Pharmacology Versus Social Process

8/14/2019 Pharmacology Versus Social Process

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Pharmacol. Ther. Vol. 80, No. 3, pp. 265275, 1998Copyright 1998 Elsevier Science Inc.

ISSN 0163-7258/98 $19.00PII S0163-7258(98)00031-X

Associate Editor: D. J. K. Balfour

Pharmacology versus Social Process: Competing or ComplementaryViews on the Nature of Addiction?

John B. DaviesCENTRE FOR APPLIED SOCIAL PSYCHOLOGY, UNIVERSITY OF STRATHCLYDE, 40 GEORGE STREET, GLASGOW G1 1QE, UK

ABSTRACT. Pharmacological/physiological models and social process/cognitive models of addiction arecompared. These are discussed both in terms of the types of data produced and the philosophies of knowledgethat underlie the two approaches. It is suggested that the notion of addiction confounds these two sets ofissues, especially with respect to the notions of volition and compulsion. The problem is highlighted by datathat reveal verbal reports to be variable and context dependent. It is concluded that a better understanding ofthe nature of addiction requires a clearer distinction between the pharmacological/physiological approach andthe social process/cognitive approach. Both approaches contribute usefully to knowledge and have predictivevalue. Confusion arises, however, where workers fail to see not merely the benefits, but also the limitations,of these two approaches to the addiction problem. pharmacol. ther. 80(3):265275, 1998. 1998 ElsevierScience Inc.

KEYWORDS. Pharmacology, attribution, verbal report, psychology, science phenomenology.

CONTENTS

1. SCIENCEVERSUSPHENOMENOLOGY . . . . . . . . . . . . 265

2. ADDICTIONAS FUNCTIONALATTRIBUTION. . . . . . . . . . . . . . . 2672.1. PSYCHOLOGYAS SCIENCE . . . . 267

3. BRIDGINGTHE GULF . . . . . . . . . . . 2684. VERBAL REPORTS . . . . . . . . . . . . . 268

4.1. FUNCTIONALDISCOURSEANDDRUGUSE . . . . . . . . . . . . . . 269

4.1.1. DIFFERENTDRUGS/DIFFERENTDISCOURSES . . . . . . . . . 270

4.1.2. TREATMENTDISCOURSE. . . 2715. A GRAND UNIFICATION THEORYOF

ADDICTION: FACTOR DELUSION? . . . . 2725.1. EXAMPLESOFSOCIAL/COGNITIVE

CORRELATESOFDRUGUSE . . . . . 2726. CONCLUSION . . . . . . . . . . . . . . . 273REFERENCES . . . . . . . . . . . . . . . . . 274

ABBREVIATION. LSD, lysergic acid diethylamide.

1. SCIENCE VERSUS PHENOMENOLOGY

The function of this review is to contrast two models of theaddiction process that stem from different sets of assump-tions; namely, the assumptions inherent in determinist andmaterialist philosophies, perhaps best summarised undersome loosely defined rubric such as materialism/logical pos-itivism or perhaps science, and those inherent in phe-nomenological and existential theories that see the condi-tion in some form or another as, for want of a better term, asoul1 sickness (for use of this term in connection with ad-diction, see Keene and Raynor, 1993). The materialist view

necessarily sees all behaviour as having a physical basis andconceptualises people as entities that basically respond tothe demands of their own internal pharmacology/physiol-

ogy (notwithstanding the fact that this may be mediated bylearning/reinforcement history), whereas the latter view,explicitly or by default, requires an extra degree of freedomin the system, permitting acts of will or volition that insome manner must transcend observable mechanisms tohave any meaning.

The aim in making such a stark contrast is, hopefully, toassist in the process of clarifying some of the issues at thecentre of the question, What is addiction? and to avoidpostulates that create confusion at the level of macrologicby virtue of tying together things that derive from different

or even exclusive philosophical domains. For example,motivational toxicity, a postulate by Bozarth (1990), cou-ples together an observable concrete pharmacological sub-strate induced in a person who has ingested drugs (

toxicity

)and a nonobservable social/behavioural inference (

motiva-tion

) made by someone else. Bozarth clearly gives primacyto pharmacological processes and animal studies, and haseven suggested that free will has a pharmacological basis(cited in Davies, 1997a; esp. footnote 5, p.15), a statementthat, if true, can only mean either that (1) pharmacology isnot what we generally think it is (i.e., a ghost inhabits themachine; see Koestler, 1975) or (2) free will, if it exists, isnot what it is generally conceptualised to be (i.e., free will is

1Throughout this paper, the word soul is used in a nonreligious sense,merely to differentiate domains of inference (1) for which no mechanismis clear or identified and (2) domains where concrete mechanism is identi-fied. Thus, it is suggested that variables such as intention, attitude,belief, etc. for some purposes might be better attributed to a knowledgecategory of soul rather than science in the absence of any clear evi-dence linking them to a known material or physical mechanism and wherethe existence of such a mechanism is presumptive rather than empiricallydemonstrated.


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266 J. B. Davies

determined by mechanism and, therefore, does not exist inthe required philosophical sense).

With these thoughts in mind, at the outset, we may notea fundamental problem with any notion of addiction thatsees the committed or determined (for a discussion of de-termined drinking, see Cameron, 1995) behaviour of drugusers as compulsive (meaning compelled) and the behav-

iour of nondrug users as noncompulsive or volitional (e.g.,drug addicts commit crimes because they have to, whereasnonusers commit the same crimes on purpose; alcohol-ics drink because they cannot do otherwise, whereas nor-mal social drinkers drink because they want to, etc.). Infact, however, it follows from a materialist point of viewthat the fact that taking drugs is shown to have real phar-macological and physiological consequences cannot be usedto differentiate drug-related behaviour from nondrug-relatedbehaviour in terms of a volition/compulsion dimension.A materialist science envisages a concrete mechanism asthe basis for all

mental and behavioural activity, whether

drug-related or not, and, therefore, may not admit constructssuch as will or volition, or any shade of these (howcould it?), into one side of the equation, but not the other.From such a standpoint, there is no such thing as will orvolition except as epiphenomena of mechanism, and con-sequently, all one can say is that certain things affect the

way the machine works.

One certainly cannot conclude thatone mode of working is more volitional than another sincethis involves crossing into a phenomenological arena that isexpressly denied by the scientific philosophy one broughtto bear on the question in the first place.

For the purposes of extending this argument, the materi-alist, logical positivist or scientific position is brieflytaken to mean the belief (the problem of how a belief fitsinto such a system is left undeveloped at this stage, for fearof an infinite regress. What is a belief? Can one modifyones beliefs, or do they simply modify themselves? Is oneresponsible for ones beliefs?) that the only objects in thebrain are tangible and concrete in the form of cells, connec-tions, and chemicals (materialism), and that intrapsychicentities (beliefs, intentions, goals, attitudes, etc.) are merelyconvenient terms to describe epiphenomena, which arenothing more than the side effects of the machine work-ing. By contrast, a phenomenological account gives pri-macy to experience, allows for a tacit or explicit differentia-

tion between the workings of the brain and the person whoowns it (dualism), and resists the unwarranted conclusionthat mechanism causes

thoughts. Instead, it gives primacyto higher-order nonobservable entities, such as motives,goals, preferences, and intentions, and entertains the ideathat thoughts might be responsible for the way the brainoperates; or alternatively, that primacy of place in anycausal theory should be given to neither, with each beingthe interactive source of causes and effects simultaneously(dialectics).

The distinction between the two approaches might be il-lustrated in sharp form, for example, by theories of schizo-

phrenia, which, on the one hand, see biochemical/pharma-

cological deficiency/imbalance as the sole and sufficientcause and effective treatment as residing in rectifying thosedeficiencies and imbalances, and a Laingian social-processview, which sees the primary cause as residing in patterns ofsocial relationships in which individual identity is deniedand effective intervention as consisting in changing thoserelationships and the affected persons reaction to and con-

struction of them (Laing and Esterson, 1973). In this lattermodel, the biochemical imbalance might be seen as conse-quential on the disturbing social perceptions and thoughtpatterns experienced by the sufferer faced with an impossi-ble or contradictory social world in much the same way thatchronic depressive patterns of thought have physical andpharmacological sequelae.

The problem is that logically both positions are tenable;that interventions from either perspective can claim somesuccesses and some (many?) failures and that in relativeterms, best results often (as with smoking) seem to involveboth pharmacological and nonpharmacological compo-

nents. The Surgeon Generals Report (1988) on the healthconsequences of smoking, for example, after an exhaustivecoverage of the behavioural (largely operant) and pharma-cological evidence, nonetheless goes on to review the ex-tensive literature indicating that nicotine patches seem towork better in the presence of counselling, social support,improved self-esteem, self-efficacy, and so forth. In a similarway, methadone replacement therapy for opiate addictsworks better and produces better outcomes within the con-text of a comprehensive regimen that takes into accountfamily situation, motivational interviewing, social support,and even how the methadone is dispensed (see Ward et al.

,1992). Clearly, if a single pharmacology were sole and suffi-cient cause, then the pharmacological intervention shouldsolve the problem without need to have recourse to con-structs such as intentions, beliefs, self-efficacy, and theother intrapsychic paraphernalia of the counsellor and thecognitive-behavioural therapist. To the extent that this isnot the case, pharmacological considerations are shown tobe only partial determinants. The opposite, of course, is alsotrue. If a social-process model were a sufficient account,then pharmacological interventions should be irrelevant,whilst social-process and social-cognitive interventionsshould be the only things to show any promise in the treat-ment setting.

That, I believe, is why the notion of addiction is such anelusive entity, and why both sides probably would do betterif the word addiction were struck from the language.Somehow the notion of being addicted to drugs requiresor induces us to embark on a dual explanation for addictedas opposed to nonaddicted behaviour. The problem withthis dual explanation, however, is that it is not simply acase of complementary explanations. The subexplanationsthat make up the total explanation are mutually contradic-tory. Free will and determinism cannot co-exist within thesame supposedly scientific account; they require theirown separate languages and sets of suppositions. For reasons

that will be examined later, terms such as cant stop are


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Addiction: Pharmacology versus Social Process 267

incompatible with a materialist viewpoint. The only de-scriptor possible from this viewpoint is that of the supposedobjective observer (i.e., doesnt stop), with no inferencespossible as to whether the observed behaviour is volitionalor not.

2. ADDICTION AS

FUNCTIONAL ATTRIBUTION

How does it come about, therefore, that two such contra-dictory explanations co-exist within the concept of addic-tion? The answer lies in the history of the word itself andthe observation that the term addiction was originally asocially functional label rather than a scientifically derivedconcept. Its purpose was to change the public attitude to-wards the problems of substance abuse away from one ofmoral censure and disease of the will and create, in itsplace, a framework within which treatment rather thanblame would be deemed appropriate. The historical devel-opment of the notion of addiction and the related concept

of alcoholism have been described comprehensively by Ber-ridge (1979) and succinctly summarised by McMurran(1994). In a historical sense, therefore, the addiction no-tion was a classic case offunctional attribution

, that is, a de-scription that had certain linguistic connotative meaningsthat would change the perception of a phenomenon in away that hopefully would lead to a desired behaviourchange; namely, a move towards humane treatment in con-trast to the whippings and cold plunges advocated by Rush(1785). The aim was to change the perceptions about, andtreatment of, people who took too much of a particular psy-choactive substance to their own and possibly societys det-

riment. Problems arose because this functional attributionbegan to be researched as if it were a scientifically derivedtruth. McMurran (1994), quoting from Szasz (1974), sug-gests that the medical profession may well have started bytreating disagreeable conduct and forbidden desire as if

they were diseases, that is using disease as a metaphor.

How-ever, over time, the metaphor became literal and the medi-cal profession came to insist that disapproved behaviourwas not merely like

a disease, but that it was

a diseasethusconfusing others, and perhaps themselves as well, regardingthe differences between bodily and behavioural abnormali-ties. (The issue of what really is

a disease raises epistemo-

logical issues that go beyond the scope of this text.)

2.1.

Psychology as Science

The aim of this section is simply to make the point thatpsychology has always aspired to be a science in the samemould as the physical sciences, and in some ways, this is un-fortunate. There are two difficulties with this aspiration.Firstly, it is a matter for concern that the model of scienceto which psychology generally aspires is Newtonian in prin-ciple and takes as axiomatic the absolute nature of measure-ment and the certainty of matter, both of which assump-tions are seriously challenged in the works of Einstein and

Heisenberg. As long ago as 1964, Koch wrote, . . . the

emerging redefinition of knowledge is already at a phase . . .which renders markedly obsolete that view of science stillregulative of inquiring practice in psychology, and Psy-chology is thus in the unenviable position of standing onphilosophical foundations which began to be vacated byphilosophy almost as soon as the former had borrowed them.

The second problem arises from the social-learning and

socio-cognitive theories that form the basis for much ofwhat psychologists bring to bear on the addiction problem.Whilst neurones, synapses, nuclei, neurotransmitters, andso forth are observable in ways that are compatible with amaterialist and determinist philosophy, postulates such asmotivation, self-esteem, peer group pressure, intention, be-lief, and attitude are not the same type of entities. Firstly,these types of things are inferences

derived from observa-tions of behaviour or from verbal reports. Furthermore, theyare linguistic constructions whose boundaries and parame-ters are very ill-defined; the mere fact that a linguistic con-struction exists does not mean that a parallel entity exists

in the brain. The danger here is reification

, a flawed type ofreasoning that converts an abstraction into a thing. Thisproblem is common in much social psychological theoris-ing, and can be found even in classic models, such as thetheories of reasoned action (Fishbein and Ajzen, 1975) andof planned behaviour (Fishbein, 1993), where verbal con-structs, such as attitudes, beliefs, intentions, subjectivenorms, and what have you, are all assumed (on the basisthat the words exist) to be real independent entities, capa-ble of independent measurement, and where the intercorre-lations between them are often taken to imply a causalmechanism.

The problem is that the material

that constitutes themechanism is often epistemologically quite ambiguouswhere social/cognitive models are concerned. Drawing flowcharts and boxes connected by arrows does not solve thefundamental problem of what

is being described. Is themodel intended to describe the way that a person actuallyworks, with all the implications that has in terms of phys-iology? Or does it merely describe a quasi-logical abstractmodel of the suggested links between certain ideas

in themind of the modeller? And what is the status of the things/entities in the boxes? What is

an intention, for example? Isit a neurological state independent of verbal report or apurely verbal response evoked by a question about inten-

tions? If the former, why is there such a slack fit between in-tention and behaviour? If the latter, why should it have anypredictive value at all? And can a person know enoughabout their own internal workings to report on them? (for adiscussion of this issue, see Nisbett and Wilson, 1977). Andif no parsimonious answer is forthcoming to these ques-tions, are we entitled to tow our pet concept to safety bypostulating a string of so-called mediating variables,whose epistemological status is equally uncertain (e.g., atti-tudes, beliefs, expectancies, self-efficacy, etc.)?

In summary, therefore, whilst psychology sees itself as ahard-nosed science in the mould of the physical sciences,

and seeks to build similar types of models, it employs mate-


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268 J. B. Davies

rials that frequently have no demonstrable physical basis.The level of existence (epistemological status) of theseentities is thus open to considerable debate. With thesethings in mind, it is unclear whether psychology, as it oper-ates in these kinds of areas, is a soft or soul science, a ma-terialist/logical positivist science, or the one deluded intobelieving it is the other.

3. BRIDGING THE GULF

So far, one major and one minor point have been made.Firstly, it has been argued that there are two contradictoryphilosophies at work within the notion of addiction;namely, materialist/determinist and phenomenological/ex-istential. Both of these views are unique and alternativeways of conceptualising human beings, and each makessense for certain purposes. Addiction, impossibly, seeks tomake these accounts complementary; something they can-not be. The notion invites us to apply a rational/decision

making framework to our fellow men/women, up to thepoint where they start to encounter problems with theirdrug use, and then to switch to a view of man/woman asmachine.

The minor point concerns the place of psychology in allthis, and the possibly unfortunate tendency for many psy-chologists in the social and cognitive fields to see them-selves as scientists in the materialist mould of physics, whenmost of their subject material consists of ideas and abstrac-tions whose physical reality remains at best uncertain.Nothing more will be said on this issue.

With respect to the major point, pharmacology/physiol-ogy or any other basically materialist approach can neverhave anything to say about the volitional or nonvolitionalwellsprings of action since they simply do not trade in thissort of concept. Discovering deeper or more complex physi-ological mechanisms can never prove that the soul(used here as a shorthand term for the sources of noncom-pulsive action) does not exist. At risk of digression, I recallfrom my childhood a number of popular science books thatfound a place on my fathers bookshelf, and his firm beliefin scientific enlightenment. He would enthuse that one dayscience would reveal the rational basis for everything;amongst other things, it would demonstrate that heavenand hell did not exist and that God was mythical. Then I

recall my amazement on discovering that Sir Bernard Lov-ell, scientist in charge of the Jodrell Bank radio telescope,was a devout Christian. Surely, if anyone was in a positionto know that heaven was not up there, and that God wasnot at home, it was Sir Bernard with his massive knowledgeof physical science and his huge telescope. The basic mis-take was to assume that the nature of heaven (if it exists) orGod (if he/she exists) was such as to be amenable to discov-ery via the radio telescope; i.e., that they were tangiblethings that would emit or reflect radio waves. On the otherhand, if God is an intangible, nonmaterial entity thatmerely inhabits

the known universe, then we will never see

him/her/it, no matter how big the telescope or how far we

travel in a spaceship. In an analogous way, searching for anonmaterial entity inhabiting the material matter of thebrain (the ghost in the machine), and capable of somesort of decision making independent of the matter of thebrain, is simply not a matter that can be addressed via a sci-ence dedicated to revealing material mechanisms. Failingto find such a ghost certainly cannot be taken as proof of

its nonexistence, when the search is oriented from a philo-sophical perspective that specifically rules out the existenceof nonmaterial entities.

To summarise, finding, for example, that ingestion of co-caine causes a rise in dopamine levels in the accumbens dueto inhibition of reuptake is occasion for celebration on thegrounds that we now understand what cocaine does, but itdoes not entitle one to the illogical claim that we now un-derstand why people take cocaine, least of all that we havedemonstrated that taking cocaine is compulsive rather thanvolitional. A materialist approach can never demonstrateanything about volition since it does not believe in a non-

material source for volitional acts, unless, like Bozarth, weseek to invent a new kind of volition that is determined bymechanism. Our conclusion, therefore, at this point is thatthe gap cannot be bridged without the most extreme vio-lence to logic and to the philosophies of science; not a goodstarting point for pragmatic discovery. Unfortunately, theconcept of addiction invites precisely such a collisionwhenever a mechanism is used to shed light on the issue ofvolitional/nonvolitional acts.

4. VERBAL REPORTS

In Section 2, the point was made that the addiction no-tion is probably best viewed in historical terms as a func-tional attribution; an explanation generated not by its log-ical or scientific coherence, but by the need to create a newclimate within which addiction problems would be treatedmore humanely. If such is the case, then there is at leastface validity in using existing theories of functional expla-nation as the basis for some research. It goes without sayingthat functional explanations (attributions) are species ofverbal report.

Much science, in all manner of realms, makes use of ver-bal reports obtained from subjects, as either dependent orindependent variables; that is, as outcome measures against

which to validate some experiment or procedure or as base-line measures on the basis of which to form categories ormake predictions. Used in this way, the literal semanticmeaning of what people say is assumed to constitute dataabout internal events taking place inside the person and inprinciple, to have the same epistemological status as dataretrieved from a computer, but subject to some degradationdue to failures of memory or attention. In fact, however, itis difficult to see how a hard-nosed scientist could ever behappy with verbal report data used in such a way. Peoplecan say what they wish to say at any time; there is no essen-tial binding mechanism, no thongs or liens, that bond any

verbal report to any aspect of objective reality, and


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speech acts are always motivated. For example, within thetheory of signal detection, one of the harder-nosed areas ofpsychological theorising (see Green and Swets, 1966), acentral feature is the variability of verbal reports aboutthings as uncontentious, for example, as whether or not alight was flashed or whether a buzzer sounded. The proba-bility of hits and false positives is a function of the rewards

and disincentives associated with the two categories of an-swer, and a key variable is the subjects criterion for sayingone thing (yes, I see it) rather than another (no, I dontsee it). It should be emphasised that this is a criterionproblem, not the difference between telling the truth andtelling lies. How much more important are criterion effectslikely to be with socially constituted reports about statessuch as addiction, where the likelihood of certain types oftreatment being obtained (e.g., methadone) or the natureof a criminal sentence (prison versus community service)are involved? For a discussion of social criterion effects, seeDavies and Best (1996) and White and Davies (1998).

The conclusion from thoughts such as these (see Davies,1997a) is that verbal reports and the pharmacology of drugaction also make unhappy bedfellows since the one is con-stituted empirically and scientifically, whereas the latterare basically soul data, deriving from motivational sourcesthat can only be assumed or inferred. Cocaine might haveobservable effects on the meso-accumbens, but it is not themeso-accumbens that says Im addicted or Im not ad-dicted. Verbal reports about addiction and craving ul-timately may have more to do with the pharmacology oflanguage than the pharmacology of addiction or craving,and failure to stop is simply failure to stop from an objectiveor scientific viewpoint (it does not enable the prefixcan or cant).

There is thus a fundamental problem where some observ-able pharmacological state is validated against verbal re-ports, although this is frequently done with respect to re-ports of craving or desire. The two phenomena (drugpharmacology and verbal report) are not linked by any nec-essary bond; the verbal reports derive from independentsources of motivation, and in principle, the person can pro-duce any type of verbal response that they deem appropri-ate. For example, Davies and Baker (1987) and McAllisterand Davies (1992) showed how verbal reports about addic-tion vary importantly between contexts and between inter-

viewers, and also according to what the subject of the studythinks thepoint of the study is

(Davies and Best, 1996, givesan account of a number of these types of artefacts). No-where is this issue more important than in the case wheresome pharmacological state is taken to indicate compulsionon the basis of associated verbal reports that the subjectcant stop. The reinforcers for the verbal report can be(and I believe often are) totally independent of the rein-forcing properties of the drug.

Briefly, therefore, it is argued that verbal reports are (1)motivated rather than having the status of unmodifiedfacts retrieved in a computer-like fashion, (2) functional

in the sense that things are said in order to achieve certain

desired outcomes, (3) not linked in any principled or neces-sary way to any particular drug pharmacology, and (4) interms of their epistemological status (their status viewed asknowledge), quite different and independent of the epis-temological status of the pharmacology on which they areassumed (erroneously, it is argued) to shed light.

4.1.

Functional Discourse and Drug Use

The preceding arguments are now illustrated by referenceto recent research work2 into the types of stories, or dis-courses, that people employ when talking about their druguse and/or drug problems. In this study, 548 interviews werecarried out with drug users in South Ayrshire (Scotland),Glasgow (Scotland), Lothian (Scotland), and Newcastle-upon-Tyne (northeast England). There were 275 initial(first) interviews, followed by 197 second (re-contact) in-terviews, followed by 76 third interviews. The interviewswere minimally structured and cued simply by an initialquestion, So what are you on, what are you using at the

moment?, or some linguistic variant on that formula. Theaim was to reduce experimenter effects and to keep charac-teristics of the type produced by forced-choice inventoriesand questionnaires to a minimum. All interviews, generallyof between 10 and 15 min duration, were tape-recorded andtranscribed prior to analysis.

An initial iterative qualitative analysis (see Miles andHuberman, 1984) of the tapes led to the postulation thatthere were basically six types of conversations offered bythe drug-using sample. Detailed description of these types,and of the attributional dimensions used to identify eachtype, are given in Davies (1997a). Furthermore, reliability

studies involving independent raters showed that the typeswere recognisable with high degrees of reliability (seeDavies, 1997a). Although each type was identified by ascore profile on a number of attributional coding scales,they may be described in everyday terms broadly as follows.

The reader should note that in line with the previous arguments,no assumptions are made about whether these discourses are trueor false. The single assumption is that they are motivated andfunctional for people at different stages of a drug-using career;not that they are true.

Type 1.

This comes most usually from younger, recre-ational drug users taking drugs such as ecstasy, cannabis,

amphetamine, and lysergic acid diethylamide (LSD), butalso from a smaller number of longer-term opiate userswho have never entered treatment. The discourse is he-donistic and problem free. They talk like drug enthusi-asts, and the discourse about drugs is positive and stableover a wide range of situations and circumstances.

Type 2.

This type of discourse is unstable and contradic-tory, alternating between a generally positive type ofview similar to Type 1 and a more negative and problem-centred view, according to the function of the conversa-

2The study cited was funded by grant No. K/OPR/2/2/D124 from the Chief

Scientist Office at the Scottish Office.


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270 J. B. Davies

tion at the time. Type 2 emerges from Type 1 when prob-lems begin to arise in connection with drug use. The per-son has to maintain a positive view in order to maintainhis/her position within a peer group, but has to adopt amore problem- or addiction-centred script for disap-proving others. (It serves this purpose because discourseabout addiction translates behaviour that is bad and

purposive into behaviour that is nonvolitional andhence, nonculpable.)

Type 3. Type 3 discourse is wholly and stereotypically ad-dicted. There is no reference to hedonism or enjoyment,the behaviour is described as forced or compulsive, anddrug use is seen as the inevitable outcome of internal(physical/dispositional) and possibly external (environ-mental) factors over which the individual has no control.The language of Alcoholics Anonymous is a good exam-ple of this type of discourse. Type 3 discourse is usually,although not always, associated with treatment or entryinto treatment.

Type 4.

This type resembles Type 2 in being context de-pendent and contradictory. It comes about when theconstraints of the addicted role (Type 3) start to breakdown either temporarily or fundamentally and the per-son concerned starts to have second thoughts. Whilstthe person still employs the addicted stereotype, he/shemay report that drug use is nonetheless a positive experi-ence and does not necessarily lead to negative outcomes.Not surprisingly, this is the stage where relapse often oc-curs or is made to happen amongst those in treatment(see Christo, 1995). Christos data suggest that relapsemay often be planned in advance rather than simplyhappening to the individual concerned in some mono-lithic and inevitable way.3

Type 5. Type 5 is the postaddiction discourse and isthe up and out discourse for the discursive system de-scribed (to differentiate it from Type 5

or down andout). Addiction is seen as something in the past. Theperson concedes that they had a problem, but now theyhave left it behind. They may be abstinent or using againin an unproblematic way (for a discussion of return tocontrolled drinking in previous alcoholics, see Heatherand Robertson, 1981), but in either case there is a newnondrug focus to the lifestyle.

Type 5

.

Type 5

is merely inferred, due to the difficulty

of obtaining usable transcripts from this group in theUnited Kingdom. This is the destination for those whohave failed the treatment system and for whom the systemhas failed. They remain outside the treatment and help-ing systems unless they are able to obtain a re-entry, where

discourse should revert to Type 3. Ongoing research inPortugal is uncovering numbers of Type 5

, due to dif-ferences in treatment regimens and living conditions be-tween Portugal and the United Kingdom. However, thenature of this discourse remains to be verified.

A full account of the derivation of this typology is given

in Davies (1997a), along with the steps taken to ensure itsreplicability and reliability. Actual (verbatim) examples ofthe discursive types are also given in that text, and also inDavies (1997b). The remainder of this section describeshow the differing types of self-presentation relate to differ-ent stages in a drug-using career, and how these relation-ships appear to be functional in different social settings.The aim is to demonstrate that verbal reports make func-tional sense as adaptations to the differing social and legalthreats that accompany different stages in a drug-use career.Note that the data presented constitute only a small part ofthe data from the cited study.

4.1.1. Different drugs/different discourses. Table 1 showshow different drugs appear to be associated with differentdiscourses. Note that the drug-use data in this analysis com-prise only street

drugs. Drugs obtained legitimately by pre-scription are excluded.

Table 1 shows the percentage of people in each stage ofthe model who used the various drugs. Data are provided forinterviews carried out on two separate occasions (Stages 1and 2) as a check for consistency. For Stage 3, numbers inindividual drug categories were too small for inferentialanalysis. For each drug, at both time periods, a chi-squareanalysis was carried out on the raw scores.

Only drugs pro-ducing significant chi-squares are included; DF118, co-caine, temgesic (buprenorphine), diazepam, and solventsdid not produce patterns of discourse over the categoriesthat differed significantly from chance. It should be notedthat for Stage 5, the number is unacceptably small. Perhapsthe most interesting features of the data concern the drugsLSD and ecstasy. For the most part, users of these drugstended to produce nonaddicted discourses of Types 1 and 2.On the other hand, heroin users tended to dominate thecentral categories of the model, with significant numbersin Stages 3 (addicted) and 4 (addicted/relapsing) of themodel. The methadone discourses are particularly worrying,

with no discourses in either the nonproblem Category 1 orthe postaddiction Category 5

. Furthermore, a subsequentanalysis (see Davies, 1997a)

ofprescribed

methadone alsoshows Types 3 and 4 discourse, to the virtual exclusion ofany other type. This remained true even when high-doseand low-dose patients were examined independently.

Cannabis and alcohol discourses, although distributed inways that differ from chance, spread across the board. Amajority in both cases occur at Stage 1, indicating a non-problematic and hedonistic discourse for the majority of us-ers, but numbers occur in every category. Both of thesedrugs can accompany other drug habits of virtually any na-

ture, thus probably accounting for their broad distribution.

3The most striking example of this type of strategic relapse occurredrecently when the author was requested to visit a Scottish prison wherethere had been certain problematic developments in the prison addictiontreatment unit. One prisoner was in a particularly bad way, as his reduc-tion prescription (lofexidine plus benzodiazepines) for opiate dependencewas due to terminate and he was still rattling rather badly. His colleaguesin the unit threatened to relapse en masse if his medication was not contin-ued, but agreed not to relapse if it was! Relapse/nonrelapse as a bargaining

strategy, to my knowledge, has seldom been mentioned in the literature.


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4.1.2. Treatment discourse. Table 2 shows the distribu-tion of discursive types for those who were in treatment/agency contact and those who were not in agency contact,at Stage 1.

The data show a clear differentiation in the types of dis-courses offered by those in treatment and those not in treat-ment. Analysis of the data for Stages 2 and 3, it should beadded, show an identical pattern (see Davies, 1997a).

There is a significant tendency for those in treatment to usethe language of helplessness and addiction, whilst those notin treatment are more likely to use the language of hedo-nism and volition. Furthermore, the data in Table 3 showthat those who came into treatment or agency contact dur-ing the course of the study

were already offering at initial in-terview addicted, nonvolitional explanations for their drugtaking. Self-definition as addict is associated with de-creased personal control over a drug habit (see Eiser, 1978,1982).

Finally, the data from the study also shed light on addic-tion as a time-based process, with individuals moving

through the discursive stages of the model at differentpoints in their drug-use career. The data strongly suggest

that this process operates under certain constraints; in par-ticular, that certain types of backward movement are notpossible within the model. The most interesting result fromthis analysis concerns subjects who were at Stage 3 at initialinterview. Table 4 shows what happened to these people atsecond and at third interviews.

The data show that subjects exhibiting Type 3 (ad-dicted) conversation at first contact either remained in

Type 3 or moved into Type 4. Four subjects actually pro-gressed into Type 5

. However, the most notable finding isthe absence of movement from Type 3 back towards thestart of the model. To date, the data from this and continu-ing studies show the single exception to the rule, illustratedin Table 4, to be the only exception.

Related analyses of movement between other cells re-veals no other adjacent pair with this type of one-way sys-tem. Finally, analysis of those at Stage 4 at initial interviewreveals a type of cycle between 3 and 4, such that there ap-pears to be a loop involving Discourses 3 and 4 aroundwhich individuals can cycle (in a 3434 manner) for

long periods, perhaps even indefinitely. Movement intoType 5

(nonproblematic, postaddiction) is possible forsome individuals, but as described in the previous para-graph, no movement back into the earlier stages of themodel was observed.

TABLE 1. Discourses Associated with Use of Different Drugs: Percentage of Users in Each Stage of the Model

Stage1

Drug Interview 1 2 3 4 5 Chi-square2

Alcohol 1 63 30 20 15 50 P 0.00012 63 33 11 8 50 P 0.0001

Heroin 1 3 37 21 29 17 P 0.017

2 16 17 23 24 25 P

NSMethadone 1 0 3 15 25 0 P 0.0022 0 8 21 16 0 P 0.113 (NS)

Temezepam 1 10 27 29 44 17 P 0.00072 26 0 32 40 12 P 0.047

Cannabis 1 90 63 27 33 33 P 0.00012 90 75 15 26 12 P 0.0001

LSD 1 47 17 0 7 02 42 17 0 1 0 Significant?

Ecstasy 1 23 27 2 9 0 P 0.00012 26 25 0 6 0 P 0.0001

Speed (amphetamine) 1 50 37 7 21 33 P 0.00012 47 58 3 16 12 P 0.0001

1Sample size (number) for the stages: Interview 1: Stage 1 30, Stage 2 30, Stage 3 120, Stage 4 89, Stage 5 6; Interview 2: Stage 1 19, Stage

2 12, Stage 3 75, Stage 4 83, Stage 5 8.2Based on raw drug abuse score.NS, not significant.

TABLE 2. Discourses Associated with Being in or Not inAgency Contact at Time 1: Raw Frequencies

Stage

Group 1 2 3 4 5 n

Clinical 3 12 117 85 6 223Nonclinical 27 18 3 4 0 52

Chi-square, P

0.0001 for 4 degrees of freedom.

TABLE 3. Discourses at Initial Interview of Those Cominginto Agency Contact during the Study

Stage

1 2 3 4 5

0 4 30 15 0


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272 J. B. Davies

A number of related analyses, multiple regression analy-ses of the dimensions that predict the discursive stages, anddetails of the procedures used to ensure blind-coding andinter-rater reliability are also given in Davies (1997b). Inconclusion, the data show that the answers one obtains toquestions about drug use depend on whom you ask, whatstage they are at in their drug-use career, and the contextwithin which the questions are asked.

5. A GRAND UNIFICATION THEORYOF ADDICTION: FACT OR DELUSION?

A certain amount of research in the area of the addictionsimputes causal relationships between an observed pharma-cological state and verbal reports of craving, desire, inabil-ity to stop, and so forth, on the basis that the two have of-ten been found to be associated (e.g., Gossop, 1990; Westand Kranzler, 1990; Shiffman et al., 1997; Kozlowski andWilkinson, 1987). It is an implicit assumption of such stud-ies that in some direct sense, the pharmacology causes theverbal reports; however, the lack of any necessary bond be-

tween the pharmacology of drug action and verbal report(or the pharmacology of verbal report) has been discussedalready. Whatever the nature of this relationship, it shouldbe pointed out that there is an equally impressive body ofknowledge concerning the relationship between drug useand all manner of social and cognitive variables whosepharmacological basis, in most cases, is not understood, butis presumed, or whose epistemological status is quite ambig-uous. Nonetheless, and perhaps paradoxically, the prag-matic relevance of these soft or soul variables in thetreatment and policy domains is beyond dispute, and gener-ally they make a contribution at least equal to that made bydrug pharmacology. Some examples are given in Section

5.1 of the kinds of associations that have been found in thesocial/cognitive domain. The examples are a highly se-lected subset from a vast body of literature.

5.1. Examples of Social/Cognitive Correlates of Drug Use

Social class appears to have a bearing on drug problems. Astudy by Leitner et al. (1993), for example, shows that dif-ferences between social classes in terms of prevalence ofever use have been steadily eroded. On the other hand,the prevalence of heavy harmful use and of use that esca-lates to more serious drugs (i.e., goes beyond cannabis and

dance drugs) is clearly related to social class, with highest

rates of harmful use still occurring in less-privileged envi-ronments with high unemployment and other factors asso-ciated with deprived inner-city areas.

A number ofrisk factors for drug use have also been identi-fied by various workers. Typical of these is the list providedby McMurran (1994), which includes drinking, smoking, re-belliousness, delinquency, dangerous driving, aggression,

poor academic achievement, lowered orientation to work,and early sexual intercourse. A similar list from Newcombet al. (1986) also includes drug use by peers, perceived druguse by parents, and poor parental relationships. Plant andPlant (1992) recently have stressed the importance of aquasi-personality dimension referred to as risk-taking.

With respect to individual psychological predictors, astudy by Davies and Stacey (1972) produced findings withrespect to adolescent alcohol use that have been replicateda number of times by other workers. Self- and other percep-tions were found to be important predictors of heavier con-sumption, particularly with respect to the factors of sex/

sociability and toughness/maturity. These were desired at-tributes, and nondrinkers were perceived as deficient inboth respects.

With respect to the thorny issues of being able to stop,Eiser and colleagues in a number of pioneering studies(Eiser, 1978, 1982; Eiser and Gossop, 1979; Eiser and Sut-ton, 1977; Eiser et al., 1977, 1978, 1985) showed clear asso-ciations between behavioural measures such as attemptingto stop, succeeding or failing in those attempts, and the be-liefthat one was addicted. Eisers early studies mostly con-cerned smokers. Using attributional theory as his theoreti-cal framework, he found that belief that one was addictedpredicted a lower likelihood of attempting to stop and alower probability of success if such an attempt was made.Self-definition thus appears to have a self-fulfilling functionin that respect; by definition, addiction implies that thepersons behaviour is not theirs to control, and this beliefappears to have an incapacitating effect. Since Eisers origi-nal study, the fact that the self-definition of addiction ap-pears to be unhelpful with people who are attempting tostop (in the sense of lowering the likelihood of effectivelytaking control of a habit) has been found or implied (in theform oflowered self-efficacy) in a number of models, includ-ing the widely employed system of change devised by Di-Clementi and Prochaska (1985). Katz and Singh (1986)

also found that belief in the addictive properties of nicotinewas associated with greater difficulty in quitting. Findingssuch as these suggest that the repeated stressing of the ad-dictive consequences of drug use in the media and in manyhealth education messages actually may be a step in thewrong direction.

There is a developing literature on controlled drug use.Some years ago, the issue of return to controlled social drink-ing by previous alcoholics was suggested by Davies (1962).It was claimed that such individuals were at large in thepopulation and furthermore, were not very difficult to find.The original work created a furore, and reputations were

won and lost over this issue. A classic text by Heather and

TABLE 4. Movement through the Model of Those in Stage 3at Initial Interview1

Stage

1 2 3 4 5 n

At second interview 0 0 56 31 2 89At third interview 1 0 17 15 2 35

1n 120.


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Robertson (1981) gives a blow-by-blow account of this af-fair. Nowadays, the possibility of returning to controlleddrinking is accepted in most circles, and most councils onalcohol accept that a return to controlled drinking is possi-ble for many previously impaired individuals, with the aimof controlled drinking being a widely employed treatmentgoal. With respect to other drugs, similar developments

have taken place very much more slowly. A collection ofrefereed papers was published by Harrison and Mugford(1994) attesting to the fact that controlled cocaine use waspossible and again, not so difficult to find. These findingswere not welcome by certain treatment and research agen-cies, and the message was resisted in some quarters ongrounds very similar to those employed by the wife of theBishop of Worcester in 1860.4 Harrison allegedly had tochange her employment in the wake of this publication. Ina broadly related vein, the classic longitudinal study of opi-ate dependency by Stimson and Oppenheimer (1982)showed the possibility of heroin users moving into and out

of drug dependency with no outside agency intervention,and more recently, Shewan et al. (1998) have identifiedcontrolled heroin users who have been using the drug regu-larly over extended periods of time for recreational purposeswithout showing indices of dependence or addiction. Theproblem with these data is that they raise fundamental ob-jections to the idea that addiction is a simple and inevitableconsequence of the ingestion of addictive substances. Atthe very least, such an idea has to be revised so as to takeinto account substantial individual difference, cognitive,and social context effects. Meanwhile, the fact that ex-tended controlled use of Class A drugs, such as heroin andcocaine, is possible and occurs is a truth that we, as a soci-ety, do not appear to wish to know about and that we arequite unable to contemplate at the present time.

Finally, a wide variety of evidence exists showing rela-tionships between social-cognitive variables, such as atti-tudes, beliefs, perceived norms, intentions, self-esteem, self-effi-cacy, attributions, family functioning, peer group pressure, lifeevents, and many more, and the occurrence of and recoveryfrom drug problems (for a good overview of these types ofissues, see Gossop, 1987). Multiple regression analyses usingthese types of variables in combination invariably accountfor substantively important percentages of variance in stud-ies of drug use.

The preceding represents only the briefest summary ofthe types of social and cognitive data available. In generalterms, we can say that a large and impressive body of refer-eed research literature exists attesting to the fact that drugproblems are associated with a wide variety of social andcognitive variables. The epistemological status of theseranges from the observable through the arbitrary, to the un-

certain, where their reality or manifestation at a pharmaco-logical and physiological level is at best an act of faithrather than a demonstrated fact. Nonetheless, in a greatmany studies, they have been found to have useful predic-tive validity.

6. CONCLUSION

Pharmacology is most usually conceived of as a hard-nosedand materialist science that seeks the roots of behaviour atthe level of tangible and observable mechanism, whoseprincipal property is that of physical and objectively verifi-able existence. Its strengths, I believe, lie in its capacity toelucidate how things work at the level of mechanism andthe effects of the ingestion of drugs (for example) on howthat mechanism works. Thus, if we want to know what theeffects of ecstasy are on the brain, pharmacology is the sci-ence that, in principle, can answer that question.

The issue of whether or not taking drugs is compulsive orvolitional, however, is basically a different type of questionthat cannot be answered in terms of pharmacological or anyother type of mechanism, since the notion of volition isan empty set so far as such a science is concerned. From anumber of philosophical standpoints, volition implies anact of will that, in turn, implies the ghost in the machine;an idea that is explicitly denied by a materialist science.Furthermore, the idea offered by Bozarth (1990), for exam-ple, that free will is just another type of mechanism, sim-ply will not do; free will, on those terms, that is determinedby mechanism does not meet the criteria either for free orwill.5 Thus, there are those issues surrounding addictionon which a pharmacological science can legitimately com-

ment and those on which it cannot comment without com-mitting violence to the philosophy of science that is its ownunderpinning.

The opposite is also true. Those dealing with softer data,including concepts, abstractions, and other phenomenawhose existence is not directly observable and which areonly inferred by the words used to describe them (e.g., self-esteem, intention, attitude, etc.), cannot legitimately claimor imply that such concepts exist as mechanisms or pro-cesses in the brain or that they have the same epistemologi-cal status as such mechanisms or processes. They may do,but in the absence of pharmacological/physiological confir-

mation, this remains an act of faith (whatever that is!); apossible, but not a necessary, conclusion. However, I be-lieve it is more parsimonious to suppose that many of theseexist merely as widely understood functional figures of speechand that the statistical associations between them arise not

4The Bishop had attended a meeting of the British Association addressedby Professor Huxley, who had expounded on the theory of evolution. Onreturning to Worcester, he acquainted his wife with the basic principles ofevolutionary theory and the body of observations that supported it. Thegood lady replied, Let us hope it is not true. But if it is, let us pray that it

does not become widely known.

5If free will is taken to imply decision making, then the problem becomesmore general. If decision making is characterised as a calculus-drivenmechanism that evaluates probabilities weighted in the light of experi-ence, then decisions are not made, they merely happen. If we wish tomaintain that decisions are made in an active participative sense andthat people can be held responsible for them (as in a court of law), then wehave to conclude that something is involved over and above the pharma-

cology. Otherwise, no one can be held responsible for anything.


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Pharmacology Versus Social Process