction theories offer—each of which co-dependency has drawn upon freely. Psychotherapy’s rising public fortunes are amply documented. Empirical studies (e.g., Veroff, Douvan, and Kulka 1981; Yankelovich 1982; Zilbergeld 1983) both verify and spawn a virtual cottage industry of concerned, if not critical, theoretical comment, including Mills’s (1959) pioneering discussion of the post-modern, psychotherapeutic search for self; Bellah, Madsen, Sullivan, Swidler, and Tipton’s (1985) “therapeutic attitude”; Gehlen’s (1980) “new subjectivism”; Sennett’s (1978) The Fall of Public Man; and Boyers’s (1975) “psychological man.” Each of these studies, in turn, echoes Berger and Luckman’s (1966) conviction that Western, pluralistic societies pose significant practical and theoretical problems for identity construction and maintenance, and Rieff’s that The Triumph of the Therapeutic ([1966]1987) constitutes no less than a cultural revolution, in which self supplants society as the priority of contemporary moral order.

The growing public acceptance of the disease model of addiction over the same time period is no less striking. Between 1979 and 1989, the total number of privately-owned addiction treatment centers more than doubled, from 2,935 to 6,036 facilities (National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism 1990), and the most recent U.S. Department of Health and Human Services study of treatment facility censuses (1990, N.B. ch. 7) reports that 1.43 million people received some form of addiction treatment during 1987. The proliferation of self-help groups modeled after AA and its 12-Step recovery program mirrors these figures. Indeed, There are 12-step programs for just about everything (there are 15 million Americans in 500,000 recovery groups and 100 million Americans are related to someone with some form of addictive behavior), and there are several hundred recovery bookstores throughout the country. (Jones 1990, p. 16)

Although one must sift through such claims cautiously, little doubt can exist that the 12-Step philosophy has captured the allegiances of a substantial minority of Americans. “Anonymous” groups specialize for life troubles ranging from drug and alcohol problems through over/ undereating, gambling, overspending, sex and love addiction, emotional volatility, child abuse, incest, and smoking. This 12-Step subculture,3 if you will, also offers support groups to assist friends and loved ones of those with the “primary” addiction in dealing with the trials of intimacy with an addict. Al-Anon, founded in 1951, the 12-Step program for those close to alcoholics, is the oldest, largest, and most well-known of these “secondary” groups. As of 1988, Al-Anon claimed 28,000 groups worldwide, 15,000 in the U.S. The meteoric rise of ACoA, much more recently, further underscores public embrace of Anonymous programs. For example, in 1981, 14 weekly ACoA meetings were registered with Al-Anon’s World Service Organization. By April 1990, this number had mushroomed to over 1,500 for the U.S., and over 200 for 10 foreign countries.4

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Although the co-dependency canon has clear affinities with these groups, less clear is where, exactly, it fits in the 12-Step subculture. The term’s original use (among addiction treatment industry personnel, starting in the mid-1970s), appeared to describe “secondary” groups; that is, co-dependents, much like Al-Anon members, are not themselves substance addicted, but in an intimate relationship with a “chemical dependent.” In the mid-to-late 1980s, however, a group of addiction counselors and people otherwise active in the 12-Step subculture began to urge a broader application of the term. These theorists (e.g., Wegscheider-Cruse 1984, 1985; Subby 1987, 1988; Beattie 1987, 1989; Bradshaw 1988, 1989, 1990; Schaef 1986, 1987, 1990) insisted that “co-dependency” is itself a “primary” disease. Even the subculture far from unanimously accepts this position,5 but many entirely endorse it.

THE EMERGENCE OF CO-DEPENDENCY Superficially, co-dependency can be and has been understood as one more psychological construct. Certainly, this is how critics have viewed it. For example, noted psychoanalyst Robert Coles argues that co-dependency is a “typical example of how anything packaged as psychology in this culture seems to have an all too gullible audience” (quoted in Kaminer 1990, p. 1). While of course accurate to say that the co-dependency canon reflects a psychology, this is tantamount to saying that the AA view of addiction, Skinnerian behaviorism, Freudian psychoanalysis, and Rogerian psychotherapy are all “psychologies.” Such an observation, while indisputable, obscures far more than it reveals. Each of these psychologies observes fundamentally different rules for truth, and, as such, produces fundamentally different life stories. Co-dependency draws upon, in particular, two of these canons: liberation psychotherapy and the disease model of addiction. “Liberation psychotherapy” is the working term used here for those human potential psychologies that call for the individual’s emancipation from the stifling demands of role-bound conduct. The disease model of addiction, of course, explains

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people’s repeated violation of sobriety and propriety norms by organic dependency upon alcohol and other drugs. Co-dependency fuses these two perspectives, and thus cannot be fully or solely understood in terms of either. Perhaps the most fundamental internal rules for truth in various psychological statements are born of the theorists’ assumptions regarding human nature and culture. This is logical enough, for the conflicts between the individual and sociocultural institutions are and have long been the province of psychotherapeutic theory and techniques. As the following discussion illustrates, to understand co-dependency in this way is certainly helpful, for its blend of two contradictory trajectories of assumptions grounds the autonomous life stories it vouchsafes adherents.

ADAPTATIONAL DISCOURSES AND ADDICTION Discourses of adaptation derive from the assumptions that (1) humans are by nature aggressive and potentially dangerous, and (2) culture, as the source of human morality and civilized existence, is both valuable and necessary for social order. These “rules” set the conditions for the truth of certain statements. One of the well-springs from which codependency draws is addictive discourse, which, as originated and practiced by AA, is a modified discourse of adaptation. Here, too, is a tacit rule that existing moral order is the standard by which to diagnose disease and gauge the nature of “recovery.” The putatively innate moral qualities or capacities of human nature are largely bracketed, in favor of the judgment that disease explains the individual’s recurrent violation of norms.6 These rules inform the following observations from an important AA text: We thought “conditions” drove us to drink, and when we tried to correct those conditions and found that we couldn’t to our entire satisfaction, our drinking went out of hand and we became alcoholics. It never occurred to us that we needed to change ourselves to meet conditions, whatever they were. (Alcoholics Anonymous World Services 1985, p. 47; emphasis added)

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These intrinsically restitutive themes recur again and again in AA literature. For example, the first of AA’s 12 Steps—“We admitted we were powerless over alcohol, that our lives had become unmanageable”—is predicated upon just such implicit but nonetheless thoroughgoing cultural conservativism: the alcoholic is powerless, after all, to behave in accordance with existing normative order, as personal and social unmanageability manifest. The general addictive rules contain several additional criteria for true statements: (1) because addicts continue drug use and thus, destructive behavior, they are diseased; (2) because diseased, they are powerless to act otherwise; (3) the pattern of misuse results in the addict’s increasingly unlivable, chaotic, and troubled life; moreover, (4) members are to address the damage the addiction does to self and others, rather than the damage that may have caused the individual’s addiction. Indeed, statements that espouse a social etiology for addiction are clearly not accorded truth value; rather, in AA argot, they evince “denial,” or “stinkin’ thinkin’,” “ an unwillingness to “own” responsibility for “getting into recovery.” In other words, members who describe their problem drinking as the product of, for example, their upbringing, are advised that such views are symptoms rather than explanations of their disease.7

CO-DEPENDENCY AND ADDICTION On the surface, co-dependency appears to be subject to the same truth rules that guide AA’s addiction model. Co-dependency theorists rely heavily upon the addiction discourse, and the 12 Steps of CoDA match AA’s with the exception of a single word in the first step: “We admitted we were powerless over others, that our lives had become unmanageable.”8 This suggests the faithful view “co-dependency” as an addiction, an alcoholism-like disease. Thus, Schaef argues that, in alcohol and drug “treatment circles, we have been saying that the disease of alcoholism and the disease of codependence . . . is [sic], in essence, the same disease” (1986, p. 29), and

Currently, we are beginning to recognize that codependence is a disease in its own right. It fits the disease concept in that it has an onset (a point at which the person’s life is just not working, usually as a result of an addiction), a definable course (the person continues to deteriorate mentally, physically, psychologically, and spiritually), and, untreated, has a predictable outcome (death). (p. 6; original emphasis)

Although CoDA’s first step states that codependents are powerless over others, somewhat paradoxically, they are also powerless over their desire to control others. This doubly powerless status informs Beattie’s observations that “a codependent person is one who has let another’s behavior affect him or her, and is obsessed with controlling that person’s behavior” (1987, p. 31); and “[c]odependents are oppressed, depressed, and repressed. . . . We try to control other people’s feelings” (p. 130). In a similar vein, she argues “[W]e cannot control life. Some of us can barely control ourselves. People ultimately do what they want to do” (p. 74). Dual powerlessness is perhaps most evident in the theorists’ catalogues of co-dependency’s symptoms, remarkably similar, regardless of whose list one consults. Beattie’s (1987, pp. 37–45) list, only partially reproduced here, is perhaps the most comprehensive. Co-dependents • • • • • • • • • • • • • •

don’t know what they want or need. abandon their routine to respond to or do something for someone else. overcommit themselves. feel harried and pressured. reject compliments or praise. get depressed from a lack of compliments or praise. have a lot of shoulds. get artificial feelings of self-worth from helping others. wish good things would happen to them. wish other people would like or love them. tend to worry. abandon their routine because they are so upset about something or somebody. feel controlled by events or people. get confused.

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• • • • • • • • • • • • • • • •

believe lies. wonder why they feel like they’re going crazy. center their lives around other people. worry other people will leave them. stay in relationships that don’t work. leave bad relationships and form new ones that don’t work either. don’t say what they mean. don’t know what they mean. find it difficult to get to the point. aren’t sure what the point is. say everything is their fault. say nothing is their fault. apologize for bothering people. avoid talking about themselves, their problems, feelings and thoughts. tend to be extremely irresponsible. tend to be extremely responsible.

This list owes a great deal to addiction theorists whose work is most often associated with ACoA rather than co-dependency, per se. ACoA’s influence on CoDA is repeatedly evident in the discourse. Woititz, for example, documents a recurrent set of characteristics among ACoAs, including their tendencies to “constantly seek approval and affirmation,” “judge themselves without mercy,” and be either “super responsible or super irresponsible [sic]” (1983, p. 4). The similarities with Beattie’s list are clear. For Woititz, however, these traits identify the non-addicted family members; she sees ACoAs, in short, as another “secondary” casualty of addiction in the family. “Co-dependency” differs in either or both of two ways: it is viewed as (1) a problem not limited to so-called “alcoholic families” and (2) a primary disease in the manner of alcoholism. However strained the analogy with alcoholism may be to the outside observer, at least two of the long-standing rules for true statements in addictive discourse—powerlessness and unmanageability—enter Beattie’s list. However, correspondences with other conditions of addictive truth are less solid. Although, for example, all the theorists suggest co-dependents repeatedly violate some version of moral order, uncertain is which or whose moral order is transgressed by such symptoms as worrying,

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centering one’s life around others, apologizing for bothering people, or wishing good things would happen. Such “violations” obviously are not judged by “traditional” cultural standards. Closer examination demonstrates that the discourse routinely strays beyond conventional criteria for addictive truth. For example, Wegscheider-Cruse defines the most likely codependents as all persons who (1) are in a love or marriage relationship with an alcoholic, (2) have one or more alcoholic parents or grandparents, or (3) grew up in an emotionally repressive family. (1984, p. 1; emphasis added)

To invoke the “emotionally repressive family” belies AA’s tacit rule that existing cultural institutions are the standard of diagnosis and recovery, rather than the disease source. Yet this theme is frequent in co-dependency discourse. For example, Subby’s definition directly echoes Wegscheider-Cruse’s. “Co-dependency” is an emotional, psychological, and behavioral condition that develops as a result of an individual’s prolonged exposure to a set of oppressive rules— which prevent open expression of feelings as well as the direct discussion of personal and interpersonal problems. . . . [It is] born of the rules of the family. (1988, pp. 26–27; emphases added)

All co-dependency theorists exhibit a similar “anti-institutional mood” (Zijderveld 1972), particularly towards those most directly responsible for primary socialization: the family, church, and schools. Schaef asserts three of our major institutions—the family, the school, and the church—actively train us not to have boundaries. They teach us to think what we are told to think, feel what we are told to feel, see what we are told to see, and know what we are told to know. This is cultural co-dependence training. We learn that the reference point for thinking, feeling, seeing, and knowing is external to the self. (1986, p. 46)

Clearly, in short, traditional rules for true statements about addiction do not hold for

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co-dependency. But the critique of cultural institutions is only one break with conventional addictive discourse. Consider this passage from AA’s Twelve Steps and Twelve Traditions: As by some deep instinct, we A.A.’s have known from the very beginning that we must never, no matter what the provocation, publicly takes sides in any fight, even a worthy one. All history affords us the spectacle of striving nations and groups finally torn asunder because they were designed for, or tempted into controversy. Others fell apart because of sheer self-righteousness while trying to enforce upon the rest of mankind some millennium of their own specification. (1985, p. 176)

These comments refer to the “tenth tradition”: AA “has no opinion on outside issues; hence the AA name ought never be drawn into public controversy” (p. 176). In striking contrast, Bradshaw claims that Something’s wrong in a society where 60 million are seriously affected by alcoholism; 60 million are sex abuse victims; 60% of women and 50% of men have eating disorders; one out of eight is a battered woman; 51% of marriages end in divorce, and there is massive child abuse. We are an addicted society. We are severely co-dependent. (1988, p. 172)

Clearly, this offers an opinion regarding outside issues—a departure itself. However, the conclusions reached indicate another point of discontinuity. Although some of his data are dubious, few would fault Bradshaw’s selection of pressing social problems. Child and sexual abuse and violence against women are indisputably serious and troubling. But one must ask in what ways these are addictions. Recall that one criterion for addiction is physiological chemical dependency. This dependency, and the body’s response when deprived (withdrawal), is perhaps the key source of the disease model’s public and medical legitimacy: at some point, the user is physiologically dependent upon the drug. To speak of addiction in the absence of a physiologically addicting substance must be seen as another genealogical break with conventional addictive discourse.

PROCESS ADDICTIONS In this departure from the rules for addictive statements, co-dependency is part of a broader project of redefining addiction to include socalled “process” or “activity” addictions. This project underlies Schaef’s observation that An addiction to food or chemicals is often called an ingestive addiction. A process addiction is an addiction (by individuals, groups, even societies) to a way (or the process) of acquiring the addictive substance. The function of an addiction is to keep us out of touch with ourselves (our feelings, morality, awareness—our living process). An addiction, in short, is anything we feel we have to lie about. (1986, p. 24; emphases added)

Moreover, if addiction is grounded in dishonesty, then the former is pervasive, at least as Schaef defines dishonesty: To be out of touch with your feelings and unable to articulate what you feel and think is dishonest. To distrust your perceptions and therefore be unwilling to communicate them is dishonest. To focus on fulfilling others’ expectations, whether they are right for you or not, is dishonest. Impression management is dishonest. (1986, p. 59)

Bradshaw’s equally broad view of addiction argues that behavior is the crucial distinction between the addict and non-addict. This holds for addictive discourse as well, but for Bradshaw the distinction rests upon whether or not the behaviors are “strategies of defense against . . . [emotional] pain” (1989, p. 88). If they are such strategies, they are mood-altering and become addictive. These behaviors include perfectionism, striving for power and control, rage, arrogance, criticism and blame, judgementalness [sic] and moralizing, contempt, patronization [sic], caretaking and helping, envy, people-pleasing and being nice. (p. 88; emphasis added)

Again, clearly the theorists strongly nurture linkages between co-dependency and AA discourse. Equally evident, however, is the

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theoretical difficulty of this investment. It stretches the rules of addictive truth in ways AA founders could not have endorsed and, indeed, feared (Alcoholics Anonymous 1985). The focus upon damage done by the disease is retained, but emphasis upon the damage done to the individual at the hands of the traditional “identity-bestowing” (Berger 1963) institutions is added. In short, this view holds that those institutions are not only shattered by, but cause, addictions. Combined with the concept of “process” addictions, this position strongly suggests that “co-dependency” is a psychotherapeutic category; a product, moreover, of a particular psychotherapeutic discourse. The life stories these materials might yield would little resemble those of AA, and only partially those of Al-Anon. The theorists’ emphasis upon cultural repressions, particularly the “control of desires and emotions,” so fundamentally differs from the dominant version of addictive discourse that it is fair to look elsewhere for genealogical antecedents.

FAMILY SYSTEMS THERAPY Theorists’ references to “dysfunctional family systems” point to another source of co-dependency discourse that warrants exploration: so-called “family systems” psychotherapies, a framework born of 1950s schizophrenia studies (e.g., Midelfort 1957) and expanded upon ever since (Bowen 1978; Ackerman 1958, 1966; Minuchin 1974, 1984; Laing and Esterson 1971). In essence, these attempt to go beyond the individualistic orientation of conventional ego or insight psychologies and to recognize the individual as part of a social system with laws and principles that transcend, indeed determine, individual behavior. Although no more useful to speak of family systems therapies as a unified discourse than of co-dependency as “psychological,” most family systems therapists share certain core concepts. This theory posits that family interactions (1) are the cumulative product of a shared history, (2) exhibit “circular causality,” and (3) follow a set of implicit “family rules.” Individual behavior, then, assumes meaning only in the family context.

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Especially in the early 1980s, a “second generation” of therapists heavily influenced by this systemic view began to apply it specifically and clinically to families with alcohol and drug problems (see, e.g., Black 1981; Woititz 1979, 1983; Wegscheider 1981; WegscheiderCruse 1984, 1985). It is since commonplace to speak of addiction as a “family disease.” That the presence of an addiction affects all family members is the guiding assumption, or, in Bradshaw’s terms, The theory of family systems accepts the family itself as the patient with the presenting member being viewed as a sign of family psychopathology. (1988, p. 27)

In essence, in this role theory of the addicted family (see Denzin 1991, ch. 7) no one gets sick alone. Rather, the alcoholic constitutes a threat to the other family members, all of whom adapt behaviorally in response. These “accommodations,” as Wegscheider-Cruse calls them (1985, p. 129), become patterned into roles, in effect, symptoms of a dysfunctional family system. The names assigned to each general pattern of adaptation imply the nature of the dysfunctional roles. Black, for example, identifies “The Responsible One, The Adjuster, The Placater, and Acting-Out Child” (1981, chs. 2, 4). Renamed and expanded, the list now includes “the enabler” (most often the spouse, who “covers up” for the addict), “the family scapegoat,” “the family hero,” “the lost child,” and “the mascot” (Wegscheider-Cruse 1985, p. 129). Despite these largely nominal changes, however, Black’s influence upon co-dependency remains unmistakable. Clearly these original applications of family systems theory to addiction abide by criteria of addictive truth: the addicted family member is said to throw the family system out of balance, and the other members, in keeping with the concept of circular causality (or “homeostasis”), attempt to compensate for the addict’s volatility and unreliability. These attempts help keep the system functioning, but at the expense of the non-addicts’ psychological wellbeing. As with the AA view, the addict is seen as sick, rather than, say, intrinsically benign or

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aggressive. The focus, then, is upon the damage the disease visits upon family members. This point of view orients such “secondary” 12-Step groups as Al-Anon and the majority of Al-Anon-recognized ACoA groups.9

THERAPIES OF LIBERATION This second application of family systems therapy shares and contributes to co-dependency’s critical stance towards traditional institutions, and resonates with what is here referred to as liberation psychotherapy, a discourse perhaps most associated with Carl Rogers (see also Maslow 1949; Montagu 1950). Liberation therapy assumes that culture is unduly repressive but not particularly necessary or valuable, and that human nature is innately gentle and loving; in short, it inverts the assumptions of adaptational psychologies. Regarding human nature, for example, Rogers says, I have little sympathy with the rather prevalent concept that man [sic] is basically irrational, and that his [sic] impulses, if not controlled, will lead to destruction of others and self. (1961, p. 194)

Indeed, “the basic nature of the human being, when functioning freely, is constructive and trustworthy” (p. 194). The principal source of human suffering, for Rogers, is the sociocultural order that requires and creates the so-called defensively-organized person. Decrying this cultural context, Rogers laments, [T]he Protestant Christian tradition . . . has permeated our culture with the concept that man is basically sinful, and only by something approaching a miracle can this sinful nature be negated. (p. 91)

Still more disturbing for Rogers is the complicity of rival psychologies in this pessimistic outlook. For example, Freud and his followers have presented convincing arguments that . . . man’s basic and unconscious nature . . . is primarily made up of instincts which

would, if permitted expression, result in incest, murder, and other crimes. (p. 91)

Over and against this understanding of culture and human nature, Rogers views life as a “process” in which the individual is free and encouraged to express and explore all emotions: “I like to think of [this process] as a ‘pure culture,’” in which “the individual . . . is coming to be what he is” (pp. 111–113; original emphasis). Key to psychological health, then, for Rogers, is individual liberation from these cultural effects: When we are able to free the individual from defensiveness, so that he is open to the wide range of his own needs . . . his reactions may be trusted to be positive, forward-moving, constructive. (p. 194)

As with the discourses of adaptation and addiction, certain rules govern the types of statements possible as a Rogerian. True statements in liberation therapy discourse must either explicitly refer to or be implicitly guided by the notions that (1) the individual is innately “constructive and trustworthy,” (2) this individual, moreover, is the “true self,” sequestered behind a wall of defenses born of repressive cultural authority, and (or) (3) emotional experience and expression best access the nature of this self. These more fundamental rules shape the family systems theory tenets that underpin co-dependency discourse.

THE “POISONOUS PEDAGOGY” Of all the theorists, perhaps Bradshaw most consistently seeks to construct a general theoretical model of “co-dependency.” He argues that “codependency” is the product of “the poisonous pedagogy”10—a set of cultural rules demanding, at bottom, “obedience, orderliness, cleanliness and the control of emotions and desires” (1988, p. 7; original emphasis). In more detail, the rules of this poisonous pedagogy include (1) control of all actions, feelings, and personal behavior at all times; (2) a standard of rigid and unrealistic perfectionism, and an expectation that one must

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always be right; (3) a propensity to assign blame to self or others “whenever things don’t turn out as planned”; (4) a no-talk rule, that forbids discussion of “any feelings, thoughts, or experiences”; and (5) mythmaking, or the tendency to deny that there are problems that warrant attention (pp. 80–82). Bradshaw argues that these cultural parenting rules translate into the psychological “abandonment” of children. Parents abandon their children by, among other things, “not modeling their own emotions” for them; “not being there to affirm their children’s expression of emotion”; “not providing for their children’s developmental dependency needs”; and “not giving them their time, attention and direction” (p. 3). Abandonment, in this expanded sense, creates a “shame-based inner core”; as a result, “the experiencing of self is painful. To compensate, one develops a false self in order to survive” (p. 3). Thus, abandonment, in the sense I have defined it, has devastating effects on a child’s beliefs about himself [sic]. And yet . . . many of our religious institutions offer authoritarian support for these beliefs. Our schools reinforce them. Our legal system reinforces them. (p. 8)

Sharing these convictions, all of these theorists understandably agree with Bradshaw that “[c]o-dependence is looked upon as normal in our culture” (p. 187). It is so viewed because the rules of the poisonous pedagogy “are carried by family systems, by our schools, our churches and our government. They are a core belief of the modern ‘consensus reality’” (p. 167; original emphasis). Indeed, “[t]he whole society is built upon the poisonous pedagogy and operates like a dysfunctional family” (p. 187; emphasis added). The rules by which contemporary American culture operates, in short, promote the use and ownership of some people by others and teach the denial and repression of emotional vitality and spontaneity. They glorify obedience, orderliness, logic, rationality, power and male supremacy. They are flagrantly anti-life. (pp. 166–167)

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The theorists, then, insist that our entire sociocultural order is based upon and demands the emotional abandonment of our children. In light of these views, Bradshaw not surprisingly contends, co-dependence is the disease of today. All addictions are rooted in co-dependence, and codependence is a symptom of abandonment. (p. 172)

The correspondences between Rogerian statements of liberation psychotherapy and co-dependency discourse are striking. Bradshaw’s “shame-based self” and Rogers’s “defensivelyorganized personality” both reflect a particular shared understanding of the relationship between self and society, wherein repressive cultural institutions and practices reduce the “constructive and trustworthy” individual to a state of painful inauthenticity.

LIFE STORIES AND “CANONICAL AUTHORITY” Given the dominant themes encoded in the theorists’ remarks, co-dependency discourse, in both the theorists’ remarks and CoDA members’ life stories, clearly and sharply contrasts with the romanticized images of home, family, church, and community that marked the resurgence of conservativism over the past decade. From this perspective, co-dependency (and related discourses) is a manifestation of post-modern cultural politics, a rejection of the “hegemonic” (Hall 1988) imagery of socalled post-Fordism (Jessop, Bonnett, Bromley, and Ling 1989; Harvey 1989; Lash and Urry 1987; Hall 1988), or, less obliquely, “Authoritarian Populism” (Hall 1988, 1991; but see also Rustin 1989). The term “populism,” here, refers to the ideological accompaniments to a post-industrial version of laissez-faire economics, declining federal obligations for and commitment to social welfare, and a law and order, authoritarian, approach to both domestic and international relations. From this view, then, CoDA exemplifies the “generalization of ‘politics’ to spheres that hitherto [have been] assumed to be apolitical; a politics of

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the family, of health, of food, of sexuality, of the body” (Hall 1991, p. 63; see also, Denzin 1990a, 1990b). While Bradshaw, Schaef, and their colleagues, do not frame their theory in explicitly political terms, they do hold the older institutional forms responsible for a great deal of personal suffering. In this, groups such as CoDA and ACoA, with their canonical tales of sexual and physical abuse practiced in the shelter of familial privacy, indict that heavily freighted image of the family that held and holds sway in recent national political discourse. In these newest groups of the 12-Step subculture, alternative life stories are told and built up out of interactions among the members. These stories enable new identities that—at least in CoDA—reject the types of life narratives the repressive cultural institutions are said to have imposed upon the subject. Co-dependency theorists’ efforts, then, can be understood as an attempt to assemble a liberating canon. Members’ remarks at various gatherings demonstrate that the theorists have, indeed, helped empower co-dependents to construct alternative stories and identities. At the May 1989 Mid-Atlantic CoDA Conference, for example, “Ann” told her audience

eating disordered, physically violent, sexually abusive, incestuous—uh, what else?—sexually addicted, co-dependent, drug addicted family, but we looked like everybody else on the block. You never would have known what was going on in my family, ’cause it looked like everybody else’s. We knew how to cover it up. . . . [W]e knew how to look good and live up to society’s expectations of how a family is supposed to look.

The boom years for the 12-Step subculture and for psychotherapy, then, reflect the search for alternative life stories (e.g., Plummer 1983, 1990a, 1990b; Denzin 1990a, 1990b). These discourses provide adherents a canonical set of terms and generalized “plot lines” from which to build personal tales. The tales echo and are grounded in rejection of American culture’s “poisonous pedagogy” and of the institutions held most directly responsible for its perpetuation. In this, co-dependency appears to be either an extension of Rogerian psychotherapy, oriented towards individual liberation and the search for one’s true self, or a mode of post-modern politics, or both. Closer analysis suggests these appearances are deceptive.

CO-DEPENDENCY AND AUTHORITY I feel like I’m brand new at recovery and the reason why this program works is because we allow each other to talk over the same things over and over and over again . . . and I used to feel so much shame in bringing up the same issues to people . . . but I feel real safe at CoDA to do that. . . . Tonight, in sharing, I got to some feelings, [and] I haven’t had the feelings. It’s the feelings that keep me in bondage. . . . [T]he feelings are coming out, but they only come out when I allow myself to be with people who I trust. . . . I was so glad when they started this program [CoDA].

Ann’s remarks echo some of the theorists’ central tenets: the prison shame creates, the importance of releasing repressed emotions, the ability and necessity to talk openly. Similarly, at the same conference, “Ken” introduced himself in ways that highlight co-dependency discourse’s opposition to traditional moral order: I was a victim of abuse, abandonment, enmeshment, and neglect. I was raised in an alcoholic,

As suggested, the CoDA canon relies to a great extent upon the theorists’ views, conceptualized and systematized life stories heard over years of clinical encounters. However, despite perhaps the best intentions, the theorists frequently slip into a position that subverts individual autonomy and their avowed conviction that the old cultural order tends to deny people the right to be, in Bradshaw’s terminology, “the very ones that they are.” This manifests itself in a powerful, albeit subtle, determinism, and a tendency to dictate the “right way” for co-dependents to behave and recover—the right story to tell, in short.

DETERMINISM AND THE NEED FOR THERAPY As do all co-dependency theorists, Bradshaw, speaking of his own “journey to wholeness” (1988, p. 203), predicates recovery upon learning to share and express emotions:

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As my trust grew, I came out of hiding more and more. I broke the no-talk rules, I shared my secrets, I was willing to be vulnerable. . . . It was true, after I expressed my emotions, I had clearer insight. (p. 200)

Bradshaw refers to this process in terms of “grief,” or “mourning”: [M]ourning is the only way to heal the hole in the cup of your soul. Since we cannot go back in time and be children and get our needs met from our very own parents, we must grieve the loss of our childhood self and our childhood dependency needs. (pp. 211–212)

Clearly, Rogerian terminology grounds the discursive and conceptual framework for the contemporary search for new and empowering life stories and forms of identity. However, it is fair to suggest that more than empowerment is at stake in the claim that mourning is “the only way,” or that one “must grieve” if one is to recover. These deterministic remarks suggest childhood events unalterably shape people’s lives. Theorists reveal this penchant again and again: “If you’re shame-based, you’re going to be an addict—no way around it” (Bradshaw 1989, p. 96); “Will an alternative lifestyle be successful? Not for the co-dependent” (Wegscheider-Cruse 1985, p. 10); “Like a sliver that works its way deep into the flesh and later becomes infected, the private shame . . . of a child’s troubled past festers on into adulthood, creating an infection of codependent anxiety” (Subby 1987, p. 95); “[O]nce it sets in—co-dependency takes on a life of its own” (Beattie 1987, p. 16). The possibility that people can and do exercise judgment and act as positive agents in straightening out their own problems is subtly but decisively denied, in favor of the theorists’ conviction that theirs is the only solution to life troubles, that those seeking recovery “must” do certain things. Among these recovery requirements is the need for therapeutic intervention: Co-dependents need a healthy adult and parent model to walk them through their fear and demonstrate for them that these terrible demons of change can’t destroy them. In large part, this

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is the role of the therapist in treatment for codependency. (Subby 1987, p. 119)

Subby’s “modeling” would appear to contradict Schaef’s criticism of “external referenting,” which she contends is “the most central characteristic of . . . the disease of co-dependence” (1986, p. 44). Indeed, Since co-dependents feel they have no intrinsic meaning of their own, almost all of their meaning comes from outside. . . . [Co-dependents] learn that the reference point for thinking, feeling, seeing, and knowing is external to the self, and this training produces people without boundaries. . . . In order to have and experience boundaries, a person must start with an internal referent (knowing what one feels and thinks from the inside) and then relate to the world from that perspective. (p. 45)

The paradox, of course, is clear enough: Only identification with the theorists as one’s external referent makes it possible to recognize the primacy of the internal referent. A similar paradox informs Bradshaw’s claim that, “I don’t want to impose my experience of the journey to wholeness on anyone else. No one can tell anyone else how to find his most authentic self” (1988, p. 203), as, regardless of his sincerity, he precedes and follows this with a series of remarks in sharp opposition: “everyone must go through a self-recovery, uncovery, discovery process” (p. 193; original emphasis); getting into recovery, “means that I’ve let go of control and I’m willing to listen to someone else and do it his way” (p. 196; original emphasis); in recovery, one must do “feeling work,” and, “while it is certainly conceivable that one could do this feeling work without formal therapy, . . . it’s highly unlikely” (p. 215); and, “[m]oving beyond myself is actually an inward journey, [and] without this journey, there is no way to know who I really am” (pp. 227, 228).

THE OBLIGATION TO EXPRESS Co-dependency theorists’ prescriptions regarding the emotions further underscore that adopting a co-dependent identity is not so

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much a liberation as a deliverance from one into another system of authority. This new system prescribes talk about the forms and consequences of one’s repression as the organizing principle for a new identity. More importantly in this context, unwillingness to divulge personal experiences is taken as a symptom of disease or the wish to stay sick. Thus, Bradshaw counsels those on the verge of recovery,

she looked at the children’s unkempt rooms and began screaming at them and telling them that ‘they never think of anyone but themselves.’ She made them responsible for her frustration, anger, and hurt. This is abusive judgment. It attacks the children’s self-esteem. . . . [This] client failed in her awareness of her own feelings. She is, in fact, highly dissociated from her feelings. (1988, p. 50)

As you seek help, you are willing to label yourself an alcoholic, co-dependent, drug addict, sex addict, etc. You are willing to trust enough to ask for help. The labeling is crucial. You can’t heal what has no name. An old 12-step slogan is “We are as sick as our secrets.” (1988, p. 204; original emphasis)

While the mother could, perhaps, have handled things differently, Bradshaw’s wellintended concern for the children entirely subsumes within his broader theoretical point the lived experience of the mother (who is, perhaps instructively, twice termed the “client”). Although the nature of the mother’s experiences is only implied in her “frustration, hurt, and anger,” they could easily include single parenthood, an ex-husband failing to maintain child support payments, employment in a dead-end and low-paying service position at the receiving end of an exhausting system of organizational authority, and so on. However, as no actual experiences beyond those theoretically useful figure into the interpretation, one is instructed that not only has this mother “failed” to transcend her frustrations, she has “failed” to be aware of her feelings and, as a result, “abuses” and “shames” her children. Rather than liberated from an oppressive normative order, this “client” is caught between rival systems of authority. In part, this reflects a common therapeutic dilemma. Even the more “systemic” therapeutic models such as family systems theory are confounded by the family’s location in still-larger social “systems” (see, in particular, Jacoby 1975): the family is, after all, enmeshed in a social world. In the present context, however, this dilemma is still more problematic because the canon from which CoDA members draw their life stories is built up out of these materials. Large and important aspects of their lives are treated peripherally, if at all. The cumulative effect of ignoring these aspects, moreover, bears an unsettling resemblance to the dynamics underlying victim-blaming (Ryan 1976). The “client’s” inability to deal “healthily” with broader social arrangements

To equate recovery with willingness to divulge one’s secrets carries the complementary belief that emotions not simply can but must be expressed. In keeping with this norm, Claudia Black, writing of Sharon WegscheiderCruse, says the latter knows, among other things, “her right and obligation to show her feelings” (1985, p. vii; emphasis added). Wegscheider-Cruse reiterates this obligation word for word in her list of “Co-Dependent Rights” (1985, pp. 135–136). Clearly, a significant difference lies between saying one should be free to express emotion, and saying that one is obliged to do so. Nonetheless, WegscheiderCruse insists that “Feelings must be expressed and reexperienced for healing to take place” (p. 120; emphasis added).

BLAMING THE VICTIMS In part, the co-dependency theorists’ authoritative impulses are built into the very nature of speaking for others. The need for theoretical generality tends to override aspects of individual experience that belie the general rule, as is evident in Bradshaw’s recounting of one clinical episode: A client of mine felt terrible because she had come home from work feeling frustrated, angry, and hurt. Instead of saying to her children—“I need time alone. I’m frustrated, angry, and hurt,”—

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that undergird individual travails is inadvertently pathologized. This also occurs in the theoretical discourse regarding other process addictions: Schaef’s discussion of “romance addiction” argues, Romance addicts also evidence a loss of spirituality and a breakdown of their own personal morality. They move progressively away from reality, truth, and normal social mores and behaviors in the service of their addiction. . . . At [the most serious level] of [romance addiction] the addict has no regard for societal mores and accepted behavior. (1990, pp. 49, 51)

Schaef’s larger explanatory framework claims all addictions “are generated by our families and our schools, our churches, our political system and our society as a whole” (p. 6; original emphasis). Here, again, it must be difficult for “addicts” to know what to do. On the one hand, culture causes their addiction[s], while on the other, their disease features violation of “normal social mores and behaviors.” In short, process addicts are caught with co-dependents in this Faustian bargain. If process addicts of whatever stripe abide by societal rules, they are sick; if they violate those rules, they are also sick.

POWER/KNOWLEDGE Although clearly the liberation of those identifying themselves as co-dependent is somewhat attenuated, the last remarks do not impugn the motives of Bradshaw, Beattie, and their colleagues. To the contrary, the sincerity of their efforts to help people construct less painful life stories only underscores Foucault’s insistence upon the inseparability of truth, knowledge, and power (N.B. 1980b). For Foucault, discursive formations, as systems of truth, are simultaneously forms of “power/knowledge.” Thus, Truth isn’t the reward of free spirits, the child of protracted solitude, nor the privilege of those who have succeeded in liberating themselves. Truth is a thing of this world: it is produced only by virtue of multiple forms of constraint. And it induces regular effects of power. (p. 131)

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Aligning oneself with the truth claims of a discursive formation, then, subjects one to the exercise of power that inheres in accomplishing and establishing that truth. Power, in Foucault’s view, is or can be both repressive and productive, an often ironic duality, as his discussions regarding “the repressive hypothesis,” sexuality, and the development of the Catholic sacrament of confession suggest (1980a, 1984c, 1984d). The central irony is that the very effort to construct a taxonomy of forbidden and “confessable” wishes, acts, and utterances incites talk about the forbidden topics, talk in the new “form of analysis, stocktaking, classification, . . . specification, [and] quantitative or causal studies” (1984c, p. 306). The apparent conviction that “everything ha[s] to be told,” in other words, translates into a “nearly infinite task of telling” (pp. 303, 304). The emergence of co-dependency demonstrates a strikingly similar relationship between the repressive and productive aspects of power/ knowledge. Drawing upon ACoA’s portrait of the alcoholic family, the co-dependency theorists have assembled a radical critique of the American family in general. The critique portrays the traditional family, and indeed all traditional U.S. cultural institutions, as practitioners of violence, abuse, and repression in the service of social order. This serves as the springboard into alternative forms of identityconstruction. The new 12-Step groups, then, are in one sense proponents of a productive power. The co-dependency discourse affords a new and better life story, one in which CoDA members can seek out the “very ones that they are,” rather than be denied their true selves in the service of repressive cultural norms. Moreover, the life stories themselves detail prior repressions and their consequences. Conversely, the canon CoDA members tap for their life stories systematically, however inadvertently, alters their lived experiences to fit neatly within its boundaries. To “explain” their lives using the theorists’ canonical contributions, members must sacrifice those aspects that lie beyond the outline of a “good” theory of “co-dependency.” While this is not particularly surprising in regard to psychotherapy, per se, which has always created and required

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particular types of life stories, it renders views of CoDA as either an example of post-modern politics or a purely minimalist theory dubious. In helping co-dependents “name their demons,” in Bradshaw’s terms (1989, p. 41), co-dependency theorists simultaneously—albeit inadvertently—validate Foucault’s insistence that knowledge is power and power is knowledge. While seeking a new, more tolerant and benign way to organize and understand identity, the theorists suffer the same impulses to categorize, objectify, and ultimately, repress, that they so forcefully reject. To be sure, the repressions take a peculiar form, one that ironically echoes Marcuse’s (1964) notion of repressive desublimation. But the co-dependency theorists, after all, do not solely set the individual free from a body of cultural denials; they at the same time subject co-dependents to a new standard of authority, a new system of power/knowledge.

REPRODUCING “POPULISM”: THE THEORISTS’ DOUBLE LOCATION CoDA members, then, both shape, and are shaped by, a particular system of truth. That system’s exclusion of broader issues of power from the canon of life narratives it avails is a theoretical “necessity.” Certainly, to include those issues would dramatically reduce, if not eliminate, therapists’ role. Again, this need not impute hidden motives of profit and prestige to theorists, as critics often suggest. More likely is that theoretical orientations shape their field of vision. In any event, allegedly unalloyed fidelity to members’ tales would be likely to miss exactly these omissions. But not only theoretical interests account for what Denzin terms repressive intrusions of ideology (1990a, p. 12). As both he and Harvey note, the interests of commodity production are similarly ideological and intrusive: “New social movements”—including ecological, feminist, pacifist, anti-racist, and “third-worldist” movements—[have] gained a stronger purchase on political consciousness . . . [b]ut these movements were frequently victims of capitalist co-optation, and even when they [were not] they too often proved a fragmenting rather than unifying force. (Harvey 1991, p. 69)

Precisely this issue of co-optation lies behind the theoretical omissions of CoDA discourse. The theorists’ double location in the postmodern world creates those elisions. Not only are they CoDA’s canon-builders, but they are themselves subject to the political economy of the treatment industry. They, too, in short, are constituted by and constitute themselves as the subjects of a technology of social control that acts in the interests of health care administrators, insurance companies, employers, schools, and the criminal justice system (Weisner and Room 1984; Weisner 1983; Rice 1989). As “professional ex-s” (Brown 1991), Beattie, Bradshaw, and their colleagues generate a liberation discourse that reflects the rules for truth of a health care system based on commodity production. They reproduce a system of power/knowledge itself predicated upon truth rules that exclude broader structural considerations, favoring instead the individualizing and depoliticizing biases of medicalization and of the demands of time-limited, fee-for-service exchange (see Rice 1989). Their discourse, which fuses a radical psychotherapeutic critique of culture with the notion of “process addiction,” reflects this double status. The identification of people’s problems as symptoms of addiction undermines their interpretation of those problems as cultural in etiology. This effectively shunts the political content encoded in their life stories off into the realm of individual moral responsibility. CoDA thus reproduces a central value of the populist cultural ideology it otherwise attacks.

NOTES 1. This article treats co-dependency as a discourse rather than a disease. To avoid confusion I distinguish between these two usages. “Co-dependency” (in quotation marks) denotes the “disease” or its “symptoms”; co-dependency (no marks) denotes the discourse itself. 2. Beattie, unlike others, does not hyphenate “codependency.” 3. “Subculture” should be understood in Matza’s (1964, 1969) sense, rather than as, say, “counterculture.” That is, 12-Step groups have historically sought to ease persons’ position in and pathway through existing social arrangements, rather than to alter those arrangements. The subcultural dimension,

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4.

5.

6.

7.

8.

9.

then, addresses how to accomplish those goals, as opposed to the goals themselves. The 1990 figures come from an April 1990, ACoA brochure, “What is IWSO [International World Service Organization]?” The 1981 figures are from a 1989 reprint of the Oct./Nov. 1986 issue of Inside Al-Anon, a regular organizational newsletter. This was a “Special Issue for and About Children of Alcoholics,” (p. 1); an editorial in this issue, “It’s All in the Family,” provides the membership data. I base this observation upon interviews with a variety of counselors, therapists, and clinical social workers, a number of whom expressed deep reservations about “co-dependency’s” meaning or therapeutic utility, to say nothing of its status as a disease. Some of these reservations, no doubt, derive from a long standing distrust between disease model advocates and formally (academically) trained mental health professionals. Although clearly still operative, this distrust appears on the wane, at least among those with whom I spoke. This view has a long lineage, traceable at least as far back as Benjamin Rush’s early version of the disease model (see, e.g., Conrad and Schneider 1980). Rush, of course, was making assumptions about human nature, but the primary assumption was that humans are intrinsically rational. This grounded Rush’s conclusion that recurrent irrational behavior must signify underlying disease. Rush, it bears mentioning, also diagnosed his Tory contemporaries as “insane,” citing their antirevolutionary views as clinical evidence. As one of the anonymous reviewers points out, AA’s conservativism is evident at the individual level, but seeing it as a mode of cultural conservativism is more problematic. The problem, from this standpoint, is that AA’s disease model contributed to the medicalization of alcoholism and thereby, indirectly, also paved the way for the emergence of the culturally “radical” CoDA discourse. Certainly, this is the case. However, at least two points must be offered in response: (1) as Conrad and Schneider, working both separately (Conrad 1975; Schneider 1978) and in conjunction with one another (1980), observe, medicalization depoliticizes deviance and, as such, further supports the interpretation that AA texts tend to buttress rather than question the cultural status quo; (2) that CoDA should emerge out of a culturally conservative discourse exemplifies exactly the type of genealogical break this article traces. It is ironic, to be sure, that CoDA derives from AA. Actually, CoDA’s 12 Steps are gender neutral, as well. For example, they do not speak of a surrender to God, “as we understood Him,” but “as we understood God.” This language sensitivity is one aspect of the more general genealogical discourse reconstruction that concerns this study. I make this distinction because there are unaffiliated ACoA groups. Indeed, the affiliation question posed a problem for the 12-Step subculture, especially Al-Anon, during ACoA’s sudden burst of popularity (see Robertson 1988 for a thoughtful discussion of the nature of these problems).

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10. Bradshaw borrows this term and many of his ideas from the psychotherapist, Alice Miller (1983a, 1983b, 1984).

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Weisner, Constance M., and Robin Room. 1984. “Financing and Ideology in Alcohol Treatment.” Social Problems 32: 167–184. Woititz, Janet G. 1979. Marriage on the Rocks. Deerfield Beach, FL: Health Communications. ———. 1983. Adult Children of Alcoholics. New York: Health Communications.

Yankelovich, Daniel. 1982. New Rules: Searching for Self-Fulfillment in a World Turned Upside Down. New York: Bantam. Zijderveld, Anton. 1972. “The Anti-Institutional Mood.” Worldview1 5(9): 32–36. Zilbergeld, Bernie. 1983. The Shrinking of America. Boston: Little, Brown and Company.

CHAPTER 17

Regulated Passions The Invention of Inhibited Sexual Desire and Sex Addiction Janice M. Irvine In the second half of the twentieth century, the invention of new sexual diseases has been central in the regulation of sexuality. In our culture, diseases, like sex, are not simple organic entities, but rather serve as expanded paradigms imbued with diverse meanings. Diseases are artifacts with social history and social practice. In the area of sexuality, the discursive practices of medicine since the nineteenth century have spawned what Foucault terms a “proliferation of sexualities,”1 most of which carry the stamp of perversion reborn as disease. Thus, the invention of sex addiction and inhibited sexual desire can be understood in light of two related historical factors of the late nineteenth century. First, a range of socioeconomic changes prompted a commercialized sexuality in which sex is increasingly privileged as fundamental to individual identity and happiness.2 Second, the medical profession usurped moral and religious authority in the area of sexuality, generated new and highly visible discourses, and promulgated the diversification of new sexual identities. As Foucault suggests, “Sex was driven out of hiding and forced to lead a discursive existence.”3 Inhibited sexual desire and sex addiction are two of the most recent medical constructions of sexual disease and disorder. The medicalization of these two conditions, with elaborate systems of diagnostic categories and treatment interventions, fashions a sexual condition or “sick role”4 and, in the case of sex addiction, an entire identity constructed around a specific sexual pattern. It would be a mistake, however, to impute sole and uncontested power to the medical

profession in the invention of the new disorders. Rather, new diseases emerge within the triangulation of medical imperatives, the demands and experiences of individuals, and cultural traditions and anxieties. This article will examine these three axes of influence. First, it will analyze the history of professional intervention in problematic behavior subsequently defined as desire dysfunctions. Second, it will explore the complexities of definition and treatment, and the implications for afflicted individuals. Finally, it will emphasize the ways in which disease reflects the cultural style of a period.5 It will suggest that, in the late twentieth century, these new diseases chart the medically legitimated boundaries of acceptable contemporary sexual experience and serve as signifiers for powerful cultural anxieties about sexuality and desire.

DISEASE NARRATIVES The construction of disease categories entails a complex set of negotiations among professionals, the general public, and afflicted individuals that is always mediated by broader cultural ideologies. The particular configuration of very different circumstances for the emergence of ideas about inhibited sexual desire and sex addiction in the mid-1970s offers clues about their powerful individual and social valence. Although modern clinicians have anecdotally noted cases of low sexual desire as early as 1972, inhibited sexual desire (ISD) was first identified in the medical literature in 1977 by two sexologists working independently:

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Harold Leif and Helen Singer Kaplan.6 Both are well-known sex therapists who reported the increasing prevalence of complaints about low libido in their clinical practices. This was a noteworthy departure from the presenting problems of most patients during this heyday in sex therapy. With the publication of Masters and Johnson’s Human Sexual Inadequacy in 1970, sex therapy had grown throughout the decade to become the most visible, lucrative, and widespread enterprise of sexology.7 On the basis of their research and clinical work, Masters and Johnson had identified several major categories of sexual problems which were eventually adopted by the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR). For men, the basic sexual dysfunctions included premature ejaculation, primary and secondary impotence, and ejaculatory incompetence (a rare condition in which a man cannot ejaculate intravaginally). Female sexual dysfunctions included dyspareunia (painful intercourse), vaginismus (a tightening of the vaginal muscles that prohibits penile penetration), and several types of orgasmic dysfunctions, broken down into primary or secondary and coital or masturbatory categories.8 These dysfunctions encompassed the range of technical difficulties to which a couple might be vulnerable, and undeniably, Masters and Johnson’s sex therapy program helped scores of people improve their sex lives. Their brief, symptomatic treatment seemed perfect for those with little experience or information about sex. The mere discovery of the program’s existence was enough to instill hope and confidence in some couples. By the late 1970s, sexologists, with their appeal to scientific legitimacy and medical authority, were riding a wave of popularity in a vast market eager for a new approach to sexual problems. Rumors of dramatic, nearmiraculous success rates for interventions with sexual problems were so persuasive that clients began reporting cures merely from sitting in the waiting room. By the end of the decade, however, sex therapists voiced a common lament about the disappearance of the “easy cases”—specifically those problems which were essentially the result of ignorance or

misinformation, and that responded well to the simple behavioral methods of Masters and Johnson. The new difficulties were reported in different ways: sexual boredom, low libido, sexual malaise, and even sexual aversion and sexual phobia. Harold Leif recommended that the diagnosis of inhibited sexual desire be applied to those patients who chronically failed to initiate or respond to sexual stimuli. The dysfunction is now routinely referred to as either inhibited sexual desire or hypoactive sexual desire. The American Psychological Association estimates that 20 percent of the population has low or absent sexual desire. Among sex therapists, ISD is now reported as the most common presenting problem, constituting half of all diagnoses, and it is considered to be the most difficult sexual problem to treat.9 More women than men are diagnosed with inhibited sexual desire, although many therapists report that the rate among males is rising.10 The concept of sex addiction had a quite different beginning, springing to life independently in several cities almost simultaneously. Not surprisingly, the idea of being addicted to sex emerged in the addiction movement among those who were in recovery from substance use. Its first manifestations were in the establishment of Twelve Step groups to contain what their members describe as “sexual unmanageability.” Sex and Love Addicts Anonymous was the first such group, started by a musician in Boston in 1977.11 He had been a member of Alcoholics Anonymous for years, had a wife, a mistress, engaged in other sexual affairs, and masturbated several times a day. His perception that his sexuality was out of control led him to find others with a similar problem so that they could “get sober.” Initially they met in private homes, but the growth of the group led them to seek a public meeting space. A local pastor was sympathetic but skeptical that his parishioners would support a group of sex addicts so he suggested a name change. Sex and Love Addicts Anonymous is now also known as the Augustine Fellowship, since one of the members had been reading Augustine’s Confessions and claimed, “he’s obviously one of us.” There are now seven different nationwide fellowships for sex addicts and co-addicts, with such names

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as Sex Addicts Anonymous, Sexaholics Anonymous, and Sexual Compulsives Anonymous. All were founded under similar circumstances as the Augustine Fellowship. Every week close to two thousand meetings for sex addicts are held across the country, and the groups are said to be growing at an annual rate of 30 percent.12 Unlike with ISD, a thriving grass-roots movement of individuals who claimed to suffer from the disorder was already in place by the time professionals engaged with the issue. Now, however, experts and clients work in tandem, since sex addiction has spawned a robust treatment industry. The diagnosis has attracted two types of professionals: the dominant group are “addictionologists” (as they now call themselves), who are joined by a smaller cohort of clinicians who treat sex offenders. Professional awareness of sex addiction was fostered by the “opponentprocess” theory of addiction introduced in the early 1970s, which suggested that a substance was no longer requisite for addiction.13 This proposal that any behavioral excess could lead to dependence fit nicely with the popular and widespread generalization of ideas about addiction represented by such figures as the workaholic, shopaholic, and compulsive gambler. Proponents of the syndrome view sex addiction within this expanded paradigm of addiction disorders. There are now scores of texts on sex addiction, and treatment programs dot the landscape. The first inpatient program for sex addicts was begun in 1985 at Golden Valley Health Center’s Sexual Dependency Unit in Minneapolis. Addictionologists claim that 6 percent of the population are sex addicts, and approximately 30 percent of these are women. Patrick Carnes, one of the foremost popularizers of the sex addiction concept, claims that one in twelve people in the U.S. is a sex addict.14

The Professional Divide The construction of new medical definitions does not simply mirror a perception of illness or problematic conditions. Rather, the discursive elaboration of disease is shaped by complex factors, including the ideological and economic imperatives of the defining professionals. It is

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noteworthy that the new diseases of ISD and sex addiction have each been fashioned by highly different professional cohorts, so that the medical discourses have progressed on parallel and quite distinct trajectories. There has been little connection or communication between addictionologists and sexologists and little overlap in specialization. There has been some veiled hostility between the groups, however, deriving from the clash of underlying ideologies and overt treatment goals. These conflicts highlight the constructed nature of the new diseases and reveal the nature of the loyalties and interests of each profession. The field of addictionology has been marked by rapid professional expansion, particularly since Solomon’s opponent-process theory of addiction provided theoretical legitimacy for the identification of almost anything as an addictive agent. Although the subsequent proliferation of addictions widened the professional domain of addictionologists into new areas such as gambling and sexuality, their medical gaze remains one of vigilance about excess and admonitions for control and management. This sexual ideology of temperance and abstinence directly opposes the vision of sexual expansion and freedom so implicit in sexology. Addictionologists have criticized many of the sex-enhancing technologies, ideologies, and practices that comprise standard sex therapy models. For example, some believe that penile implant surgery, a lucrative procedure that is quite acceptable among sexologists, signifies and reinforces sex addiction.15 And addiction experts challenge sexologists on their unbridled enthusiasm for the unrestricted use of fantasy and pornography, for their encouragement of masturbation, and for their celebration of virtually any sexual activity between consenting adults. Sex addicts, it is thought, may need to practice celibacy and eliminate fantasy and sexually explicit material “in order to attain and maintain sobriety,” and sex therapists may simply retraumatize them or facilitate a relapse by the espousal of sexual freedom.16 While addictionologists may accept the dominance of sexologists in many areas of sexuality, they are staking out their turf and becoming more visibly critical of sex therapists for an alleged

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lack of effectiveness in the treatment of sex addicts.17 Sexologists, on the other hand, have struggled for professional legitimacy and a viable commercial market for over a century.18 They pride themselves on scientific rigor in their work and on fairly unqualified acceptance and support of all sexual expression. The very concept of sex addiction—that there can be too much sex—threatens the foundations of the profession. Until the early 1990s, sexologists have largely responded to the emerging diagnosis of sex addiction with sarcasm, disavowal, or attacks on its scientific credibility. In a 1988 anthology on sexual desire disorders, sexologists Sandra Leiblum and Raymond Rosen noted that sex addiction was beginning to receive considerable attention. They described the affected individuals as “sexual enthusiasts,” and noted that they “tend to be admired or envied rather than diagnosed.”19 Helen Singer Kaplan claimed that sex addiction is exceedingly rare,20 and is “a media term that doesn’t have any scientific validity or meaning.”21 Possibly because of his work in treating sex offenders with Depo-Provera,22 noted sexologist John Money was initially a supporter of the new diagnosis, telling the New York Times in 1984 that he had seen many patients who were sex addicts. “Their hypersexuality often exceeds normal capacities,” he noted.23 By 1989, however, Money vehemently reversed his position, charging that “the pathologizing of sex by inventing a hitherto unknown disease, sexual addiction” constituted a strategy of “the sexual counter-reformation” that has exercised a destructive effect on the advancement of the science of sexology.24 Professional antagonisms have slowly begun to dissipate into mutual ambivalence largely because of the impact of the AIDS epidemic. This is because sexologists, who have been unable to avoid widespread social anxiety about freer sexual mores, have begun fashioning their practices accordingly. Workshops and interventions such as one entitled “Falling in Love Again” abound for the sexually and relationally bored who are terrorized into monogamy by fear of HIV infection. It is not uncommon for sexologists to chart their professional course

through the changing currents of cultural ideologies about sex and gender. Sexology has never presented an uncomplicated vision of sexual liberation. Rather, the field has historically managed the contradictions of a progressive sexual message and the need for conservatism and scientific credibility in order to achieve cultural legitimacy and economic viability. Despite these antinomic imperatives, sexologists generally advance a sexual value system of greater freedom and participation. Yet the cultural sex panic exacerbated by AIDS has foregrounded the addictionologists’ message of sexual chaos and terror of sexual excess. The sexologists’ exhortations to sexual pleasure and experimentation look increasingly unwise and unhealthy, and they have begun integrating some of the ideas, if not the wholesale diagnosis, of the sex addiction field. The historical narrative, then, of the construction of inhibited sexual desire and sex addiction reveals a clear bifurcation between two professional cohorts, marked by ideological tensions and distinct border anxiety. As experts laboring on opposite poles of the same continuum of sexual anxiety and control, however, these professionals share a possibly insoluble conundrum: the task of precise clarification and definition of their disease.

DEFINING AND TREATING THE DISORDERS OF DESIRE The assertion of exact definitional and diagnostic criteria poses an enormous challenge when “disease” is a generalized set of signifiers of cultural chaos and social control. The fabric of overdetermined diseases such as sex addiction and inhibited sexual desire is woven from the diverse threads of professional expertise and ideologies, cultural beliefs about sex, and the attempts of individuals to make sense out of their own sexual experiences. Nevertheless, the medical legacy of the doctrine of specific etiology25 has inspired each field to generate myriad hypotheses concerning the individual causes of the disorders. These etiological theories of inhibited sexual desire and sex addiction are not totalizing discourses but rather an amalgam of diverse and sometimes nebulous

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perspectives. There is conflict within sexology and addictionology over the origins and nature of their respective disorders, and it would be incorrect to imply a simple unity or consensus. Despite few rigorous research studies, there has been much speculation on the basis of clinical samples and case studies. There are debates over the influences of environment, family, individual personality, and biological factors such as neurochemistry. Since the nineteenth century, however, professionals have assiduously tracked the etiology of sexual conditions within a biomedical tradition that quantifies desire and locates “this search for the primeval urge in the subject itself.”26 It is this impulse to map desire and its varied disorders in the body itself that represents historical congruence among sexuality professionals and establishes a common theoretical terrain for both inhibited sexual desire and sex addiction. A pervasive and largely assumed underpinning of both sex addiction and ISD is the representation of sexual desire as a biological drive or surging energy that is either flooding uncontrollably or woefully diminished. There is the intuitive belief that sex, specifically sexual desire, resides in the body. This essentialist assumption is not surprising, since it infuses mainstream cultural norms about sexuality as well as the theoretical foundation of sexual science.27 As historian Jeffrey Weeks noted about nineteenth-century sexology’s search for the origins of sexual behavior, “biology became the privileged road into the mysteries of nature.”28 Over a hundred years later, although few theorists would unequivocally advance a strict biological determinism in the etiology of ISD or sex addiction, strong essentialist themes resonate throughout the discourses of the desire disorders. The literature of both professional cohorts reflects a striking emphasis on the brain as the site of sexual desire and the source of its myriad manifestations. Advances in neurochemistry converged with the technological revolution in computers to produce a cyborgian vision of sexuality and desire characterized by images such as “hard-wiring,” “circuitry,” “programmed into the brain,” and “fixed into the system.” In this representation, the bedrock

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of desire and its concomitant sexual possibilities reside within regulatory mechanisms of the brain that are alternately perceived as impervious to change or quite vulnerable to disruption. The biological basis of sexual desire is most advanced in the work of Helen Singer Kaplan, who pioneered the notion of inhibited sexual desire and who is likely one of the most unreconstructed essentialists within sexology. In her 1979 landmark text on ISD called Disorders of Sexual Desire, Kaplan defines sexual desire as an “appetite or drive which is produced by the activation of a specific neural system in the brain.”29 In sociobiological terms, Kaplan describes the importance of sexual desire: Sexual desire is a drive that serves the biologic function of species survival. It instills a strong erotic hunger that prods us to engage in species specific behavior that leads to reproduction. It moves us to find a mate, to court, to seduce, to excite, to impregnate, to be impregnated.30

For Kaplan, desire is experienced when a specific neural system in the brain is activated, prompting genital sensations and an openness to and interest in sex. When this system is inactive or inhibited, the person “loses his appetite” or “the brain has ‘decided’ that it is too ‘dangerous’ to have sex.”31 Addictionologists tend to discuss sexual desire very little other than to implicitly regard it as an inherent physiological drive that has spiraled out of control. This discourse harkens back to the eighteenth-century perspective described by Weeks that “desire was a dangerous force which pre-existed the individual, wracking his (usually his) feeble body with fantasies and distractions which threatened his individuality and sanity.”32 Significantly, within the sex addiction literature, the moniker “desire” is generally superseded by its moral ancestor “lust.” Even so, brain-centered sexual theories are even more prolific among addictionologists than sexologists. The dominant theme proposes that a finite number of polymorphous sexual possibilities are locked into the brain in early childhood and subsequent behavior is virtually predetermined. The lovemap theory

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of sexologist John Money has been enthusiastically deployed by addictionologists, who find the notion of behavioral options programmed into the brain in childhood a compelling explanatory concept. Money describes the lovemap as “a developmental representation or template, synchronously functional in the mind and the brain, depicting the idealized lover, the idealized love affair, and the idealized program of sexuoerotic activity with that lover, projected in imagery and ideation, or in actual performance.”33 The lovemap allegedly incorporates into the brain a range of social inputs transmitted through sensory mechanisms. In addition, scientific breakthroughs in neurochemistry have informed the development of an essentialist sex addiction model since, as Patrick Carnes notes, “studies generated greater scientific awareness that addiction could exist within the body’s own chemistry.”34 Sexual desire and addiction are thus viewed as coterminous physiological events inside the body. These models enable addictionologists to explain the intransigence of repetitive problematic sexual behavior. It has been encoded into the hardwiring of the brain. It is not uncommon to hear addictionologists suggest, for example, that our brains spontaneously move into preset programs of activities,35 that the linchpin of co-dependency is the inability to change behavior because it has been programmed in during childhood,36 or that male and female brains are crucially different so that the exact same trauma early in childhood can affect a female differently than a male.37 As we will see, these theoretical perspectives on sexual desire disorders are crucial in that they shape treatment strategies. Although they occupy considerable space, the brain-centered theories of sexuality are not hegemonic. More recently, sexologists are divided on the centrality of a biologically based model of desire. Many still adhere to a solidly essentialist theory, and scores of studies claim the androgens as the “libido” hormone.38 Other sexologists have posited multidimensional models that privilege psychological and cognitive factors in shaping desire.39 The medical literature frequently describes marital difficulties, fear, and anger as underpinnings of inhibited sexual desire. As Helen Singer Kaplan

notes about women who experience ISD in the context of ongoing relational discord, “it is not possible for most people to feel sexual desire for ‘the enemy.’”40 And many addictionologists link sex addiction and co-dependency to trauma, child sexual abuse, and a breakdown in spirituality.41 On infrequent occasions, clinicians will point to the role of broader cultural messages that result in complex and often contradictory imperatives about sex. Even when these professionals invoke more expansive hypotheses to explain the desire disorders, however, they are largely theoretically located in what anthropologist Carole Vance terms the “cultural influence model.”42 In this view, sexuality, although influenced by culture, is thought to encompass universal forms of expression driven by an inner force or impulse. Vance notes, “Although capable of being shaped, the drive is conceived of as powerful, moving toward expression after its awakening in puberty, sometimes exceeding social regulation, and taking a distinctively different form in men and women.”43 While the cultural influence model as it appears in professional theories of desire disorders is a marked improvement over rigidly essentialist frameworks, it retains determinist assumptions. And unlike social construction theory, it leaves unexamined the radical mediation of sexuality by history and culture. Only infrequently, for example, does the literature on sex addiction and ISD acknowledge the role of societal norms about sex in shaping desire. Aside from theoretical congruence concerning the nature and origins of desire, however, both professional cohorts face the challenge of precisely elucidating the parameters of their new diseases. The experts constructing sex addiction and inhibited sexual desire share a common conceptual and practical problem of definition: the decisive question of how much is too much and how little is too little. This indeterminacy is a familiar dilemma in describing sexual disorders. Kinsey was famous for anecdotally defining the promiscuous individual as “someone who’s getting more than you are.” Similarly, Masters and Johnson struggled for a reasonable definition of premature ejaculation. For example, given the range of partners a man

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might have, he might be premature with one partner and not with another. For ISD and sex addiction, professionals have given diagnostic weight to outside referents. For sex addicts, repeated criminal offenses can serve as a surrogate marker for the subjective experience of being out of control sexually. An angry and dissatisfied partner is often the impetus for someone to seek professional treatment for ISD. Yet again, the fundamental subjectivity is inescapable, and calls to mind the exchange in Annie Hall between Woody Allen and Diane Keaton when their therapist asks how often they have sex. He says, “Hardly at all. Only three times a week,” while she replies, “All the time. At least three times a week.” Clinicians admit that, especially with ISD, the concept of desire discrepancy is inevitably relational, so that individuals can easily shift diagnoses depending on their partner. Ultimately both ISD and sex addiction rely heavily on self-diagnosis and serve as beacons for the individual who feels a sense of inadequacy or incongruence with cultural or interpersonal sexual norms. Yet despite their inevitably subjective character, professionals have tried to establish quantifiable frames for their diseases. The nomenclature committee of the American Psychiatric Association recognized inhibited sexual desire as a clinical entity in 1980 and it was included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), thus making it an official mental illness. The DSM-IIIR (1987) elaborated this classification further by dividing the disease into two categories: Hypoactive Sexual Desire Disorder and Sexual Aversion Disorder.44 The definition of HSD is vague but implies that the person must be distressed or that there must be an inherent disadvantage to low sexual interest (anger of a spouse, for example). Helen Singer Kaplan describes HSD as either primary—a rare lifelong history of asexuality—or secondary, in which there is a loss of sex drive after a history of “normal sexual development.” Kaplan describes the typically situational HSD woman as the one who feels very erotic during the many years of her precoital experiences. She felt desire and erotic

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pleasure during “petting,” but she loses sexual interest after she has engaged in coitus, or after marriage, or after childbirth, i.e., in situations which on a symbolic and unconscious level represent danger.45

The diagnosis of ISD remains controversial among sexologists, with little consensus regarding operational criteria. Some sexologists have even suggested that the disorder is so vague and diagnostic boundaries so blurred that ISD, as a “catch-all” diagnosis, represents the schizophrenia of sex therapy.46 Many negotiate these difficulties with the strategy summarized by sex therapists Sandra Leiblum and Ray Rosen that “you know it when you see it.”47 Proponents of the sex addiction diagnosis suffer similar definitional quandaries, resulting in a myriad of checklists and screening questionnaires to determine one’s vulnerability. Many subscribe to the AA maxim: If you think you’ve got a problem, you probably do. The Sexual Dependency Unit at Golden Valley defines sex addiction as “engaging in obsessive/compulsive sexual behavior which causes severe stress to addicted individuals and their families.”48 Sex becomes the organizing principle of the addict’s life, for which anything will be sacrificed. In addition, sex addiction can include the following behaviors when they have “taken control of addicts’ lives and become unmanageable: compulsive masturbation, compulsive heterosexual and homosexual relationships, pornography, prostitution, exhibitionism, voyeurism, indecent phone calls, child molesting, incest, rape and violence.”49 Among the several Twelve Step groups, definitions of sex addiction vary, as do the concepts of what constitutes “sobriety.” Yet among both professionals and recovering sex addicts, two themes are consistent. First, whatever the behavior, it is practiced compulsively. And second, the common enemy is lust, which is thought to drive the sex addiction cycle. In a manner reminiscent of the social purity movements of the late nineteenth and early twentieth centuries, lust is thought to lead the victim into uncontrollable and destructive behavior. Lust, therefore, must be eliminated. Sexaholics Anonymous is perhaps the most restrictive in this sense, in that freedom from lust occupies

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center stage in the definition of sobriety. The literature states that: Any form of sex with one’s self or with partners other than the spouse is progressively addictive and destructive. Thus, for the married sexaholic, sexual sobriety means having sex only with the spouse, including no form of sex with one’s self. For the unmarried . . . freedom from sex of any kind. For all . . . progressive victory over lust.50

Again, as in the social purity movements, addictionologists view sex as simply one of the falling dominoes in a downward-spiraling cycle of destruction that may include, among other elements, eating, gambling, drugs, and alcohol. One professional, for example, described as vulnerable “a particular kind of woman very involved with fantasy who is a compulsive masturbator, compulsive overeater, and reads romance novels.”51 Addictions are described as multiple and often interchangeable. Ann is another case described in the treatment literature: Ann spent almost every night in cocktail lounges searching for men. After several years of emotionally empty one night stands, she came to the realization that she and the men she seduced were simply using each other sexually. In desperation she swore off the bar scene and joined her friend Judy in small stakes bingo and card games. Within one month, Ann had identified several high stakes poker and bingo games and had become totally absorbed in her new-found gambling compulsion.52

To discourage such symptom substitution, professionals are warned that treatment must include all the addictions. Self-help groups thus cast an ever-widening net to include such compulsions as excessive masturbation, gambling, bingo, and romance novels. In her landmark, best-selling text Women, Sex, and Addiction, Charlotte Kasl expands the system of addiction even further by intertwining sexual co-dependency with sex addiction in women. Co-dependent (or co-addict) was a term originally created to describe the partner of an alcoholic. Kasl has broadened the definition to refer to a “devastating disease”

in which a woman has sex anytime she doesn’t want to, in order to maintain a relationship or placate a partner. Co-dependency, Kasl notes, is “women’s basic programming” and is only a slight exaggeration of the culturally prescribed norm for women.53 Despite internal disagreement and confusion among sexologists and addictionologists over the etiology, definitions, and operational criteria of their diseases, some consistent treatment strategies have evolved. These are shaped by the biomedical infrastructure central to the construction of the desire disorders. For regardless of documented social correlatives such as abuse, power differences in heterosexual relationships, or cultural pressures as possible etiological factors, the disease model of sexual desire disorders retains prominence. Sex addiction is considered dangerous, and by some, such as Anne Schaef, “a progressive, fatal disease.”54 Likewise, sexologists view inhibited sexual desire as a serious and intractable disease. Unlike the other sexual dysfunctions, it has a poor prognosis with available treatment. Treatment strategies for both sex addiction and inhibited sexual desire remain steadfastly fixed on the individual (or often in the case of ISD, the couple), with the goal of management, adjustment, or regulation of sexual desire and sexual behavior. The most common interventions are individual or couples therapy, sometimes supplemented with pharmaceuticals. For sex addiction, Twelve Step groups are an essential complement to either inpatient or outpatient treatment. The professional reliance on organic, neurochemical explanations for both ISD and sexual addiction has predictably led to the search for a “magic bullet” as experts in both fields look hopefully and confidently to the future of neurochemistry for unlocking the determinants of their diseases. Meanwhile, drug treatment is used as an adjunct to treatment for both dysfunctions. The antidepressant drug Wellbrutin was once the great treatment hope for ISD until it was found to trigger seizures. Now, despite lack of evidence of efficacy, testosterone is being prescribed for low sexual desire in premenopausal women.55 Prozac is often prescribed for sex addiction, although there

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is much controversy and suspicion among sex addicts about using a drug to treat an addiction.

MEDICALIZING DESIRE In our culture, both disease and desire are medical events, individual experiences, and social signifiers. There is no linear relationship between medical ideology and individual behavior. We are not passively shaped by broader medical ideas; yet neither does our medical discourse directly reflect an internal, universal experience of individuals. The content of medical diagnoses is shaped by social, economic, and political factors. And both specifically medical and broader cultural ideologies operate in the construction of individual experiences of sexual desire. Not simply a biological urge, sexual desire is a culturally constructed composite. It is imperative, therefore, to analyze the contemporary medicalization of sexual desire along these three dimensions. The nineteenth century marked a shift in scientific investigation of sexual matters. Hence, sexuality has represented a site of expansion and control by the medical profession, with its interests in delineating the nature of sexual impulses and constructing new psychological categories of behavior. The themes in ISD and sex addiction of sexual conflict, chaos, and disorder are familiar legacies from more than a century of a medical gaze onto sexual expression. The invert, the sexual psychopath, the hypersexual female, and the onanist are but some of the historically demonized characters who step from the text of a medical discourse of definition and regulation.56 It is not surprising, then, that professionals in the late twentieth century would conceptualize concerns regarding sexual desire as major medical problems, since historically physicians have played a significant role not only in the management of sexual behavior but in defining the existence, appropriateness, and ideal object of sexual desire or passion. Broader societal constructs of desire have largely been based not on the felt experiences of individuals, but on ideological beliefs about sexuality and gender. For example, permission for any individual woman to experience desire,

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discuss sexuality, initiate a sexual encounter, or present herself as passionate varies historically and culturally. Carl Degler has documented the variability in nineteenth-century medical advice literature regarding desire in middleclass women. One theme speaks to the strength of women’s passion; another articulates the stereotypic Victorian view that women approach sex “with shrinking, or even with horror, rather than with desire.”57 Further, Nancy Cott has related variations in the dominant ideology about women’s passion through the eighteenth and nineteenth centuries not to changes in individual and interpersonal sexual experiences, but to cultural shifts in metaphoric systems about the nature of women. Passionlessness, she argues, transformed women’s image in the nineteenth century to one of spirituality, away from the eighteenth-century view of women as lustful creatures prone to sexual excess.58 The most recent medical constructions of desire disorders reinscribe historically familiar themes of morality, regulation, the ambivalence of pleasure, and the ruin of excess and depravity. The power of medical ideology in the construction of sexual desire derives from its expansion, its authoritative voice. There must be cultural recognition that desire problems are diseases with a subsequent adoption of the language and concepts of dysfunction. This process is facilitated by popular representation, and by the early 1990s, both ISD and sex addiction had achieved a certain currency within popular culture. For sufferers of low sexual desire, articles abound on DINS (dual-income, no sex), casting ISD as the latest malady for yuppies too tired from an active day on Wall Street to have sex. And at least one popular self-help manual has appeared, entitled Not Tonight, Dear, in which the author promises that “the mental nature of desire makes it particularly amenable to improvement through reading.”59 Given that our cultural balance consistently tilts away from pleasure and toward prohibition, the idea of sex addiction has more thoroughly captured the popular imagination. In addition to the thousands of Twelve Step groups, the afflicted may call a National Sexual Addiction Hotline. The National Enquirer reported that Rob Lowe had entered a sexual addiction clinic,60

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and Arnie Becker on “L.A. Law” began to describe his sexual exploits as “satyriasis.” The shift in the sexual spirit of our times is perhaps best captured by Erica Jong’s new book, Any Woman’s Blues, in which the central female character is a sex addict who in the end joins a Twelve Step group.61 A New York Times ad blazoned, “In the seventies, Erica Jong taught women how to fly . . . now she shows them how to land.”62 Through their widespread dissemination of the concepts of inhibited sexual desire and sex addiction, these popularizations continually reassert and legitimate the idea that cultural ideologies about appropriate sexual expression are valid medical conditions responsive to individual intervention and cure. The existence of inhibited sexual desire and sex addiction as medical diagnoses ensures that proposed solutions will be individual rather than structural/cultural. In part ideological, this therapeutic trajectory is also driven by a financial motor, and clearly economic incentives are central to medical expansion. Treatment for sexual desire problems is a vast and lucrative commercial venture. The revenues of Sex and Love Addicts Anonymous, for example, soared to over $100,000 after Hazelton took over distribution of their central text in 1988.63 Golden Valley Health Center employs an international public relations firm to manage the scores of daily calls received from around the world about the Sexual Dependency Unit. And sexologists report that at least half of the clients coming for sex therapy present with claims of low sexual desire.64 The large numbers of individuals engaged in treatment for desire problems speak to the widespread acceptance of medical constructs and the availability of professionals who offer medical diagnosis and treatment. But perhaps most importantly, it indicates the pain and confusion experienced by so many people concerning their sexual desire and behavior. In this respect, then, it is important to evaluate the medicalization of desire by its therapeutic impact. How does the existence of ISD and sex addiction as disease entities shape individual experiences of sexuality? Has the creation of these diseases either limited or expanded other options for thinking about sexual desire? What

does it mean to take on the identity of a sex addict? If one feels little sexual desire, is it helpful to define that absence as a disease? Does it matter that it is clinicians who will offer the range of answers to the Cosmo girl who wonders “how much sex is enough?” While there are anecdotal or clinical reports, the desire disorders are too new for the emergence of a nuanced ethnographic and phenomenological literature on the meanings of these diagnoses for men and women. But speculation about the broader cultural implications and the limits of individual impact is possible given our knowledge about the nature of medicalization and of the particular theoretical contours of both inhibited sexual desire and sex addiction. The imposition of a biomedical paradigm over social events or problems may suggest potential advantages. These include the increased recognition it promotes and the conceptual framework it offers for worried individuals. Further, a medical diagnosis confers legitimacy on a particular set of difficulties. The seemingly neutral and scientific language of disease may offer palpable relief to those who secretly worry that their sexuality is inadequate or out of control. Especially when the definitional options are those of morality or personal failure, a medical diagnosis may sound more dispassionate and, significantly, admits one to a high-tech arena of research and psychotechnology.65 Ultimately, however, medical diagnosis offers a false neutrality, for, “as illnesses are social judgments, they are negative judgments.”66 Disease designations connote discomfort, deviance, treatment, and cure. Sexologists and addictionologists, for example, have reified the desire disorders into static and simplistic categories. Diagnostic profiles and checklists are purposely vague so as to be inclusive of a wide range of behaviors. One profile for sexually addicted women includes and indicts behavior as diverse as “multiple and serial relationships; affairs; one night stands; cruising bars, health clubs, etc.; personal columns; masturbation; fantasy; preparing and dramatizing; S/M; exposing; dangerous situations; self abuse; suicidal and homocidal; relationships with sexual compulsive men.”67 The ideal model presented for sexually addicted women is a social purity

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vision of a spiritually based, monogamous sexuality that is always relationally oriented.68 Any variation from this is pathologized, and within the sex addiction field, retro-purity terms have reemerged, such as “promiscuity,” “nymphomania,” and “womanizer.” Accepting the disease model of inhibited sexual desire and sex addiction in exchange for a moral framework proves, then, to be a bad bargain, for the taint of stigma and deviance inheres in these expansive diagnostic categories. Reliance on individual treatment solutions remains a major shortcoming of the medical model. In the case of ISD and sex addiction, the obvious limitation is that, in the absence of social and historical insight, the problem is located within the individual chemistry or psyche and is presumed amenable to medical intervention. The inadequacy of a biomedical approach to treatment is glaring with the desire disorders, even when one looks at etiology as defined by the professionals themselves. Despite the preoccupation with lovemaps and brain circuitry, professional literature suggests a broader range of social correlatives. ISD is frequently related to fear, anger, and marital problems; some studies suggest that power struggles and lack of respect are major dynamics for ISD in women.69 Sex addiction is linked to childhood sexual trauma.70 Given this data, a sociohistorical approach to treatment would suggest the need for a more encompassing strategy for change. Yet clinicians articulate no social vision to end sexual abuse, challenge the primacy of the nuclear family, end the double standard, improve sex education, or expose destructive and coercive sexual ideologies. Significantly, there are no treatment outcome studies for sex addiction, and ISD is widely considered the most difficult sexual problem to treat. Medicalizing desire, then, cannot really be said to eliminate moral stigma or enhance “cure.” Other potential effects are difficult to discern clearly. There is some concern that the message from the proliferation of sexual diseases privileges certain styles of sexual expression and marginalizes others. At least one sex therapist has been critical of the broader therapeutic milieu of sex therapy, whose emphasis on sexual enhancement techniques increases the “pressure

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we all are under to ‘always say yes.’”71 It is widely recognized that the discourse of sickness can readily become coercive, and there is evidence that this is increasingly true for the sexual dysfunctions.72 One client in therapy for ISD voiced precisely this complaint about her husband’s appropriation of the disease frame: But he’s got this hang-up about my having to have sex the way he does. “Doesn’t it feel good to you?” he asks. So, I rub my earlobe and say, “yeah, and this feels good, too, but I never think about rubbing my earlobe and if I do I don’t say, ‘Wow, I can’t wait to do it again.’ I like Chinese food, but if I had to go a year without any, I wouldn’t be miserable.” He says I’m inhibited and don’t know it and that I need therapy. When he gets angry he calls me an uptight, frigid bitch, and says I’m sick.73

Yet individuals internalize disease models in highly variable ways, and it is important to acknowledge that despite coercive potential, scores of people report relief and validation from the desire diagnoses. Individuals also negotiate these diagnostic systems idiosyncratically. With sex addiction, for example, there are clearly individuals who instrumentally select from the menu of treatment options, attending recovery groups for the structure, support, and community, but eschewing the adoption of a full-blown identity. Countless others, however, opt for wholesale acceptance of the addiction ideology as an explanatory device for their fears, and they find solace in their “sobriety” from the disease. The AIDS epidemic has been the perfect impetus for many to define behavior as out of control that once would have been perfectly acceptable, and in 1986 the national gay newsmagazine The Advocate reported that thousands of gay men were reporting that they suffered from the disease of sex addiction.74 The out-of-control behavior defined by the men themselves ranged from masturbation once or twice a month by a devout Catholic to relentless cruising of peep shows. All claimed to experience great relief from their “sexual recovery plans.” This underscores the importance of individual needs and cultural anxieties in the construction of disease categories. For inhibited sexual desire

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and sex addiction serve as contemporary disease categories that help people create meaning out of their sexual experiences. The diagnoses offer the hope of achieving “normalcy” to those who experience their sexual desire as either inadequate or out of control. They are bipolar constructs that map the contradictory cultural landscape regarding the negotiation and management of appropriate sexuality. These disorders emerged in the mid-1970s and flourish during an era of distinct and palpable tensions regarding sexual norms. They are informed by the dichotomous contemporary ideology in which sex is simultaneously heralded as the linchpin of individual fulfillment and denigrated as the source of chaos, exploitation, and death. Desire, too, is a cultural trope for both pleasurable satisfaction and dangerous, possibly alien, hunger. Historian Joan Jacobs Brumberg and philosopher Susan Bordo speak to this ambivalence and fear in their analyses of anorexia nervosa.75 Women are terrified and repelled by visions of themselves as voracious, needy, yearning, and hungering without restraint. “Appetite,” Brumberg writes, “is an important voice in female identity.”76 Yet appetite, whether for food or for sex, carries with it the hope of satisfaction and the fear of wanting too much or of needing and not getting. Desire is not neutral. Cultural attitudes toward high levels of sexual desire reflect this pleasure/danger dichotomy.77 We are assured by experts on ISD that “an increase in sexual desire is invariably beneficial,” since high levels of sexual desire inspire people to exercise, watch their weight, dress with flair, groom themselves carefully, and otherwise operate as healthy, attractive individuals.78 For sex addicts, however, it is “the athlete’s foot of the mind. It never goes away. It always is asking to be scratched, promising relief.”79 Desire, then, will either make you a better person or ruin your life. These bifurcations, so dramatically visible in this era of epidemics such as AIDS, were apparent in the sexual ethos of the 1970s as well. The glut of media information about sex during that decade reflected both a growing openness and increasing sexological expertise. Further, the public challenges of the feminist and lesbian and gay liberation movements to hetero/

sexist imperatives created new sexual space. Many women were empowered not merely to avoid exploitive sex, but to seek out fantasy, orgasms, and thrills. Feminist consciousnessraising groups facilitated both a critique of existing sexual relationships and the exploration of new sexual terrain. A study of married couples in the early 1970s revealed greater sexual experimentation among white couples of all classes. Mainstream books like The Joy of Sex, The Sensuous Woman, and My Secret Garden spoke to a new sexual spirit. By the late 1970s, women had become increasingly active partners, and couples were enthusiastically proclaiming the importance of sex to a good relationship.80 Yet this sexual enthusiasm was striated with oppositional impulses. The persistence of the double standard thwarted many women’s pursuit of sexual freedom. Feminist organizing drew greater public attention to sexual violence as a mechanism for the social control of women. And the plethora of sexual options touted by sexologists and the media were experienced by many merely as increased pressure. The glaring disjuncture between expectations of an easy sexual pleasure and the realities of failed sex helped create a cultural basis for the successful development of clinical programs of sex therapy. The growing New Right launched challenges to sex education, legalized abortion, and gay liberation, reinscribing notions of abstinence, morality, and sexual self-control on the collective psyche. The calls for sexual restraint became, of course, even more widespread and entrenched throughout the 1980s with the emergence of the AIDS epidemic. On parallel tracks, then, inhibited sexual desire and sex addiction mark these contradictory themes of sexual freedom contrasted with growing sexual fear and prohibition. Together they constitute a set of regulatory discourses and serve as social signifiers that shape individual experience. However, medical diagnoses function differently for individuals and may operate fluidly and unpredictably in the culture. While constructed diseases like ISD and sex addiction play a central role in the creation and reinforcement of the traditional sociosexual order, the diagnoses might also contain the seeds of disruption

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and opposition. For example, the diagnostic binarisms of inhibition and excess easily suggest gendered sexual norms, and in fact, early on, demographics revealed more women diagnosed with ISD while men largely filled the ranks of sex addicts. The disorders therefore reified a normative system of sex/gender relations. For women, ISD was simply a reformulation of historical diagnoses of frigidity, implying withholding unresponsiveness. Conversely, the male sex addict represents a more extreme version of male sexual energy and aggression. As the male/female ratios become more equivalent, the definitions are still internally gendered. For example, the profiles of male and female sex addicts are quite different. Men are identified as sex addicts when they exhibit repetitive and extreme forms of behavior. Often they are prone to violence, or are engaging in behavior such as fetishism. This is not the typical standard for female sex addiction. Instead, women sex addicts are described as risking victimization or using sex to feel vicariously powerful. Women sex addicts are said to prepare and dramatize, unlike men. As one therapist said, “We’re talking about picking the right music, picking the right clothes, picking the right make-up.”81 These rituals may extend for hours or days before being sexual. Clear ideas about appropriate sexual behavior for women emerge in the definition of sex addiction. Charlotte Kasl, who has been the major spokesperson on female sex addiction, links sex addiction in women to a break from having sex in a loving relationship and within a larger spiritual context. In a revealing statement that reflects cultural ideologies about inherent differences between male and female sexuality, she claims, “Sex addiction in women reflects an internalization of male norms of sexuality involving power, aggressiveness, and control.”82 In fact, the idea of aggression and extreme sexual behavior among women is so taboo that the concept of sex addiction quickly splintered, with women identifying instead as sexual co-dependents, romance addicts, and relationship addicts. Yet in a cultural moment of instability and ambivalence, the diagnoses of ISD and sex addiction may signify the manner in which sex/

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gender boundaries are also being eroded. ISD, as it is recently constructed, draws on feminist assertions of the importance of pleasure and desire for women. Despite its many shortcomings, the diagnosis of ISD can serve as a cultural protest by women: a demand for satisfaction in sex and a refusal to settle for less. Similarly, the construct of sex addiction is sometimes formulated as a complaint against sexual accommodation and exploitation of women. Feminists in the field claim that addiction often represents women’s escape from “the powerless feelings of codependency.” Co-dependency has been described as a “disease of inequality” in which oppressed people must understand and accommodate those in power.83 For some of these women, then, the struggle against sex addiction may serve as a fundamental challenge to restrictive gender roles. Similarly, some men who identify with either ISD or sex addiction have criticized traditional male sexual expectations. It is too soon to tell whether the male who identifies with ISD will simply be silently ridiculed and despised while the female sex addict will remain an anomaly destined for “Oprah.” But the new diagnoses clearly allow for more than the simple recuperation of normative roles. These deconstructions simply suggest that, like the nineteenth-century proliferation of sexualities, the invention of contemporary medical categories is not one-dimensional in effect. Discourse, as Foucault notes, produces and reinforces power but also exposes and destabilizes it. The creation of new sexual disorders reinscribes traditional sex/gender relations while possibly providing a site for resistance, however minimal. Central to this resistance, however, is a consistent and sharp awareness of how these new diseases, as signifiers of social relations and anxieties, are generally supportive of dominant political interests and social structures. This is especially true in an era when, as medical experts are asserting guidelines about “safer” and hence “appropriate” sex, many individuals feel more vulnerable and therefore susceptible to medical definition, intervention, and control. Continual challenge of medical definitions is essential, particularly as the new desire disorders become widespread. For despite the potential for

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some regrounding of sex/gender relations, the tendencies of medicalization are such that ISD and sex addiction can easily become social practices inimical to the goals of feminism and the lesbian/gay movement. We must remember that in the earlier social purity movements, feminist themes resounded through movements that were otherwise conservative and anti-sex.84 The social purity themes of lust, degradation, and loss of control inherent in the sex addiction construct should give us pause, particularly, for example, as the model is being suggested as salient to the area of sexual abuse and sex offenders.85 After decades of scholarship suggesting that power inequities and gender oppression underpin most sexual violence, feminists should be wary of models that suggest that rapists and sexual abusers suffer instead from individual dysfunctions. And despite enthusiastic identification by scores of lesbians and gay men, sex addiction has gotten little, and decidedly negative, attention in the gay press. The one major article in The Advocate, entitled “Reinventing the Sex Maniac,” rightfully worried that sex addiction was simply a new expression of homophobia and self-hatred.86 Inhibited sexual desire and sex addiction are not demon diagnoses; they have offered validation and community to many. But since the biomedical model is a severely limited paradigm for understanding sexuality on either a social or personal level, it is clearly time for an alternative popular and accessible frame for people to understand their experiences or engage in collective discussion and support for sexual concerns. Progressive movements currently articulate a public and oppositional discourse that inserts the elements of history, cultural ideologies, and power relations into any analysis of sexuality. The next challenge is to create the space for individuals to determine how the personal might be political in their sex lives. Otherwise the new desire disorders stand as uncontested models in which sexual anxieties, discomfort, and problems inhere in the individual body or psyche rather than the body politic.

NOTES 1. Michel Foucault, The History of Sexuality, Vol. 1: An Introduction (New York: Pantheon, 1978), 48.

2. John D’Emilio and Estelle Freedman, Intimate Matters: A History of Sexuality in America (New York: Harper & Row, 1988). 3. Foucault, The History of Sexuality, 33. 4. Talcott Parsons, “The Sick Role and the Role of the Physician Reconsidered,” Health Society 53 (1975), 257–78. 5. Elizabeth Fee, “Henry E. Sigerist: From the Social Production of Disease to Medical Management and Scientific Socialism,” Milbank Quarterly 67, supplement 1 (1989). 6. See Sandra R. Leiblum and Raymond C. Rosen, “Introduction,” in Sexual Desire Disorders, eds. Leiblum and Rosen (New York: Guilford Press, 1988), vii. 7. See Janice M. Irvine, Disorders of Desire: Sex and Gender in Modern American Sexology (Philadelphia: Temple University Press, 1990), for a discussion of sexology’s history. 8. William Masters and Virginia Johnson, Human Sexual Inadequacy (New York: Bantam Books, 1970). 9. Leiblum and Rosen, “Introduction,” in Sexual Desire Disorders. 10. Anthony Pietropinto and Jacqueline Simenauer, Not Tonight, Dear: How to Reawaken Your Sexual Desire (New York: Doubleday, 1990). 11. This history is from Richard F. Salmon, “A History of the 12-Step Fellowships for Sexual Addicts and Co-Addicts,” presented at the National Conference on Sexual Compulsivity/ Addiction, Minneapolis, 21 May 1990. 12. Ibid. 13. Richard Solomon, “The Opponent-Process Theory of Acquired Motivation,” American Psychologist 35 (1980), 691–712. 14. Daniel Goleman, “Some Sexual Behavior Viewed as an Addiction,” New York Times, 16 October 1984. 15. Audience discussion during Carole G. Anderson, “Assessment and Treatment of the Sexual Dependency, Eating Disorders, Sexual Trauma Complex,” presented at the National Conference on Sexual Compulsivity/Addiction, Minneapolis, 20 May 1990. 16. Ginger Manley, “Sexual Health Recovery in Sex Addiction: Implications for Sex Therapists,” American Journal of Preventive Psychiatry and Neurology 3, no. 1 (Spring 1991). 17. Mark Schwartz, “Four Paraphilias: Victim to Victimizer Triumph over Tragedy,” presented at the National Conference on Sexual Compulsivity/ Addiction, Minneapolis, 20 May 1991; and Manley, “Sexual Health Recovery in Sex Addiction.” 18. See Irvine, Disorders of Desire, for a discussion of sexology’s strategies to achieve professional legitimacy. 19. Leiblum and Rosen, “Introduction,” in Sexual Desire Disorders. 20. Goleman, “Some Sexual Behavior Viewed as an Addiction.” 21. Craig Rowland, “Reinventing the Sex Maniac,” The Advocate, 21 January 1986: 45.

REGULATED PASSION 22. Judy Foreman, “Drugs May Help Sex Offenders,” Boston Globe, 5 March 1984. 23. Goleman, “Some Sexual Behavior Viewed as an Addiction.” 24. John Money and Margaret Lamacz, Vandalized Lovemaps: Paraphilic Outcome of Seven Cases in Pediatric Sexology (New York: Prometheus Books, 1989). 25. Renee Dubos, Mirage of Health (New York: Harper & Row, 1959). 26. Jeffrey Weeks, Against Nature: Essays on History, Sexuality, and Identity (London: Rivers Oram, 1991), 70. 27. See Jeffrey Weeks, Sex, Politics, Society: The Regulation of Sexuality since 1800 (New York: Longman, 1981); Weeks, Against Nature; Irvine, Disorders of Desire. 28. Weeks, Against Nature, 70. 29. Helen Singer Kaplan, Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy (New York: Brunner/Mazel, 1979), 9. 30. Ibid., 78. 31. Ibid., 25. 32. Weeks, Against Nature, 70. 33. Money and Lamacz, Vandalized Lovemaps, 43. 34. Patrick J. Carnes, “Sexual Addiction: Progress, Criticism, Challenges,” American Journal of Preventive Psychiatry and Neurology 2, no. 3 (May 1990), 1. 35. Ian Forster, “Co-Dependency: A New Description and Theory—A Correlation between CoDependency and the Development of Addictive Disease,” presented at the National Conference on Sexual Compulsivity/Addiction, Minneapolis, 21 May 1991. 36. Ibid. 37. Schwartz, “Four Paraphilias.” 38. Leiblum and Rosen, “Introduction,” in Sexual Desire Disorders. 39. See ibid. for the parameters of this debate. 40. Kaplan, Disorders of Sexual Desire, 90. 41. See, for example, Patrick J. Carnes, Out of the Shadows: Understanding Sexual Addiction (Minneapolis: CompCare Publications, 1983), and Charlotte Kasl, Women, Sex, and Addiction: A Search for Love and Power (New York: Ticknor & Fields, 1989). 42. Carole S. Vance, “Anthropology Rediscovers Sexuality,” Social Science and Medicine 33, no. 8 (1991), 875–84. 43. Ibid., 878. 44. Leiblum and Rosen, “Introduction,” in Sexual Desire Disorders. 45. Kaplan, Disorders of Sexual Desire, 63–64. 46. Clearing-Sky and Thornton, cited in Leiblum and Rosen, “Introduction,” in Sexual Desire Disorders, vii. 47. Leiblum and Rosen, Sexual Desire Disorders, 8. 48. “Sexual Addiction,” brochure of the Golden Valley Health Center. 49. Ibid. 50. Quoted in Richard Salmon, “Twelve Step Resources for Sexual Addicts and Co-Addicts,”

51.

52.

53. 54. 55. 56.

57.

58. 59. 60. 61. 62. 63. 64. 65. 66. 67.

68. 69. 70. 71. 72. 73. 74.

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presented at the National Association on Sexual Addiction Problems of Colorado, 1989. Keziah Hinchen and Anne McBean, “Sexually Compulsive or Addicted Women,” presented at the National Conference on Sexual Compulsivity/ Addiction, Minneapolis, 21 May 1990. Marvin A. Steinberg, “Sexual Addiction and Compulsive Gambling,” American Journal of Preventive Psychiatry and Neurology 2, no. 3 (May 1990), 40. See Kasl, Women, Sex, and Addiction. Anne Schaef, Escape from Intimacy: The PseudoRelationship Addictions (San Francisco: Harper & Row, 1989), 34. See Irvine, Disorders of Desire, for a discussion of ISD and drug treatment. Gayle Rubin, “Thinking Sex: Notes for a Radical Theory of the Politics of Sexuality,” in Pleasure and Danger: Exploring Female Sexuality, ed. Carole S. Vance (Boston: Routledge & Kegan Paul, 1984), 267–318. Carl Degler, “What Ought to Be and What Was: Women’s Sexuality in the Nineteenth Century,” in Women and Health in America, ed. Judith Walzer Leavitt (Madison: University of Wisconsin Press, 1984), 40–56. Nancy Cott, “Passionlessness: An Interpretation of Victorian Sexual Ideology, 1790–1850,” in Women and Health in America, ed. Leavitt, 57–69. Pietropinto and Simenauer, Not Tonight, Dear, 6. “Rob Lowe in Sex Addiction Clinic,” National Enquirer, 5 June 1990. Erica Jong, Any Woman’s Blues (New York: Harper & Row, 1990). New York Times Book Review, 4 February 1990. Salman, “A History of the 12–Step Fellowships.” See Leiblum and Rosen, “Introduction,” in Sexual Desire Disorders, and Pietropinto and Simenauer, Not Tonight, Dear, 4. S. Chorover, “Big Brother and Psychotechnology,” Psychology Today (October 1973), 43–54; Pietropinto and Simenauer, Not Tonight, Dear, 4. Peter Conrad and Joseph Schneider, Deviance and Medicalization: From Badness to Sickness (St. Louis: C. V. Mosby Company, 1980), 31. Handout from Keziah Hinchen and Anne McBean, “Sexually Compulsive or Addicted Women,” presented at the National Conference on Sexual Compulsivity and Addiction, Minneapolis, 21 May 1990. See Kasl, Women, Sex, and Addiction. See Irvine, Disorders of Desire, for an expansion of this argument. See Kasl, Women, Sex, and Addiction, and press release from Golden Valley Health Center, 1990. Bernard Apfelbaum, “An Ego-Analytic Perspective on Desire Disorders,” in Sexual Desire Disorders, eds. Leiblum and Rosen, 78. See Irvine, Disorders of Desire, for a broader examination of these issues. Pietropinto and Simenauer, Not Tonight, Dear, 20. See Rowland, “Reinventing the Sex Maniac.”

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75. Joan Jacobs Brumberg, Fasting Girls: The History of Anorexia Nervosa (New York: Plume, 1988), and Susan Bordo, “Anorexia Nervosa: Psychopathology as the Crystallization of Culture,” in Feminism and Foucault: Reflections on Resistance, eds. Irene Diamond and Lee Quinby (Boston: Northeastern University Press, 1988), 87–118. 76. Brumberg, Fasting Girls, 265. 77. Carole S. Vance, ed., Pleasure and Danger: Exploring Female Sexuality (Boston: Routledge & Kegan Paul, 1984). 78. Pietropinto and Simenauer, Not Tonight, Dear, 15–16. 79. Carnes, Out of the Shadows, vii. 80. See Irvine, Disorders of Desire, for a discussion of these cultural patterns. 81. Anne McBean, “Assessment and Treatment of Sexually Compulsive Women: A Guide through the

82. 83. 84.

85. 86.

Labyrinth,” presented at the National Conference on Sexual Compulsivity/Addiction, Minneapolis, 19 May 1991. Kasl, Women, Sex, and Addiction, 43. Ibid., 31. See Ellen Carol DuBois and Linda Gordon, “Seeking Ecstasy on the Battlefield: Danger and Pleasure in Nineteenth-Century Feminist Sexual Thought,” in Pleasure and Danger, ed. Vance, 31–49, and Margaret Hunt, “The De-Eroticization of Women’s Liberation: Social Purity Movements and the Revolutionary Feminism of Sheila Jeffries,” Feminist Review 34 (Spring 1990), 23–46. Judith Lewis Herman, “Considering Sex Offenders: A Model of Addiction,” Signs 13, no. 4 (1988), 695–724. Rowland, “Reinventing the Sex Maniac.”

CHAPTER 18

Gambling and the Contradictions of Consumption A Genealogy of the “Pathological” Subject Gerda Reith Gambling has always been regarded as problematic, although the precise nature of the problem it presents varies according to sociohistorical context and cultural climate. Today its status is particularly complex and is constituted from a configuration of medicalized discourses that reflect broader socioeconomic tensions within society more generally. This article considers the creation of the modern “problem gambler” as a unique cultural figure who is both created through, and represents, the contradictions of late-modern consumer societies. As such, its focus is not on the motivations and explanations for “normal” or social gambling, which are complex and diverse, but rather on the ways in which problem gambling, as a distinct social phenomenon, is configured within Western societies as a whole.

THE ETHIC OF PRODUCTION For much of its history, gambling has been considered a fundamentally problematic human activity and criticized as degenerate and sinful for its nonproductive nature, its deliberate courting of the irrational forces of chance, and its disruptive and immoral effects on populations. As such, it has been persistently prohibited and/or regulated by states that feared its potentially incendiary effects on their workforces and its disorderly effects on social cohesion (Lears, 2003; Reith, 1999). The blind democracy of chance in gambling divorced reward from effort or merit, undermining the ideology of meritocracy in secular societies and of faith in providential

determinism in religious ones. Counterposed to these, the lottery winner was neither necessarily worthy nor deserving—simply lucky. And rich. By divorcing the creation of wealth from the efforts of labor, gambling undermined the Protestant work ethic and so threatened the accumulation of wealth that formed the basis of capitalist societies. The stability of industrial nations depended on the rational management of time and money through diligent labor, investment, and self-discipline: virtuous pursuits that were flouted by the actions of the gambler. In contrast to the gradual accumulation of earned—and therefore justified—wealth, gambling was characterized by the idle squandering of time and money in economically unproductive activities. Games of chance never actually created wealth but only redistributed it in a way that was out of all proportion to the efforts of those involved, with the result that any gains made from such games were regarded as undeserved—and therefore illegitimate— wealth. The sudden fluctuations in prosperity inherent in gambling games threatened the order of the social hierarchy by transforming poor individuals into wealthy ones or vice versa, reversing social distinctions, and undermining economic productivity in a way that tended to worry those with most to lose while proving extremely appealing to those with everything to gain. As the group most committed to the ideological foundation of the Protestant work ethic, the bourgeoisie were also the class most virulently opposed to all forms of gambling and were the driving force behind a range of legislative attempts to curtail and prohibit the

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playing of games of chance, especially among lower socioeconomic groups (Dixon, 1991; Munting, 1996; Reith, 1999). In general, however, such critical approaches did not possess a distinctive notion of problem gambling as an activity separate from normal gambling; rather, all gambling was assumed to be potentially problematic, both as an immoral activity in its own right as well as one that could lead to further vice and disruption.

THE COMMODIFICATION OF CHANCE In many respects, the contemporary problematization of gambling can be seen as a continuation of the discourses that criticized its undermining of the ethic of productive labor and its promotion of the ideology of unearned wealth. But in other important respects, today’s dialogue brings its own unique perspective to the phenomenon and reconfigures it in new ways. The proliferation of gambling and problem gambling in the late 20th and 21st centuries is in part a result of the commercial expansion of the industry itself. But equally important is the growth of new discursive formations that develop in conjunction with changes in the structure of Western economies and reflect wider contradictions within them. Since the 1970s in particular, the gambling industry has undergone a period of dramatic liberalization and deregulation, with a loosening of legal restrictions on promotion and expansion resulting in the massive proliferation of commercial gambling as a global enterprise, with a central place in Western economies. Governments around the world have legalized lotteries, casinos, and sports betting as well as machine-based gambling, such as slots and video lottery terminals (VLTs), as sources of vast profit for both state and commercial enterprise. At the same time, new technologies such as the Internet have launched gambling into cyberspace, breaking down national boundaries and posing complex regulatory challenges. In the U.S. alone, expenditure on gambling (i.e., amount wagered minus payouts for winnings) increased from $10 billion to $50 billion between 1982 and 1997 as the size of the

industry increased tenfold (National Research Council [NRC], 1999). Similar expansion can be found elsewhere, with annual expenditures in Australia and the United Kingdom now exceeding AU$11 billion and £7 billion, respectively (Department of Culture, Media, and Sport [DCMS], 2001; Productivity Commission, 1999). At the same time, shifts in the fabric of social life, including increasing secularization, the declining influence of arguments concerning the “immorality” of gambling, and the spread of consumerism, have created a climate that is conducive to the proliferation of gambling as a mainstream leisure activity. The development of the commercial strategies of market research, advertising, and branding has been used to develop a variety of products and opportunities to gamble: From “convenience” to “resort” gambling—from the purchase of lottery tickets and scratch cards at corner stores to the development of destinations such as Las Vegas—games of chance have been commodified as heterogeneous products, offering a diverse range of choices for ever-increasing numbers of consumers (Reith, 1999). Participation has not only increased but also widened to include, for the first time, the middle class—the group traditionally most hostile to all forms of gambling—in a move that has finally “normalized” the activity. Such legitimation is reflected in shifting nomenclature, at least on the part of the industry, whose use of the euphemistic term gaming, with its connotations of play and leisure, dissociates games of chance from their older, “harder” connotations of betting, wagering, and inevitably, financial loss. Lotteries represent the apogee of this trend: With their links to public services and “good causes,” they attract language the rest of the industry can only dream of, with patrons described as “playing,” “participating,” or enjoying a “flutter”—but never actually “gambling” proper. These trends of liberalization and proliferation can be located within wider changes in Western economies, most notably, the move toward political and fiscal policies of neoliberalism and the rejection of broadly Keynesian principles of market regulation. These are characterized by the state’s reduced intervention in

GAMBLING AND CONTRADICTIONS OF CONSUMPTION

social and economic life, its decreasing responsibility for the provision of public services, and its promotion of competitive enterprise. In particular, this “minimal state” is characterized by increasing unwillingness to levy unpopular taxation on voting populations. In the revenue vacuum created by such policies, the economic utility of gambling as a voluntary, albeit regressive, form of taxation to state and federal coffers is obvious. Through direct involvement in lotteries and extensive taxation of commercial operations, states extract vital revenue from games of chance with which to fund public services (Abt, Smith, & Christiansen, 1985; Goodman, 1995). For example, in 2003, lotteries contributed $14.1 billion to U.S. state governments (North American Association of State and Provincial Lotteries, 2003); the U.K. gambling industry provided some £1530 million to the government in 2000 (DCMS, 2001) and the Australian industry AU$4.4 billion in the same year, an almost fourfold increase in real terms since the 1970s (Della Sala, 2004). Such profits are either added to general tax revenue or else designated for particular services, with education, health care, and housing projects being popular beneficiaries. And so, as the presence of the state in the regulation of public life is scaled back, so its involvement in the business of gambling increases. It is this symbiotic relation between commercial profit and state revenue that has provided much of the impetus for the liberalization and promotion of gambling toward the end of the 20th century and into the 21st. In this convergence of commerce with chance, the state-sponsored fantasy of the big win turns the ethos of production and accumulation on its head, advocating the benefits of massive, unearned wealth over the satisfaction of modest gains in a shift that reflects not only the transcendence of the work ethic but also the promotion and celebration of a new kind of “consumption ethic.” The values of risk taking, hedonism, and instant gratification are promoted in lottery advertisements that urge consumers to live for the present (“Forget it all for an instant”; U.K. scratch card), reject work (“Work is nothing but heart attack-inducing drudgery”; Massachusetts lottery), embrace

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risk (“Lotto—the biggest risk of becoming a millionaire”; Netherlands lottery), and dream of a life of leisure (“The freedom to do what you want to do, year after year”; Queensland Golden Casket), all for a simple purchase (“All you need is a dollar and a dream”; New York lottery). Appeals to the democracy of chance continue and are now associated with the aspirations of the American Dream—anyone can be lucky, bountiful state lotteries do not discriminate, and the downtrodden McWorker has as much chance of winning as the Ivy League lawyer. As the U.K. lottery slogan puts it, “It could be YOU!”

QUANTIFYING THE PROBLEMATIC SUBJECT: THE CONSTRUCTION OF THE “PATHOLOGICAL GAMBLER” It was into this climate that the “pathological gambler” as a quantifiable entity was born, when it was introduced into the reference manual of mental disorders used by the American Psychiatric Association (1980), the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III).1 What is perhaps most immediately striking about its appearance is the fact that although steeped in a climate of commercial proliferation and economic deregulation, explanations of gambling problems were seldom couched in terms of consumer behavior but were rather discussed within a reductive, materialistic epistemology of sickness and disease. The syndrome was first described as an impulse control disorder: a compulsion characterized by an inability to resist overwhelming and irrational drives. Focus soon shifted to its addictive characteristics, however, and it was reclassified in terms similar to those for psychoactive substance dependency in DSM III-R in 1987 and then refined again in DSM-IV in 1994, with the term pathological gambling consistently used to reflect its chronic, progressive character (American Psychiatric Association, 1987, 1994; Lesieur & Rosenthal, 1991). The DSM-IV screen contrasts pathological with social and professional gambling on the basis of the presence or absence of the values of reason and discipline: Social gambling

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is defined by its “predetermined acceptable losses” and professional gambling where “risks are limited and discipline is central” (American Psychological Association, 1994, p. 283). Underlying its checklist of symptoms is a focus on loss of control as the organizing principle for pathology, reflected in criteria such as repeated unsuccessful attempts to stop gambling and irritability when attempting to stop as well as others such as preoccupation and tolerance, which reflect the assumption of the physiological basis of the disorder. Meanwhile, another screen—the South Oaks Gambling Screen (SOGS; Lesieur & Blume, 1987)—was developed for the clinical diagnosis of gambling problems, again with loss of control as a guiding principle of categorization, and became widely used for the measurement of gambling problems throughout the population. In general, behavior is viewed as existing on a continuum, with “problem,” as opposed to “pathological,” gambling regarded as a less severe condition, defined in terms of its harmful effects to the individual and its disruptive effects on economic productivity, familial breakdown, and crime.2 It has been estimated that up to 2% of the population in the U.S. experience gambling-related problems, with 0.8% considered pathological (NRC, 1999). Around 1.1% of Australians experience moderate, and a further 1% severe, problems with their playing (Productivity Commission, 1999), and around 0.8% of Britons are regarded as problem gamblers (Sproston, Erens, & Orford, 2000). With the development of a system of classification and nomenclature, a distinct type of individual, with a checklist of symptoms that could be measured and compared against a norm, came into existence. For the first time, the problem of gambling was given a name, quantified, separated from normal gambling, and legitimated within the domain of medicine. With the recognition of pathological gambling as a psychiatric disorder came a proliferation of interest in the subject, with the establishment of a range of medical, legal, academic, and treatment professionals as well as lay groups and formal organizations, all with their own conception of and interest in the problem (Volberg, 2001). A range of explanations for the syndrome were proposed, many of which tended to

simply “explain” it in terms of a description of the features that characterized it. Whereas psychological research focused on what appeared to be the fundamental impulsivity and irrationality of gamblers, medical research attempted to locate biochemical and neurological bases for the disorder, and public health perspectives used a variety of approaches to estimate the prevalence of problems and calculate patterns of risk across populations. All of this resulted in a somewhat messy overlapping of discourses that configured problem and pathological gambling in a range of different ways: as a mental disorder, a physiological syndrome, or sometimes a (calculable) combination of all of these things, expressed as factors of risk. Despite widespread interest in what appears a significant social phenomenon, social theorists have, on the whole, paid relatively little attention to problem gambling, with the result that it remains an inadequately understood entity and an under-theorized area of human behavior. Some accounts that are pertinent here, however, have noted the wider discursive processes within which the problem has been located (Castellani, 2000) and have argued that the medicalization of gambling is part of the more general medicalization of marginal or deviant behavior that has historically been applied to phenomena such as drug taking and mental illness and is often associated with middle-class participation in an activity (Conrad & Schneider, 1992; Rosecrance, 1985). To an extent, the (medicalized) creation of the pathological gambler can be seen as an instance of such a “made-up” or socially constituted individual. However, it can also be said that all behavior defined as problematic is socially constituted in some way—“made up” through a process of comparison, separation, and exclusion on the basis of dominant values and beliefs. Furthermore, the problematization of gambling occurred not when it was considered marginal or deviant but at precisely the point when it became a mainstream leisure activity. Given this, what is perhaps more interesting here is the conditions under which gambling came to be constituted as problematic at all and, moreover, what the nature of

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its configuration tells us about broader social conditions.

THE CONSUMPTION ETHIC The recent shift in the status of commercial gambling has to be seen in the context of the general transformation of Western societies from industrial, production-based economies toward those organized around consumption and the provision of services. This trend, often described as “post-” or “late” modern, is characterized by the elevation of consumption as an organizing feature of social life, with an elective affinity to neoliberal ideologies of freedom, choice, and consumer sovereignty. As Zygmut Bauman (1998) puts it, we have moved from a “production ethic” to a “consumption ethic,” characterized by the values of self-fulfilment, hedonism, and desire. Here, consumption has a crucial role in the creation and realization of both individual and social identity, with consumers using the acquisition and display of commodities to mediate social relationships and to construct a coherent “narrative of the self” (Giddens, 1991). This formulation is based on a very specific view of consumption as a regulatory force as well as a means of self-expression, which is located in the economic and political structures of affluent Western neoliberal societies. Here, the reduction in external sources of governance—the economic deregulation of markets and the withdrawal of the state from interference (or perhaps more accurately, funding) in ever more areas of public and private life—is accompanied by an increasing emphasis on forms of individual self-control. The demand is for consumers to govern themselves through their consumption habits, with the ideal of consumer sovereignty based on autonomous individuals shaping their own trajectories through their actions in the marketplace. Crucially, these self-determining agents are responsible for their own welfare, security, and future happiness independent of wider systems of social support: aims that are realized through prudent decision making and rational and controlled consumption (O’Malley, 1996; Nikolas Rose, 1999). As such, the ideologies of

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free choice and consumer sovereignty actually become the regulatory principles of modern life. Ironically then, the very freedom of consumers is also the means of their regulation and is based on the subjugation of irrational urges and desires to rational forethought and prudence. Crucial to the notion of a modern consumer ethic as discussed here, then, is a dualistic conception of consumption both as a medium of self-control as well as a form of self-expression. The tension inherent in this formulation stems from an aspect of what Daniel Bell (1976) first identified as the “cultural contradiction of capitalism.” In essence, this refers to the conflict between a production-centered ethic, based on rational discipline, control, and work, and a consumption-centered one, founded on hedonism, self-expression, and instant gratification. Modern society presented individuals with a paradox: on one hand encouraged to consume, to give in and abandon themselves to the pleasures of self-fulfillment, and on the other, to exercise self-control and restraint, imperatives that Bell regarded as fundamentally irreconcilable and indicative of a deep contradiction inherent within capitalist systems. Today it is clear, however, that these apparently oppositional ethics are not mutually opposed, and that they cannot only coexist but can in fact be complementary. The practices of consumption associated with modern neoliberal systems actually embody both the imperatives of self-expression and self-restraint. The values of the Protestant work ethic have not been transcended, merely internalized in an activity that is on one hand free and unrestricted but, on the other, controlled by responsible and rational consumers themselves. In this formulation, the ethic of consumption actually embodies many of the values traditionally associated with production while configuring them in terms of individual self-control.

GAMBLING AND THE CONSUMPTION ETHIC It is within this context of increasing consumerism, economic deregulation, and the emphasis on internal forms of restraint that the

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emergence of problem gambling as a distinct social phenomenon becomes possible. As a feature of these broad socioeconomic trends, the increasing liberalization and deregulation of commercial gambling is accompanied by rising demands for self-regulation and responsible gambling by players themselves. It is no longer the prerogative of the industry, the state, or the courts to restrict the consumption of games of chance; this is now up to the individual, who becomes responsible for his or her own fate at the tables. It is now the task of the sovereign consumer to temper his or her enjoyment of the thrills of gambling with a prudent awareness of the risks involved, to exercise self-control, to manage losses and, in extreme cases, even to exclude himself or herself from gambling venues altogether—because no one else will.3 At the same time, the shift toward a society dominated by consumption sees a shift in the location of gambling problems. From being defined primarily in terms of their opposition to the values of production, now the problems posed by gambling are reconfigured in terms of consumption—at least the particular notion of consumption that is embodied in neoliberalism. Although the unproductive effects of problem gambling, in terms of its disruption to economic, social, and familial life and its financial costs to society as a whole, are still very much alive and integral to critical discourses,4 the issues have become more complex today. In a climate where gambling has become a hugely profitable enterprise that is inextricably linked with the political and economic institutions of the state, where it is promoted as a legitimate form of consumption, and where the majority of the population—including large sections of the middle class—regularly participate, arguments about its undermining of the ethic of production become less certain. In such a climate, problem gambling emerges as a problem of inappropriate consumption whose defining features—lack of control and loss of reason—are conceived as attributes that undermine the ideal of consumer sovereignty and the basis of the consumption ethic. Indeed, the checklist of symptoms in the problemgambling screens reads as a negative image of this ideal: In place of the autonomous, rational,

self-controlled, and responsible consumer, we have one characterized by dependence, irrationality, lack of self-control, and an irresponsible attitude to money, family, and work relations. At this point, it is instructive to look more closely at the notion of problem gambling itself, through an in-depth analysis of the discourses in which it is constituted. Within these, the problematic subject is configured in a variety of ways that, although not reducible to any single explanatory type, are defined in terms broadly antithetical to the ideology of modern consumer societies. The remainder of this chapter will examine these claims more closely. The following discussion is organized loosely around the themes of loss of control, reason, and dependence and their intersections with notions of risk and therapy, which are regarded as the primary axes around which the notion of pathology is defined. Such a division is somewhat schematic; it is imposed simply for what is hoped are purposes of narrative coherence. It is likely that a range of different types of problem gambler exist, and it is stressed that neither they, nor the various discourses surrounding their behavior, fit neatly into any one of these areas, which are not intended to be regarded as discrete or mutually exclusive but, on the contrary, are characterized by frequent overlaps, contradictions, and divergences.

THE UNCONTROLLED SUBJECT Psychological research has focused on what appear to be the fundamental impulsivity and irrationality of problem gamblers, describing their inability to overcome impulses to act on the spur of the moment without consideration of the long-term consequences, their compulsion to repeat behavior over and over again (Blaszczynski, McConaghy, & Frankova, 1990; Zuckerman, 1979), and their drive to seek intense experiences in a spiraling quest for ever more exciting sensations (Coulombe, Ladouceur, Desharnais, & Jobin, 1992; Griffiths, 1993). Such accounts present an image of the problem gambler as an individual who is fundamentally out of control: a creature driven by a restless desire for novelty, excitement, and action and propelled by forces that are unwilled

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by their helpless owner. Indeed, problem gamblers appear to be overwhelmed by the experience of gambling itself, living from moment to moment, oblivious to their surroundings and to the passage of time, repeating increasingly desperate attempts to chase their losses until eventually the erosion of their bankroll or the limit of their credit forces them to stop. Although the motives for gambling are as heterogeneous as games themselves, it appears that for many problem gamblers, playing is not simply about winning money—at least, not in any straightforward, rationalist sense—with even the DSMIV admitting that “most individuals with pathological gambling say that they are seeking ‘action’ (an aroused, euphoric state) even more than money” (American Psychiatric Association, 1994, p. 283). The uncontrollable desire for excitement and thrills is so overwhelming that even money loses its value in the face of it, becoming devalued to the status of little more than a plaything, a counter in a game (almost literally, in the case of the use of chips in the casino). Although representing the supreme measure of value in the world outside, for problem gamblers, money is simply the medium of play, the price of a good time, or alternately, the cost of an escape from a bad one. Either way, it is dissociated from material consumption and prized not as an end in itself but for its ability to allow continued consumption in repeated play. The inveterate gambler Fyodor Dostoevsky, who would by today’s standards be considered pathological, articulated this indifference toward money when he stated that “the main thing is the play itself: I swear that greed for money has nothing to do with it” (Dostoevsky, 1914, p. 119). Implicit in such discourses is the notion of problem gambling as an activity that undermines the values of productivity, rational accumulation, and the efficient use of time and money. But also implied is its challenging of notions of acceptable consumption. The urge for instant gratification and arousal, the giving in to impulsive pleasures, and the lack of self-control in the face of powerful craving are expressions of uncontrolled consumption, based on desire and immediacy and unrestrained by will or reason. The exclusive focus

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on the present and the uncontrolled betting on impulsive urges that characterize the behavior of the problem gambler are the antithesis of the rational decision making and forward thinking that defines the actions of the responsible subject. The desire for sensation over gain, for action over profit, contradicts ideas about the utilitarian value of money, but it also undermines ideas about the creative potential of money for building up self-identity and reinforcing social relationships. Money is the great facilitator of the sovereign consumer; the medium of selfsufficiency, self-expression, and social cohesion, to be handled with the appropriate attitudes of responsibility and respect; all of which is undermined by the problem gambler’s insouciant approach to playing with rather than for it. Underlying such accounts is the issue of excessive consumption through the misuse of money or, rather, lack of money: money spent inappropriately, money spent on the wrong things. In place of the consumption of tangible goods with which to realize and express the self, this repetitive, immaterial form of consumption signals its surrender to impulsivity and its overwhelming by compulsion instead. Problem gambling is here conceived as a problem of will: a lack of control, driven by impulse and sensation, which in some respects invokes the (now discredited) hybrid state “disease of the will,” a condition originally applied to alcoholism to account for its apparent status as both physiological disease and moral shortcoming (Valverde, 1998).

THE IRRATIONAL SUBJECT Cognitive psychological research has investigated what is regarded as the fundamental irrationality of problem gambling behavior, as evidenced by players’ possession of a range of cognitive distortions and superstitions. The DSM-IV classified these as “disorders in thinking,” with clinicians and researchers pointing to a range of traits, including biased evaluations of outcomes (Gilovich, 1983), notions of near misses (Reid, 1986), and illusions of control (Langer, 1975), which describe problem gamblers’ tendency to overestimate their influence

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in games of chance, attribute losses to external factors, hold out unjustified optimism in the likelihood of winning, misperceive patterns in random events, and to trust to mysterious, influential forces such as luck (Gadboury & Ladouceur, 1989; Wagenaar, 1988).5 In general, this approach is based on the assumption that some kind of cognitive deficit lies at the root of problem behavior, whether a misunderstanding of probability, a lack of knowledge about odds and risk, or a faulty system of perception. Cognitive explanations of problem gambling, and the forms of treatment that are based on them, are founded on a model of rational economic action in which individuals make informed decisions based on calculations of the benefits and risks of various forms of activity. In this model, gambling is a form of economic behavior with negative expected value (i.e., gamblers can expect to lose) and so is regarded as antithetical to the self-interest of rational consumers. Such economistic accounts have a tendency to regard gamblers as investors, calculating the best return on their stakes, and so reduce the engagement with chance to a mistaken calculation, an irrational misunderstanding of the laws of economics and probability. As one analysis put it, it is a case of “faulty or irrelevant incoming information . . . producing erroneous behavioural output” (Zangeneh & Haydon, 2004, p. 28). In these types of discourse, problem gambling is conceived primarily as an epistemological problem: a disorder of cognition based on deficient reason, ignorance, and misunderstanding, which can be rectified by the input of “correct” information and/or various forms of therapy. This is not the place for criticisms of such reductive approaches to consumption6 nor for wider exploration of the motivations for gambling, which, as has already been pointed out, are complex and beyond the remit of this article. However, suffice it to note a contradiction that emerges from the discourses of problem gambling reviewed so far. Underlying cognitive explanations of problem gambling is the assumption that in general, gamblers are playing mainly to win money, and it is their involvement in such patently long-odds games that makes their actions a futile, and therefore

irrational, form of economic activity. However, as we have seen, at the same time a considerable body of research suggests that problem gamblers are not in fact primarily motivated by financial rewards but frequently by a quest for “action” or sensation. This results in a situation whereby supposed attempts to win money through gambling is defined as irrational, and yet playing without concern for winning is regarded as pathological! In these competing interpretations, problem gamblers quite literally cannot win.

THE DEPENDENT SUBJECT Emphasis on its similarity with dependent substance use has encouraged the search for a physiological basis for pathological gambling, with a range of biochemical, genetic, and neurological research investigating the material bases of the disorder. Although researchers emphasize the interaction of biological with wider environmental factors, and despite the fact that definite associations have yet to be established, such a focus points to the primary role of physiological factors in determining the causes and aetiology of pathological gambling.7 To this end, neurological studies have used magnetic resonance imaging (MRI) technology to attempt to identify the physiological profiles of subjects’ brains (Breiter, Aharon, Kahneman, Dale, & Shizgal, 2001; Potenza et al., 2003), substances such as noradrenalin and serotonin have been associated with impulsive disorders and craving, and more controversially, genetic predispositions have been implicated in pathological gambling (Comings, 1998; DeCaria, Bergaz, & Hollander, 1998). From this, pharmacological interventions, including lithium and selective serotonin reuptake inhibitors, have been suggested as possible means of treating the aberrant body. These kinds of approaches can be seen as presenting a narrative of the pathological gambler as a distinct type of individual whose actions are primarily reducible to physiological processes located deep in the body but beyond conscious control. Indeed, in the dramatic visual imagery of MRI scans, we can see the breakdown of Cartesian dualism: the attempt

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to peer into the brain tissue of the problematic subject as if the “location” of the problem were somehow to be found there. It is not the case that such medical models are foisted on a reluctant population of gamblers, however, for support for such classifications often actually comes from players themselves.8 Since the 1950s, the belief structure of the selfhelp movement Gamblers Anonymous (GA) has been wedded to a strict notion of mental and physiological disorder, which actually converges with the epistemological foundations of some of these medical approaches. Although claiming that compulsive gambling is an emotional problem, GA also advocates its disease status, claiming, “Compulsive gambling is an illness, progressive in its nature, which can never be cured, but can be arrested” (Gamblers Anonymous, n.d.). Pathological gamblers, then, do not exist only in clinics and diagnostic screens but as real players who actively identify themselves as such and adopt the language of medicine to articulate, and in some cases lend authority to, their condition. In these kinds of accounts, pathological gambling is configured primarily as an ontological problem—a problem of being—with the pathological gambler defined as the wrong type of subject: one whose identity is determined by incurable disease and whose behavior is characterized by irreversible loss of control. Indeed, this notion of a determined state of being is shared by GA, which states that “once a person has crossed the invisible line into irresponsible, uncontrolled gambling he or she never seems to regain control. . . . No real compulsive gambler ever regains control” (Gamblers Anonymous, n.d.). The notion of pathology that is involved in these discourses is anathema to the neoliberal ideal of consumer sovereignty. The overwhelming of the faculties of self-control and reason by the presence of disease implies an abnegation of responsibility, which means that morally—and sometimes legally—pathological gamblers cannot be held responsible for their actions, far less take charge of their future welfare (Castellani, 2000; Nelson Rose, 1986). In place of the autonomous, sovereign consumer, engaged in the project of constructing identity and shaping his or her own trajectory through responsible

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consumption, we have an individual who is instead dependent and determined by his or her relation to disease, overwhelmed by a single choice, compelled to repeat the same form of consumption over and over again in an irrational cycle that leads to self-destruction. Furthermore, this is a permanent state of being, as pathological gambling is regarded as a chronic type of disorder that may be kept in check but from which the individual can never fully recover, hence GA’s advocacy of total abstinence as the only way of guaranteeing “sobriety.” In this configuration, we find the inversion of the ideal of consumer sovereignty, where choice is replaced with repetition, autonomy with dependence, and freedom with constraint.

REFORMING THE SUBJECT The problem gambler that emerges out of formulations of public health and psychological expertise is subject to various types of therapeutic intervention that attempt to reform the irrational, impulsive drives that lie at the root of pathology and so reshape the problematic behavior on which it is based. To this end, counseling focuses on the development of decision-making strategies to regain control of excessive expenditures of time and money, on fostering techniques for managing risk and budgeting with finances, on cognitive restructuring to modify irrational expectations of gambling, and on the examination of motivations and moods and the raising of self-awareness and esteem to develop tactics for coping with, and so resisting, urges to gamble.9 Such strategies are embedded in wider socioeconomic contexts, namely, the growing influence of the disciplines of psychology, psychiatry, and psychoanalysis, which Nikolas Rose (1999) calls the “psy sciences.” These specialist forms of knowledge are part of a wider process of what Foucault (1991) calls “governmentality”: a form of control that is carried out through the shaping of particular kinds of subjectivity—the inculcation of norms and values—rather than the more overt enforcement of rules and discipline and that is part of the trend toward the reduction of external regulation and increased emphasis on individual

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self-control in everyday life. Here, individuals are key to their own management and are engaged in the continual inspection of their internal states and modification of their own behavior. The psy sciences are integral to this, defining notions of normality and abnormality and helping to shape subjectivity in ways that are compatible with prevalent socioeconomic imperatives and cultural values. In the present case, this involves the fostering of the values of self-control, responsibility, and reason among the citizen-consumers of Western societies. Ultimately, as Cruickshank (1996) points out, therapy itself becomes a form of governance, a means of acting on ourselves “so that the police, the guards and the doctors do not have to do so” (p. 234). The medical and psychiatric discourses of problem gambling are deeply embedded in this therapeutic project. With their construction of diagnostic criteria and measurement of norms, the clinical screens allow the evaluation and assessment of gambling in terms of standards of “appropriate” behavior as well as create a climate in which individuals themselves can engage in an ongoing process of introspection and selfexamination. At the same time, they generate an army of professional counselors and therapists, whom Nikolas Rose (1999) calls “engineers of the human soul,” who provide treatment to reform the irrational drives—and therefore the aberrant behavior—of the problem gambler. As he puts it, “Psychological expertise now holds out the promise not of curing pathology, but of reshaping subjectivity” (p. xxxi). The very criteria of the gambling screens are located in and defined by this therapeutic trend, for despite their supposedly objective taxonomies, their explanatory power actually rests on a range of criteria that is socially relative and deeply subjective. Both the DSM-IV and the SOGS identify pathology on the basis of individuals’ judgments on their motivations and moods, including evaluation of states such as preoccupation, excitement, and loss of control, whereas its indirect effects are experienced as negative emotions, such as guilt, anxiety, and depression that derive from spoiled relationships, unsatisfactory jobs, financial worries, and general existential ennui. The screens are remarkably silent on the issue of what is,

after all, the medium and the signifier of both gambling and problem gambling: money. Attitudes and behavior relating to money, such as borrowing, stealing, or lying about it, as well as chasing losses, are judged more important than the actual amounts of money wagered or lost (far less money lost relative to income),10 which does not form part of the critical score of the SOGS. Indeed, the syndrome of pathological gambling is regarded as quite distinct from heavy or even excessive expenditure on gambling, and pains are taken to point out that the two are not synonymous (e.g., Volberg, Gerstein, Christiansen, & Baldridge, 2001). It is not money—in an absolute or relative sense—that is important here, but rather loss of control of money that acts as a measure of pathology. And in this sense, the definition of problem gambling becomes potentially limitless: When evaluation of one’s own subjective feelings about wins and losses is the criteria of pathology, anyone can experience problems, and the distinction between normal and problematic behavior starts to collapse. In this scenario, the various forms of intervention and therapy represent strategies to regain control: technologies to restructure the inner world—the motivations, moods, and cognitions—of the problem gambler to return the out-of-control subject to the status of selfactualization and responsibility. Ultimately, these therapeutic and public health approaches to problem gambling are based on the optimistic assumption that their subject—although perhaps irrational and irresponsible—can nevertheless be transformed. Whether through the therapeutic reform of their inner states or appeals to reason via the provision of appropriate information, these discourses hold out the hope that problematic subjects can ultimately be restored to the status of rational, self-governing consumers—to gamblers who can control their playing, their finances, and themselves.

CONCLUDING COMMENTS From our review so far, it has become evident that discourses of problem gambling configure their subject in a variety of different ways: a

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mental disorder, a physiological syndrome, and a public health issue, with gamblers variously defined in terms of their impulsivity, irrationality, and dependence. Although not reducible to any single explanation, such medicalized accounts nevertheless implicitly define their subject through its opposition to the values of modern neoliberal societies in terms of its loss of autonomy, reason, and control; its at-risk status; and its requirement for therapy. Within these discourses, we can see a continuation of criticisms of gambling in terms of its unproductive nature: its undermining of the work ethic, its waste of time and money, and its irrational investment in the capricious forces of chance. But at the same time, we can also see the emergence of a new critical discourse, for the distinctly modern phenomenon of problem gambling configures the subject in new ways. In modern societies dominated by consumerism as a mode of social life as well as commercial exchange, it is the relation of gambling to consumption, as well as to production, that is under scrutiny. Such a focus highlights some of the contradictions of modern consumer societies, namely, the increasing emphasis on individual self-control through freely willed practices of consumption that accompanies the reduction in external forms of regulation in economic and social life. As consumerism proliferates on an ever wider scale and becomes less restrained by formal mechanisms, so demands for control go deeper into the individual and, in particular, his or her consumption practices. In this climate, practices of consumption come to have a peculiarly ambivalent role as both a source of self-realization and a means of self-restraint. As a feature of this trend, the liberalization of the gambling industry and the widespread promotion of gambling as a form of consumption by the economic and commercial institutions of the state exist in uneasy relation with rising demands for self-governance and responsible gambling by individual players themselves. They must now balance their enjoyment of the thrills of gambling with a prudent awareness of the risks involved and exercise the appropriate levels of self-restraint and caution at all times.

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The problem gambler is the result of these contradictions: an individual who fails to manage his or her ambivalent freedom and so upsets the delicate balance between self-expression and self-control, desire and discipline, and consumption and production that social stability rests on. Not only does problem gambling undermine the values of the production ethic, it also undermines those of the consumption ethic. As behavior that is unbalanced by the exercise of reason, responsibility, or crucially, self-control, it opposes the central tenets of consumer sovereignty. Nor does it contribute to that other aspect of the consumption ethic, the process of self-actualization. Rather than the consumption of material goods with which to enrich and express the self, the endless repetition of dematerialized consumption in diminishing cycles of loss that is involved in gambling appears not only wasteful but supremely insubstantial, contributing nothing to the “narrative of the self” in which Western consumers are supposed to be engaged.11 In a way, this peculiar form of consumption appears as the consumption of nothing at all. The possibility that individuals might chose to risk their money on something as insubstantial as the operation of chance seems a perversion of the very freedom of choice that liberal Western societies value so much and, as such, is expelled and classified as “other,” in a move that gives birth to the pathological gambler as a distinct historical subject.

NOTES 1. This is not to imply that a conception of gambling as a problem had not existed up until this point, for although, as has been outlined already, the activity of gambling itself had been considered problematic for centuries, the precise nature of the problem it posed had not been quantified, nor did it have a distinct subject. Late 19th- and early 20th-century discussions of problem gambling were informed by psychoanalytic and functionalist perspectives, describing gamblers in general as deviants who played out of masochism or neurosis or in an attempt to compensate for socioeconomic deprivation (Bergler, 1970; Devereaux, 1949; Freud, 1928). 2. In reality, however, it can be difficult to distinguish between the two, which are often used interchangeably. In any case, definitions of pathological gamblers must include problem gamblers, because the

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3.

4.

5.

6.

7.

8.

9.

former will have been the latter at some point, and both can experience variations in severity over time in “careers” that often move between stages of problematic behavior. In diagnostic terms, however, pathological gambling is generally used to define those who meet more than five criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994), and problem gambling fewer than five (Lesieur & Rosenthal, 1991). This is not meant to imply that there are no restraints on behavior. As Marianna Valverde (1997) has pointed out, liberalism conceals a “hidden despotism” whereby those who cannot or will not regulate themselves are subject to a variety of forms of disciplinary control. In the case of problem gamblers, interventions range from voluntary therapy to compulsory counseling and rehabilitation and even, in cases where legal transgressions have occurred, court orders, fines, and imprisonment. Indeed, cost-benefit analyses of the activity estimate the financial costs of problem gambling to be some $5 billion in the U.S. per year (National Research Council [NRC], 1999). It should be noted that many of these beliefs, especially those relating to luck, are actively encouraged in the promotion and advertising of commercial gambling. Many studies have criticized this model of “rational economic man” (Campbell, 1987; McCracken, 1988), pointing to the need to explain heterogeneous motivations such as desire, excitement, and sociality to understand consumer behavior. Such criticisms also apply to gambling, which is, after all, a particular form of consumption itself and not simply an interchange between profit and loss. This should not be taken to imply that such research posits biological factors as the only explanation for pathological gambling, and indeed, many researchers recognize the complex interdependence between a variety of environmental and psychological variables. However, in general, this focus on the biology of addiction represents a shift in the locus of “the problem” away from external, societal factors involved in excessive consumption and toward internal, material processes within the body of the individual subject itself. As such, this approach has been criticized for an incorrect assumption of causation for regarding physiological factors as causes rather than observable effects of behavior and for a reductive approach to human behavior. See, for example, May (2001); Peele (1985); and Szasz (1974). Indeed, Gamblers Anonymous was partly responsible for the recognition of problem gambling as a psychiatric disorder and for the development of the criteria for the DSM-III to measure it (Custer & Milt, 1985). These include, for example, psychoanalytic, behavioral, and cognitive therapies as well as addiction-based and self-help treatments. See NRC (1999) for a review.

10. How concerned an individual feels about the amounts they have lost depends, to some extent, on how much they have to lose so that, quite simply, those with more money will be able to postpone the devastation of bankruptcy for longer than those on lower incomes. In the case of gambling, then, it is possible to almost literally buy one’s way out of the label of pathology. 11. It is noteworthy that credit, for example, is not treated in the same manner. Credit debt is substantial, and the effects on society are widespread and similar to those of problem gambling: loss of productivity, crime, and disruption of relationships. This divergence appears puzzling although may be partly explained by the uses to which credit is put: generally to purchase material products and socially validated experiences, such as clothes, cars, and vacations. The rewards of gambling are insubstantial, however; at the end of the game, there is nothing to show for the time spent playing. In this sense, even an unworn outfit seems to make more sense than an empty wallet.

REFERENCES Abbott, M., Volberg, R., Bellringer, M., & Reith, G. (2004). A review of research on aspects of problem gambling. Report to the Responsibility in Gambling Trust, U.K. Auckland, New Zealand: Auckland University of Technology. Abt, V., Smith, J. F., & Christiansen, E. M. (1985). The business of risk: Commercial gambling in mainstream America. Lawrence: University of Kansas Press. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Bauman, Z. (1998). Freedom. Milton Keynes, UK: Open University Press. Bell, D. (1976). The cultural contradictions of capitalism. London: Heinemann. Bergler, E. (1970). The psychology of gambling. Madison, CT: International Universities Press. Blaszczynski, A. (2001). Harm minimization strategies in gambling: An overview of international initiatives and interventions. Melbourne: Australian Gaming Council.

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Blaszczynski, A., McConaghy, N., & Frankova, A. (1990). Boredom proneness in pathological gambling. Psychological Reports, 67, 35–42. Breiter, H. C., Aharon, I., Kahneman, D., Dale, A., & Shizgal, P. (2001). Functional imaging of neural responses to expectancy and experience of monetary gains and losses. Neuron, 30, 619–639. Campbell, C. (1987). The romantic ethic and the spirit of modern consumerism. Oxford, UK: Basil Blackwell. Castel, R. (1991). From dangerousness to risk. In G. Burchell, C. Gordon, & P. Miller (Eds.), The Foucault effect: Studies in governmentality (pp. 281–299). Chicago: University of Chicago Press. Castellani, B. (2000). Pathological gambling: The making of a medical problem. New York: State University of New York Press. Collins, A. F. (1996). The pathological gambler and the government of gambling. History of the Human Sciences, 9(3), 69–100. Comings, D. E. (1998). The molecular genetics of pathological gambling. CNS Spectrums, 3(6), 20–37. Conrad, P., & Schneider, J. W. (1992). Deviance and medicalisation: From badness to sickness (2nd ed.). Philadelphia: Temple University Press. Coulombe, A., Ladouceur, R., Desharnais, R., & Jobin, J. (1992). Erroneous perceptions and arousal among regular and occasional video poker players. Journal of Gambling Studies, 8(3), 235–244. Cruickshank, B. (1996). Revolutions within: Self government and self esteem. In A. Barry, T. Osborne, & N. Rose (Eds.), Foucault and political reason: Liberalism, neoliberalism and rationalities of government (pp. 230–239). Chicago: University of Chicago Press. Custer, R., & Milt, H. (1985). When luck runs out: Help for compulsive gamblers and their families. New York: Facts on File. Dean, M. (1999). Governmentality: Power and rule in modern society. London: Sage. DeCaria, C. M., Bergaz, T., & Hollander, E. (1998). Serotonegenic and noradrenegenic function in pathological gambling. CNS Spectrums, 3(6), 38–47. Della Sala, V. (2004). Les jeux sont fait? The state and legalised gambling. Working paper, University of Trento, Italy.

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Department of Culture, Media, and Sport. (2001). Gambling review report. London: HMSO Stationary Office. Devereaux, E. (1949). Gambling and the social structure. Unpublished doctoral thesis, Harvard University, Cambridge, MA. Dixon, D. (1991). From prohibition to regulation: Bookmaking, anti-gambling and the law. Oxford, UK: Clarendon. Dostoevsky, F. (1914). Letters (E. C. Mayne, Trans.). London: Chatto and Windus. Foucault, M. (1973). The birth of the clinic: An archaeology of the human sciences. New York: Vintage. Foucault, M. (1976). The history of sexuality (Vol. 1; R. Hurley, Trans.). Harmondsworth, UK: Penguin. Foucault, M. (1991). Governmentality. In G. Burchell, C. Gordon, & P. Miller (Eds.), The Foucault effect: Studies in governmentality (pp. 87–105). Chicago: University of Chicago Press. Freud, S. (1928). Dostoevsky and parricide. In J. Strachey (Ed.), Collected papers (Vol. 5, pp. 222–243). London: Hogarth. Gadboury, A., & Ladouceur, R. (1989). Erroneous perceptions and gambling. Journal of Social Behavior and Personality, 4, 411–420. Gamblers Anonymous. (n.d.). www.gamblersanonymous.org. Giddens, A. (1991). Modernity and self-identity. Cambridge, UK: Polity. Gilovich, T. (1983). Biased evaluation and persistence in gambling. Journal of Personality and Social Psychology, 44, 1110–1126. Goodman, R. (1995). The luck business: The devastating consequences and broken promises of America’s gambling explosion. New York: Free Press. Griffiths, M. (1993). Tolerance in gambling: An objective measure using the psychophysiological analysis of male fruit machine gamblers. Addictive Behaviors, 18, 365–372. Hacking, I. (1986). Making up people. In T. Heller, M. Sosna, & D. Wellbery (Eds.), Reconstructing individualism: Autonomy, individuality, and the self in Western thought (pp. 222–236). Palo Alto, CA: Stanford University Press. Hodgins, D.C., & el-Guebaly, N. (2000). Natural and treatment-assisted recovery from gambling

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problems: A comparison of resolved and active gamblers. Addiction, 95, 777–789. Korn, D., & Shaffer, H. (1999). Gambling and the health of the public. Journal of Gambling Studies, 15, 289–365. Ladouceur, R., Boisvert, J.-M., & Dumont, J. (1994). Cognitive behavioral treatment for adolescent pathological gamblers. Behavior Modification, 18, 230–242. Langer, E. (1975). The illusion of control. Journal of Personality and Social Psychology, 32, 311–328. Lears, J. (2003). Something for nothing: Luck in America. New York: Viking/Penguin. Lesieur, H., & Blume, S. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal of Psychiatry, 144(9), 1184–1188. Lesieur, H., & Rosenthal, R. (1991). Pathological gambling: A review of the literature. Journal of Gambling Studies, 7, 5–39. May, C. (2001). Pathology, identity, and the social construction of alcohol dependence. Sociology, 35(2), 385–401. McCracken, G. (1988). Culture and consumption: New approaches to the symbolic character of consumer goods and activities. Minneapolis, MN: Indiana University Press. Munting, R. (1996). An economic and social history of gambling in Britain and the USA. Manchester, UK/New York: Manchester University Press. National Research Council. (1999). Pathological gambling: A critical review. Washington, DC: National Academy Press. Norris, F. (1982). McTeague. Harmondsworth, UK: Penguin. (Original work published 1899) North American Association of State and Provincial Lotteries. (2003). NASPL lottery resource handbook. Geneva, OH: Author. O’Malley, P. (1996). Risk and responsibility. In A. Barry, T. Osborne, & N. Rose (Eds.), Foucault and political reason: Liberalism, neo-liberalism and rationalities of government (pp. 189–207). London: University College London Press. Peele, S. (1985). The meaning of addiction. San Francisco: Jossey-Bass. Potenza, M., Steinberg, M., Skudlarsky, P., Fulbright, R., Lacadie, C., Wilbur, C., et al. (2003). Gambling urges in pathological gambling: A functional magnetic resonance imaging

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CHAPTER 19

Governing (through) the Internet Pathological Computer Use as Mobilized Knowledge Lori Reed THE EMERGENCE OF A NEW DISORDER Drugs, alcohol, sex. As we enter the 21st century we’re getting a little better at recognizing and treating addictions that have haunted humanity for centuries. But with this new age also comes a strange new kind of addiction. It can cause people to abandon their work, their spouses, their children, while they sit alone for hours on end talking to strangers [via the computer]. (Dateline NBC, 18 February 1997: 8) Internet addiction is real. Like alcoholism, drug addiction, or compulsive gambling, it has devastating effects on the lives of addicts and their families: divorce, job loss, falling productivity at work, failure in school, and in extreme cases, criminal behavior. The problem has already reached epidemic proportions in the United States, and the number of ‘netaholics’ continues to grow rapidly as more households and businesses go on-line. (Young, 1998, book jacket) The Internet just might be emerging as the addiction of the millennium, surpassing even TV with its pervasive grip on our minds and souls. (Young, 1998: 13)

Throughout the late 1990s, news media reported that an emergent epidemic of psychological disorder threatened to overtake the minds of people across the US and, potentially, across the entire globe. Newspaper headlines read: “Study Says Some Can Be Addicted to the Net” (Los Angeles Times, 5 May 1996); “Online Junkies Are as Dependent as Other Abusers” (Los Angeles Times, 13 August 1996); “Internet

May Be Addiction for Some Users” (Belluck, 1996). Reports about the disorder have also appeared on television shows such as the NBC Nightly News (1997), Dateline NBC (1997), and The Maury Povich Show (1998). Many of these reports based their information on controversial research conducted by psychologists and psychiatrists who assert that such extreme computer addictions are legitimate clinical conditions and that they are a growing danger (Griffiths, 1995a, 1995b, 1997; Young, 1996a, 1996b, 1998). Symptoms of Internet Addiction Disorder (IAD) include: a need for more time online to achieve satisfaction; obsessive thinking about being online; neglect of work; disruption of familial relationships; financial hardship due to Internet activity, among other indications (Belluck, 1996; Young, 1998). Professionals and users have formed support groups and clinics for the treatment of pathological computer use. This article addresses the phenomenon of Pathological Computer Use (PCU) as a case study into the cultural dimensions of science and technology. The historical emergence of psychological, medical, and popular discourses surrounding people’s “pathological” relationships with computers is a useful one for understanding the complex ways that scientific discourses and technological practices are produced—socially, culturally, and politically. Most research on pathological computer use originates from within clinical psychology, psychiatry, and the human sciences, and works to discover computer pathologies, to locate their origins, to identify particular personality types

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most “at risk,” and to manage the pathologies (Brenner, 1997; Greenfield, 1999; Griffiths, 1995a; Young, 1996a, 1996b, 1998). By contrast, the approach taken here is conceptualized through historical, social and cultural studies of media, science and technology. From this view, computer technologies, scientific “truths” and the effects of such “truths” are highly implicated in economic, cultural and political practices. Following Woolgar, Rose (1990, 1998), and Blackman and Walkerdine (2001), I argue that “computer fear” and “computer addiction” (as knowledge produced by and through the “psy” disciplines toward the “configuring of users”) function contextually toward the production, negotiation, and management of people’s developing relationships with this new media technology even while they define and produce—or govern—related definitions of “appropriate” and “inappropriate” or “normal” and “abnormal” social practice such as property, consumerism, and labor efficiency. In other words, this article explores how the discourse on “healthy” computer use functions as a normalizing discourse—and as an apparatus of governance—by mapping “correlations between fields of knowledge, types of normativity, and forms of subjectivity” in a particular context (Rose, 1998: 11). If the psychological sciences can be said to play a prominent role in the regulation of the population (Blackman and Walkerdine, 2001), this article demonstrates how the knowledge practices surrounding “computer addiction” are implicated in ways in which human beings negotiate the “conduct of conduct”—how people regulate and govern others (and regulate and govern themselves) through the production of truth (Rose, 1998). While this most recent public spectacle surrounding Internet addiction may be a largely American phenomenon, it is precisely for this reason that it is rich for cultural analysis. At the same time, American culture and American psychology do circulate and have effects transnationally. Indeed, computer addiction is not contained within the U.S. In 1997, for instance, Reuters commissioned an international study on information addiction (a purportedly related disorder) in which researchers queried 1000 executives across the UK, U.S., Germany,

Ireland, Singapore, and Hong Kong. The report, “Glued to the Screen: An Investigation into Information Addiction Worldwide,” revealed that “over three quarters of respondents agreed that PCs, the Internet and information could be addictive in the future. . . . Managers in Singapore are particularly concerned about this (83 percent) as are those in Ireland (88 percent)” (1997: 36). In 2000, the First World Conference on Internet Addiction (2000) gathered representatives from Germany, the U.S., and Switzerland. To be sure, the proliferation of computer technologies and questions and debates about “healthy” and “unhealthy,” “normal” and “abnormal” computer use productively link to key issues at the intersections of technology and culture, micro and macro politics, theory and practice. And, in this way, “computer addiction” functions as a locus point from which to address some of the most pressing issues regarding the emergence of computer technologies and computer culture: the production of information commodities, labor efficiency, and changing definitions of “ethical” computer use (Trigaux, 1998). The focus here is not on whether “computer addiction” is real or not but, rather, how it is historically produced as an object of knowledge and how it functions as an apparatus of social regulation (Blackman and Walkerdine, 2001). Thus, while predictions of a global “epidemic” of computer addiction may or may not actually materialize, the particular sites of its formation and mobilization provide fruitful ground for investigating the cultural aspects of science and technology as they connect to broader theories and practices of governance. Toward this end, it is significant to map where the discourse emerged, how and where it gained legitimacy, and how and where it has been deployed and to what effects. Scientific articles that describe, assess, and offer advice about “computerphobia” and “computer addiction” have been published in journals such as The American Academy of Child and Adolescent Psychiatry (Keepers, 1990), Clinical Psychology Forum (Griffiths, 1995b), The Journal of the American Medical Association (Ross et al., 1982), The Canadian Medical Association Journal (O’Reilly, 1996), Journal of Organizational Behavior Management (Davidson and Walley, 1985), and School Counselor (Soper

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and Miller, 1983). The surface level of the discourse indicates that “computer addiction” gains significance in relationship to particular institutional arrangements and assemblages: the discourse forms within and connects knowledge practices from psychology, business, education, communications, social work, criminology, and others. These studies have produced and legitimized various definitions of “normal” and “abnormal,” “healthy” and “unhealthy” computer use and they also prescribe interventions to control “pathological” reactions to computers. At the same time, these prescriptions are linked to particular codes of conduct in other areas of the lived social realm. In “private” life, for example, such prescriptions lay out notions of desirable family and sexual relations (Young, 1998); legal action has mandated supervised computer use for some hackers (Sterling, 1995); businesses draw on it as a rationale for surreptitious monitoring of computer use (Young, 1998); organizational management regulates computer addiction toward workplace efficiency (Davidson and Walley, 1985; Young, 1998).

THE ADVENT OF PATHOLOGICAL COMPUTER USE: MANAGING COMPUTER FEAR AND ADDICTION Throughout the short history of computing the notion of the “crazy” computer “addict” has circulated in American culture as ubiquitous urban legend. Anecdotal reports of (usually) young men who spend hours—even days—at their computer terminals while they neglect their hygiene, nutrition, and social relationships have circulated for years. At least since the 1970s, avid computer programmers and hackers have been called “addicts” by psychologists, researchers, and lay observers of computer users. Weizenbaum (1976) described computer programmers sitting “transfixed” at their terminals, working “until they nearly drop, twenty, thirty hours at a time. . . . The extreme phenomenon of the compulsive programmer teaches us that computers have the power to sustain megalomaniac fantasies” (1976: 124–30). Yet, while such computerphiles were considered to be eccentric and obsessive, the computer “addict” was often hailed as being useful to science, to

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industry and to culture, toward producing technological innovation, and in establishing a widespread cultural techno-enthusiasm (Campbell-Kelly and Aspray, 1996: 237; Levy, 1984; Shotton, 1989: 260). Although the concept of “computer addiction” circulated from the 1960s–1980s, a more pressing concern, particularly in the U.S. workplace, was computer fear or “cyberphobia.” At first, computers were known to be large military war machines that required complicated technical knowledge. As the technology changed, and as computers became potential consumer items and increasingly important to corporate efficiency, there formed increased concern with the identification and management of computer fear. Economic efficiency demanded a large population of willing and efficient computer users. In 1983, for example, Weinberg tested computer users by wiring them to galvanic skin response measuring devices while they used computers. Weinberg found that one third of subjects were “cyberphobic” and five percent exhibited symptoms of phobia: nausea, dizziness, sweating, and high blood pressure. To cure people of cyberphobia, Weinberg gradually exposed them to electronic calculators, then electronic games, and eventually simple computer programs (Rice, 1983). In another attempt to cultivate widespread responsible computer use, Davidson and Walley warned that “pathological reactions of employees to computers” were on the increase, and suggested that “the behavioral extremes warrant the concern and action of employers as well as therapists” (1985: 49, 41). They urged corporations and health professionals to collaborate in managing computer anxieties, and to produce computerphilic and efficient employees. Indeed, it was during this time that “computer anxiety” and “computerphobia” entered the popular and medico-psychological lexicon. The Encyclopedia of Phobias, Fears and Anxieties included “computerphobia” in its 1986 edition. Books such as Overcoming Computer Fear (Berner, 1984) and Silicon Shock (Simons, 1985) instructed (potential) computer users on how to become comfortable with the new machine. Guides for purchasing and using computers were published in magazines

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like Business Week (“How to Conquer Fear of Computers,” 1982), Personal Computing (“Teaching CEOs to Use Personal Computers,” Meyer, 1985) and Time (“Dealing with Terminal Fear,” Taylor, 1982). These articles advised people how to manage technological change and transform computerphobics into confident computer users. Computer fear, once viewed as relatively insignificant and “normal,” became a “pathology” when such fear became a barrier to the mainstreaming of computers. In response, marketers and spokespersons encouraged people to overcome their fear and learn to love the computer. Art Salsberg, editor of Computers and Electronics, proclaimed that “we are rapidly moving into an awesome information age where hardly anyone will be untouched by computer technology. This being the case, the smart move is to embrace computers as early as you can” (1983: 6). Technology psychologists were hired by some businesses to offer practical skills to overcome computer fear. One business card read: “Combat negative thoughts, eliminate self-doubts, reduce anxiety—increase your confidence around computers” (cited in Greenly, 1988). In one seminar, success arrived when a student could print out their own “graduation certificate” via computer: “Congratulations! You are now computer confident!” (Greenly, 1988). At the same time, computers began to be perceived as a potential addiction even for non-hackers or non-programmers (Hiltz and Turoff, 1993; Kerr and Hiltz, 1982). Kleiner (1980: 534) declared that “people can use networks without being addicted, but there isn’t a network without some addicts.” He offered that “perhaps regulating measures are necessary to keep people from ruining (enhancing?) their lives.” Omni magazine (see Fjermedal, 1987: 22) warned of a new group of “online junkies” who were falling victim to “a silent and growing addiction” to computers. Starker (1983) described the unusually avid computer use he observed as “microcomputer mania.” Much of the emergent discourse on computer “addiction” referred to computer games, which garnered particular fear and criticism (Nilles, 1982; Ross et al., 1982; Soper and Miller, 1983). Keepers (1990), for example, described a boy

who stole money, forged checks and skipped school to play video games. Nilles (1982: 87) described “computer catatonia,” a condition in which game “addicts” were “afflicted with the rapture of the beep.” Similarly, Ross et al. (1982) reported a psychiatric condition they named “Space Invaders Obsession.” They described three men who each “reported a sharp [obsessive] increase in time, energy and money devoted to playing Space Invaders in the immediate weeks before their respective marriages” (1982: 1177). By the late 1980s, the rearticulation of computers from feared war machines to useful business tools and home appliances proved largely successful (Campbell-Kelly and Aspray, 1996; Lubar, 1992; Reed, 2000). The vehemence of drug and addiction metaphors as applied to computers also became particularly pervasive, accepted, and effective. While debates grew as to how people should use computers, the notion of “computer addiction” was made possible— or culturally intelligible—in part through the specific historical convergence of American ideals from 1960s drug counterculture, 1980s cyberpunk technoculture, and the contemporaneous formation of self-help culture and the “culture of addiction.” Leary’s claim that “the PC is the LSD of the 1980s” (in Elmer-DeWitt, 1993: 63) represents this particular cultural nexus, as does Rushkoff’s term “cyberdelia,” which emphasizes the embodiment of this confluence in figures such as Leary and John Perry Barlow (Grateful Dead member and founder of the Electronic Frontier Foundation) (see Dery, 1996). Kandall (1994), suggests that it was the drug-related “excesses” of 1970s U.S. culture that incited the formation of the 1980s “culture of addiction.” Rapping (1996) similarly describes this cultural formation and highlights a shift from the 1950s in which addictions were “allergies” that randomly affected bodies, to the 1980s in which “addictive personalities” and “behavioral addictions” formed intelligible frameworks through which “obsessive” behavior could be understood. In response to this psychologization of addiction, individually mobilized coping strategies have been put forth toward the production of the selfresponsible subject.

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In Foucault’s terms (1980: 105; 1988: 18–19; cf. King, 2001), the usefulness and economy of the addiction discourse (minimum expenditure for maximum return) as a power strategy and an apparatus of governance is that it does not function repressively to achieve its ends. On the contrary, the transformation of the addicted self draws on, utilizes, and mobilizes the subject’s ability to act autonomously, to make use of rehabilitative discourses to care for and work on themselves. More specifically, the psychologization of “addictive behavior” and the translation of computer use through the discourses on addiction connect individual “healthy” computer use to the commercial need for productive labor, marketable products, and active consumers. For example, the practice of translating computer use into a matter of health and dividing computer use into the “healthy” and “unhealthy” has been enacted toward the management of intellectual property and computer hacking. Sterling (1995) argues that it was precisely because hackers gained unpaid access to information commodities that there emerged a widespread “hacker crackdown.” Both John Perry Barlow and Timothy Leary were ardent supporters of using computers for liberatory purposes in the 1980s. Similarly, Levy (1984) describes early computer hacking as motivated by political purpose as much as technical ones. Many hackers lived by the “hacker ethic” and the proclamation that “information wants to be free,” and computer hacking has been mobilized against the centralization of power and the commodification of information. Computer addiction as a dividing practice and mechanism of regulation functioned during the crackdown on “addicted” hackers during the 1980s–1990s, and is acutely exemplified in the regulation and (self-) transformation of the hacker Kevin Mitnick.

FROM “HEROES” TO “ELECTRONIC TERRORISTS”: HACKERS CAN’T ‘JUST SAY “NO” ’ TO COMPUTERS In the 1980s–1990s, with burgeoning use of computer networks, computer security became increasingly important to industry and the state. Issues of intellectual property received

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particular attention as corporate profits relied on control over production and distribution of information commodities. As such, computer hackers, who readily gained unpaid access to these commodities, and who had previously been perceived as curious, benign, yet scientifically and economically useful “eccentrics”—even “heroes” (Levy, 1984)—became transformed into feared “electronic terrorists” (Johnson, 1989) who threatened personal privacy, national security, and intellectual property. Thus, there developed an increased urgency regarding how to deal with computer hackers: [H]ow should society, and the law, best define their actions? Were they just browsers, harmless intellectual explorers? Were they voyeurs? . . . Should they be sternly treated as potential agents of espionage, or perhaps as industrial spies? Or were they best defined as trespassers, a very common teenage misdemeanor? Was hacking theft of service? Was hacking fraud? Maybe it was best described as impersonation. . . . Perhaps a medical metaphor was better—hackers should be defined as ‘sick’, as computer addicts unable to control their irresponsible, compulsive behavior. (Sterling, 1995: 58)

How should industry and the state deal with computer hackers? How should their activities be defined? What are the social and legal consequences of such treatment? Sterling explains that increased political and commercial import of the Internet meant that “society was now forced to tackle the intangible nature of cyberspace-as-property. . . . In the new, severe, responsible, high-stakes context of the ‘Information Society’ of the 1990s, hacking was called into question” (1995: 17). Similarly, Allman (1990: 25) described that a string of legal cases meant that “computer hacking itself was on trial.” The “frontier” of cyberculture must adapt to societal demands, as “in the waning of the old Wild West, the time may have come for hackers to hang up their guns” (1990: 25). As a co-product of such struggles, Sterling suggests that the notion of hackers as “computer addicts” gained cultural and legal validity. This designation played a key role in the legal cases of hackers such as Mitnick and others,

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as it functioned to justify legal and cultural demands for regulated computer use. In the U.S., designations of “computer addiction” have generally resulted in increased jail-time, rehabilitative therapy, and/or intensive supervised computer use (Danks, 1998). Interestingly, Danks explains that “outside of the US, hackers with ‘computer addiction’ are rarely incarcerated” (1998: 1). Indeed, Akdeniz (1996: 1) suggests that some hackers have been praised for revealing inadequate security in computer systems. U.S. Senator Leahy suggested a similar “usefulness” for “addicts” by declaring that restrictive computer use could prohibit technological innovation: We cannot unduly inhibit the inquisitive 13-yearold who, if left to experiment today, may tomorrow develop the telecommunications or computer technology to lead the United States into the 21st century. He [sic] represents our future and our best hope to remain a technologically competitive nation. (Sterling, 1995: 281)

This tension between the beneficial “usefulness” and dangerous “threat” of “computer addicts” continued into the 1990s and became significant as intellectual property and public computer use grew. What formed was an ongoing and dual need for the commercial sector to encourage and cultivate computer use and to limit and direct that use toward profitable ends. By situating “computer addiction” in relationship to what Sterling (1995) calls “the hacker crackdown,” we can connect definitions of psychological disorder and the crisis surrounding control of computer networks— or electronic “law and disorder”—that Sterling describes. In Mitnick’s case and that of others, the notion of “computer addiction” became a key factor in sentencing: rehabilitative therapy, probation, and/or supervised computer use. For example, in the case of the Atlanta Three, hackers were “specifically forbidden to use computers, except for work or under supervision” (Sterling, 1995: 283). The issue of supervised computer use for convicted hackers is a controversial one that has recently received much attention. The Electronic Frontier Foundation

(1991) criticized this use of “computer addiction” and argued that it denied hackers their basic U.S. constitutional rights of free association and right to employment. They argued that the notion of “hackers-as-addicts” is mobilized in the service of state and corporate desires to strictly control and regulate computer networks at the expense of individuals (1991: 2). Out-of-control “addicts” are viewed as dangerous and threatening, and therefore seen to require complete abstinence from computer use (Bloombecker, 1998). It was this notion from the addiction discourse—that one can never be cured of addiction—that allowed for the 1990s sentencing mandates of supervised computer use, as exemplified in Mitnick’s case. Variously described as “America’s Most Celebrated Cybercriminal” (Quinn and Evenson, 1995), the “Darkside Hacker” (Hafner and Markoff, 1991), and an “electronic terrorist” (Johnson, 1989: 29), Mitnick was released from prison in 2000 after being denied bail and incarcerated for over 4 years for illegal computer use. Since 1982, Mitnick has been arrested several times. In his 1989 case, after much negotiation, Mitnick’s lawyer argued that Mitnick was a “computer addict.” The resulting sentence was 1 year in prison plus 6 months in a 12-step addiction rehabilitation program, and was the harshest ever in a computer fraud case (“Drop the Phone,” 1989: 49). Mitnick was released in 1990, only to be arrested again in 1995 for violating probation by using computers. Throughout his cases, headlines warned that Mitnick’s computer use was a strange and threatening “obsession” (Johnson, 1989: 1): “Kevin Mitnick’s Digital Obsession” (Quitner, 1994); “Computer an ‘Umbilical Cord to His Soul’: ‘Darkside’ Hacker Seen as ‘Electronic Terrorist’” (Johnson, 1989). Media and courtroom representations portrayed Mitnick as a “darkside hacker” (Hafner and Markoff, 1991; Johnson, 1989), a “computer wizard” (Murphy, 1989: 3), an “extreme threat who could wreak electronic chaos if he got near so much as a telephone without supervision” (Klein, 1989: N1). Rumors of Mitnick’s technical skills included that he could “launch nuclear missiles by whistling into a telephone,” and that he could “turn

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a Sony Walkman into a transmitter that could be used to bug the warden’s office” (Penenberg, 1999: 51). As mentioned previously, Mitnick was denied bail when it was ruled that “armed with a keyboard, [Mitnick] posed a danger to the community . . . and he needs to be detained and kept away from a computer” (Murphy, 1988: 1). Significantly, Mitnick was deemed particularly threatening because he was “unstable” and had a “compulsive” personality disorder. Hafner and Markoff (1991: 72) describe Mitnick in 1988: “[H]is compulsive side had won out over his fear of the consequences and now here he sat, handcuffed to a bench. It was a conflict that would play itself out for years to come as Kevin’s obsession intensified.” Hafner and Markoff emphasized Mitnick’s “addiction” by describing that ‘something seemed to be beyond his control: he would say he wanted to stop the breaking as soon as they finished the project they were working on, but once they had finished one project, Kevin always wanted to start another . . . Kevin was obsessed” (1991: 127). Johnson (1989: 29) interviewed investigators who described Mitnick’s unusual condition: “Mitnick had such a special feeling for the computer that when an investigator . . . accused him of harming a computer . . . he got tears in his eyes.” One investigator explained that “the computer to him was more of an animate thing. . . . There was an umbilical cord from it to his soul” (1989: 29). Mitnick’s lawyer described that Mitnick’s “behavior had all the hallmarks of an addiction, where he’d spend hours and hours in front of the computer and he didn’t have the standard motives—like greed—for what he was doing” (Klein, 1989: N1). Rosetto, Mitnick’s counselor, described hacking as “the only thing [Mitnick] knew that could give him a high” (Klein, 1989: N1). Later, Shimomura and Markoff drew on psychological experts to link Mitnick’s computer crime with more violent repetitive crimes: The FBI experts argue that the same compulsive behavior, and the same craving for power drives both kinds of criminals. These behavioral scientists theorise that in each of the cases the criminals have a need for a fix, which becomes increasingly frequent. (Shimomura and Markoff, 1996: 152)

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In this context, it is difficult not to perceive Mitnick as uncontrollably “addicted” to computers, and the comparison to serial killers emphasizes both extreme danger and clinical pathology. Thus, in 1989, while it was novel that Judge Pfaelzer sentenced Mitnick to addiction treatment, it was not an unintelligible action. Prosecutors drew on Mitnick’s status as a compulsive personality and “computer addict” to argue for restricted computer use, and stated that any computer access could tempt Mitnick into criminal behavior. As a result, Mitnick was denied access to computers, even computers without network access, even after his release from prison in 2000. While eventually repealed, these probationary restrictions were the most limiting conditions ever imposed on a hacker in the U.S. (Poulsen, 1999). Mitnick’s case is significant in that the seemingly minor, momentary, and even residual defense strategy from 1989 has continued to emerge and be mobilized toward corporate control of the networks. In this sense, the effects of “computer addiction” in Mitnick’s individual case affect much broader cultural, economic, and legal regulations of computer networks. Some authors have drawn on Mitnick’s case as a rationale for tighter security for all computer networks (see “Superhighway Robbery,” 1995). At the same time, a “souring public mood toward hacking” was said to be working against Mitnick as he became the symbol for computer obsession gone awry and in need of reigning in. Halbert (1997: 170) explains that the pathologization of traits of computer hackers can imply that “anyone who dares to invade the intellectual property of the government or corporations is engaged in un-American activities.” Such pathologizations “signify that people are out of control, outside of the normal boundaries of ethical conduct. They are no longer responsible to themselves and others, and are unable to maintain the requirements of citizenship” (Blackman and Walkerdine, 2001: 127). The spectacle of Mitnick’s “irresponsible,” “unethical,” and “pathological” behavior, then, is one way that the “normal,” “healthy” computerusing self is defined. Also, by labeling hackers “abnormal” and “criminal,” and using law

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enforcement to affect particular behaviors, may legitimize and naturalize arbitrary classifications even while they obscure powerful economic relationships in the computer industry (Halbert, 1997). For example, early in the history of computing, Hanson (1978) astutely observed that industry became nervous about public use of computer networks but was less concerned about its own practice of accessing information about consumers. Mitnick’s successful computer addiction defense, the extensive media coverage of him as a dangerous, out-of-control addict, and his recent and subsequent (self-)transformation into an “ethical hacker” (Trigaux, 1998) who helps the commercial sector secure its information commodities, provide an exemplary (and productively destabilized) model for the “successfully rehabilitated” pathological computer user. In this way, the introduction of psychological and medical diagnoses of computer addiction into the clinic and courtroom legitimate, specify, and formalize the designation of “computer addict” to produce particular social-technological regulating effects.

A WORKING DIAGNOSIS: CORPORATE ENGAGEMENTS AND THE SPONSORSHIP OF HEALTH AND ILLNESS Employers must realize that they also need a clear set of rules and policies governing Internet usage to ensure that everyone will approach the Internet with a common understanding. (Young, 1998: 212)

By the late 1980s, Shotton (1989) responded to anecdotal accounts of computer addiction in the UK, including accounts of “addicted” computer hackers, by conducting her own study of computer use. Shotton concluded that computer dependency existed but that it was not a clinical pathology. Nor did it particularly threaten computer users themselves. In the U.S., the drive to “officialize” computer use disorders did not gain significant momentum until the mid-1990s with the advent of “Internet Addiction Disorder” (IAD) by Goldberg in 1995 and its subsequent adoption by

Young (1996a) and others (Brenner, 1997; Griffiths, 1995a, 1995b, 1997). Beginning in 1994, psychologist Kimberly Young began to work toward professional, clinical, and public support for the recognition of IAD (and Pathological Computer Use [PCU]) as a legitimate mental disorder. More specifically, Young’s goal was to have IAD included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a category of mental pathology. However, the IAD designation proved to be a controversial one, and Young’s efforts to gain acceptance by the American Psychiatric Association encountered significant debate. Young established the Center for Online Addiction (COLA) in 1995. At this same time public use of computer networks grew rapidly and there emerged much public concern about what were the most appropriate and efficient ways to engage with this new technology. In 1996 Young published the results of a 2-year study of Internet behavior and (mis) use. Young’s study (and Internet addiction) gained wide public attention through a barrage of media reports, and the popular and professional debate surrounding IAD grew. Since then, many researchers, psychologists, and journalists have written about IAD, and the debate about the “reality” of the disorder continues (Belluck, 1996; Brenner, 1997; Griffiths, 1997; Grohol, 1995, 1997; Young, 1996a, 1996b, 1998). Young has gained credibility by connecting IAD and PCU to the DSM through building analogies first to Substance Dependence, and then to Pathological Gambling and disorders of impulse control. This association has been usefully put into clinical practice and has given form to IAD, allowed it to materialize and function as a clinical disorder. In the U.S., and increasingly across the globe, within clinical psychiatry and psychology, an officialized site for the achievement of, and an authoritative anchor-point for, the production and acceptance of a “fact” of mental disorder is its inclusion in DSM, a clinicians’ resource for the identification and treatment of mental disorders. As Hacking (1996) describes, the DSM is an internationally utilized and standardized reference manual for the American

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Psychiatric Association’s criteria for the identification, classification, and treatment of mental illness. Respected psychiatric journals require research results to be presented to conform to the standards of the DSM, and insurance companies and health plans reimburse hospitals according to the DSM code system (1996: 10). According to Rogler (1997: 9): “In the US, the DSM is central to the vast system of mental health care, and, directly or indirectly, it has influenced judicial deliberations, third-party payments, budgetary allocations by private and governmental bodies, and many other key institutional functions.” One significant effect of the DSM for Internet addiction is that it mobilized psychologists, clinicians, and researchers to quantify and empirically document the existence of the disorder, to locate causes and to identify populations most “at risk.” This resulted in the advent of detailed surveys to collect data about people’s computer use, the application of diagnostic criteria to their behavior, and an authoritative assessment of their “appropriate” or “inappropriate” use of computers. In addition to Young’s (1996a, 1996b) Internet Addiction Survey/Diagnostic Questionnaire, modeled on the DSM criteria for Substance Dependence/Pathological Gambling, there are other measuring instruments oriented toward computer use, including Brenner’s Internet Addiction Questionnaire, Maclean Hospital’s self-diagnosis scale, questionnaires by researchers and journalists, and others. Hacking explains that “an illness becomes an object of knowledge when it is identified, as its causes are discovered, and as methods of prevention, treatment, or cure are developed. Measurement is a second route to knowledge, and the two routes cross” (1996: 96). “Objective” systems of measurement, like questionnaires, can function toward the validation and legitimation of a “fact” such as IAD. And it is here that it becomes clear that the problematic under consideration is not only one of epistemology, but it is, as Rose (1990: 8) describes, that of “identification, classification, and normativity, and to a generalised form of regulating conduct, ‘governing’ people” and the “making of people amenable to having things done to them.” That

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is, the psychological examination functions, as Nadeson (1997: 201) describes, as a form of bio-power, as: a discourse and set of techniques that participate in [a] system of government. [Historically] it was the increased significance attached to the normal that ensured the emergence and growth of the discourse and practices of psychology. Diverse social institutions (e.g. the workplace, family, school, medicine) drew on psychology to govern their populations and, in so doing, produced subjectivities that were more sensitized to and receptive to the power of the norm. Psychological assessments (such as the examination, the interview, the questionnaire) were developed that allowed individuals to be compared to normative standards and eventually, to better ‘know’ themselves.

Foucault (1978) argues that historically exams functioned as a technique of power by making individuals visible to the gaze of authorities within an objectifying framework (e.g., based on normative IQ, work output), but that they also introduced individuality into the documentation of subject populations. Individual responses could be coded so that they could be located, captured, and fixed within a comparative system. Regarding the workforce, for example, the discipline of psychology allowed for the identification of deviant workers and the scientific allocation of workers to job positions . . . [and] the exam functioned as the arbitrator of the truth of the individual by formalizing and inscribing individual differences within a calculable framework. (Nadeson, 1997: 202)

With computer pathologies, the implication is that the discourse on computer use functions to inscribe difference and normativity in line with institutional interests, to redefine or reinvent power relations through and surrounding computer networks. For example, the regulation of addictive computer use has been used as justification for increased fees for network access, legal constraints on computer use, and to legitimize employer surveillance of employee computer use. In her self-help book on IAD, Caught in the Net: How to Recognize the Signs of Internet

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Addiction and a Winning Strategy for Recovery, Young (1998) offers guidelines to identify and treat Internet addiction. Toward this end, she divides “everyday life” into four discrete (if arbitrary) categories: family, relationships, school, and work. Immediately, the identification and diagnosis of IAD functions within and toward particular institutional arrangements. The “problem” of IAD is defined in terms of the breakdown of the nuclear family, misrepresentation of “true” and “appropriate” gender, the disruption of monogamous couplings, poor educational performance, and diminished labor productivity. Successful recovery entails the reordering of these idealized arrangements: the reassemblage of the nuclear family, restoration of “true” gender, successful academic performance, and increased work productivity. Young offers guidelines for how to recognize Internet addiction and how to recover (or help someone recover) from the disorder in accordance with these “major categories of everyday life” (1998: 16). For example, Young recommends that schools limit the number of allowable hours online and eliminate 24-hour computer labs. She rationalizes that colleges do not provide 24-hour alcohol access for students and, because computers are similarly addictive, access to them should also be restricted (1998: 177–93). In the workplace, Internet addiction is increasingly used synonymously with “Internet Misuse” and the Center for Online Addiction (COLA) asserts that Internet addiction can result in low profit margins, reduced efficiency, and potential disability and unemployment lawsuits (“Corporate Seminars,” 2001). Earlier in the history of computing, Davidson and Walley (1985) similarly warned that “pathological reactions of employees to computers were found to be on the increase.” They suggested that such “behavioral extremes warrant the concern and action of employers as well as therapists” (1985: 49, 41). In “Dataholics: Scourge of the Modern Workplace?,” McWilliams (1996) emphasized the danger that employees may “crave” information and that information can be “habit-forming.” As a response to similar concerns, Young (1998: 10) offers advice for employers to “limit or

monitor their worker’s online usage to ensure that the Internet is used properly on the job and does not become a source of diminished productivity or distrust.” To prohibit employees from wasting or stealing time, or otherwise poaching from employers, Young hails the “growing availability of monitoring software as a tool for employers. . . . And it’s all completely non-obtrusive so that employees will never know who is snooping” (1998: 197). Like Young, Greenfield (1999: 157) is a proponent of web-monitoring software for health and productivity. Indeed, increased use of cybersurveillance software is used to determine which employees are wasting company time (Blitzer, 2000). The translation of Internet “misuse” into a discourse of “health” and “illness” allows for such employer interventions by transforming the act of computer monitoring from one of surveillance and discipline into one of health promotion and self-improvement (self-regulation) toward a better, happier, more virtuous subject (Umiker-Sebeok, 1997). To aid in such “health promotion,” Young (1998) recommends businesses adopt an Internet Code of Conduct that employees agree to and sign: “By adopting this code or developing one like it, employers demonstrate a responsible and aware attitude toward the Internet and encourage a responsible approach by their workers” (1998: 214). Greenfield similarly proposes that employers develop an explicit Internet policy (1999: 157). Young’s suggested Code includes a list of acceptable and unacceptable Internet behaviors. Acceptable behaviors include: communications for professional purposes; “effective,” “ethical,” and “lawful” use of the Internet; chat and email for official business only. Unacceptable behaviors include: use for personal gain or advancement of personal views; use that disrupts company operations; use that interferes with employee productivity. Other advised regulations include: all messages are the property of the company and are public information; the company has the right to access and monitor all information; restricted Internet access to functions necessary to the job: “An administrative assistant or clerical worker could only access email. A middle manager could use email, newsgroups, and the Web but

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could not enter chat channels. Only executives could access all Internet functions” (Young, 1998: 210). For individual addicts to regulate their own Internet use, Young (1998) provides a selfassessment examination to determine if one is an addict: How often do you find that you stay online longer than intended? How often does your job performance or productivity suffer because of the Internet? How often do you become defensive or secretive about your Internet use? How often do you block out disturbing thoughts about your life with soothing thoughts of the Internet? (1998: 31–3). To approach the examination as a “confessional” technology, it can be said that “the individual is provided with a system of statements, a vocabulary, for knowing themselves. However, this process of self-identification is simultaneously a practice of subjectification: the individual is identified by norms of identity used for selfrecognition” (Nadeson, 1997: 206). Thus, in therapy, the individual “voluntarily” commits “to his or her self-development, and manifests the willingness to accept the responsibility of a contract for freedom. . . . [I]t is through the promotion of lifestyle by the mass media and by experts that the modern self is governed” (Rose, 1990: 257). Through this process of “willful” self-actualization, “dissatisfied selves can, through therapy, refurbish and reshape themselves in directions they desire. Therapy is a technology of individuality for the production and regulation of the individual who is ‘free to choose’” (Rose, 1990: 228). As one Internet addict explained her desire for recovery: “All I want is the freedom to continue to use my time in quality, creative, inspiring, educational and helpful ways that are Internet related without knowing that doing so is truly at the expense of physical survival” (from IASG discussion, 31 May 1998). Once (self-)identified as a pathological computer user, Young offers practical skills and techniques to help addicts regain control of their lives, to remake themselves and to “free” them from compulsive online behavior (e.g., carry positive reminder cards, listen to the voices of denial; Young, 1998: 80, 84). Computer users are encouraged to care for and

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“free” themselves according to these guidelines, to self-regulate computer use. For example, Young suggested to one addict that he produce a strict schedule of online sessions and “advised that he fill out and carry reminder cards listing the five harmful effects of using the Net and the five benefits [to him] of moderated usage” (1998: 203). Greenfield similarly prescribes what he terms “cyberbalance,” an approach to daily living that includes “controlled” online usage as one part of a “complete life” that also includes activities such as socializing and cultivating individual interests (1999: 162). The skills for living produced through therapeutic discourse illustrate the use of expert knowledge toward shaping human experience, and illustrate points of intersection among practices for the governing of others and techniques for the government of oneself through practices of “freedom” and “choice” (Rose, 1998: 3–4). Thus, the self-making practices of the “computer addict” are acts of self-regulation of individual conduct in relationship to much broader apparatuses of governance.

CONCLUSION: THE USES OF COMPUTER PATHOLOGY You are in the best position to learn how to use the Internet and not abuse it. (Young, 1998: 11, addressing people who have yet to use the Internet)

Hacking (1996) explains that a culture cannot support a clinical condition without a collaborative social setting, and the participation of individuals afflicted with the disorder. In other words, there cannot be “computer addiction” without the cultural intelligibility of the concept, and the self-actualizing “computer addict.” In its particularity, “addiction” is a cultural concept that draws on and utilizes American ideals of the autonomous, self-actualizing, and self-responsible individual. In that context, the usefulness of the computer addiction discourse is precisely that it encourages individuals to work on themselves, to make and remake themselves—to (self-)configure users—in line with expert knowledge and institutional interests. As described here, the psychologization

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and individualization of “addictive behavior,” and the translation of computer use through the discourses on addiction, connect individual healthy computer use to the commercial need for productive labor and marketable products. Rehabilitative therapy, then, is an economical and “voluntary” practice with the goal of “bettering” oneself ultimately toward a much broader and collective “self-actualization” and self-regulation of the population. In this way, Internet addiction may be mobilized toward the creation of responsible computer use (ethical hacking, productive workers) even while it legitimates institutional apparatuses of control that, in circumstances unrelated to health promotion, may be rejected as inappropriate corporate behavior (submitting oneself to online surveillance; submitting to examinations regarding “personal” habits). At the same time, prescriptions on computer use spoken through discourses on “health” position employers as benevolent institutions that work collaboratively with employees to cultivate a self-actualized population (see King, 2001 for analysis of a similar dynamic). The therapeutic literature on computer addiction constitutes a significant source of knowledge toward “configuring users” by providing practical instruction to new users about how to use computers (Woolgar, 1991). Not inconsequentially, the specific production of “healthy” computer use is also the production and regulation of information commodities, labor productivity, and capitalist efficiency. This article investigates the cultural formation of “healthy” and “unhealthy” computer use as a product of social and commercial needs. As a social technology, and as an apparatus of governance, “computer addiction” functions to sort out answers to newly forming and transforming questions about where and how computer technologies should be assembled into existing—if contested—social organizations: Who should use computers? When? For what purpose? If definitions of “pathological” computer use are not a scientific inevitability, it is important to interrogate how they are articulated to broader macro-political processes such as, in this case, capitalist interests in the regulation of computer networks and the

formation of commercial intellectual property and productive labor. In her study of how television was introduced into American culture, Spigel (1992) demonstrated that, in volatile situations, particular social forces must draw on various mechanisms of control to invent and reinvent their positions of authority. They must also encourage and cultivate subjects to act in line with these interests. This article describes how the discourse on pathological relationships with computers functions toward the production and regulation of the individual body and individual conduct in the service of a broader, particular, and material governing of the social body.

NOTE I would like to thank Paula Saukko, Sheri Wills, and the anonymous reviewers for their helpful comments on an earlier version of this article.

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Quinn, Michelle and Laura Evenson (1995) ‘The Downfall of a Computer Wiz: How a Lonely Misfit Became the FBI’s Most Wanted Hacker’, San Francisco Chronicle (17 Feb.): A1. Quitner, Joshua (1994, 27 February) ‘Kevin Mitnick’s Digital Obsession’, Time Magazine. [Accessed July 1999: http://www.indy.net/~ sabronet/news/kmit8.html] Rapping, Elayne (1996) The Culture of Recovery. Boston, MA: Beacon Press. Reed, Lori (2000) ‘Domesticating the Personal Computer: The Mainstreaming of a New Technology and the Cultural Management of a Widespread Technophobia, 1964’, Critical Studies in Media Communication (17)2: 159–85. Reuters (1997) ‘Glued to the Screen: An Investigation into Information Addiction Worldwide’. [Accessed at: http://about.reuters.com/ rbb/research/addict.htm] Rice, Berkeley (1983) ‘Curing Cyberphobia’, Psychology Today (Aug.): 79. Rogler, Lloyd H. (1997) ‘Making Sense of Historical Changes in the Diagnostic and Statistical Manual of Mental Disorders: Five Propositions’, Journal of Health and Social Behavior 38: 9–20. Rose, Nikolas (1990) Governing the Soul: The Shaping of the Private Self. New York: Routledge. Rose, Nikolas (1998) Inventing Ourselves: Psychology, Power, and Personhood. New York: Cambridge University Press. Ross, Donald, Douglas Fineston and Gordon Lavin (1982) ‘Space Invaders Obsession’ (letter to the editor), Journal of the American Medical Association 248(10): 1177. Salsberg, Art (1983) ‘Compuphobia’, Computers and Electronics 21: 6. Shimomura, Tsutomu with John Markoff (1996) Takedown. New York: Hyperion. Shotton, Margaret (1989) Computer Addiction? A Study of Computer Dependency. London: Taylor & Francis. Simons, Geoff (1985) Silicon Shock: The Menace of the Computer Invasion. New York: Basil Blackwell. Soper, W. Barlow and Mark J. Miller (1983) ‘Junk-Time Junkies: An Emerging Addiction among Students’, The School Counselor (Sept.): 40–3. Spigel, Lynn (1992) Make Room for TV: Television and the Family Ideal in Postwar America. Chicago, IL: University of Chicago Press.

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Starker, Steven (1983) ‘Microcomputer Mania: A New Mental Disorder?’, Hospital and Community Psychiatry 34(6): 556–7. Sterling, Bruce (1995) The Hacker Crackdown: Law and Disorder on the Electronic Frontier. New York: Bantam Books. ‘Superhighway Robbery: Crime Waves on the Internet’ (1995) Los Angeles Times (21 Feb.): B4. Taylor, Alexander, III (1982) ‘Dealing with Terminal Phobia’, Time Magazine (19 July): 82. Trigaux, Robert (1998) ‘Hackers: Computer Security’s Rock n’ Roll Pioneer’, St Petersburg Times. [Accessed August 2001: http://www. sptimes.com/Hackers/monhackercover.html] Umiker-Sebeok, Jean (1997) ‘The Semiotic Swarm of Cyberspace: Cybergluttony and Internet Addiction in the Global Village’, Semiotica 117(2–4): 239–96.

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Weizenbaum, Joseph (1976) Computer Power and Human Reason. New York: W.H. Freeman. Woolgar, Stephen (1991) ‘Configuring the User’, in John Law (ed.) The Sociology of Monsters: Essays on Technology, pp. 57–99. New York: Routledge. Young, Kimberly (1998) Caught in the Net: How to Recognize the Signs of Internet Addiction and a Winning Strategy for Recovery. New York: Wiley. Young, Kimberly S. (1996a) ‘Internet Addiction: The Emergence of a New Clinical Disorder’. [Accessed March 2000: http://www.netaddiction. com/research/articles/emergence.html] Young, Kimberly S. (1996b) ‘Psychology of Computer Use: XL. Addictive Use of the Internet: A Case that Breaks the Stereotype’, Psychological Reports 79: 899–902.

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CHAPTER 20

Constraint Theory A Cognitive, Motivational Theory of Dependence Richard Hammersley INTRODUCTION Many theories of addiction or dependence assume it to be a pathological state that is progressively caused by various factors, primarily the pharmacological properties of drugs and alcohol (Booth et al., 2010; Robbins, Ersche, & Everitt, 2008), and secondarily genetics (Enoch, Gorodetsky, Hodgkinson, Roy, & Goldman, 2011; Wei et al., 2011), psychological processes, both normal (Leventhal & Schmitz, 2006) and pathological (Mills, Teesson, Darke, & Ross, 2007; Schilling, Aseltine, & Gore, 2007), and dysfunctional socioeconomic conditions (Foster, 2000; Seddon, 2000). Addiction research strives to understand how this pathological state of dependence comes about, and how it might be prevented and treated. This article will develop an alternative theory that dependence is caused by a lack of constraints, not a combination of active causal factors. The dominant conceptual paradigm for understanding dependence has been encapsulated as “Addiction is defined as a chronic, relapsing brain disease” (National Institute on Drug Abuse, 2010). This key document takes the strong reductionist position that drugs change brain function in ways that suffice to explain the adverse effects of drugs on behaviour, without mentioning any of the psychological or social factors long considered important (Zinberg, 1984). We shall refer to this paradigm as the NPP paradigm, which assumes that (1) addictive drugs (here “drugs” include alcohol unless otherwise stated) alter neuropsychological motivation systems and (2) these alterations (including as yet undiscovered ones) are the sole and sufficient

cause of disorders of substance dependence; social and psychological factors can be reduced to NPP. However, (3) these alterations may only occur in some people, in some genetic, developmental, psychological, or social conditions. A problem with this third assumption is that it allows an indefinite number of supplementary explanations of dependence, which can arbitrarily cover any eventuality. Finally, (4) the paradigm assumes that the neuropsychological alterations that constitute addiction need to be treated by abstinence, to prevent continued harmful interaction between brain and drug. This assumption is theoretically empty because abstinence is actually an outcome, not an intervention (imagine “stay alive” being heralded as a cure for cancer; but how?). Alternatively, addiction might be treated by reversing or blocking neurological alterations with pharmacology or other neuroscience interventions. Moreover, the purpose of psychological and social interventions against drugs is to facilitate abstinence, for the NPP effects of drugs cannot readily be managed or controlled by the person, at least if susceptible according to assumption 3. While many addiction researchers, including biological scientists, would question some of these assumptions, the NPP paradigm is culturally sustained and sometimes its assumptions are either assumed implicitly, or challenged less robustly than they could be (Hammersley & Reid, 2002). As will be seen: Assumptions 2 and 4 of NPP are not supported by research evidence, while assumption 3 becomes the crux of the entire problem of dependence, as formulated by Constraint Theory.

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Constraint Theory of motivation and drug use accepts that drugs affect the brain; often in more durable and subtle ways than addiction research previously envisaged (NPP assumption 1). Drugs have effects that are reinforcing, or that people and animals can learn are reinforcing. There is developing evidence that separate, interacting brain systems underlie (a) mood effects of drugs (b) engaging in previously reinforced behaviours and (c) the “incentive salience” of the reinforcer; i.e., the person or animal’s tendency to attend to it, and think about it (Beckmann, Marusich, Gipson, & Bardo, 2011; Berridge & Robinson, 1998; Wyvell & Berridge, 2000). In humans, the mood system most probably involves the entire cognitive apparatus, rather than mood being formed primarily by physiological changes (Hammersley & Reid, 2009). People indeed take drugs because they can improve mood, learn that drugs are salient to them, and they will exert effort to obtain and consume drugs. As dependence increases these tendencies become stronger and there are more marked brain alterations. These changes describe dependence at the biological level, but they are not its causes. For, the NPP effects of drugs can be overridden by cognitive effects, and how this occurs to form dependence is described by Constraint Theory. Dependence occurs when a drug is used with few constraints on its use. The neuropsychological changes themselves are neither necessary, nor sufficient causes of dependence: Not necessary because people can exhibit signs of dependence to substances and behaviours without there being specific neuropsychological changes involved; Not sufficient because people can consume enough of a drug to cause the changes without exhibiting signs of dependence. Both these claims are controversial and will be elaborated below.

CONSTRAINT THEORY: DEPENDENCE AS THE ABSENCE OF CONSTRAINTS Dependence, or problematic substance use, or “substance use disorder” (DSM5.org, 2010) (hereafter “dependence”) occurs in the absence of specific constraints on substance use. As will be seen, these constraints turn out to be well known. NPP theories have problems

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accounting for four classes of phenomena that constraint theory can explain: (1) Dependence can occur for substances and activities with weak or entirely generic neuropsychological effects, where NPP theories require ad hoc supplementary explanations. (a) On drugs, such as MDMA (Bruno et al., 2009), which do not seem to cause dependence easily in most users (although they clearly affect neuropsychology). (b) On activities and substances that have no psychopharmacological effects (they may have general neuropsychological effects, such as arousal), including pathological gambling (Raylu & Oei, 2002), problematic internet use (Kittinger, Correia, & Irons, 2012), exercise addiction (Berczik et al., 2012), although this may have dependence relevant neuropsychological effects, and carrots (Kaplan, 1996). (c) On substances that are widely used in benign ways, despite being potentially dangerous and addictive, such as overthe-counter analgesics (Abbott & Fraser, 1998) and prescription opiates prescribed for serious acute pain (Nicholson, 2003). (2) Constraint theory allows dependence to occur in a gradated manner, rather than as a discrete state that is distinct from normality. Fewer constraints tend to mean more signs of dependence. Moreover, a marked change in one or more constraints on dependence can have dramatic effects on recovery. For example, many people cease to be dependent by simply stopping use at some time (Ditton & Hammersley, 1996; Granfield & Cloud, 1999; Mullen & Hammersley, 2006). This is inexplicable if dependence comprises a major and hard to reverse alteration in the person’s NPP. Often people quit for what appear to be relatively minor reasons, compared to their previous life difficulties that did not lead to protracted cessation (Mullen & Hammersley, 2006; Orford et al., 2002). (3) It ceases to be necessary to explain why some people can use addictive drugs heavily and protractedly without exhibiting clinically significant signs of dependence. There are data in this regard for heroin (Shewan &

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Dalgarno, 2005; Warburton, Turnbull, & Hough, 2005), cocaine (Ditton & Hammersley, 1996; Transform, 2009), and alcohol (Orford et al., 2002; Robertson et al., 1987), particularly when “unobtrusive” users are studied who have neither been arrested nor sought treatment. Clinical samples of substance users tend to be biased towards people who have been the least capable of managing their substance use. The causes of drug use are in part as NPP proposes, but the causes of dependence are NPP causes, plus lack of constraints. (4) Generally, NPP interventions have not worked for drug dependence. Substitute prescribing can be effective in reducing illicit drug use and various detoxification regimes can be helpful, but these are augmented by psychological therapy (Seivewright, 2000) and a detoxified patient is not necessarily free of their drug dependence (Day & Strang, 2011). Other more ingenious interventions, including vaccinations, most recently against cocaine (Wee et al., 2012), electrical stimulation, most recently deep brain stimulation (Chen & Liu, 2012), and blocking opiate receptors with naloxone (Schecter, 1980), now abandoned, have not worked as yet. The basic problem is that people can override such interventions by increasing dose. As with disulfiram (Allen & Litten, 1992) interventions can be overridden if the patient is willing to persist with use regardless. Two neurologically active medications, naloxone and acamprosate, do have modest benefits in treatment for alcohol dependence (Dranitsaris, Selby, & Negrete, 2009; Kranzler & Van Kirk, 2001; Roesner, Leucht, Lehert, & Soyka, 2008), although their mechanisms of action remain uncertain. In understanding how NPP interventions might work, the issue of motivation appears to be important.

WHY ARE ALL USERS NOT DEPENDENT? A longstanding theme in addiction research and treatment has been to assert the inevitability of addiction given the right biopsychosocial conditions (Hammersley & Reid, 2002), despite

evidence that there is no inevitability to, and indeed considerable difficulty predicting, the life course and outcome of substance dependence (Ogborne & Stimson, 1975; Orford et al., 2002; Valliant, 1995). Not only is there considerable variability, but also a reasonably high recovery rate compared to other common mental health problems. Additionally, research is skewed towards the study of drugs and dependence, despite most users not being dependent. To illustrate, Web of Knowledge (http://webofknowledge. com, accessed 10/1/2013) locates approximately 45,000 references with the keyword “heroin.” Of these, only 30% (13,000) also do not contain addic* or depend* as keywords. The drugs researched in-depth clearly have pharmacological effects on brain systems involved in motivation. The most definite data comes from animal research with opiates and cocaine (Robbins et al., 2008). However, even for those drugs the specific contingencies of learning and the environment are critical in determining outcome (Alexander, Beyerstein, Hadaway, & Coambs, 1981; Chauvet, Lardeux, Goldberg, Jaber, & Solinas, 2009; Fritz et al., 2011; Gipson, Beckmann, El-Maraghi, Marusich, & Bardo, 2011; Griffin, Lopez, & Becker, 2009; Quadros & Miczek, 2009; Quick, Pyszczynski, Colston, & Shahan, 2011; Solinas, Thiriet, El Rawas, Lardeux, & Jaber, 2009). So, even in animals set and setting matter in determining the behavioural outcomes of substance use, meaning that drugs are not sufficient causes of dependence. This means that it is unlikely to be possible to redefine the behavioural syndrome of dependence into a small number of biological disease entities. Similarly, human research finds that chronic cocaine and heroin users can follow pathways other than a trajectory of increasing use and symptoms of dependence (Hammersley, 2011). Broadly—as will be theorised here—most human substance use involves cognitive constraints that make dependence less likely.

INDIVIDUAL DIFFERENCES: DEFICIENCIES AND RISK FACTORS As not everyone who uses a drug becomes dependent, the NPP paradigm invokes supplementary explanations (Kuhn, 1962), which

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generally postulate that certain biological, psychological, or social characteristics predispose a person to dependence, given access to the drug. Biological characteristics include having various sorts of genetic susceptibility. Genetic variations clearly do affect how people respond to alcohol (Dick & Foroud, 2003), although none of them is a sole and sufficient cause of dependence. There may also be genetic variations in the response to cannabis (Decoster et al., 2011), and it seems likely that the same will be found to apply to heroin (Nielsen et al., 2010) and cocaine (Anon, 2011). Putative psychological ones include personality characteristics and disorders, deficiencies in child-rearing, attachment and socialisation, learning and educational difficulties, and problems that result in self-medication or escape coping, whether or not this is beneficial. Social characteristics include lacking social skills, associating with people with drug problems, living in an environment where drugs are widespread and tolerated, and being poor or socially excluded (see, Hammersley, 2008, Chapter 5 for further discussion). Such supplementary explanations postulate that certain forms of deficiency are required for dependence to develop. The implicit assumption is that people who are “sufficient” will not become dependent. Most commonly, “deficiencies” are called “risk factors.” Constraint theory makes this assumption explicit, and central: People who have sufficient constraints on their substance use will not become dependent. However, a lack of constraints does not imply defectiveness. There are social and psychological conditions where many normal people with access to a drug will become dependent—being a U.S. soldier in Vietnam remains the canonical example for opiates (Robins & Slobodyan, 2003). Moreover, some of the concepts and attributions that define “dependence” are socially constructed (Davies, 1997; Peele, 1990; Szasz, 1974). For example, the standard diagnostic criteria for dependence from the American Psychiatric Association (1994) and the World Health Organisation (see http://www.who.int/classifications/icd/en/, accessed 8/1/2013) require the clinician to make qualitative judgements about the significance or

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magnitude of problems, and to attribute those problems to substance use, having excluded other causes. Explanation in terms of deficiencies or risk factors is problematic, because no single risk factor, or small cluster of risk factors, suffices to predict who will become dependent, or which “high risk” people will not. A related difficulty is that the risk factors approach tends to confuse two different meanings of “prediction”; prediction in the sense of forecasting and prediction in the sense of a causal understanding (Morton, 2004). Risk factor models can modestly forecast which people in a population are more likely to become dependent. Typically, such models explain less than a third of the variance in future substance use and often considerably less. Forecasts are not powerful enough to predict, or change, individual behaviour. A major problem is that the best predictor of future substance use is usually current and past substance use, which are confounded with other “risk factors” (Elliott, Huizinga, & Ageton, 1985). So, including drug use as a predictor leaves only a residue of variance for other variables to predict, some of which may only be weakly correlated with use. Excluding drug use as a predictor makes other variables seem to predict drug use at follow up, when they may not. A causal model of how and when effects should occur is required (Cohen, Cohen, West, & Aiken, 2002), but only rarely provided.

DEPRIVATION AND DEPENDENCE Generally, using social risk factors is particularly problematic because it is unclear how a social factor can cause a supposedly biological condition like dependence, and because social concepts are particularly prone to slippage of meaning. Additionally, superficially independent socially constructed labels can interact. For example, although the definition of a “truant” and a “substance user” are superficially independent, a child found not at school and taking drugs may well be labelled a truant, while one sitting at home unwell in front of the TV, whose alcoholic parent has forgotten to phone the school, may get the benefit of the doubt. When all the definitions are based

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on self-report then the confounding of different concepts is even more problematic. People who are already stigmatized by drug dependence may be less reluctant to report other bad things than those whose wrongdoings are more concealed. In contrast, psychological factors may perhaps be reduced to biology, in theory at least. Yet, there is a strong association between socioeconomic status and dependence. Poverty, lack of education, social exclusion, and being of minority ethnicity can all greatly increase the prevalence of drug and alcohol dependence. However, drug use is not most common amongst people in more deprived areas: In England and Wales by postcode area, younger, less settled, people tend to use more than older, more settled ones, while the least and most affluent people tend to use slightly more than those of middle income (Home Office, 2011). Moreover, it is people in rising urban areas, not highly deprived areas, who are most likely to use illegal drugs. Indeed the only common drug where prevalence of use, rather than problems, may be correlated with deprivation is heroin (Neale, 2000) and these data may be biased by underreporting of use of more stigmatised drugs (Patton, 2003). Similarly, alcohol problems are correlated with deprivation, but alcohol use is not (Pollack, Cubbin, Ahn, & Winkleby, 2005). NPP cannot easily explain the links between deprivation and dependence, particularly as, even in extremely deprived areas, most people do not become dependent, when, if it were biologically determined, they should, given their levels of stress, social exclusion and alienation, lack of alternatives, and exposure to substances. Constraint theory reverses the question to ask why many people do not become drug-dependent under conditions when they should be at high risk of doing so? Next, the paper will explore what can be theorised without assuming the addictive properties of drugs. It will draw upon social attribution theory (Davies, 1997; Reinarman, 2005) and social constructionism (Plumridge & Chetwynd, 1999; Szasz, 1974), but go beyond the unappealing idea that dependence is largely illusory to suggest that it is formed and

sustained by cognitive factors, particularly cognitions about interpersonal and social issues, as are many other extreme and distressing mental health problems with biological components including depression (Beck, 2008), psychosis (Tarrier, 2010), obsessive-compulsive disorder (Abramowitz, 1998), and eating disorders (Fairburn, 2008).

A COGNITIVE, TELEOLOGICAL ALTERNATIVE The importance of cognitive factors has been theorised before (Miller & Rollnick, 2002; Orford et al., 2002; West, 2006), what is novel here is a preliminary exploration of the cognitions that generally prevent dependence, rather than of those that cause it. As will be seen, many of these cognitions are teleological, based on personal deliberate purpose oriented towards the future. People commonly think and do specific things with the purpose and intent of ensuring that they do not use drugs too much or become dependent. This type of teleological behaviour management is neither remarkable, nor unique to dependence. It is also often inexact and fallible. For example, people budget to ensure that they do not spend too much money, but in the UK mean household debit is about 1.5 times posttax income (The Economist, 2011). Much of the literatures on topics including debit, work stress, and obesity emphasise the importance of external and situational influences on these problems, as well as the importance of people making poor risk decisions based on incomplete information that tends to neglect longer term considerations and often fails to consider properly all the information available at the time of choice (Slovic, 2000). Drug dependence is no different.

CONSTRAINTS ON DRUG USE VERSUS CONSTRAINTS ON DEPENDENCE From Becker’s (1953) seminal work onwards, sociological and anthropological research has emphasised the role of constraints in governing substance use. Research has tended to conceptualise substance use as deviance, emphasising

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social and cultural constraints and norms on substance use, which are socially constructed (Golub, Johnson, & Dunlap, 2005). This tradition of research tended to question, more-or-less strongly, whether dependence or addiction has any biological reality, leading to a large disjuncture between this tradition and health-related research on dependence, and to only a weak distinction between drug use and drug dependence (Reinarman, 2005). There is research on the social processes and conditions of becoming and being a heroin user (Agar, 1973; Johnson et al., 1985; Levy & Anderson, 2005; Weppner, 1981), a cocaine/crack user or dealer (Bourgois, 1995; Reinarman, Murphy, & Waldorf, 1994), and an “alcoholic” or heavy drinker (Alasuutari, 1992; MacAndrew & Edgerton, 1969). A key theme in this type of work is of the deviant subculture that supports and sustains specific forms of drug use that are regarded as highly problematic by mainstream culture. As substance use has diversified and become more commonplace, even normalised (Aldridge, Measham, & Williams, 2011), the idea that dependence is sustained by a deviant subculture looks weaker because firstly many people use drugs—even purportedly highly addictive ones—but are at most part-time deviants who do not gain their primary identity from drug use. Secondly, polydrug use has become the norm with people not necessarily being affiliated highly with some drugs rather than others. Thirdly, there is increasing recognition of the fact that mainstream cultural values actually promote and support inebriation and intoxication (Hammersley & Dalgarno, 2012), and scientifically no justification for distinguishing alcohol dependence from heroin dependence in terms of how problematic it is (Nutt, King, Phillips, & Independent Sci Comm Drugs, 2010). Fourthly, modern understandings of risk (Beck, 1992; Slovic, 2000) suggest that fear and concern about certain drugs are primarily about fear of the new, which tends to be perceived as alien and uncontrollable, hence dangerous. While like-minded heavy substance users tend to congregate together, this may be caused by dependence rather than being its cause. They congregate together to pool resources regarding the obtaining and consuming of drugs or

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alcohol, because their heavy use may be repugnant to others in many ways, including simply being boring, and because they share common interests and values, including less concern about “danger” than others. This lack of concern may be devil-may-care deviance, sensation-seeking, or a lack of the constraints that others have. It remains true that drug users learn how to use drugs in such “deviant” groups, even if it is a parttime deviance. But people neither arrive at such a group, nor linger, at random. A drug naïve person entering a room of people using a particular drug at a party can leave, sit down and partake but not repeat the experience often, or get involved with enthusiasm. Moreover, nowadays, drug choices are seen more as matters of individual preference that have fewer consequences for friendship and socialisation than they may have had in the past (Aldridge et al., 2011). Additionally, one common pattern of drug use is to restrict extreme use to specific social events and occasions, for instance going clubbing (Hammersley, Khan, & Ditton, 2002), or a skiing holiday (Hammersley, Ditton, Smith, & Short, 1999). Consequently, Constraint Theory does not assume that constraints arise from a deviant subculture. Nor does it assume that dependence is a matter of social definition, so that very similar behaviours involving a different substance, or different people, would be judged and labelled differently. Rather, it assumes that dependence is what happens to ordinary drug users, when they lack cognitive constraints on use.

COGNITIVE CONSTRAINTS Constraints exist at the cognitive, or psychological level, as some form of representation or model that is used to make behaviour choices. The cognitive architecture of this model is a matter for empirical investigation. It is plausible that this might be similar to that of the extended Theory of Planned Behaviour (TPB) (McMillan & Conner, 2003; Peters, Kok, & Abraham, 2008) where various cognitions lead to the formation of intentions to act, which in turn lead to actual constraint behaviour. As with other health-related behaviours, constraining substance use is something that people intend more often than they actually do.

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However, as will be seen, Constraint Theory includes elements that cannot be easily mapped on to TPB.

WHAT MOTIVES DO PEOPLE HAVE FOR NOT BECOMING DEPENDENT? There is much more research on dependent people seeking to explain their dependence than there is on non-dependent substance users. There is however enough research to be able to give an informed list of the reasons why people who are not dependent stop using or moderate use of specific substances, although the evidence is better for some of these reasons than for others and reasons for not using has almost never been the direct topic of research. Much of the evidence comes indirectly from social science research on drugs. Consequently, the reasons are most available in the knowledge of researchers, so this list was designed by writing a preliminary list of all the types of reason that people could have for stopping or moderating substance use, then in 2009 circulating this to eight colleagues in the UK who research non-dependent substance use and amending the list according to their suggestions, by collapsing reasons that were judged to be essentially the same, and including additional reasons. Finally, the list was circulated to 10 practitioners in the UK who treat and research dependent substance use for further feedback, of whom five provided feedback. This stage of the process showed that dependent people’s motives for stopping or moderating use overlap with nondependent motives, but are not identical in magnitude. The list given here is theoretically saturated (Glaser & Strauss, 1970), in that by the end of the process researchers’ and practitioners’ additions and amendments had ceased to contribute new information. Thus, it is a classification of all the common reasons for stopping or moderating use known to the expert participants. Some of the reasons are well-evidenced in the academic literature, while some are wellknown but lack formal evidence. Each constraint is mapped on to Zinberg’s (1984) well-known drug, mind-set, setting typology, although the reasons elicited here do not map fully on to the typology. Where possible, the constraints are

also mapped on to the main elements of the extended Theory of Planned Behaviour. Some do not map because they are about drug effects, or about the context or setting of use, which are beyond the scope of TPB. People stop or moderate their substance use because: (1) They have explicit and active religious or other moral beliefs that prohibit use (set; attitude/anticipated regret). There is a well-known relationship between religion and temperate habits (Edlund et al., 2010; Good & Willoughby, 2011), although of course religious adherence is fallible and temperance can lapse with it. (2) They become jaded of consumerism/materialism (set; attitude/anticipated regret). For drugs, this can include becoming jaded about having to hang about drug users and dealers in order to get drugs (Levy & Anderson, 2005; Mullen & Hammersley, 2006). It can also involve rejecting the values marketed by the alcohol industry or any other relevant industry. (3) People important to them are strongly opposed to use and that opposition matters to them (set/setting; subjective norm). Or, those people (family, friends, colleagues) consider their use to be escalating to unacceptable levels. The impact of systemic therapies on substance use, which amongst other things get users to recognise the concerns of their families, is one example (Orford et al., 2002). (4) Opportunities for taking the substance are reduced by life circumstances (setting; perceived behavioural control [PBC]). For instance, closer parental supervision reduces opportunities for adolescent substance use, although substance use makes supervision harder (Clark, Kirisci, Mezzich, & Chung, 2008). (5) They have other things to do that conflict with use of that particular substance (setting; PBC). “Maturation” often involves responsibilities that make use more difficult. For example, child care whilst intoxicated or hungover can be problematic (Taylor, 2003).

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(6) Sympathetic friends to use with are not available (setting; subjective norm/PBC). For example, the Vietnam veterans who had used heroin there most likely to inject heroin afterwards were those whose home networks facilitated it. Other users simply quit (Robins & Slobodyan, 2003). (7) The substance does nothing for them (drug), which applies, not only, to a surprising number of politicians who tried marijuana. Other drug effects are not always blatant, or require learning, or the right setting to appreciate, and can feel ineffective to some (Orford et al., 2002; Shewan & Dalgarno, 2005). (8) They dislike the effects (drug; anticipated regret), but there is no research on people who try a drug and never use it again. (9) They lack the stresses and strains that lead to a desire for hedonistic, present oriented escapism (set/setting). There is a wellknown link between stress and increased substance use (Jacobsen, Southwick, & Kosten, 2001; Pohorecky, 1981). (10) They like the effects too much, compared to other things. (Drug; PBC) That is, they recognise a risk of immoderate use for them and therefore avoid the drug. This is sometimes given as a reason for not using heroin. People can use this strategy with any drug and those that do sometimes describe themselves as having “addictive personalities” despite research repeatedly failing to find any such construct—i.e., they believe that they are unlikely to make moderate use of something they enjoy, so best avoid it. (11) They have a health scare, or serious health problems (Drug; Anticipated regret), although what concerns one person may not another (Neale, 2000; Orford et al., 2002). (12) They recognise immanent dependence (drug; PBC). This phenomenon is less-well researched than it should be, but it is clear that drinkers can cut back or abstain for a while as a moderation strategy (Orford et al., 2002), that cocaine users often take similar steps (Ditton & Hammersley, 1996), and that some long-term heroin

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users adopt a strategy of carefully controlled use (not every day for example) to prevent dependence (Shewan & Dalgarno, 2005). (13) They are concerned about the legal risks involved (setting; anticipated regret). This tends to be most evident when users may jeopardize their careers by detected use (Shewan & Dalgarno, 2005). (14) The substance is not readily available (setting). Dependent people may seek it out, non-dependent, or less heavily dependent, people tend to stop or reduce frequency of use (Weatherburn, Jones, Freeman, & Makkai, 2003). (15) The substance is unduly expensive relative to other factors (setting; Anticipated regret). This is a common reason for moderating cocaine use (Ditton & Hammersley, 1996). The practitioner-researchers identified two further reasons for stopping or moderating substance use for people who recognise that they are substance dependent: First, they may recognise their dependence and this suffices to motivate them to moderate or quit. But often they remain ambivalent about their dependence long after it is obvious to others (Oser, McKellar, Moos, & Moos, 2010). Second, they may experience an epiphany that leads to a change in life circumstances that transforms them out of substance use. This sometimes involves participation in a mutual assistance or other treatment or religious regime, but sometimes epiphany is merely that “When the time comes (to quit heroin) I believe you will know it” (Mullen & Hammersley, 2006, p. 81). Interestingly, these moments of epiphany seem inexplicable, instantaneous and not teleological at all. Dependent people have often been thorough many such moments when likely future outcomes could have strongly motivated change, but they did not change. Given that there are at least 15 types of reason for stopping or moderating substance use, people with none of these reasons may be relatively unusual. Indeed, a range of surveys on a range of substances suggests that only about 1/10 substance users show signs of dependence

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(Hammersley, 2008), leaving 9/10 users who have reasons to stop or moderate their substance use and therefore do so. Without sufficient constraints, if a person has ad libitum access to a substance that is reinforcing, then he or she will tend to become dependent. While it is unclear that any drug meets strict criteria for being a primary reinforcer, the drugs in wide use have some effects that many people can learn to enjoy. Constraint Theory may perhaps also be applied to other things that are readily reinforcing, such as sex and gambling. It is not particularly designed to explain apparent dependence on things that most people do not find reinforcing, such as carrots, but it predicts that “dependence” can only occur given that the individual finds an activity reinforcing: In the absence of constraints an obsessive collector will amass. Conversely, there is no need to cognitively constrain a behaviour that the person does not find reinforcing. That is, drug dependence can only develop if the person uses a drug that they learn to enjoy. Constraints are reasons and they are cognitive. The objective severity of the things that ought to constrain a person’s drug use matters far less than the extent to which they believe those things are severe. This applies even to constraints that initially appear to be easily counted. For example, “lack of sympathetic friends to use with” reads as if one could get research participants to enumerate their drug using friends. But in reality, people may feel and believe that there is nobody that they can use with, although nearby are many acquaintances with whom they could easily use, if they chose to lower their standards of friendship, or associate with people, or go places that they consider undesirable. The theory suggests that there is no need to address the question of what leads drug users to dependence: The NPP effects of drugs lead to dependence, but people can constrain and control how they think and behave when experiencing those effects. This, in turn, explains why the search for causes of dependence has been elusive and why people often report that dependence came upon them without awareness, intent or plan. Moreover, it can explain

why everyone who uses does not become dependent and why some people who use heavily for long periods of time seem much less dependent than others; because they have more constraints. The next section will test constraint theory against the problem of social deprivation being correlated with substance dependence.

EXPLAINING THE LINK BETWEEN DEPRIVATION AND DRUG DEPENDENCE For a variety of reasons, socioeconomic deprivation tends to make less likely the constraints that prevent users becoming dependent. First of all (constraints 1–3 & 13), the mind set of people in deprived areas may be more tolerant of intoxicant use, bling, and partying, and fewer people who matter to the person may genuinely be opposed to intoxication, although they may be ferociously opposed to specific drugs (Alasuutari, 1992; Golub et al., 2005; Hammersley & Dalgarno, 2013; Haw, 2004; Levy & Anderson, 2005). Moreover, there is more likely to be mistrust in and disregard of the law. Young people learning to use drugs in deprived areas can have a negative view of the police and have experiences of being hassled or arrested in ways they find unfair. They are unlikely to be concerned about a criminal record, because they do not imagine a career where this would matter and sometimes positively aspire to the relatively affluent and prestigious life of a gangster (Golub et al., 2005; Haw, 2004). Secondly (constraints 4–6 & 14), deprivation can be associated with a lack of employment or occupation, meaning that people can spend the effort it takes to use drugs a lot, that drug use is less likely to conflict with other occupations, and that there are financial and social attractions of use and drug supply (Forsyth, Hammersley, Lavelle, & Murray, 1992; Haw, 2004). Some research from the deviance perspective has characterised drug dependence as an occupation or career that can give meaning to an otherwise underemployed life (Agar, 1973; Golub et al., 2005; Maruna, 2008). This extends to substance use being a cohesive force

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in socialisation, although this is only officially acknowledged for alcohol (Cabinet Office, 2003) and often denied for opiate users who, retrospectively, tend to portray that social life as inauthentic and dishonest (Mullen & Hammersley, 2006). Moreover, drug and alcohol retail outlets are concentrated in deprived areas (Forsyth et al., 1992; Pollack et al., 2005) making them more available. Thirdly (constraints 7–10), while drug effects do not vary as a function of deprivation, in a deprived neighbourhood it may be more feasible and acceptable to use another drug instead of one the person dislikes (cannabis instead of alcohol for instance) and the common drug effects may alleviate tedium (Dreher, 1983), make mood more positive, and reduce stress, which is a function of the size of the relative deprivation (Yngwe, Fritzell, Lundberg, Diderichsen, &

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Burstrom, 2003), although income also matters (Jones & Wildman, 2008). Fourth (constraints 11, 12, & 15), the adversity of deprived neighbourhoods can mean that future personal health can be low priority compared to the cash and glamour of drugs (Golub et al., 2005), and health improvements are not taken as seriously. For example, there is now a substantial class differential in tobacco smoking rates. In the absence of other activities substance use can be an affordable—although not cheap—pastime that is enjoyable and also provides escape from mental, social and physical adversities, for example amongst the homeless (Thompson, Rew, Barczyk, McCoy, & Mi-Sedhi, 2009). Spelled out like this it is obvious why substance dependence is correlated with deprivation. Table 20.1 summarises some key features of Constraint Theory.

Table 20.1 Summary of Constraint Theory of Drug Dependence Constraint 1. Religion/morals

2. Anti-consumerism 3. People opposed to use 4. Lack of opportunity 5. Conflict with other occupations 6. Lack of access to other users 7. Lack of effect on them 8. Dislike effects 9. Lack of stress 10. Like effects too much 11. Health 12. Imminent dependence 13. Legal risks 14. Unavailable 15. Expense relative to benefits

Relationship to deprivation

Type of prevention

Can change quickly as a motivator for quitting?

Less likely (more accommodation of drugs and alcohol) Less likely Less likely (more accommodation) Less likely Less likely

Norms

Yes, sometimes

Norms Norms

No Yes

Norms Norms

Yes Yes

Less likely

Norms

Yes

Neutral Neutral Less likely Less likely (higher threshold) Less likely (fatalism) Less likely (higher threshold) Less risky Less likely Expense same, or less, but higher benefits

Self-management Self-management Self-management Drug information

No Yes No Yes

Drug information Drug information

Yes Yes

Regulation Regulation Regulation

Yes Yes No

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IMPLICATIONS FOR PREVENTION NPP tries to prevent substance dependence by promoting abstinence, by reducing availability, and by reducing demand for drugs, which includes as yet speculative attempts to blockade drug effects in the brain. Working from the assumption that dependence is inevitable given sufficient substance use, prevention under this paradigm routinely confounds the prevention of substance use and the prevention of substance dependence/problematic use. Substance use and a desire for intoxication are as old as history and it seems highly unlikely that they can be completely prevented (Hammersley & Dalgarno, 2012), while tackling some drugs rather than others is not a scientific, evidencebased activity (Nutt et al., 2010). It may be impossible, and perhaps undesirable, to prevent substance use. NPP has little to offer in terms of permitting some use, but preventing dependence. In contrast, constraint theory offers a clear and simple account of how to prevent substance dependence (Table 20.1); by maintaining or increasing constraints on use. There are four broad ways of doing this: by addressing social norms about appropriate and inappropriate drug using practices (constraints 1–6); by teaching effective management of less than positive psychological states (7–9); by providing accurate information about drug effects and the course of dependence (10–12); by regulation of drugs (13–15), which is not achieved by complete banning, for this hands “regulation” to the entirely unregulated illegal drugs industry. Effective prevention and harm reduction practices already fit into this framework, although some of them are highly controversial in the addiction paradigm, such as providing honest information about the relative harms of different drugs, or admitting uncertainty about the extent to which a novel drug is dangerous.

IMPLICATIONS FOR BEHAVIOUR CHANGE One way of evaluating a theory of behaviour is to assess the extent to which the theory can be used to implement behaviour change (Michie & Johnston, 2012). Constraint theory

and the NPP paradigm both assume that dependence involves a “habit” in its strongest sense: a recurrent, often not fully conscious, pattern of behaviour that has been acquired through frequent repetition. It is also uncontroversial that some drugs are more habit-forming than others, due to their NPP effects (Nutt et al., 2010), but with enough repetition any habit can be learned. Behaviour change occurs by replacing the habit with other behaviours, either by abstinence, or by gradually altering the habit, for instance by using less harmful substitute drugs. In NPP, the potency and irresistibility of the habit is sometimes emphasised by labelling it a “disease.” Psychological interventions are conceptualised as supporting abstinence, rather than as treating dependence. For example, the abstinent person may experience a flood of the negative thoughts and feelings that they had been suppressing with alcohol or a drug, and they need to learn to cope with this. Or they may experience cravings for the drug, although sometimes cravings lead to relapse and sometimes they do not, and sometimes relapse seems to occur without craving (Drummond, Litten, Lowman, & Hunt, 2000). NPP cannot explain why some people can quit such habits seemingly with little preparation and almost on a whim, while others cannot. The mystery deepens, dependent people can struggle with their habits for years, make unsuccessful repeated, highly planned quit attempts, with complex and expensive professional support, finally to simply stop one day. The mystery deepens further once one accepts the existence of heavy substance users who do not fully fit criteria for drug problems. Apparently, despite having strong habits, some people can quit, and others can avoid dependence. How is this possible? According to constraint theory, habits can stay strong, but the constraints on them can change. Sometimes these constraints change gradually, but sometimes they can change quickly or even in a one-trial manner. Table 20.1 shows which constraints may be able to change quickly. When a constraint changes quickly then the person may stop or moderate their habit. For example, some people change their ways because they suddenly have custody of

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children. Some people give up a drug because they are prosecuted for possessing it. Different people value different constraints differently, but when there is a rapid change in the strength of constraints on drug use, then dependent people may moderate or quit, not because they did not really have a habit after all, but because the constraints have changed. For example, after protracted use of morphine for pain relief in hospital, a patient may show little or no behavioural or psychological dependence once free of pain and leaving hospital. Constraint theory predicts that seemingly spontaneous or inexplicable quit attempts occur when constraints change suddenly. Constraints are cognitive because they are how people think and feel about things, not how they objectively are. This means that people may not be retrospectively aware of how their cognitions changed, and the process may seem mysterious (Ericsson & Simon, 1984). Gradual changes in constraints are better understood. Effective interventions focus on facilitating personal change in the client by changing behaviours and cognitions, including motives. Such interventions include cognitive behavioural therapy (Beck, Wright, Newman, & Liese, 1993)

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and motivational interviewing (Miller & Rollnick, 2002). It appears that interventions that more endorse NPP, such as those using Minnesota model 12-steps approaches, actually use similar methods, but conceptualised as dealing with relapse from abstinence, rather than as achieving abstinence. Constraints against drug dependence can often be weakened by people having other psychological and social problems, because they have less to lose by heavy drug use. Moreover, most popular drugs impair cognition and may prevent constraints from being fully exercised, so chronic intoxication can cause a downwards spiral of dysfunctionality. Table 20.2 summarises the theory as a typology of dependence, combining two continua, habit strength and the extent of constraints on use. Globally, responses to drug use have tended to involve increasing external constraints on use, by, often harsh, legal sanctions and attempts to restrict supply. According to the scheme of Table 20.2, this will be of some benefit for drugs that have a high potential for habit formation, such as the opiates, but of little or no benefit for drugs with less habit formation potential.

Table 20.2 A Typology of Dependence Habit strength Constraints

Little habit

Weak habit

Strong habit

Low constraints on substance use

Heavy recreational use. Excessive engagement with unusual behaviours.

Severe intractable dependence; the ‘addict’ stereotype.

Some constraints

Controlled substance use without dependence

High constraints on substance use

Temperance or abstinence

Dependence amenable to psychological treatments, including self-help. Substitute prescribing may be problematic if it develops the habit. Dependence most likely to resolve without treatment, for example by simple unaided cessation. Controlled or unobtrusive patterns of use, which can fit criteria for dependence, but are not visible to medicine or the law.

Dependence amenable to substitute prescribing plus psychological treatments, including self help. Temporary dependence, which resolves itself, e.g., on opiates prescribed for acute pain, or during a holiday bout of cocaine use.

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PREDICTIONS AND DEVELOPMENTS A potential difficulty with Constraint Theory is that as yet there is no way of quantifying the strength of different constraints. Also, the role of individual differences needs to be established, as does the relative power of the different constraints and their architecture. For example, when and how can a person’s strong personal values against substance use override absence of all other constraints on use? Additionally, because constraints are fundamentally cognitive, their logical representation and the processes underlying them are matters for empirical research. For example, how do different constraints combine to produce behaviour? As discussed above, the TPB framework may be extendable to incorporate constraints. Nonetheless, the theory makes some predictions that are open to empirical test. Focussing first on predictions that appear to be unique to the theory: (1) The conventional account is that dependence often involves heavy use despite huge constraints on use. This should only be so if one considers “constraints” to be objective facts. According to Constraint Theory, the more cognitive constraints a person has on use of a particular drug, the less likely they will be to become dependent on it. Conversely, people who score highly on measures of dependence will have few constraints on use of that drug. (2) Constraints are cognitive so people’s constraint cognitions should be better predictors of their dependence status than is their objective situation. For example, amongst high risk populations, such as the homeless, people who are much less dependent should exhibit higher levels of cognitive constraints. If constraints are more social and situational, then the theory is little advance on previous more sociological theories of drug use. (3) It is not the absolute strength of individual cognitive constraints that affect behaviour, but their relative strength compared to each other and to other motivators of behaviour. For instance, severe lack of money by itself

is often not a good constraint on alcohol or drug dependence. For this reason, there shall not necessarily be a strong correlation between the strength of any particular constraint and the severity of dependence. (4) When a constraint changes suddenly then dependence may suddenly increase, or decrease. For example, the loss of family who care about the person’s drug use can escalate dependence. The immediate likelihood of a potentially fatal health problem can reduce dependence. However, as discussed above, how constraints interact may be more important than the strength of specific constraints, so a sudden change in any given constraint may lead to behavioural change in one person, but not in another. (5) Dependence can occur on any activity that has become highly reinforcing for the person, under conditions were there are few constraints upon the activity. This can include eccentric hobbies, collections, and obsessions, as well as socially valued but extreme activities such as elite sports, and excessive interactions with electronic media.

CONCLUSIONS A limitation of this theory is that the expert knowledge used to form it came entirely from the UK. However, should people’s common motives for not becoming dependent differ markedly cross-culturally, then this would hardly support the addiction paradigm, which predicts a relatively uniform pattern of dependence everywhere. People’s attitudes to drugs and addiction do differ markedly across cultures, but this can be accommodated within constraint theory. For example, in a culture that is extremely temperate and concerned about addiction more people avoid drug use, mainly for reasons 1–3. Reversing the problem of dependence solves some thorny problems in addiction research. If dependence is caused by a lack of common constraints on substance use, then there is no need to work out a complex set of causes of dependence. Additionally, the theory can explain how and why social deprivation tends to be correlated

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with dependence. Finally, the theory offers some clear implications for prevention and treatment, including a theoretical understanding of why techniques known to be effective work, and a promising typology of types of dependent people. There is also a need for more research on the psychological and social, rather than biological, causes of dependence.

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CHAPTER 21

The More the Merrier A Multi-Sourced Model of Addiction Velibor Bobo Kovac INTRODUCTION It is widely recognized that the consequences of drug misuse represent a huge problem to contemporary society, inflicting damage to individuals as well as to society at large. In terms of health-related issues, the research community and policy makers are highly motivated to understand the causes of drug use in order to develop effective social policies, suitable health protection strategies, and treatments that might reduce the problems associated with this phenomenon. Hence, various scientific fields such as philosophy, sociology, medicine (biochemistry, neurobiology, physiology, and genetics), political science, economics, and psychology are in constant pursuit of the processes and underlying mechanisms that could improve our ability to understand the drug use that leads to the development of addictive behaviors. However, the different theoretical disciplines tend to employ definitions and terminology deeply embedded in their own scientific field, and as such tend to offer accounts of addiction that are restricted to their own scientific field or discipline. Apart from discipline-based approaches, there exist a number of excellent journal review articles, books and edited volumes on the topic that aim to provide a more comprehensive understanding of addiction (Davies, 2000; Elster, 1999b; Elster & Skog, 1999; Loewenstein & Elster, 1992; Orford, 2001; Peele, 2000; Rachlin, 2000; Robins, Everitt, & Nutt, 2010; Skog, 1997; Vuchinich & Heather, 2003; Walters & Rotgers, 2012; West, 2001, 2006; Wiers & Stacy, 2006).

Most of these approaches are thorough, theoretically sound, and undoubtedly useful. However, the existing theoretical propositions, although extensive in scope and specific in detail, nevertheless fail to provide an answer to a simple question that seems to challenge common sense: why would somebody who is aware of the harmful and even fatal consequences of their actions initiate and continue inflicting harm on themselves, for reasons that are not apparent to the outside observer (e.g., Rose & Walters, 2012)? The aim of this chapter is to introduce a model of addiction that addresses this question by attempting to integrate the various theoretical approaches to addiction into one framework. The novelty of the present approach is its sole focus on answering the question of why people become involved in behaviors that may end in their self-destruction and in spite of experiencing negative reactions from others close to them and society at large. The main point argued here is fairly simple, as it claims that the majority of contemporary accounts of addiction are not mutually exclusive; the occurrence of one process does not preclude the occurrence of another. In fact, the framework sketched here will suggest that the majority of these accounts are in effect supportive of each other and work together in order to shape a context in which addiction flourishes. In fact, this model advocates the view that the strength of addiction is in the layered complexity of the problems an individual faces and not solely on the strength of one particular process or mechanism. This underlying logic resembles the reasoning of

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Orford (2001), who suggests that there exists a common underlying ground for all “excessive appetites” and that different addictions share more common features than distinctive ones (Graham et al., 2008; Larkin, Wood, & Griffiths, 2006). Although this approach might appear simple, prosaic, or obvious, the idea of such a multi-sourced understanding of addiction is nonetheless largely overlooked in the contemporary addiction literature. As Reinarman and Granfield suggest in Chapter 1 of this anthology, the leading perspectives tend to accentuate the importance or strength of one specific process or mechanism, neglecting the possibility that the persistence of addiction might be rooted in the multiplicity of mechanisms that influence human behavior. This chapter is organized in the following manner. First, a multi-sourced model of addiction is presented (Figure 21.1) and the components of the model are outlined. These components represent an “umbrella” for various understandings and approaches to addiction in current literature. Second, the argument is made that all the processes and mechanisms outlined in the model can be functional and supportive of each other at the same time. The main point is the proposition that the reason it is so hard to quit doing or consuming something is the complexity of each individual life-situation and the specific ratio between many possible processes and mechanisms that support addiction. Finally, this chapter outlines the theoretical/ practical implications and possible limitations of this model.

Social, historical, and cultural environment

Pre-dispositions

Neurobiology

Past actions/ Current choices

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Past

Future

Figure 21.1 A Multi-Sourced Model of Addiction.

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SOCIAL, CULTURAL, AND HISTORICAL ASPECTS: MACRO-LEVEL ANALYSIS Macro-level approaches to addiction represent a joint effort among the social sciences to be heard on an issue that traditionally has been a domain of medicine and mental health. Early as well as contemporary cultural and social theoretical approaches to addiction are firmly embedded in traditions attempting to understand the concrete and symbolic aspects of human action in different social contexts. This body of work encompasses predominantly sociological, anthropological, criminological, philosophical, and psychological approaches. It aims to understand how the patterns of addictive practices are formed across cultures, different historical developments, and populations, as well as under the influence of various social pressures. In this perspective, the development of addiction is to a great degree influenced by potent social processes that dominate the specific culture and are further inflated by the manner in which they are presented in popular culture and media (Blake, 2007; Carter, 2007; Davies, 1997; Grist, 2007; Sulkunen, 2007). Macro-analyses of addiction employ a number of different methodologies and include virtually all types of social conditions and influences from the concrete and individual (Reid, 1978) to the symbolic and collective (Danesi, 1993; Heilbronn, 1988; Skog, 1985). The common theme in a number of macro-level analyses is that addiction represents: (1) an historical, cultural, and social construction that appears in various forms and degrees (Room, 1985; Marshall, 1979) and (2) a non-universal social process that tends to vary according to historical circumstances and functional mechanisms operating in any given social environment (Alexander, 2000; Heath, 1982; Manning, 2007; Peele, 2000; Room, 2003; see also the chapters in Part 1 of this volume). Thus, when seen through macro “spectacles,” addictive behaviors are perceived as unstable and having ever-changing tendencies in that characterizations, meanings, and definitions of this phenomenon tend to vary considerably across

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cultures, social settings, and historical discourses (Cohen, 2000; Davies, 1997). The basic idea behind this approach is both logical and intuitive: Environments that stimulate human senses though direct experiences, observational learning, conditioning mechanisms, and essentially all stimulating audio or visual pathways, are theoretically associated with addiction (e.g., Caudill & Marlatt, 1975; Cornish, 1978; Drummond, 2001; Reid, 1978). Accumulated evidence suggests that specific stimulating arrangements in the social and cultural environment influence the developments of addiction on all levels from individual to collective (Hall, Hunter, & Spargo, 1993; Reith & Dobbie, 2011). Furthermore, the contextual and historical factors that might increase the level of average consumption in a general population are explicitly associated with the prevalence of addictive behavioral patterns (Hall et al., 1993). The early sociological analyses provided a basis for estimating the number and types of people whose drug use practices deviated from the norm, i.e., who are excessive in their consumption (Rose, 1985). Hence, the “stimulating” contexts in a specific society might, through a number of facilitating mechanisms, result in establishing patterns of behavior that increase average consumption over time. The risks associated with social and cultural contexts that support daily or habitual consumption are apparent. There is a reasonable concern that these consumptionstimulating contexts might, over time, increase the number of people who experience difficulties in controlling their behavior, consequently creating a societal problem (Room et al., 2009). It is important to note that there is no necessary connection between overall consumption in specific contexts and addiction for several reasons (e.g., implications of direct causality, existence of methodological issues associated with measurement of consumption patterns in specific countries, relatively rapid dynamic changes in specific cultural contexts). Mere consumption neither equals nor implies addiction. Nevertheless, analyses of prevalence and collective consumption patterns in specific cultural contexts can provide useful insights into mechanisms that facilitate the development of

addiction, as well as estimates of the number of people experiencing difficulties controlling their behavior in specific cultural contexts (Skog, 1985). In sum, the development of sociological theories of addiction, beginning with Lindesmith (1938), deepened our understanding of the symbolic and interpretative meanings of addictive behavior. This was a historically valuable step, first because the sociological macroapproach to addiction shows the centrality of an interactive dynamic between individuals, various influences found in the surrounding environment, and symbolic interpretations of actions. This constituted a significantly broader approach to addiction compared to the dominant medical, psychoanalytical, psychiatric, and psychological traditions (Lindesmith, 1938; Weinberg, 1997). Second, this broadening of the scientific scope of analysis paved the way for other possible avenues for research on addiction, such as the importance of language and power issues. Third, from their beginning, sociological analyses helped expose a variety of myths surrounding addiction, which were based on misconceptions, attributional biases, and politics that reflected and helped reproduce asymmetrical power structures in the society (Davies, 2000; Duster, 1970; Finagarette, 1988; Hammersley & Reid, 2002; Peele, 1985; Szasz, 1974). The influence of such historical, cultural, and contextual factors on the development of addiction is now generally accepted. What is often neglected, however, is how these macro-mechanisms interact and support each other in setting the “stage” on which addictive behaviors develop and get perpetuated.

PAST ACTIONS/CURRENT CHOICES: BEHAVIORAL SCIENCE AND TEMPORAL DISCOUNTING Addictive behavior patterns usually develop over prolonged periods of time. This is important because doing something repetitively in the past establishes a baseline for the estimation of future actions (see Skog, 2003). The accumulated momentum of past actions exerts a powerful influence on current choices, typically

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through a warped perception of future time and experience (Loewenstein & Elster, 1992). A common theme in behavioral economics is that people base their choices on previous (often unhealthy) behavior patterns (Ainslie, 2001; Becker & Murphy, 1988; Rachlin, 2000). Behavioral economics provides several concepts that are useful in understanding addiction (e.g., elasticity of demands), but one core concept in most theoretical and empirical studies in behavioral economics is temporal discounting (Bickel & Marsch, 2001; Bickel & Yi, 2008). Temporal discounting refers to the observation that delayed rewards are commonly reduced in value over time (Bickel & Marsch, 2001). Briefly, temporal discounting describes situations in which patterns of previous consumption influence future choices in the sense that delayed courses of action are less “counted on” than the effects of immediate choices, hence “time discounting.” There are two different types of temporal discounting. The exponential version of this process holds that increased delay in time and decreased value of the reward are fixed, proportional, and constant over time. For instance, the Rational Choice Theory (Becker & Murphy, 1988) argues that addiction is based on rationality in the sense that individuals are able to evaluate the potential costs and benefits of their choices and that they choose the one that will maximize their “investments.” Costs and benefits refer to values that are external to the actor and usually possible to quantify. The term rational refers to the notion that individuals maximize utility over time in a time-consistent manner in the sense that greater consumption early on influences consumption in the future. Thus, people are future-oriented and fully informed even when they choose to consume potentially addictive goods. While they are aware of the costs both in economic and health terms, they still value the present consumption more and discount the possible future costs of consumption. In short, people make the best of their situation given their beliefs, which are grounded in the knowledge or information available to them. Other behavioral theorists argue that that people often engage in addictive behaviors

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without full knowledge of all “pro and con” variables. For instance, the primrose path model of addiction (Herrnstein & Prelec, 1992a) suggests that people become addicts based on incorrect beliefs about the dangers of consumption. Furthermore, the “naïve” addict does not take into account the value of future consumption as a “rational” addict does. The “naïve” addict simply compares the value of consumption now against abstaining now. An alternative proposition that blends the notion of a fully aware addict with that of a naïve addict is that people are aware of potential dangers of addiction but take a calculated risk (Orphanides & Zervos, 1995). Thus, people do not choose to become addicts but in essence take a calculated risk in the belief that they are able to control their urges. These three models from behavioral economics differ sharply on the point of these individuals’ understandings of their consumption. In the first model, people know everything and attempt to quit when losses are greater than gains, while in the second model, people are essentially not interested in the available information and prefer to enjoy consumption now. Finally, in the third model, people are aware of the danger but think that they are generally smarter than people in the previous two models. One obvious problem with this approach to addiction is the suggestion of behavioral consistency regarding preferences pertaining to future choices. The main point on which behavioral theories diverge revolves around a prediction of consistency versus a reversal of preferences over time. The exponential model suggests that if I choose to abstain from consumption today, I will choose not to consume at some point in the future—even in situations when, say, cigarettes are available. It follows that the theory of rational addiction and its spin-offs seem to downplay the role of temptation (e.g., craving) or a simple reversal in preferences that cause people to opt for potentially self-destructive behavior in the present. In contrast to exponential discounting, the idea of hyperbolic discounting promotes the idea of internal conflict and describes people as impulsive in that they will reverse their preferences if the tempting alternative becomes suddenly available

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(Ainslie, 2001). In other words, an initial choice to wait for delayed but larger reward (i.e., self-control) is abandoned in situations where chances for immediate gratification are real. The basic logic behind hyperbolic discounting, where people exhibit a preference reversal and choose a smaller, faster reward over a larger, delayed reward, provides a behavioral definition of impulsivity (Bickel & Marsch, 2001). Thus, temporal discounting with hyperbolic function explicitly connects addictive behaviors to high impulsivity by suggesting that people who experience self-regulatory problems also have severely narrowed future orientation. Stated simply, this view holds that people often choose drugs now in the moment and care less about future consequences. The problem that challenges self-regulation is that the value of the desired reward increases drastically as the time of choice approaches. The suggestion for successful self-regulation is that people must realize that giving in to a desired temptation once increases the possibility that s/he will make the same choice again when a similar situation is encountered in the future (Anslie, 2001). The implication is that one must “bundle” impulsive choices in packages and perceive them as categories to be avoided (addiction, sickness, bad health; Ainslie, 2001; Rachlin, 2000; Read et al., 1999) in the hope that the strength of these “bundled” cognitions might alter perceptions enough to get people to look above and beyond their immediate impulses and choose the behavior with positive long-term consequences. In sum, the contributions of behavioral economic theory in general and of the specific concept of temporal discounting are well documented and clearly relevant to addictive behaviors. Although behaviorist analyses tend to be narrow in scope and typically ignore or fail to include alternative explanations, they have identified certain mechanisms that appear to be common to most addictive behaviors.

PREDISPOSITIONS: THE ISSUE OF SUSCEPTIBILITY There are few ideas in the field of addiction more intuitive than the proposition that addicts are not randomly “selected” but rather share some

specific personality dimension that increases their chances of pursuing an addictive career (Munafò, Zetteler, & Clark, 2007). The idea is tempting and popular for several reasons. First, it is simple and easily conveyed to the general public. Second, it sits comfortably within prevailing individualist assumptions in holding that addiction happens for a reason, and that addicts themselves are partly to blame. And it reinforces belief in the idea of a just world (Lerner, 1977) in which bad things do not happen to “good” people. The proposition that some characteristic inside an individual is responsible for the development and continuous pursuit of stimulating activity typically appears in two interrelated approaches. The medical approach to addictive dispositions is connected to genetics, and numerous studies point to the role of genetic predispositions in the development of addiction (e.g., Goldman & Bergen, 1998). With regard to alcoholism, for example, studies of twins have suggested that genetic influences on addiction are substantial (Goldman, Oroszi, & Ducci, 2005; Heath et al., 1997; Li et al., 2003; Pickens et al., 1991). However, although efforts to map the human gene pool have expanded rapidly in recent decades and showed some impressive results, it is now clear that genetic influences on addiction do not uniformly follow the classical pattern of gene transmission and inheritance. While there is substantial empirical evidence of genetic components in addiction, it is now widely accepted that susceptibility to addiction is inherited as only a general tendency or vulnerability, which may or may not develop into addiction, depending on specific environmental and social influences. Findings suggesting that abuse of one type of drug is predictive of abuse of other drugs, as well as being associated with other psychiatric disorders (Grant et al., 2004) also supports the view that to the extent addiction is inherited, it takes the form of a general tendency. Those findings pose the question of whether addictions are “merely” behavioral expressions or symptoms of some deeper, underlying personality trait. If so, and if addictive behaviors are comorbid with various psychiatric disorders – depression, anxiety, antisocial personalities, emotional and behavioral

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disorders, and attention deficit hyperactivity disorder—then they may share a common genetic inheritance (Kendler et al., 2003). The second approach, thematically closely related to genetic heritage, is based on interactive effects of certain personality dispositions that have been found to be associated with repetitive drug-seeking behavior and the onset of addiction. For example, the tendency toward novelty or sensation seeking (Zuckerman, 1994) is frequently associated in literature with addiction (Andrucci et al., 1989; Jaffe & Archer, 1987; Mitchell, 1999). The general idea here is that people who score highly on novelty or sensation seeking are more prone to experimenting in potentially harmful, risky, or unknown behaviors. Another popular candidate is the concept of impulsivity, which is frequently identified as a factor in addictive behaviors (Bickel & Marsch, 2001). Impulsivity in various forms is often associated with addiction through other overlapping mechanisms, such as temporal discounting (Ainslie, 2001), loss of control (Lubman, Yücel, & Pantelis, 2004), or urges and cravings (Loewenstein, 1999). In simplified form, impulsivity describes a situation where people show reversal in preferences and change their future plans in favor of immediately rewarding actions. Although this tendency might be overcome by strategic self-control (Ainslie & Monterosso, 2003), impulsivity was nevertheless predominantly perceived as a stable personality disposition, and as such resistant to change. Future time orientation (FTO; Zimbardo & Boyd, 1999) or consideration of future consequences (CFC; Strathman et al., 1994), is yet another personality characteristic often associated with addictive behavior. Our perception of time constantly regulates our physical and psychological sense of distance to achieving desired goals; the time distance between decision point and action point is typically characterized by shifting cognitions and emotions (Ainslie, 2001). A number of theorists have dealt with the manner in which people experience time and actively create a relation between current actions and future outcomes (Lewin, 1951; Nuttin, 1985). This approach is especially notable in the work of Zimbardo and Boyd (1999), who developed

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a general theoretical framework that suggests that people differ in their temporal orientations and ability to mentally construct past, present, and future events. Similarly, people differ in their consideration of future consequences (Strathman et al., 1994); some tend to sacrifice immediate benefits for future benefits to a greater extent than others. Individual differences in FTO and CFC are taken to be a relatively stable personal characteristic, which describes the manner in which people perceive and define the relation between current actions and their potential outcomes. In relation to addiction, the proposition is that immediately rewarding prospects tend to immerse people in the present rather than the past or future, and that as a consequence they experience less meaningful thought and self-awareness (Ainslie & Monterosso, 2003). In such a state of “cognitive deconstruction” (Twenge, Catanese, & Baumeister, 2003) people tend to have a narrow focus on stimuli that are immediately present and ignore other aspects of their situation. And finally, some researchers note the basic human tendency to seek pleasure and avoid pain as potential mechanism that facilitates and perpetuates the addiction (e.g., Cloninger, 1987). People who have low thresholds for pain as a personality characteristic, for example, tend to escape an unpleasant or aversive stimulus using drugs to alleviate negative states. The combination of low tolerance for unpleasant states and high need for low-cost enjoyment thus increases the likelihood that people will find themselves in a web of temptations that reduces their capacities for self-control. In sum, there exist a number of propositions in current literature that indicate that people’s predispositions play an important role in the “recruiting” process. Furthermore, the literature suggests that all these personality characteristics overlap, are theoretically related, and probably supportive of each other. Although it is certainly possible to identify other features of personality that could be associated with specific phases of addiction, the common underlying idea for a majority of these propositions is more or less the same: some individuals have a fairly stable

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personality disposition that increases the likelihood of addictive behaviors.

NEUROBIOLOGY Over the past two decades, neurobiologists have made considerable progress in understanding the interplay between key brain structures and chemical neurotransmitters (Robins et al., 2010). The early focus in this research centered on mapping the brain structures involved in the functioning of the so-called reward or pleasure circuits involved in addiction (Olds & Milner, 1954). The subjective experience of reward and euphoria that is elicited by electrical brain stimulation to these circuits has been identified as one of the most powerful mechanisms known to neurobiology (Gardner & David, 1999). As Kalant notes in Chapter 6, activation of the so-called pleasure center involves many interconnected brain areas, e.g., ventral tegmental area, substantia nigra, hypothalamus, medial forebrain bundle, septum, amygdala, neostriatum, nucleus accumbens, olfactory tubercle, and portions of the cingulate and frontal cortices. All these brain structures have been found to transport reward and pleasure-related signals (Gardner & David, 1999). The neurotransmitter dopamine has been identified as playing a fundamental role in an individual’s subjective experience of pleasure or reward. Consequently, many versions of the “dopamine theory of addiction” have been launched, converging on idea that brain stimulation based on intake of addictive substances increases the neurotransmission and density of the dopamine-containing cells in the brain region known as nucleus accumbens (Balfour, 2004; Tomkins & Sellers, 2001). The brain pathway for this transmission runs from the ventral tegmental area in the midbrain to the limbic areas, e.g., nucleus accumbens and the amygdala, which are traditionally associated with emotional responses. Frequent drug intake activates the brain reward circuit that links the mesolimbic dopamine system and amygdala and results in neuroadaptive changes in neurotransmission. Although it is virtually impossible to find a text on neurobiological aspects of addiction that does not contain

references to the brain’s “pleasure” circuit and/ or to role of mesolimbic dopamine system, the advances in this field in recent decades have moved beyond these concepts (Kalant, 2009). Despite impressive progress in the neurology of addiction, an exclusive focus on the chemical processes and brain structures that have been made visible and measurable has significant shortcomings. The more knowledge neurobiologists developed about addictive behavior, the more clear it became that the addiction process is more complex than increased activity of dopamine in the nucleus accumbens or stimulation of a particular brain region (e.g., Emmanuel & Onaivi, 2008). There is growing doubt in the field that increased knowledge of the brain can provide a full account of addiction (Kalant, 2009; see also Chapter 1 of this volume). Contemporary research has slowly begun to shift away from sole explorations of the neural and chemical elements in the brain and toward the connections and interactions these molecular or neurochemical structures have with behavioral, motivational, and cognitive processes (Everitt et al., 2010). More detailed knowledge of brain structures and neurochemical elements has led some researchers to shift their focus toward the psychological processes involved in the interpretation and meaning of changes in the brain. One early example of this view is the incentive-sensitization theory of addiction (Robinson & Berridge, 2001). According to the theory, repeated exposure to addictive substances leads to change in brain circuits over time and results in hypersensitivity to well-learned substances and the contextual cues that are reliably associated with drug intake. The consequence of this sensitization process is an emergence of the psychological state of “wanting” or “craving,” which at some point governs human behavior even in the absence of the initial pleasure (Berridge, 1999). This theory suggests that changes in the brain as well as simple stimulus-response habituation-based accounts of addiction are only the starting points for development of the complex interaction between personality characteristics, contextual cues, cognitive learning, and motivational processes. The incentivesensitization theory is a psychological model

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of addiction that is based on neurobiological arguments but that includes a number of factors traditionally associated with other, more contextual approaches. The second example of combining latent psychological processes with neurobiological processes is opponent process theory, originally designed as psychological theory of motivation (Solomon & Corbit, 1974). As the name suggests, the opponent process theory is defined by two opposing processes in terms of dynamics and organization: an a-process that is intensive, immediate, and tolerant, and a b-process that appears after the a-process has diminished, and tends to get more powerful with repeated exposure (Solomon, 1980). This general homeostatic principle where two opposing processes tend to balance each other has been applied to addiction, where initial drug-taking behavior is similar to the a-process in which euphoric sensations are experienced, followed by a period without drug intake when the system tends to revert to a stand-by position (e.g., Koob and Le Moal, 2001). In the context of addiction, the problem is that drug-taking results in a relatively sharp and immediate rise of positive feelings followed by aversive or negative feelings. Over time, the internal dynamic between these processes tends to move the original position of the organism to new levels or new set points. If this is done too rapidly or in a way in which organisms are not able to respond sufficiently, a state of chronic deviation from the original point of reference is reached and selfregulatory systems can become dysfunctional. These sorts of formulation of incentivesensitization theory and opponent process theory suggest that the neurobiology of addiction is becoming more connected to psychologically oriented approaches and more receptive to the inclusion of latent constructs. Recent reviews in this field explicitly state that the molecular and neurochemical processes must be ultimately interpreted in terms of psychological, cognitive, and behavioral processes (e.g., Everitt et al., 2010). While most neuroscientists still perceive addiction as a brain disease that is most appropriately approached from the medical point of view, there is movement toward integration with other levels and types of analysis.

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In sum, the role of neurological processes in all stages of addiction is evident. Advances in neurobiological research on brain structures, genetic epidemiology (twins and siblings studies), candidate genes for susceptibility to addiction, and animal models of addictive behavior all have their promise. Nevertheless, it has become apparent that all this accumulated knowledge must be integrated with sociological and psychological models if we are to achieve a comprehensive understanding of addiction and develop appropriate treatment programs.

UNDERLYING PROCESSES/ MECHANISMS There are number of underlying psychological mechanisms and processes noted in the current literature that are said to be central to drug-taking behavior. All focus on nonobservable, latent, or hypothetical processes that are inferred from empirical observations of behaviors in natural settings. For example, one general notion that has gained a prominent place in the field of addiction is that human behavior is predominantly guided by associative strengths and elicited either by repetition or guided by strong environmental cues (Bargh, 1996; Drummond, 2001). The associative strengths, which are reinforced by increased repetition of behaviors or elicited by contextual cues, are typically characterized as being part of unconscious, automatic, and habitual processes. In general terms, the idea of automatization proposes that goal pursuit mostly occurs outside of conscious awareness and cognitive guidance (Bargh, 1996). It is hypothesized that various goals are mentally represented in a manner that is similar across all cognitive structures. With repeated practice, these goal representations are reflected in the behavioral patterns, which are habitually, even automatically activated by stable features of one’s environment (Fitzsimons & Bargh, 2004). Early approaches of this sort equated automaticity with lack of conscious monitoring and as such were exclusively associated with unconscious processing. Later definitions expanded the criteria for characterization of automatic actions and principally focused on lack of awareness,

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efficiency (minimal use of cognitive resources), absence of intention, and uncontrollability. The role of such automated and habitual processes in relation to addictive behaviors has been widely observed (Tiffany, 1990). There is a consensus in the contemporary literature that the psychological mechanisms central to addictive behaviors are automatic and occur outside the individual’s introspection and with relatively low levels of self-awareness (Sandor, 2009; Stephens and Marlatt, 1987; Wiers and Stacy, 2006). For instance, automated processes that bypass conscious decision-making are related to a well-established smoking pattern and appear to be important for understanding tobacco dependence (Waters & Sayette, 2006). Furthermore, smoking is traditionally portrayed as an automatic and habitual behavior that is performed with minimum explicit cognition (Baxter & Hinson, 2001). Addictive responses are elicited and strengthened based on associative links established over time between environmental cues or stimuli and behavioral responses, following the basic premises of classical and operant conditioning theory. In this view, contextual signals may work together to provoke conditioned responses, which directly and automatically lead to drug-taking behavior. Initially neutral stimuli in the environment (e.g., specific places, occasions, friends, etc.) become paired over time with drug consumption and produce conditioned responses (Drummond, 2000). Hence, the power of these associations reliably results in consumption/behavior, bypassing the higher cognitive processes. The pairings between conditioned and unconditioned stimuli historically precede propositions that see addictive behaviors as perpetuated by rewarding or reinforcing consequences in terms of operant conditioning (stimulus–response outcome; Li, 2000; Littleton, 2000). While the responses in classical conditioning are based on the general innate ability to learn associations between conditioned and unconditioned stimuli in a fairly passive manner, the responses in operant conditioning theory implicate active learning processes. People learn through repeated experiences that specific responses reliably lead to specific reinforcing or rewarding consequences.

The contingency of stimuli delivery is conditioned on particular operant responses, which in turn tend to increase the probability that similar behavior will be repeated (O’Brien, 1975). In this view, drug intake will then be reinforcing, either as directly rewarding or as a reliever of negative symptoms. Thus, positive reinforcement functions as a reward that strengthens a conditioned response after it has occurred, while negative reinforcements are removed when the desired response (e.g., drug use) has been obtained. This behavioral pattern will be repeated effortlessly in the future with minimal involvement of explicit cognitive processes. In sum, the importance of automaticity in the development and perpetuation of addiction has been well-documented. However, the expansion of the automaticity paradigm and the historical significance of various forms of conditioning have resulted in a general view of addiction as a “simple” psychological process that occurs mainly in an automatic fashion and outside the individual’s consciousness (e.g., McCusker, 2001; Sandor, 2009). Although this view might be correct, it is nevertheless plausible to suggest that automaticity does not work alone and should, therefore, be analyzed along with other compatible neurobiological, historical, and sociological accounts of addiction.

DISCUSSION: REASONS TO CONTINUE Imagine now “John,” who has “suddenly” received a strict warning from his physician that his body will be seriously damaged if he continues to drink, indeed, that he will die as a direct consequence of his drinking if he does not stop. John has understood the situation and is determined to follow his physician’s advice. Yet after a few days of struggle, John has a few drinks and gradually falls back into his previous pattern of regularly consuming alcohol. His apparent inability to stop, despite serious and potentially fatal consequences, is a puzzle for his family, physician, outside observers, community, and experts in the field. The overall aim of this chapter is to assemble the available theoretical pieces of this puzzle in the hope of arriving at a cogent explanation of

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addiction. We start by looking back to the current model (Figure 21.1). Let us imagine that John grew up in a country where average alcohol consumption was relatively high with few restrictions in terms of availability, i.e., where it was common and easy to drink frequently. Advertisements and environmental triggers associated with alcohol were widely displayed. Furthermore, the intake of alcoholic beverages was widely seen as being “cool.” It follows that during John’s socialization process he was often exposed to situations where alcohol was present and that he acquired friends who were used to enjoying an occasional drink. He grew up in the family where alcohol was commonly consumed, even encouraged. John was also an impulsive child; early in his life, he began to exhibit a general tendency to value immediate gratification, which frequently interfered with his long-term planning abilities. After a while, John’s time perspective in terms of pursuing delayed rewards gradually diminished, especially when an object of desire, i.e. alcohol, was present. John’s family history resembles his present life; his father and some other family members had a similar problem in the past. Prior to drinking in his youth, John also tended to show signs of mild depression or anxiety while growing up. He was also drawn toward exploring and being stimulated by novel sensations. On the other hand, John also had a low threshold for tolerating unpleasant states of mind and tended to compensate for this by pursuing immediate pleasures. These tendencies might contribute to the fact that John became more and more impulsive in the sense that his previous long-term plans were frequently abandoned when attractive alternatives were available. This life history and personality profile, interacting with repeated exposure to alcohol, might easily lead to a change in John’s brain circuits over time and result in hypersensitivity to well-learned contextual cues often associated with drinking. Repeated consumption of alcohol likely would have sharpened the experiential gap between his euphoric enjoyment and aversive negative states when alcohol was not available. It is then not surprising that John’s drinking became habitual in terms of automatic performances: he was surrounded

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with a variety of environmental cues that reliably evoked his desire for drinking; and then, when he drank, the pattern was perpetuated by immediate positive reinforcement. Moreover, the list of potentially addiction-compatible processes goes beyond those presented in the multi-sourced model of addiction: identity issues (e.g., self-verification), graduate entrapment (e.g., gateway hypothesis), experience of social fulfilment (Rachlin, 2000), self-medication (Khantzian, 1985), and probably many others. Putting all of this together, we can see that John might be inclined to perceive drinking as a rational choice, even when facing fatal consequences. In short, in this extreme situation, John had little chance of escaping some sort of addiction at some point in life. The point is that all the processes and mechanisms in the model, and perhaps others not mentioned here, are more or less compatible and jointly support the development and sustenance of addictive behaviors. In the multisource model, the outcome of addiction is a contingent matter of synergy among the many social, environmental, historical, psychological, neurological, and chemical mechanisms simultaneously at work. The result is a behavior pattern that is extremely resistant to change. The basic idea of a synergistic effect of these various processes is of course not new in the field of addiction, but this simple proposition nevertheless yields several important implications. First, a multi-sourced model of addiction does not favor any single mechanism, process, or paradigm as being the primary cause of addictive behavior, as is often the case (for exceptions, see Orford, 2001; Peele, 1985; West, 2006). Thus, addiction is not seen as stemming from any one process (e.g., automaticity), nor even any simple interactive effect of environment, personality dispositions, and neurochemistry. The multi-sourced approach takes a step further in: (1) detailing and grouping the multiple sources of addiction in one integrative model; and (2) proposing that these sources are not mutually exclusive in that they conjointly form a strong behavioral pattern. Second, the model reflects the view that the causes of addiction could be accounted for in association with any social behavior without

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implying either pathology or a principal governing mechanism, or suggesting that something went wrong in terms of personal development. Consequently, it is argued here that the popular view of addiction—as a paradox of people not being able to stop a single activity even in the face of fatal consequences—is actually more a complex conjuncture in which powerful psychological, physiological, and sociological processes simultaneously shape people’s behavioral choices. Third, and perhaps most important, the multi-source model emphasizes the significance of individual perception of addiction and individually tailored approaches to its treatment. Every case of addiction is a unique combination of circumstances, as opposed to the generally accepted view of addiction that fits all such combinations. It follows that it might be useful to design individual and personalized treatments that pay attention to the specific ratio between all possible processes and mechanisms supporting the development and perpetuation of addiction. The common approaches to addiction treatments today tend to accentuate the similarities between people in terms of specific drugs or behavior patterns and to group them into distinct categories. Such approaches often neglect individual differences of personal history and the contributions of the several specific processes summarized here. Although there certainly exist a number of common denominators for specific addictions (e.g., alcohol) or even across them, it is nevertheless difficult to see how abstracted notions of, say, alcoholism would match the individual variations that are characteristic of each personal history. In other words, the logic of the present model implies that treatment programs should combine the available knowledge on the workings of specific drugs with the consideration of the specific configurations of the multi-sourced influences outlined here. Hence, practitioners of addiction treatment need instruments that are theoretically broad and yet sensitive enough to map the many possible combinations of relevant contributing causes in order to more effectively address addiction problems. Fourth, the multi-source model might help explain why some people quit “cold turkey,”

some after a while, some with treatment and some without, some with major difficulties and some with minor difficulties, and some never. By mapping the whole situation, with all background variables and interacting causal mechanisms, one would be able to identify addicts and gain insight into the strength or volume of their addictions. Although mapping all possible causal variables represents an enormous and complex project, the basic idea of assessing both the breadth of the problem and relative strength of each process/mechanism is nevertheless workable.

LIMITATIONS The present analysis suffers from a number of limitations. The first and most serious is that the whole proposition is overambitious; the model is excessively complex and includes virtually all processes/mechanisms from contextual to neurological. However, this complexity is necessary in order to account for the extraordinary and ever-expanding range of addictive behaviors and why individuals with addictive behaviors are notoriously resistant to change. Thus, although the main idea is relatively simple (the many domains of variables and processes work together synergistically), it was necessary to present them as a complex model of addiction comprised of several distinct categories of cause. Second, due to complexity of the model, these distinct categories were presented rather summarily. This runs the risk that some of the formulations might be perceived as imprecise or vague, but space limitations allow only a sketch of the model here. Third, the notion that a multi-source model of addiction consists of distinct categories of cause is misleading because some of the constituent processes proposed could be placed in several categories. For example, incentive sensitization and opponent process theory could also be placed in the section about underlying mechanisms as well as be theoretically connected to conditioning theories. Fourth, for reasons of length, I was not able to include other potentially relevant theoretical proposals, such as gateway theory, self-medication, addiction as attribution, and a few more. Finally, I do not

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discuss how addiction is defined or make any conceptual clarification between addiction, drug use and misuse, dependency, etc. (see Chapter 1). This chapter sidesteps such definitional clarification because the multi-source model sketched here (1) consists of perspectives that traditionally perceive addiction in a fundamentally different manner (disease vs. choice vs. culturally constructed phenomenon vs. existence of addiction at all) and (2) advocates a pluralistic approach to understanding and treating addictions that attempts to move beyond contemporary ideological debates over the essential nature of addiction.

CONCLUSION A well-known Indian parable describes a group of people standing in the dark and touching an elephant in order to learn what it is like. None are able to actually see the elephant, so each one feels a different part, but only one part, such as the animal’s side, leg, or tusk. They then compare notes and learn that they are in complete disagreement. Although they all are correct in their interpretations of the separate parts, they do not understand that their observations are partial truths that are not mutually exclusive but are indeed completely compatible. Given the immense body of accumulated empirical and theoretical work on addictions, the different groups of scholars and scientists often follow the same logic as the people in the parable for whom an intensive focus on one distinct part of the phenomenon is taken to be defining. Conversely, our starting position was that the majority of the processes found in the current literature to be contributing causes of addiction have simultaneous validity, each with its specific domain of optimal relevance and explanatory power. Thus, the present conclusions suggest that there are sufficient grounds for promoting the idea that: (1) many causal mechanisms of addiction are compatible and operate simultaneously; (2) that various combinations of these mechanisms contribute to development and persistence of addiction; and (3) that the resulting complexity of multiple possible combinations indicates the necessity of perceiving—and treating accordingly—each

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‘case’ of addiction as the product of a unique conjuncture of causal influences.

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CREDIT LINES

Bruce Alexander. The Roots of Addiction in Free Market Society from Canadian Centre for Policy Alternatives, April 2001. Reprinted with permission from the Canadian Centre for Policy Alternatives. Philippe Bourgois, Disciplining Addictions: The Bio-politics of Methadone and Heroin in the United States from Culture, Medicine and Psychiatry 24: 165–195. © 2000. Used by permission of Kluwer Academic Publishers. David T. Courtwright, The NIDA Brain Disease Paradigm: History, Resistance, and Spinoffs from BioSocieties, 2010, 4: 137–147. Used by permission of Palgrave Macmillan. Molly Dingel, Katrina Karkazis and Barbara Koenig, Framing Nicotine Addiction as a Disease of the Brain: Social and Ethical Consequences from Social Sciences Quarterly, 2011: 5, 1363–1338. Used by permission of Wiley. Kathryn Fox, Ideological Implications of Addiction Theories and Treatment from Deviant Behavior, 1999, 20: 209–232. Used by permission of Taylor & Francis. Robert Granfield and William Cloud, Social Capital and Natural Recovery: The Role of Social Resources and Relationships in Overcoming Addiction without Treatment from Substance Use and Misuse, 1999, 36: 1543–1570. Reproduced with permission of Taylor & Francis, Inc., via Copyright Clearance Center. Richard Hammersley. Constraint Theory: A Cognitive, Motivational Theory of Dependence from Addiction Research and Theory, 2014, 22: 1–14. Reproduced with permission of Taylor & Francis, Inc. via Copyright Clearance Center. Janice Irvine, Regulated Passion: The Invention of Inhibited Sexual Desire and Sex Addiction from Social Text, 1993, 37: 203–226. Used by permission of Duke University Press. Harold Kalant, Not Only in Our Brains: What Neurobiology Cannot Tell Us About Addiction from Addiction, 2010, 105: 780–789. Used by permission of Wiley. Velibor Kovac, The More the Merrier: A Multi-Sourced Model of Addiction from Addiction Research and Theory, 2012: 1–14. Reproduced with permission of Taylor & Francis, Inc., via Copyright Clearance Center. Michael Moss. “The Extraordinary Science of Addictive Junk Food,” adapted from the book Salt Sugar Fat: How The Food Giants Hooked Us for The New York Times, © 2013 by Michael Moss. Used by permission of Random House, an imprint and division of Random House LLC. All rights reserved. Lori Reed, Governing (through) the Internet: The Discourse on Pathological Computer Use as Mobilized Knowledge from European Journal of Cultural Studies, 2002, 5: 131–153. Used by permission of Sage Publications Gerda Reith, Gambling and the Contradictions of Consumption: A Genealogy of the Pathological Subject from American Behavioral Scientist, 2007, 51: 33–55. Used by permission of Sage Publications. John S. Rice, A Disease of One’s Own: Life Stories, Co-Dependency, and the Search for Identity from Sociological Quarterly, 1992, 33: 337–64. Used by permission of Wiley.

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Robin Room, The Cultural Framing of Addiction from Janus Head, 2003, 6: 221–234. Trivium Publications. Used by permission of the author and Trivium Publications. Joseph Schneider, Deviant Drinking as a Social Accomplishment from Social Problems, 1978, 25: 361–372. Used by permission of University of California Press. Rebecca Tiger, Drug Courts and the Logic of Coerced Treatment from Sociological Forum, 2011, 26, 1. Used by permission of Wiley. Darin Weinberg, Praxis, Interaction and the Loss of Self-Control from Intoxication and Society, Edited by Jonathan Herring, Ciaran Regan, Darin Weinberg and Phil Withington, published 2012. Reproduced with permission of Palgrave Macmillan Constance Weisner and Robin Room, Financing and Ideology in Alcohol Treatment from Social Problems, 1984, 32: 167–184. Used by permission of University of California Press.

CONTRIBUTOR BIOGRAPHIES

ABOUT THE EDITORS Robert Granfield is Professor of Sociology and Founding Chair of Civic Engagement and Public Policy at the State University of New York at Buffalo (UB). He is also an associate research scientist at the Research Institute on the Addictions at UB and has been a Visiting Scholar at Middlebury College and Harvard Law School. In 2010, he was the Fulbright Research Chair in International Humanitarian Law and Social Justice at the University of Ottawa. He has been a principal investigator on numerous research grants in the areas of law, addiction, prevention, and treatment. Dr. Granfield is the author of Making Elite Lawyers: Visions of Law at Harvard and Beyond and co-author of Coming Clean: Overcoming Addiction without Treatment; Recovery From Addiction: A Practical Guide to Treatment Self-Help and Quitting on your Own, and Private Lawyers in the Public Interest: The Evolving Role of Pro Bono in the Legal Profession. He has also published numerous articles on law, drug use, and addiction. Craig Reinarman is Professor of Sociology and Legal Studies at the University of California, Santa

Cruz. He has been a postdoctoral fellow at the Alcohol Research Group at the University of California, Berkeley; a Visiting Scholar at the Center for Drug Research at the University of Amsterdam; Visiting Professor at Utrecht University in the Netherlands; a member of the Board of Directors of the College on Problems of Drug Dependence; and a principal investigator on research grants from the U.S. National Institute of Drug Abuse. Dr. Reinarman is the author of American States of Mind and co-author of Cocaine Changes: The Experience of Using and Quitting and Crack in America: Demon Drugs and Social Justice. He has also published many articles and chapters on drug use, addiction, law, treatment, and public policy.

CONTRIBUTORS Bruce K. Alexander is a psychologist and Professor emeritus at Simon Fraser University in Vancouver, British Columbia, Canada. Professor Alexander is the author of Peaceful Measures: Canada’s Way Out of the War on Drugs and The Globalization of Addiction: A Study in Poverty of the Spirit. He has also published numerous articles on drug use and drug policy including the pioneering experiments on “rat park,” which shook up the addiction field by demonstrating that socially housed lab rats who were allowed to engage in other activities did not ingest opiates in addictive fashion. Philippe Bourgois is Richard Perry University Professor of Anthropology and Family and Commu-

nity Medicine at the University of Pennsylvania. He was founding Chair of the Department of Anthropology, History and Social Medicine at the University of California, San Francisco, from

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1998 through 2003. He is the author of numerous articles and books including Righteous Dopefiend (co-authored with Jeff Schonberg). This book won the 2010 Anthony Leeds Prize for Urban Anthropology. His previous book, In Search of Respect: Selling Crack in El Barrio, won the 1996 C. Wright Mills Award and the 1997 Margaret Mead Award. William Cloud is Professor in the Graduate School of Social Work at the University of Denver. He

is the co-author of three books on natural recovery from addiction: Recovery from Addiction; Promoting Self-Change from Substance Dependence; and Coming Clean: Overcoming Addiction without Treatment. His current research is focused on evaluating the Department of Housing and Urban Development’s HOPE VI public housing revitalization project. David T. Courtwright is Presidential Professor of History at the University of North Florida. He is the author of Dark Paradise: Opiate Addiction in America Before 1940; Forces of Habit: Drugs and the Making of the Modern World; and other books on American and world history, frontier environments, and, most recently, the culture war that has roiled U.S. politics since the 1960s. He has also published numerous journal articles on the history of drug use and drug problems. Molly J. Dingel is Assistant Professor of Sociology at the University of Minnesota, Rochester. She conducts research on the social aspects of science and medicine with a focus on how imaging technology, genetic studies, and knowledge of disease transmission are changing the field of medicine. She has published numerous articles in journals such as Addiction and Social Science Quarterly. Kathryn J. Fox is Associate Professor of Sociology at the University of Vermont. She is the co-author, with Michael Burawoy and others, of Ethnography Unbound: Power and Resistance in the Modern Metropolis and the author of numerous articles on public health approaches to HIV among injection drug users, drug and alcohol treatment, and offender reentry. In 2013, she was awarded a Fulbright Senior Scholar award to study at the Victoria University in Wellington, New Zealand. Richard Hammersley is Professor of Health Psychology at the University of Hull in England. He is the

author of several books and research articles in the area of addiction, drug use, and eating disorders. He is a member of the Scottish Government’s National Drug Evidence Group and serves on the editorial board Addiction Research and Theory. He is the author of Drugs and Crime and co-author of A Very Greedy Drug: Cocaine in Context and Ecstasy and the Rise of the Chemical Generation. Janice M. Irvine is Professor of Sociology at the University of Massachusetts. She is the author of

Talk about Sex: The Battles over Sex Education in the United States and Disorders of Desire: Sexuality and Gender in Modern American Sexology as well as numerous articles. She has been the recipient of several fellowships including a 2009 Fulbright award for study at the University of Zebreb in Croatia. Harold Kalant is Professor Emeritus in the Department of Pharmacology and Toxicology at the Uni-

versity of Toronto. Among the contributions arising from his research has been the recognition of the cardinal importance of interactions among behavioral, environmental, and pharmacological factors in the development of tolerance and dependence. He has authored or edited 23 books and 370 journal articles, book chapters, and reports. In addition to receiving numerous awards for his scholarship, Professor Kalant is a Fellow of the Royal Society of Canada, and the first Honorary Fellow of the British Society for the Study of Addiction.

C O N T R I B UT O R B I O G R APH I E S

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Katrina Karkazis, is a cultural anthropologist and Senior Research Scholar with the Center for Biomedical Ethics at Stanford University. Her research on contemporary biomedicine has examined the social aspects of disease categories, including the medical management of infants born with intersex diagnoses. Her work has appeared in the American Journal of Bioethics, the British Medical Journal, and the New York Times. She the author of Fixing Sex: Medical Authority, and Lived Experience. Barbara A. Koenig is an anthropologist who studies contemporary biomedicine. She is Professor of

Biomedical Ethics and Medicine at the College of Medicine, Mayo Clinic, and an Affiliate Faculty of the Center for Bioethics, University of Minnesota, Minneapolis. She is the author of numerous articles and co-author of Revisiting Race in a Genomic Age. Velibor Bobo Kovac is a professor in the Department of Education at the University of Agder, in Kris-

tiansand, Norway. His research centers on the social-psychological aspects of addiction, tobacco use, and the roles of cognition and intention in cessation from smoking and other addictions. He has published this research in many scientific journals, including Addiction Research and Theory, International Journal of the Human Sciences, the British Journal of Health Psychology, and Nordic Studies on Alcohol and Drugs. Harry G. Levine is Professor of Sociology at Queens College and the Graduate Center, City University

of New York. His research and writings have focused on drugs, alcohol, and food in historical context. He is the co-author of Crack in America: Demon Drugs and Social Justice. His research on the history of addiction and alcohol prohibition has received several distinguished scholarship awards. He has also published widely on international drug policy, the war on drugs, and racial bias in marijuana possession arrests. In 2013 he was awarded a Senior Scholar Distinguished Achievement Award from the Society for the Study of Social Problems. Michael Moss is an investigative reporter for The New York Times. He won the Pulitzer Prize for

explanatory reporting in 2010 for his writings on food safety in the meat industry. Before coming to the New York Times, Mr. Moss reported for the Wall Street Journal, Newsday, and the Atlanta Journal-Constitution. He also has been an adjunct professor at the Columbia University School of Journalism. He is the author of Salt Sugar Fat: How the Food Giants Hooked Us. Lori Reed is an independent scholar living in Washington, DC. She is the author or co-author of several books on computer addiction including High on Technology: Computer Addiction and Cultural Regulation. She also co-edited Governing the Female Body: Gender, Health, and Networks of Power. Gerda Reith is Professor of Social Sciences at the University of Glasgow in Scotland. She has pub-

lished widely on gambling and other problematic forms of consumption, particularly those considered risky or “addictive,” the ways they are experienced by different social groups, and how they might be regulated to reduce their impact on public health. She is the author of Consumption: Regulation and Excess and The Age of Chance: Gambling and Western Culture. John S. Rice is Associate Professor in the Department of Sociology and Criminology at The University of North Carolina, Wilmington. He has published many scholarly articles and book chapters as well as a book, A Disease of One’s Own: Psychotherapy, Addiction, and the Emergence of Co-Dependency. Robin Room is currently Professor of Alcohol Policy Research at the School of Population Health of the University of Melbourne and the Director of the Centre for Alcohol Policy Research (CAPR)

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at Turning Point Alcohol and Drug Centre. He was formerly a researcher and then Scientific Director at the Alcohol Research Group (Berkeley) until 1991. He then served as Vice President for research at the Addiction Research Foundation of Canada. In 1999 Professor Room was appointed professor and founding director of the Centre for Social Research on Alcohol and Drugs at Stockholm University. He is the author of numerous books and hundreds of research articles in alcohol and drug studies. He is the recipient of several awards for his scholarship, including the Jellinek Memorial Award for Alcohol Studies. Joseph Schneider is Ellis and Nelle Levitt Professor of Sociology at Drake University. His main areas of current research, writing, and teaching are science and knowledge studies, cultural theory, and masculinity. His published work includes numerous books and articles on the social construction of deviance, social problems theory, illness, family caregiving in China, ethnography, and feminist science studies. He was the editor of the journal Social Problems. He is the author of Having Epilepsy and Donna Haraway: Live Theory; co-author of Deviance and Medicalization; and co-editor of Studies in the Sociology of Social Problems. Rebecca Tiger is Assistant Professor of Sociology at Middlebury College. Her research and teach-

ing explores the intersection of punishment, social control, critical addiction studies, and media culture. Her recent book, Judging Addicts: Drug Courts and Coercion in the Justice System, examines the re-emergence of rehabilitation in the criminal justice system focusing on the medicalized theories of addiction that are used by advocates of drug courts to justify criminal justice oversight of drug users. She is also the co-editor of Bioethical Issues, a volume of Advances in Medical Sociology. Darin Weinberg is University Senior Lecturer in the Sociology Department and a Fellow and Director of Studies at King’s College, University of Cambridge. He has published extensively in the areas of addiction, mental illness, science studies, and social theory. In 2011 he received the Melvin Pollner Prize in Ethnomethodology from the American Sociological Association for his book, Of Others Inside: Insanity, Addiction, and Belonging in America. He is also the author of Contemporary Social Constructionism and co-editor of Talk and Interaction in Social Research Methods and Intoxication and Society. Constance Weisner is Professor in the Department of Psychiatry in the School of Medicine at the University of California, San Francisco, and a senior research scientist at the Kaiser Permanente Northern California Division of Research. Dr. Weisner has published extensively in scientific journals on the epidemiology of alcohol and drug problems; the interaction among alcohol, drug, mental health, and medical problems; and on clinical trials, outcomes and cost-effectiveness of various modalities of addiction treatment.

INDEX

Note: Page numbers followed by f indicate figures, by p indicate pictures, by t indicate tables, and by n indicate notes abstinence: from alcohol 25, 26, 30, 35, 36, 52; from computer use 268; from drugs 189; versus maintenance 161, 165 acamprosate 77–8 Adams, John 27 Adderall 10 addiction: defined and described 4–5, 73–4, 78; see also critical studies of addiction; disciplining addictions; discovering addiction addiction-as-disease 1–2, 3, 5, 15, 17; see also deviant drinking as disease; disease concept addictionologists, in sex addiction and inhibited sexual desire 235, 236, 237–8 addiction theories and treatment 159–71; abstinence versus maintenance 161, 165; Alcoholics Anonymous treatment approach 159, 160, 162, 163, 165–6, 168; Antabuse 164; class-based assumptions and hidden arguments 159; codependents 163; craving 160; destigmatization 168; disease concept 159–60, 169n3, 169n4; drug abuse industrial complex 162; financing of treatment 162–4; for-profit alcohol treatment facilities 162; health insurance 162, 163; hidden arguments in the structure of treatment 165–7; hidden class arguments in treatment goals 164–5; historical context 160–1; methadone maintenance treatment approach 159, 160, 162, 163–4, 166–8; Narcotics Anonymous 169n5, 169n8; personal responsibility 161–2; political ideologies and hidden arguments 159; private treatment centers 163; role of professionals 162; social and structural influences 159; substitution therapy 160, 162; treatment in context 160; 12-step model 162, 163, 168, 169n5, 169n10; use of the term addiction 168n1; U.S. Supreme Court 161

addiction treatment see treatment addictive junk food 127–40; academia 128; aggressive marketing 138, 139; American Cancer Society 128; American Heart Association 128, 137; baby boomers 136, 137; baby carrots 139–40; Behnke, James (Pillsbury) 127, 129; Bible, Geoffrey (Philip Morris) 133; bliss point 131, 136; Brazil 139; Brownell, Kelly 128; Cadbury Schwepps 129–32; Campbell 30, 138; Carey, Al (FritoLay) 137; Centers for Disease Control and Prevention 128; Cheetos 136–7; childhood obesity 127; Clinton, Bill 137; Coca-Cola 127, 129, 131, 138–40; cohort studies 136; color 131; conjoint analysis 130; convenient prepackaged lunch for children 132–4; cravings 131, 136, 138; diabetes 129; Dichter, Ernest 137–8; Doritos 131; Drane, Bob 132–5; Drane, Monica 134; Dr Pepper 129–32; Dunn, Jeffrey (Coca-Cola) 138–40; Eckert, Bob (Kraft) 134; emerging obesity epidemic in U.S. 127–9, 135; fat 132, 133; Finland’s salt habit 135; focus-group sessions 132; food-science experts 127; Frito-Lay 135–7, 138; Fun Pack 133; General Foods 130; General Mills 127, 138; Gladwell, Malcolm 130; Go-Gurt 128; gout 129; Harvard School of Public Health 138; hypertension 129, 135; Jamwich 139; Karppanen, Heikki 135; kids in control concept 134; Kilduff, Jack (Dr Pepper) 129; Kraft 127, 130, 132–4; Lay’s potato chip varieties 136; line extensions 129; Lin, Robert (Frito-Lay) 135, 138; Lucky Charms 128; Lunchables 133–5; lunchtime 132–5; Mars 127; Martin Dearborn Partners 139; Maxed Out 133; meeting of food company C.E.O.s in 1999 127–9; Monell Chemical Senses Center

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136; Moskowiz, Howard 130–2; mouth feel 131, 136; Mudd, Michael (Kraft) 127–8; Mukherjee, Ann 137; Nestle 127, 138; New England Journal of Medicine study 138; Obama, Barack 138; Oscar Mayer 132–4; PepsiCo 129, 130, 138; Philip Morris 132, 133; Pillsbury 127; Prego spaghetti sauce 130; processed foods 127, 128; processed meat 132–4; Procter & Gamble 127; public health community 127; Putman, Todd 139; Red Fusion 129–30; Reisner, Michele 131; Rimm, Eric 138; Riskey, Dwight 136; salt 135, 136, 137; salt/sugar/fat levels in processed foods 128, 135, 138; Sanger, Stephen (General Mills) 128–9; secretary of agriculture 128; sensoryspecific satiety 131; 7-Up 132; snacks in place of real meals 136; Snapple 132; Stacy’s Pita Chip Company 137; sugar 130, 133, 134; symposium for nutrition scientists (1985) 135; taste 129, 131; U.S. Army meals-ready-to-eat 131; vanishing caloric density of Cheetos 137; warning labels on packages 135; Witherly, Steven 136–7; Yoplait 128 Advocate, The (gay newsmagazine) 243, 246 African American addicts 184n2 African Americans prescribed pain medication 99 Al-Anon’s World Service Organization 216 Alcohol and Drugs History Society 42n94 Alcoholics Anonymous 1, 4, 13, 35; alcohol treatment financing and ideology 148, 152, 153, 155, 155n3; “allergy” to alcohol 55, 160; Bill W. 48, 155n3; co-dependency 216, 217–18, 220, 229n; deviant drinking as a disease 54, 55–6; loss of control over drinking or drug use 45, 48; loss of control over one’s life 45; success attributed to the program 56; and temperance advocates 26, 31; treatment approach 159, 160, 162, 163, 165–6, 168 Alcoholism Subcommittee, World Health Organization 56 alcohol metabolism and nutritional research 54 alcohol prohibition campaign 34 alcohol treatment financing and ideology 143–58; accountability 143; aggressive outreach and intervention 155; Alcoholics Anonymous 148, 152, 153, 155, 155n3; Amended Food Stamp Act of 1977 147; American Medical International (corporation) 149; background 143–4; case study of changes in alcohol services in California 143; changes in the process and ideology of treatment 152–3; changing functions and characteristics of alcohol treatment 149–51; clientele shifts 150–1, 154; co-alcoholic 154, 155n6; community-based agencies 144; Comprehensive Care Corporation (Comp

Care) 149; confidentiality compromises 153–4; conservative politics 143; contracting for social welfare 145–6, 151; court-referred clients 154; development of the modern alcohol treatment system 144–5; drunk driving programs 154; employee assistance programs 152; federal project grants 145; fiscal crisis 143; food stamps 145; for-profit corporations 149; halfway houses 147, 151; health insurance 145, 148, 149, 152; Health Maintenance Organization Act of 1973 148; Hughes, Harold 149; inebriate asylums 148; Medicaid 145, 154; medicalization of deviance 143; medical profession’s power 143; Medicare 145; National Alcohol Research Center Grant 155; National Council on Alcoholism (NCA) 149; National Drug and Alcoholism Treatment Utilization Survey (1979) 148; National Institute on Alcohol Abuse and Alcoholism (NIAAA) 144, 145, 148, 155; National Institute on Mental Health 144; non-government agencies operating on contract 143; private for-profit agency growth 148–9, 151–2; private treatment agencies 143; public alcohol treatment system since 1980 145–8, 146t; role conflicts for therapists 153; shift from county to contract programs 146t; shifts in alcohol treatment 151–5; social action groups 151; third-party coverage 143, 146, 148; Veterans Administration hospitals 155n4 Alexander, Bruce K. 7, 17n3, 67, 107, 315; see also roots of addiction in free market society Ambien 10 Amended Food Stamp Act of 1977 147 American Bar Association 160 American Cancer Society 128 American Heart Association 128, 137 American literature, functions of addiction in 47–9 American Medical Association 169n10; Committee on Alcoholism 57 American Medical International (corporation) 149 American Psychiatric Association: definition of substance use disorder 5, 18n11; diagnostic criteria 281; sex addiction and inhibited sexual desire 239; on smoking 91; see also Diagnostic and Statistical Manual of Mental Disorders American Psychological Association 234 American Sociological Association 68 amphetamines 12, 74 ancient bacchanalian drinking traditions 2 anhedonia 83 “Anonymous” self-help groups 1, 37, 216 anorexia nervosa 244 Anslinger, Harry 66 Antabuse 164

I N DEX

anti-depressant medications 83 Anti-Drug Abuse Acts (1986) 188 Anti-Saloon League 34 anxiety disorders 8, 10 attention deficit hyperactivity disorder (ADHD) 10–11, 18n24, 113 Augustine Fellowship 234–5 automaticity paradigm 303, 394 Bacon, Seldon 59n2 Barlow, John Perry 266, 267 Beattie, Melody, Codependent No More 215, 227, 228, 228n2 Becker, Arnie 241 Becker, Howard 15 behavioral addictions 1, 5, 9, 11, 12, 17, 83, 109; see also process or “activity” addictions behavioral problems 5 behavior modification, nicotine addiction research study 95, 96 Behnke, James (Pillsbury) 127, 129 Bell, Daniel 253 Beman, Nathan 31–2 beneficiaries of the drug war 119, 123n64 Benezet, Anthony 29 Bennett, Bill 65 benzodiazepines 10, 12 Bible, Geoffrey (Philip Morris) 133 biochemical changes triggered by drug consumption 62, 67 biological criteria, cultural framing of addiction 44f, 46 biological reductionism 6–7 biomedicalization 91, 95, 99, 100; see also medicalization biomedical theories of addiction and their limitations 82–4 bio-politics of substance abuse 172 biopower in action 179–80 Black, Claudia 226 blaming the victims 226–7 Boorstin, Daniel 36 Bordo, Susan 244 Bourgois, Philippe 13, 117, 172, 315–16; see also disciplining addictions Bradshaw, John: co-dependent books by 215, 223–8, 229n10; see also co-dependency brain as site of sexual desire 237 brain deficits due to chronic drug use 7–8 brain-deprived neurotropic factor 91 brain’s pleasure center and reward circuitry 6 Breugel, Peter, The Fight between Carnival and Lent (painting) 2, 3p Brownell, Kelly 128 Brumberg, Joan Jacobs 244 buprenorphine 67, 77–8

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bupropion 95 Bureau of Narcotics 65 Bush, George H. W. 65 Bush, George W. 65 Byrd, William 26 Cadbury Schwepps 129–32 Campbell, Nancy 15, 63 Campral 67 cancers 91, 100 cannabis 66; see also marihuana capitalism 113 cardiovascular disease 91, 100, 132, 135 Carey, Al (Frito-Lay) 137 Carnes, Patrick 235, 238 Cass, Lewis 31 Castel, Robert 64 Caught in the Net (Young) 272 causal attribution as cultural construction 44 Center for Court Intervention 190 Center for Online Addiction 270, 272 Centers for Disease Control and Prevention 128 Chalmers, James 30 Channing, Walter 31 Chantix 67, 95 Cheetos 136–7 childhood obesity 127 cholesterol 132 chronic fatigue syndrome 2 chronic relapsing brain disease (CRBD) 6, 10, 16, 278 cirrhosis of the liver 57 Civilizing Process, The (Elias) 7 classical and operant conditioning theory 304, 306 clinical picture of intoxication 52 Clinton, Bill 65, 137 clogged arteries 132 Cloud, William 9, 13, 196, 316; see also social capital and natural recovery Clutterers Anonymous 1 co-alcoholic 154, 155n6 coca chewing 9 Coca-Cola 127, 129, 131, 138–40 cocaine 4, 9, 12, 35, 64, 66, 74, 77, 83; constraint theory 280, 283; mixes well with methadone 179; in Vancouver (“Terminal City”) 109, 110 cocaine addiction 117–18 co-dependency 1, 11, 163, 215–32; adaptational discourses 217–18; and addiction 218–20; Al-Anon’s World Service Organization 216; Alcoholics Anonymous 216, 217–18, 220, 229n; “Anonymous” self-help groups 216; and authority 224; background 215–16; Beattie, Melody, Codependent No More 215, 227,

321

322

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228, 228n2; blaming the victims 226–7; Bradshaw, John, co-dependent books by 215, 223–8, 229n10; circular causality 221; Co-Dependents Anonymous 12 Steps 218, 229n8; Co-Dependents Anonymous numbers in 1990 215; commodity production 228; conservatism resurgence 223; determinism and the need for therapy 224–5; disease model of addiction 216, 217, 229n6; disease versus discourse 228n1, 229n5; emergence of co-dependency 217; family systems therapy 221–2, 226; family rules 221; first National Conference of Co-Dependency (1989) 215; human nature and culture 217, 222; human potential psychologies 217, 222, 223; liberation discourse 228; liberation therapies 217, 222; life stories 215, 216, 221, 226, 227, 228; life stories and canonical authority 223–4; new social movements 228; the obligation to express 225–6; the “poisonous pedagogy” (Bradshaw) 222–3; political economy of the treatment industry 228; “populism”: the theorists’ double location 228; power/knowledge 227–8; process or “activity” addictions 220–1, 228; social problems 220; symptom list of 218–19; therapy and addiction 216–17; 12-step subculture 216–17, 224, 228n3 Co-Dependents Anonymous 12 Steps 218, 229n8 cognitive appraisals 197 cognitive behavioral therapy 289 cognitive deconstruction 301 cognitive psychological research 255–6 Coles, Robert 217 collective conscience 2 commodification of chance 250–1 Communist Manifesto (Marx and Engels) 111, 121n7 community-based agencies 144 comorbidity with various psychiatric disorders 91, 300–1 Comprehensive Care Corporation (Comp Care) 149 computer fear see Internet addiction disorder computer games 266 computer security 267, 269 confidentiality compromises 153–4 constraint theory 278–95; addiction defined as a chronic, relapsing brain disease (CRBD) 278; addiction research implications 290–1; alcohol addiction 283; American Psychiatric Association diagnostic criteria 281; background 278–9; behavior change implications 287t, 288–9; cocaine 280, 283; cognitive behavioral therapy 289; cognitive constraints 283–4; cognitive effects 279; a

cognitive teleological alternative 282; constraints on drug use versus constraints on dependence 282–3; deficiencies and risk factors 280–1; dependence as the absence of constraints 279–80; deprivation and dependence 281–2; deviant subculture 283; Extended Theory of Planned Behavior 283–4, 290; heroin 279, 280, 283; a limitation of constraint theory 290–1; link between deprivation and drug dependence 286–7, 287t; Minnesota model 12-step approaches 289; motivational interviewing 289; motives not to become dependent 284–6, 287t; neuropsychological changes 279; not all users dependent 280; NPP paradigm 278–9, 282, 286, 288, 289; phenomena that constraint theory can explain 279–80; predictions and developments 281, 290; prevention implications 287t, 288; substitute prescribing 280; summary of constraint theory of drug dependence 287t; typology of dependence 289, 289t; U.S. soldiers in Vietnam 281; World Health Organization diagnostic criteria 281 consumer sovereignty 253 consumption ethic 253, 259 contextual factors 6, 10–12, 78 contracting for social welfare 145–6, 151 cosmetic psychopharmacology 10 Cott, Nancy 241 court-referred clients 154 Courtwright, David T. 9, 62, 316; see also National Institute on Drug Abuse brain disease paradigm craving 46–7, 52, 57, 73, 78, 160; addictive junk food 131, 136, 138 CRBD see chronic relapsing brain disease criminalization of drug use 187, 193 criminal justice system 13, 52 critical studies of addiction 1–21; addiction-asdisease 1–2, 3, 5, 15, 17; addict or ex-addict identity 15; Alcoholics Anonymous 4, 13; American Medical Association 4; American Psychiatric Association definition of substance use disorder 5, 18n11; background 1–2; behavioral addictions 1, 5, 9, 11, 12, 17; biological reductionism 6–7; brain deficits due to chronic drug use 7–8; brain’s pleasure center and reward circuitry 6; “chronic relapsing brain disease” (CRBD) 6, 10, 16; contextual variables 6, 11; criminal justice system 13; cultural dislocation 7; defining addiction 4–5; dopamine neurons 6, 8; drinking traditions from classical antiquity through the Middle Ages 2; drug courts 13; drug policy reform movement 1; ethnographic methods for research 15, 18n27; expanding

I N DEX

addiction 11–14; The Fight between Carnival and Lent (Breugel) 2, 3p; functional magnetic resonance imaging (fMRI) 6; habitual drunkenness 3; historicizing addiction 2–4; injection equipment and syringe sharing 13; lived experience of addiction 14–15; mass consumption cultures with immediate gratification 7; media and digital devices 11; medicalization of addiction 4, 9; methadone maintenance 13; moral character of the individual 4, 17n6; “natural recovery” from addiction 13; neuroscience technologies 6, 11, 14, 16, 18n13; pathologizing addiction 10–11; pharmaceutical companies 11, 12; physiological dependence 4, 8–9, 14; Prohibition 4; research biases and funding decisions 14; scientific literature 14; Second Great Awakening 3; self-control 3, 4, 7; social class and addiction 13; social conditions contributing to addictive behaviors 12, 14; social versus biologic factors 8–9, 15; temperance movement 3–4; time as a commodity 4, 11; tolerance to drugs used 4; user cultures 7; withdrawal symptoms 4, 8; World Health Organization definition 4–5; Yale Center for Alcohol Studies 4; see also elementary principles of critical addiction studies Crosby, Howard 33 cultural dislocation 7 cultural framing of addiction 43–50; Alcoholics Anonymous loss of control over drinking or drug use 45, 48; background and history 43–4; biological criteria 44f, 46; causal attribution as cultural construction 44; classifications of psychiatric disorders 45; constructivist frame 49; craving for substances 46–7, 48; culturebound syndrome 44, 49; culture of individuation and individualism 45; Diagnostic and Statistical Manual of Mental Disorders (DSM-4) 45, 49n13; “diseasing of America” (Peele) 47; elements of addiction 44–7, 44f; the experience of addiction 49; functions of addiction in American storytelling 47–9; The ICD-10 Classification of Mental and Behavioural Disorders 44f, 45, 46, 47, 49n12; mystery of addiction concept 45, 47–8; possession by an alien spirit 45, 46, 48; psychological criterion 44f, 46–7; temperance movement 44, 45; time as a commodity 46 cultural influence model 238 culture-bound syndrome 44, 49 Danforth, Samuel 27 Davies, John 85 decriminalization 1–2

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Degler, Carl 241 DeGrandpre, Richard 113 Democrats 65–6 demographic variables 64 demonic possession 53 Depo-Provera 236 deprivation and drug dependence 286–7, 287t desire, celibacy 235 destigmatization 168 deviant drinking as a disease 51–61; abstinence from alcohol 52; Alcoholics Anonymous 54, 55–6; alcoholism as an allergy of the body 55; alcoholism is a social rather than a scientific or medical accomplishment 59; Alcoholism Subcommittee, World Health Organization 56; alcohol metabolism and nutritional research 54; American Medical Association, Committee on Alcoholism 57; American temperance movement 53–4; background 51; clinical picture of intoxication 52; colonial foundations 52–3; craving 52, 57; criminal justice system 52; demonic possession 53; “disease of the will” (Rush) 52; first and third of the “Twelve Steps” of Alcoholics Anonymous 55–6; habitual drunkenness 52; humanitarian solution 52; impact in the law and U.S. Supreme Court rulings 59n9; individual responsibility 52; inebriate asylums 53, 54; An Inquiry of the Effects of Ardent Spirits Upon the Human Body and Mind (Rush) 52; Jellinek model 54, 56–8; Journal of Inebriety 53; Journal of Studies on Alcohol 58, 59n3; Keller’s “medical definition” of alcoholism 58; Laboratory of Applied Physiology at Yale University 54; loss of control over drinking 52, 53, 56–7, 58; medicalization of deviance 51, 57, 59n8; mental illness 53–4, 55; moral degeneration 52; narcotics 57; National Council on Alcoholism 55; physicians and labels of sickness and disease 51; physiological dependence 57; physiological reaction to alcohol (allergy) 55; policy formation 54–5; post-prohibition rediscovery 54–8; progression of alcoholism 59n7; psychological dependence 57; public education 55; Quarterly Journal of Studies on Alcohol 54; religious control 52; removing a stigmatized label 55; Research Council on Problems of Alcohol 54; social and political construction 51; social control 51; social historical overview 58–9; Standard Classified Nomenclature of Disease 57; treatment and therapy 52; “world views” of the time 52; Yale Center for Alcohol Studies 54–5, 59n4 diabetes 129

323

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Diagnostic and Statistical Manual of Mental Disorders (DSM-III/DSMIII-R/DSM-IV) 251, 255, 258, 260n2 Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR) 234, 239 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 45, 49n13 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 73 Diagnostic and Statistical Manual of Mental Disorders (DSM-V) 5 Diagnostic and Statistical Manuel of Mental Disorders (DSM) 95, 96, 100 diagnostic promiscuity 10 Dichter, Ernest 137–8 Dickens, Charles 114 Dingel, Molly J. 90, 316; see also nicotine addiction research study disciplining addictions 172–86; African American addicts 184n2; bio-politics of substance abuse 172; biopower in action 179–80; biopower, power/knowledge, and the specific intellectual 172–3; birth of the methadone clinic 178–9; cocaine mixes well with methadone 179; disciplining the dosage: biomedicine’s power/knowledge nexus 180–2; distinction between heroin and methadone 172, 173; from dope to medication 173–4; dosage levels 179–80; economic productivity 172; “Effective Medical Treatment of Opiate Addiction” (National Consensus Development Panel) 176; engaging Foucault with harm/risk reduction 183–4; ethnographic critique of methadone treatment programs in the U.S. 172; ethnographic vignettes 174–5, 179, 181; federal biomedical versus populist prohibitionist and abstinence discourses on methadone 175–6; fieldwork descriptions and street conversations 172; fortified wine 179; Foucault, Michel 172; “Just-Say-No-ToDrugs” moral abstinence discourse 176; local discourses on methadone: New York versus San Francisco 177–8; medical prescription of heroin in Switzerland 182–3, 184; methadone maintenance 172; moral discipline 172, 174; National Institutes of Health 175–6; neurotransmitters 174; pregnant heroin addicts 179; Republicans in Congress 178; social control 172; “take-home doses” and daily attendance at clinics 178; Valium 179 discovering addiction 25–42; abstinence from alcohol 25, 26, 30, 35, 36; the addiction model 38; Alcohol and Drugs History Society 42n94; Alcoholics Anonymous and temperance advocates 26, 31; alcohol prohibition campaign 34; background 25–6;

capitalist spirit 36; colonial-era ideas contrasted with 19th and 20th century 26; discovery of addiction 29–34; The Disease Concept of Alcoholism (Jellinek) 32–33; drunken drivers 37–8; the Enlightenment 36; habitual drunkenness 25, 26, 27, 35, 38n6; inebriate asylums 32, 40n61; the liquor trust 34; location of the source of addiction 25–6, 33; loss of control 25, 30; mental illness 36; moral treatment 36; the novel (literary form) 37; paradigm changes 34–5; “paroxysms” in drunkenness 29; “post-addiction” model of drug and alcohol problems 37; progressive disease 25; proliferation of “Anonymous” groups 1, 37; Protestant and Puritan heritage 36; Puritan ministers 29; role of physicians 39n32; social context of addiction 35–8; social order and self-control 36; temperance movement ideology 25, 30–4, 41n82, 41n93; traditional views 26–9 disease concept 2, 159–60, 169n3, 169n4, 189; chronic relapsing brain disease (CRBD) 6, 10, 16, 278; co-dependency 216, 217, 229n6; The Disease Concept of Alcoholism (Jellinek) 32–3; nicotine addiction research study 90; see also National Institute on Drug Abuse brain disease paradigm dislocation as the precursor of addiction 114–18 disorders in thinking 255–6 dopamine 63, 64, 91, 92, 302; and the reward system 74–6 dopamine neurons 6, 8 Doritos 131 Dostoevsky, Fyodor 255 Drane, Monica 134 drinking traditions from classical antiquity through the Middle Ages 2 Dr. Jekyll and Mr. Hyde (Stevenson) 48 Dr Pepper 129–32 drug abuse industrial complex 162 drug courts 13, 92, 187–95; abstinence from drugs 189; alternative to incarceration 194; Anti-Drug Abuse Acts (1986) 188; background 187; Center for Court Intervention 190; coerced treatment 187–8, 191; components of 190; criminalization of drug use 187, 193; description of drug courts 188; disease model of addiction 189; focus on the community 190–1; Freeman-Wilson, Karen 190; fusing rehabilitation and punishment 193; goals of 190, 193; implications 192–4; methods in research study 188–9; Narcotic Addict Rehabilitation Act (1966) 187; National Association of Drug Court Professionals 190; parental authority figure of 191–2; Progressive Era reformers 193; race

I N DEX

considerations 193; Rockefeller Drug Laws (1973) 187–8; sanctions 191–2; structure of 188; theories of addiction and recovery 189–92; Treatment Alternatives to Street Crime 187; War on Drugs 187, 188, 194 Drug Enforcement Administration 66 Drugs, Brains, and Behavior: The Science of Addiction (NIDA) 62, 66–7 drug using networks 202 drunken drivers 37 Dunn, Jeffrey (Coca-Cola) 138–40 Duster, Troy 67–8 eating disorders 11, 12; see also food addiction Eckert, Bob (Kraft) 134 economic productivity 2, 172, 249 Edwards, Jonathan 27, 33, 39n26; Freedom of the Will 28–9 “Effective Medical Treatment of Opiate Addiction” (National Consensus Development Panel) 176 Ehrlichman, John 65 Elders, Jocelyn, as Surgeon General 65 Electronic Frontier Foundation 266, 268 elementary principles of critical addiction studies 15–17; consequentialist conceptualization of policy 17; contextual element 16; historical and cultural specificity 16; multi-disciplinary and multi-vocal investigative strategy 17; social inequality and differential consequences 16; sociological contingencies 16; see also critical studies of addiction Elias, Norbert, The Civilizing Process 7 Emerson, Ralph Waldo 36 emphysema 91 employee assistance programs 152 Engels, F. 111, 121n7 environmental factors 77, 78 epilepsy 99 erectile dysfunction 10 Erikson, Eric 107, 121n2 ethnographic research 15, 18n27; loss of self-control and addiction 86, 88; of methadone treatment programs in the U.S. 172 Evangelisti, Valerio 114 excommunication 107 exile 107 exponential discounting 299 Extended Theory of Planned Behavior 283–4, 290 family systems therapy 221–2, 226 fast food 14 fatalistic attitude 96, 97, 98 Fight between Carnival and Lent, The (Breugel) 2, 3p

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financing see alcohol treatment financing and ideology Finland’s salt habit 135 first World Conference on Internet Addiction (2000) 264 fMRI see functional magnetic resonance imaging food addiction 14; see also eating disorders food industry processes 18n26 food stamps 145 Foucault, Michel 25, 35–6, 172; exams as a technique of power 271; inseparability of truth, knowledge, and power 227, 228; psychologization of addiction 266, 267; on sex 233; usefulness and economy of the addiction discourse 267 Foxcroft, Thomas 27 Fox, Kathryn J. 13, 159, 316; see also addiction theories and treatment Franklin, Benjamin 27, 36 Freedom of the Will (Edwards) 28–9 Freeman-Wilson, Karen 190 free markets see roots of addiction in free market society Freud, Sigmund 222 Frito-Lay 135–7, 138 functional magnetic resonance imaging (fMRI) 6, 75, 92 Gamblers Anonymous 1, 257, 260n8 gambling 5, 6, 9, 11, 12, 249–62; cognitive psychological research 255–6; commodification of chance 250–1; consumer sovereignty 253; the consumption ethic 253, 259; contradictions of late-modern consumer societies 249; cultural contradiction of capitalism 253; the dependent subject 256–7; Diagnostic and Statistical Manual of Mental Disorders (DSM-III/DSMIII-R/DSM-IV) 251, 255, 258, 260n2; disorders in thinking 255–6; economic productivity 249; the ethic of production 249–50; explanations for the syndrome 252; Gamblers Anonymous 1, 257, 260n8; gambling and the consumption ethic 253–4; genetic predispositions 256; ideology of meritocracy 249; implications 258–9; impulse control disorder 251; and the Internet 250; irrational forces of chance 249; the irrational subject 255–6; liberalization and deregulation of gambling industry 250, 254, 259; lotteries 250, 251; mainstream leisure activity 252; medicalization of gambling 252, 259; money 258; motives for gambling 255; neurological imaging 256; “normal” or social gambling 249, 251–2; the pathological gambler 251–3, 260n2; pharmacological interventions 256; physiological basis for

325

326

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INDEX

gambling 256–7, 259, 260n7; professional gambling 252; prohibition and/or regulation by states 249; protestant work ethic 249; public health issue 259; reforming the subject 257–258; screens for gambling 251–2, 254, 258; South Oaks Gambling Screen 252, 258; state revenues from gambling 251; strategy of public finance 14; therapeutic interventions 257–8, 260n3, 260n9; the uncontrolled subject 254–5 gamma aminobutyric acid 74 gastritis 57 gateway theory 306 General Foods 130 genetic predispositions 63, 76–7, 91, 256, 300, 303 genetic research 90; changing how addiction is understood 94–6; leading to unrealistic expectations for treatment 95–6; and personal responsibility for cessation 95–8 genome-wide association studies 91 Gladwell, Malcolm 130 globalization 108, 111, 120 glutamate systems 91 Go-Gurt 128 Golden Valley Hospital Center, Sexual Dependency Unit 235, 239 Gough, John B. 32 governing (through) the Internet see Internet addiction disorder Granfield, Robert 1, 9, 13, 196, 315; see also critical studies of addiction; social capital and natural recovery Grant, Marcus 48 Gray, John 113, 119 habitual drunkenness 3, 25, 26, 27, 35, 38n6, 52 hackers can’t “just say no” to computers 267–70; see also Internet addiction disorder Haggard, Howard 54 Haldeman, Bob 65 halfway houses 147, 151 Hall, Wayne 92 Hammersley, Richard 8, 278, 316; see also constraint theory harm reduction 208; as pillar of intervention 118 Harrison Act of 1914 35 Harvard Medical School study, social capital and natural recovery 196 Harvard School of Public Health 138 health insurance 145, 148, 149, 152, 162, 163 Health Maintenance Organization Act of 1973 148 health problems and smoking 91 hepatitis C 13, 110, 176 Herd, Denise 48

heroin 8, 12, 77, 109; constraint theory 279, 280, 283; illegality of 169n13; medical prescription of heroin in Switzerland 182–3, 184; methadone maintenance 13, 169n15; pregnant heroin addicts 179; see also disciplining addictions historicizing addiction 2–4 HIV/AIDS 13, 109, 110, 176; sex addiction and inhibited sexual desire 236, 243, 244 Hobsbawn, Eric 114 Hughes, Harold 149 human potential psychologies 217, 222, 223 hyperbolic discounting 299–300 hypertension 129, 135 “hypoactive sexual desire disorder” (in women) 10 iatrogenic addiction 11–12 ICD-10 Classification of Mental and Behavioural Disorders, The, World Health Organization 44f, 45, 46, 47, 49n12 immediate gratification 7, 300 immigration 120 impulse control disorder 251 impulsivity 76–7, 91, 300, 301; nicotine addiction research study 91 incentive-sensitization theory 302–3, 306 Independent Order of Good Templars 34, 40n73 Inebriate Association 32, 53 inebriate asylums 32, 40n61, 53, 54, 148 information addiction 264 inhibited sexual desire (ISD) first identified in medical literature 233, 234, 239, 245; see also sex addiction and inhibited sexual desire injection equipment and syringe sharing 13 insomnia 10 instantaneous addictions 117–18 institutional commitments, social capital and natural recovery 202 intellectual property 267, 268, 269, 274 International Chamber of Commerce 113 International Monetary Fund 113 Internet 108, 114 Internet addiction disorder 1, 5, 9, 11, 12, 14, 263–77; abstinence from computer use 268; Atlanta Three 268; Caught in the Net (Young) 272; Center for Online Addiction 270, 272; computer fear 264, 265, 266; computer games 266; computers as business tools and home appliances 266; computer security 267, 269; constitutional rights 268; Diagnostic and Statistical Manual of Mental Disorders 270–1; Electronic Frontier Foundation 266, 268; emergence of a new disorder 263–265; first World Conference on Internet Addiction

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(2000) 264; and gambling 250; hackers can’t “just say no” to computers 267–70; “healthy” computer use 264, 265, 274; implications 273–4; information addiction 264; information commodities 267; intellectual property 267, 268, 269, 274; Internet Code of Conduct 272; Internet policies for companies 272–3; interventions 265, 268, 273, 274; managing computer fear and addiction 265–7; measuring instruments oriented toward computer use 271; Mitnick, Kevin 267, 268–70; pathological computer use 263, 270, 274; personality types most at risk 263–4, 266, 269, 271; reports on television shows 263; scientific articles in journals 264–5, 271; support groups and clinics for 263; symptoms of 263; uses of computer pathology 273–4; web-monitoring software 272; a working diagnosis 270–3 Internet Code of Conduct 272 Irvine, Janice M. 233, 316; see also sex addiction and inhibited sexual desire Jackson, Andrew 31 Jackson, Edwin 26 Jellinek, E. M. 4, 37, 45, 54; The Disease Concept of Alcoholism 32–3, 56–7, 169n4; model of 54, 56–8; phases or stages of alcoholism 57, 59n6 Jong, Erica, Any Woman’s Blues 242 Journal of Inebriety 53 Journal of Studies on Alcohol 58, 59n3 junk food see addictive junk food “Just-Say-No-To-Drugs” moral abstinence discourse 176 Kalant, Harold 6, 73, 302, 316; see also neurobiological research on addiction Kaplan, Helen Singer, Disorders of Sexual Desire 234, 236, 237, 238, 239 Karkazis, Katrina 90, 317; see also nicotine addiction research study Karppanen, Heikki 135 Kasl, Charlotte, Women, Sex, and Addiction 240, 245 Keller, Mark 28, 37, 58, 77 Keynesian economics 113 Kiecolt, Jill 201 Kilduff, Jack (Dr Pepper) 129 Kinsey, Alfred Charles 238 Koenig, Barbara A. 90, 317; see also nicotine addiction research study Kolb, Lawrence 63 Kovac, Velibor Bobo 296, 317; see also multisource model of addiction Kraft 127, 130, 132–4

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Laboratory of Applied Physiology at Yale University 54 Lay’s potato chip varieties 136 Leary, Timothy 266, 267 Leiblum, Sandra 236, 239 Leif, Harold 234 Lemert, Edwin 45 lesbian and gay liberation movements 244, 246 Leshner, Alan 62 Levine, Harry G. 3–4, 25, 43, 44, 317; see also discovering addiction Liddell, Francis 117 life options, social capital and natural recovery 198, 201 life stories, co-dependency 215, 216, 221, 226, 227, 228 Lindesmith, Alfred 8–9, 15 Lin, Robert (Frito-Lay) 135, 138 lived experience of addiction 14–15 Locke, John 28 Lonely Crowd, The (Riesman, Denny, and Glazer) 37 loss of self-control and addiction 25, 30, 63, 67, 73, 82–9; alcohol 52, 53, 56–7, 58; anhedonia 83; background 82; behavioral addictions 83; biomedical theories of addiction and their limitations 82–4; crack cocaine 83; distinguishing selves and addictions in therapeutic practice 86–9; elements of recovery work 86–8; ethnographic research 86, 88; extant sociological self-centric theorizing 86; moral order of communal living 87, 88; mysterious loss of self-control 85; nicotine 83; nonhuman agency of people’s addictions 86; overwhelmed by desire to use drugs 84, 85, 88; pharmacological therapeutic interventions 83; physical addictions 82–3; psychological addictions 82–3; relapse 83; the self as human agent in social interactions 82, 86–8; sociological theories of addiction and their limitations 84–5; sociology of the loss of self-control 82, 85; therapeutic practice in treatment programmes 88; tolerance 82; withdrawal symptoms 82, 83 Lost Weekend, The (film) 47, 48 lovemap theory, sex addiction and inhibited sexual desire 237–8, 243 Lowe, Rob 241 “low T” (testosterone) 10, 18n22 Lucky Charms 128 Lunchables 133–5 Lunestra 10 Lybrido 10 magnetic resonance imaging (MRI) 92 Mann, Mrs. Marty 55

327

328

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marijuana 35, 118; decriminalization initiatives 64; plantations in British Columbia 120 Mars (company) 127 Marsh, John 32 Martin Dearborn Partners 139 Marx, Karl 111, 121n7 Massachusetts Temperance Alliance 32 Massachusetts Temperance Society 31 mass consumption cultures with immediate gratification 7 Masters, William and Virginia Johnson, Human Sexual Inadequacy 234, 238 Mather, Cotton 26, 27 Mather, Increase 26, 27, 28, 29 McKenna, P. 119 media and digital devices 11 Medicaid 145, 154 medical approach to addictive dispositions 297, 300 medicalization: of addiction 4, 9; of desire 233, 241–6, 245–6; of deviance 51, 57, 59n8, 143 medical prescribing of mood-altering drugs 67 medical profession’s power 143 Medicare 145 mental disorders 5, 36, 53–4, 55, 62–3; and social rank 8 methadone 83; dosage levels 179–82; for maintenance in treatment 13, 65, 159–68; see also disciplining addictions methadone clinics 178–9 methamphetamines 12, 66 Miller, Alice 229n10 Miller, Perry 29 Minnesota model 12-step approaches 289 Mitnick, Kevin 267, 268–70 Monell Chemical Senses Center 136 Money, John 236, 238 moral character of the individual 4, 17n6 Moran, Richard 89n2 Morgagni, Giovanni 64 Moskowiz, Howard 130–2 Moss, Michael 12, 127, 317; see also addictive junk food motivation and learning 62, 68 motives not to become dependent 284–6, 287t MRI see magnetic resonance imaging Mudd, Michael (Kraft) 127–8 multi-source model of addiction 79, 296–312, 297f; addiction as attribution 306; amygdala 302; automaticity paradigm 303, 394; background 296–7; classical and operant conditioning theory 304, 306; cognitive deconstruction 301; comorbidity with various psychiatric disorders 300–1; dopamine 302; environmental cues 303; exponential discounting 299; gateway theory 306; genetic

predispositions 300, 303; hyperbolic discounting 299–300; immediate gratification 300; implications 305–6; impulsivity 300, 301; incentive-sensitization theory 302–3, 306; individual and unique combination of circumstances 306, 307; interactive effects of certain personality dispositions 301; limitations 306–7; macro-level analysis 297–8; medical approach to addictive dispositions 297, 300; neurobiology 297f, 302–3; nucleus accumbens 302; opponent process theory 303, 306; past action/current choices 297f, 298–300; predispositions 287f, 300–2; primrose path model of addiction 299; reasons to continue 304–6; research literature of theoretical propositions on addiction 296; “reward” or “pleasure” circuits 302; selfmedication 306; self-regulatory problems 300; simultaneous validity 307; social/cultural/ historical environment 38, 297–8, 297f; synergistic effect 305, 306; temporal discounting 299, 300, 301; underlying processes/mechanisms 297f, 303–4 mystery of addiction concept 45, 47–8 Nabi Biopharmaceuticals 95 Naloxone 13, 83 naltrexone 77–8 Narcotic Addict Rehabilitation Act (1966) 187 narcotics 57 Narcotics Anonymous 169n5, 169n8 National Alcohol Research Center Grant 155 National Council on Alcoholism (NCA) 55, 149 National Drug and Alcoholism Treatment Utilization Survey (1979) 148 National Institute on Alcohol Abuse and Alcoholism (NIAAA) 1, 144, 145, 148, 155 National Institute on Drug Abuse brain disease paradigm 1, 62–9, 91, 92; addiction treatment policies 64; biochemical changes triggered by drug consumption 62, 67; biological essentialism 67; demographic variables 64; dopamine 63, 64; Drugs, Brains, and Behavior: The Science of Addiction 62, 66–7; funding research 63; genetic predispositions 63; history 62–4; important groups in the addiction field 64; key elements 62; loss of control 63, 67; marihuana decriminalization initiatives 64; medical personnel actors 64, 65, 67; mental illness 62–3; methadone maintenance 65; motivation and learning 62, 68; neuroimaging studies 62; neuroscience 62, 63; nicotine 63; personality disorders and nonmedical addiction 63; pharmaceutical companies 67; physicians prescribing moodaltering drugs 67; police or law enforcement

I N DEX

64–5, 66, 67; political actors 64, 65–6, 67; positron emission tomography (PET) scans 64; practical therapeutic value 67; preventative and therapeutic action 62; prevention 66; public policy 5, 64, 68; relapse prevention 63; repeated cycle of abstinence and relapse 84–5; resistance 64–8; single-nucleotide polymorphisms (snips) 64; social contextual variability of drug effects 84; social-scientific actors 64, 65, 67–8; supply reduction of drugs 66; therapeutic approaches 65; using and non-using self-concepts 84; withdrawal 63, 64 National Institute on Mental Health 144 National Institutes of Health 175–6 National Sexual Addiction Hotline 241 National Temperance Society 32, 53 nationwide fellowships for sex addict and co-addicts 234–5, 241 “natural” communities of friends and families 209–10 natural disasters 107 natural recovery from addiction 13, 196; see also social capital and natural recovery Nature (publication) 7–8 NCA see National Council on Alcoholism Nestle 127, 138 neurobiological research on addiction 73–81; “addiction” and “dependence” accepted as synonymous 73; addiction defined and described 73–4, 78; American veterans of the Vietnam War 78; analogy with aeronautical engineering 79; anticipated reward and experienced reward 75; complex models that include interaction at all levels 79; contextual factors 78; craving 73, 78; Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM-IV-TR) 73; dopamine and the reward system 74–6; the drug alone does not cause addiction 77; environmental factors 77, 78; experiential learning 75; functional magnetic resonance imaging (fMRI) 75; gamma aminobutyric acid 74; genetic aspects of addiction 76–7, 78; impulsivity 76–7; integrative or synthetic process in science 78–9; intracellular signaling systems 79n1; loss of control 73; neurotransmitters 76–7; Parkinson’s disease treatment 75–6; pharmacological interventions 77; physical components 73, 75, 77; prevention of addiction 78; reductive or analytical process in science 78–9; Royal Society of Canada ad hoc committee 73; “self-administration” of a drug 73, 77; serotonin 76–7; “soldier’s disease” in American Civil War 73; synaptic plasticity 79n1; tolerance 73, 75, 77; treatment-induced abstinence 77; treatment of addiction 78; U.S.

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Public Health Service hospitals 78; ventral tegmental area of the brainstem 74; what neurobiology cannot tell us about addiction 77–9; withdrawal symptoms 73, 78; World Health Organization Expert Committee 73 neurobiology 297f, 302–3 neurochemical explanations, sex addiction and inhibited sexual desire 240, 243 neurological imaging 92, 256 neuropsychological changes, in constraint theory 279 neuroscience technologies 6, 11, 14, 16, 18n13, 62, 63 neurotransmitters 76–7, 91, 92, 174 New England Journal of Medicine study 138 New York State Medical society 160 NIAAA see National Institute on Alcohol Abuse and Alcoholism Nicholls, James 39n30 nicotine 63, 73, 83 nicotine addiction research study 90–106; African Americans prescribed pain medication 99; American Psychiatric Association on smoking 91; anti-smoking campaigns 100; background and history 90–3; behavior modification 95, 96; biomedicalization 91, 95, 99, 100; brain-deprived neurotropic factor 91; comorbid disorders 91; conclusion 100–1; control policies 100; description of sample and recruitment 93, 93t–4t; Diagnostic and Statistical Manuel of Mental Disorders (DSM) 95, 96, 100; as disease of the brain 90; dopamine 91, 92; drug courts 92; fatalistic attitude 96, 97, 98; functional magnetic resonance imaging (fMRI) 92; genetic predisposition to addictions 91; genetic research 90; genetic research and personal responsibility for cessation 95–8; genetic research changing how addiction is understood 94–6; genetic research leading to unrealistic expectations for treatment 95–6; genome-wide association studies 91; glutamate systems 91; impulsivity 91; in-depth interviews with 86 experts 90; interdisciplinary understanding 90; key questions in research 90; legal implications 92; magnetic resonance imaging (MRI) 92; medicalization 91; methods 93–4; National Institute on Drug Abuse paradigm 91, 92; neuroimaging studies 92; neurotransmitters 91, 92; nicotine vaccine 95, 96; personality predilections to addictions 91; pharmaceutical industry 96; pharmaceutical interventions 95, 100, 101; positron emission tomography (PET) 92; prevention programs 100; results 94–100; risk identification 98; risk-taking 91; schizophrenia 91, 98; serious health problems

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and smoking 91; serotonin 91, 92; social/ cultural/structural influences 92–3, 101; stigmatization of smoking 91, 98–100, 101; Surgeon General’s Report on Smoking and Health (1964) 100; tobacco in native New World cultures 90; twin studies 91 nicotine vaccine 95, 96 NicVAX 95 Nixon, Richard 160 non-government agencies operating on contract 143 nonhuman agency of people’s addictions 86 Not Tonight, Dear (self-help manual) 241 NPP paradigm 278–9, 282, 286, 288, 289 Obama, Barack 138 opiates 4, 114; accepted as addicting 25; Lindesmith’s study 8, 15; nonaddictive users of 123n61; prescribed by physicians 11–12; use in 19th century England 122n37 “opponent-process” theory of addiction (Solomon) 235, 303, 306 Oscar Mayer 132–4 ostracism 107 overdose deaths 13 Overeaters Anonymous 1, 12 Owen, Robert 111 OxyContin 12 past action/current choices 297f, 298–300 pathologizing addiction 10–11 Paxil 18n24, 67 Peele, Stanton 5, 14, 47, 67, 85 PepsiCo 129, 130, 138 personality disorders and nonmedical addiction 63 personality predilections to addictions 91 personal responsibility 161–2 PET see positron emission tomography Pfizer 95 pharmaceutical companies 11, 12, 67 pharmaceutical interventions 77, 83, 95, 100, 101 Philip Morris 132, 133 physiological components 73, 75, 77; addictive dependence 4, 8–9, 14, 57, 82–3; basis for gambling 256–7, 259, 260n7; reaction to alcohol (allergy) 55 Pillsbury 127 Pinel, Philippe 35 pleasure renunciation 2 Polanyi, K. 113, 121n3 police and law enforcement 64–5, 66, 67; as pillar of intervention 118 policy see public policy political actors 64, 65–6, 67

political ideologies and hidden arguments 159 polyneuropathy 57 positron emission tomography (PET) 64, 92 possession by an alien spirit 45, 46, 48 “post-addiction” model of drug and alcohol problems 37 power inequities and gender oppression 246 predispositions 287f, 300–2 Prego spaghetti sauce 130 prescription medications 10 prevention 66, 78; nicotine addiction research study 100; as pillar of intervention 118; and therapeutic action 62 primrose path model of addiction 299 private for-profit agency growth 148–9, 151–2 private treatment agencies 143 problematizing intoxication 2 processed foods 127, 128; see also addictive junk food process or “activity” addictions 220–1, 228; see also behavioral addictions Procter & Gamble 127 Progressive Era reformers 193 Prohibition 4 Protestant and Puritan heritage 36 Prozac 10, 18n24, 240 psychological addictions 44f, 46–7, 57, 82–3; sex addiction and inhibited sexual desire 238 psychological integration 107, 108, 111, 115, 118, 121, 121n2 public alcohol treatment system since 1980 145–8, 146t public education 55 public health community 127 public policy 2, 5, 9–10, 13–14, 64, 68; criminalization in 13; drug policy reform movement 1; formation of 54–5 Putman, Todd 139 Quarterly Journal of Studies on Alcohol 54 race considerations 193 Ray, Marsh 84–5 Reagan, Nancy 65 Reagan, Ronald 65, 188 recovery without treatment see social capital and natural recovery Reed, Lori 263, 317; see also Internet addiction disorder Reinarman, Craig 1, 315; see also critical studies of addiction Reisner, Michele 131 Reith, Gerda 249, 317; see also gambling relapse 83; prevention of 63; repeated cycle of abstinence and relapse 84–5

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religious control 52 religious piety 2 Republicans 65, 66; in Congress 178 research biases and funding decisions 14, 63 Research Council on Problems of Alcohol 54 research literature of theoretical propositions on addiction 296 “reward” or “pleasure” circuits 302 Rice, John S. 215, 317; see also co-dependency Richard Nixon 65 Rimm, Eric 138 Riskey, Dwight 136 Ritalin 10, 18n24, 113 Robbins, Lee 8 Rockefeller Drug Laws (1973) 187–8 Rockefeller, John D., Sr. 66 Rockefeller, Nelson 65 Rogers, Carl 222 Room, Robin 2, 4, 12, 15, 43, 143, 317–18; see also alcohol treatment financing and ideology; cultural framing of addiction Roosevelt, Franklin D. 113 roots of addiction in free market society 107–26; assimilation policy 115; attention deficit hyperactivity disorder (ADHD) 113; Australia 111; behavior addictions 109; beneficiaries of the drug war 119, 123n64; British Columbia 110; capitalism 113; changing the debate with political action 118–19; counterexample: instantaneous addictions 117–18; crack cocaine addiction 117–18; directions for political change 119–20; dislocation 107, 111–18, 120, 121n1; England 111–12; English language 108; four pillars of intervention 118, 119; free markets, dislocation, and addiction 107–8, 122n16; free market society as a cause of dislocation 111–14; getting at the roots of addiction 118; globalization 108, 111, 120; Hudson’s Bay Company 116; Hurons of eastern Canada 115–16; immigration 120; International Chamber of Commerce 113; International Monetary Fund 113; Internet 108, 114; Keynesian economics 113; macrocosm 110–11; mass addiction 108; microcosm 109; migration of Asians to Canada 109; native Canadians 109, 114–16; Orcadians in Canada 116–17; Orkney Islands in Scotland 116; potlatches 109; print and electronic media 118; professional addiction researchers 108; psychological integration 107, 108, 111, 115, 118, 121, 121n2; Roosevelt government 113; Scottish Highlands 111–12, 123n69; social change 120–1; substitute lifestyles 108; “Terminal City” (Vancouver) 109, 110; Theodore, Archbishop of Canterbury 122n34; transcontinental railway

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in Canada 109–10; transnational organizations 113, 120; U.S. middle class 113; Vancouver’s history of dislocation and addiction 109–10, 116; World Bank 113, 120; World Trade Organization 113, 120 Rosenberg, Charles 2 Rose, Nicholas 10, 257, 258 Rosen, Raymond 236, 239 Royal Society of Canada ad hoc committee 73 Rush, Benjamin 3, 26, 29, 32, 35, 90; An Inquiry of the Effects of Ardent Spirits Upon the Human Body and Mind 52; model of habitual drunkenness 30 Salsberg, Art 266 salt/sugar/fat levels in processed foods 128, 135, 138 Sanger, Stephen (General Mills) 128–9 Satel, Sally 64 Saukko, Paula 274 Schaef, Anne Wilson 48, 240 schizophrenia 91, 98 Schneider, Joseph W. 4, 51, 318; see also deviant drinking as a disease scientific literature 14 Second Great Awakening 3 Seeley, John 4, 15 self-control 3, 4, 7 self-efficacy and self-esteem, social capital and natural recovery 201 self-medication 306 serotonin 10, 76–7, 91, 92 7-Up 132 sex addiction and inhibited sexual desire 11, 233–48; addictionologists 235, 236, 237–8; The Advocate (gay newsmagazine) 243, 246; American Psychiatric Association 239; American Psychological Association 234; anorexia nervosa 244; Augustine Fellowship 234–5; background and history 233, 234–5; Becker, Arnie 241; behavior list in sex addiction 239, 242; Bordo, Susan 244; brain as site of sexual desire 237; Brumberg, Joan Jacobs 244; Carnes, Patrick 235, 238; celibacy 235; clinical programs of sex therapy 244; Cott, Nancy 241; cultural ideologies 233; cultural influence model 238; defining and treating the disorder of desire 236–41; definition of sobriety 240; Degler, Carl 241; Depo-Provera 236; Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR) 234, 239; diagnostic profiles and checklists 239, 242; disease narratives 233–6; double standard 243, 244; drug treatment 240; fantasy and pornography 235; feminist movement 244; Golden Valley Hospital Center, Sexual

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Dependency Unit 235, 239; HIV/AIDS epidemic 236, 243, 244; “Hypoactive Sexual Desire Disorder” (DSM-IIIR) 239; inhibited sexual desire (ISD) first identified in medical literature 233, 234, 239, 245; invention of 233; Jong, Erica, Any Woman’s Blues 242; Kaplan, Helen Singer, Disorders of Sexual Desire 234, 236, 237, 238, 239; Kasl, Charlotte, Women, Sex, and Addiction 240, 245; Kinsey, Alfred Charles 238; Leiblum, Sandra 236, 239; Leif, Harold 234; lesbian and gay liberation movements 244, 246; lovemap theory 237–8, 243; Lowe, Rob 241; lust 239–40, 246; mainstream books 244; Masters, William and Virginia Johnson, Human Sexual Inadequacy 234, 238; masturbation 235; medicalizing desire 233, 241–6, 245–6; Money, John 236, 238; moral stigma 243; National Sexual Addiction Hotline 241; nationwide fellowships for sex addict and co-addicts 234–5, 241; neurochemical explanations 240, 243; New Right 244; Not Tonight, Dear (self-help manual) 241; “opponent-process” theory of addiction (Solomon) 235; penile implant surgery 235; power inequities and gender oppression 246; premature ejaculation 238–9; the professional divide 235–6; Prozac 240; psychological and cognitive factors 238; regulation of sexuality 233; research studies 237, 243; Rosen, Raymond 236, 239; Schaef, Anne 240; sex addiction cycle 239; sex addiction movement 234–5; Sexaholics Anonymous 239–40; Sex and Love Addicts Anonymous 234; sex education 243, 244; sex enhancing techniques 235, 243; sexologists 235, 236, 244; “ Sexual Aversion Disorder” (DSM-IIIR) 239; sexual co-dependency 240; sexual dysfunction in men 234; sexual dysfunction in women 234; sexual liberation 236; social anxiety about freer sexual mores 236; social purity movements 240, 246; subjectivity in defining (Annie Hall) 239; symptom substitution 240; testosterone 240; treatment industry 235, 242; treatment options 243; Weeks, Jeffrey 237; Wellbutrin 240; women sex addicts 242–3, 245 Sexaholics Anonymous 239–40 Sex and Love Addicts Anonymous 234 sexologists, sex addiction and inhibited sexual desire 235, 236, 244 Shoppers Anonymous 1 Silkworth, W. D. 55 single-nucleotide polymorphisms (snips) 64 Smith, Adam 108, 114 Snapple 132

Sobell, Linda 197 social action groups 151 social and political construction 51 social and structural influences 159 social capital and natural recovery 196–211; age, education, gender, and occupation of sample 200t; avoidance-oriented and approachoriented conditions 197; background 196–8; brief intervention 209; cognitive appraisals 197; conventional life 202; drug using networks 202; emotional economy 205; fear of exposure 204; harm-reduction approach 208; Harvard Medical School study 196; health benefits 203; ideology 203–5; implications 208–10; institutional commitments 202; intimates 206, 209; life options 198, 201; living a double life 202; maintaining relationships 205–8; methods of the study 198–200, 199t, 200t; middle-class lives 202; “natural” communities of friends and families 209–10; natural recovery 196; obligations to others 204; personal relations 201; protection of due process 203; public pronouncement 197; re-commitment to institutions 206; religion 206; remaining employed 202, 203; reported years of addiction and years since addiction 199t; resources of parents 207; self-change 201; self-efficacy and self-esteem 201; sense of belonging 106; social capital 198, 201–2; social class 200; social context 197, 200–1; social position 201; stability 202–3; tough love 209 social class and addiction 13 social constructions 5 social context of addiction 12, 14, 35–8; social capital and natural recovery 197, 200–1; variability of drug effects 84 social control 51, 172 social/cultural/historical environment 38, 297–8, 297f social/cultural/structural influences 92–3, 101 social historical overview, deviant drinking as a disease 58–9 social interactions 86–8 social order and self-control 36 social-scientific actors 64, 65, 67–8 social versus biologic factors 8–9, 15 social welfare, contracting for 145–6, 151 sociological theories of addiction and their limitations 84–5 “soldier’s disease” in American Civil War 73 solitary confinement 107 Sons of Temperance 34 South Oaks Gambling Screen 252, 258 Spectra Intelligence 95 Spencer, Herbert 111

I N DEX

spontaneous remission see social capital and natural recovery Stacy’s Pita Chip Company 137 Standard Classified Nomenclature of Disease 57 Star Is Born, A (film) 47 state revenues from gambling 251 Stevenson, R. L., Dr. Jekyll and Mr. Hyde 48 Stewart, Mother 32 storytelling, functions of addiction in 47–9 suicide 2, 107 Surgeon General’s Report on Smoking and Health (1964) 100 symptom substitution, sex addiction and inhibited sexual desire 240 synaptic plasticity 79n1 synergistic effect 305, 306 Szasz, Thomas 88 talk therapy 6 temperance movement 3–4, 44, 45, 53–4; ideology of 25, 30–4, 41n82, 41n93 temporal discounting 299, 300, 301 theories of addiction and recovery 189–92 third-party coverage 13, 143, 146, 148 Tiger, Rebecca 13, 187, 318; see also drug courts time as a commodity 4, 11, 46 tobacco in native New World cultures 90 Todd, John E. 33 tolerance 4, 73, 75, 77, 82; as biological criterion 46, 57 tough love, social capital and natural recovery 209 Townsend, William 111 treatment 2, 9, 78; financing of 162–4; for-profit alcohol treatment facilities 162; ideological implications 167–8; as pillar of intervention 118; politics of 12–13; private treatment centers 163; privatized 12–13; for sex addiction and inhibited sexual desire 240, 243; substitution therapy 160, 162; see also addiction theories and treatment; addiction treatment programs; alcohol treatment financing and ideology Treatment Alternatives to Street Crime 187 Trotter, Thomas 41n93, 90 Tuke, William 35 12-step model 162, 163, 168, 169n5, 169n10 12-step subculture, co-dependency 216–17, 224, 228n3 twin studies, nicotine addiction research study 91 underlying processes/mechanisms 297f, 303–4 untreated recovery see social capital and natural recovery U.S. Army meals-ready-to-eat 131 user cultures 7

U.S. Public Health Service hospitals 78 U.S. soldiers in Vietnam 8, 78, 281 Valium 10, 12, 179 Valverde, Marianna 260n3 varenicline 95 ventral tegmental area of the brainstem 74 Veterans Administration hospitals 155n4 Viagra 10, 67 Vickers, Roy Henry 109 Vietnam see U.S. soldiers in Vietnam Volkow, Nora 62, 63, 64 warning labels on packages 135 War on Drugs 187, 188, 194 Washington Home in Boston 53 Watergate scandal 65 Weber, Max 36 Weeks, Jeffrey 237 Wegscheider-Cruse, Sharon 226 Weinberg, Darin 5, 82, 318; see also loss of self-control and addiction Weisner, Constance 12, 143, 318; see also alcohol treatment financing and ideology Wellbutrin 67, 240 Whitman, Walt 31 Wills, Sheri 274 Wise, Roy 6 withdrawal symptoms 4, 8, 48, 57, 63, 64, 73, 78, 82, 83 Witherly, Steven 136–7 Woman’s Christian Temperance Union 32 Woman’s Crusade 32 Woodward, Samuel B. 31, 32 World Bank 113, 120 World Health Organization: Alcoholism Subcommittee 56; definition of addiction 4–5; diagnostic criteria 281; The ICD-10 Classification of Mental and Behavioural Disorders 44f, 45, 46, 47, 49n12 World Health Organization Expert Committee 73 World Trade Organization 113, 120 Xanax 10 Yale Center for Alcohol Studies 4, 35, 54, 59n4 Yoplait 128 Young, Kimberly 270; Caught in the Net: How to Recognize the Signs of Internet Addiction and a Winning Strategy for Recovery 271–2 Young Men’s Temperance Society of New Haven 32 Zinberg, Norman 15

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