The preceding chapters have traced the development of attribution theory from early studies of the phenomenology of physical and social causality, through the contemporary formulations of Kelley, Weiner and others, to the notion of functional attribution and the idea that explanations can serve psychological purposes for the explainer. With respect to addiction, prominence has been accorded to the work of Eiser who showed how the type of explanation offered for using a drug varied predictably according to the nature of the drug use, as well as having implications for expectancies and future behaviour. It was also Eiser who suggested that, within a given society, the appropriate explanations for drug use were learned at the same time as the drug using habit itself was acquired.
To support these arguments, a number of studies have been cited illustrating the attributional nature of answers to questions. Whilst many of these studies were concerned with addiction, reflecting the subject matter of this book, it is a fact that most of the existing attributional evidence comes from groups of people with no drug or other problems. It is important to emphasise that making attributions is not a unique characteristic of drug users or other deviant groups, but a process that engages us all at various times. Consequently, it would be quite incorrect to visualise attribution as something in which problem groups engage, but which has nothing to do with explanations offered by non-problem, or 'normal', groups. The underlying processes are assumed to be common to all, within a given culture.
Attributions and Lies
It is also important to reiterate that attribution and attributional research reflect the manner in which explanations are derived and their subsequent functionality, but say nothing whatsoever about the validity or 'truth' of the explanations themselves. Attribution research clearly does not offer some way of discriminating between truth and lies; least of all does it represent a unique way of investigating the quality of the verbal reports of deviant or 'bad' people.
However, it seems that these essential facts about the nature of attribution theory are not always grasped, and the term 'attribution' is sometimes misused. For example, at a recent conference (October 1990) a speaker reported findings from a recent life-event study, in which people were interviewed about the possible causal role of stressful events in mediating psychological problems. A member of the audience questioned the validity of the data, which he was clearly entitled to do given the known problems in this area. But the precise form of the question was most revealing.
'Are these reports true, do you think?' he asked. 'Or are they just attributions?'
This type of confusion is fairly widespread. Due to a lack of appreciation of how attribution theory developed, and of the nature of the hypotheses that may and may not be derived from the body of theory, some individuals appear to employ the term simply as a user-friendly word for lying. The implication is that people either give true causal accounts of their behaviour OR they make attributions.
From such a standpoint, all manner of elementary confusions follow. For example, when asking regular drug users to explain their addiction (as in the Coggans and Davies study op cit) they must give addiction-type (internal-stable) explanations if they are to be truthful; otherwise they are just 'making attributions' (i.e. lying). And in the McAllister and Davies study (op cit), despite the clear functional shift revealed, the heavy smokers were 'telling the truth' at the second interview, whereas at the first interview they failed to do so (they just 'made attributions'). It appears that the failure to grasp the interactive nature of the cognition/behaviour dialectic leads to naive expectations that events will 'cause' verbal explanations in a direct way. For example, if drug users say they cannot stop using because they are addicted, that is simply because they are. If they say they crave their drugs, that is because they do.
Faced with this type of view, which sees behaviour and verbal reports as simple cause and effect, with deliberate falsification as the only mechanism capable of disrupting the connection, it is difficult to know how to make any further progress; yet the view is a popular one, and appears to underlie a good deal of questionnaire and interview-based research at the present time. The functional interpretive and constructive aspects of cognition and language appear to be denied, there are no shades of meaning, no awareness of nuance or of implication, no 'implicit theories', and equally-valid but alternative forms of representation simply do not exist. The assumption appears to be that people think in only the most rudimentary manner; there is only one reality, and people either represent it, or they tell lies. But perhaps most importantly, the entire symbolic-interactionist nature of language is ignored both historically and philosophically; language is downgraded to the level of a vicarious literal transaction whose only function is either to represent reality correctly, or else to deliberately obscure it.
By contrast, the functional attribution perspective indicates that human actions can be explained in a virtually limitless number of alternative ways; that the people to whom the explanations are addressed can be expected to make quasi-logical inferences on the basis of those explanations; and that by choosing one form of explanation rather than another, the explainer exercises a degree of control over the inferences that others will in fact make. The differing forms of explanation involved vary primarily in the emphases given to particular elements. For example, most human action comes about as a result of the interaction of a plethora of internal and external factors of various kinds; but by stressing particular subsets of these we can influence the conclusions arrived at by others. Within such a process, there is no sharp dividing line between truth and lies, so the application of such labels is arbitrary and subjective.
Where Does Truth Lie?
Attribution theory then explains certain things about the process of explanation, and permits the derivation of hypotheses which may be tested; but it reveals neither truth nor lies. With respect to explanations for illicit drug use, the present text argues that the passive and helpless state implied by the word 'addiction' derives from an 'implicit theory' (Ross 1989 op cit) which is primarily functional within a particular context, and that in other contexts people can and indeed do explain similar acts in terms which imply greater control and volition.
However, whilst addiction is revealed primarily as a functional form of explanation in a given context, from an attributional standpoint we cannot go further and assert that therefore people really are in control of their drug use simply because they report being in control in other contexts. Demonstrating that the state implied by the language of addiction is a functional form of attribution does not enable us to conclude that therefore a different form of explanation must be 'true'. If addiction and helplessness are functional in one context, then control and volition may be functional in another. Consequently, if we argue for the truth of either of the central styles of attribution, (i.e. on the one hand, a compulsion explanation, or on the other a volitional explanation of drug use) we make exactly the error outlined at the start of this chapter.
On the face of things, we have arrived at an impasse in which all that exists is functional explanation, with the real nature of the drug-using experience becoming if anything even more elusive than it was before. In fact, however, the answer to the riddle is obvious, if a little difficult to accept at first sight; namely, there is no single 'truth' to be found. The nature and consequences of drug use cannot be divorced from the contexts within which it takes place; the experience and social consequences of drug use are not fixed entities, but vary according to the social, legal and other sanctions that surround the activity. Consequently, the reports of drug users about their experiences and behaviour are primarily revealing about the circumstances and conditions under which drug use takes place, rather than revealing immutable and certain facts about the inevitable nature of drug use itself. In circumstances where drug users regularly behave like stereotypical junkies, and report that their drug use is beyond their capacity to control, we must therefore turn our attention outwards and try to identify those aspects of the social world that make such types of behaviour necessary, and that provide the functional basis for the accompanying reports of helplessness and addiction.
Drug Use and Context
The evidence from studies of the attributional nature of addiction implies that the meaning, experience and implications of using mind-altering substances vary according to context. In most of the experimental and quasi-experimental studies reviewed in previous chapters, the level of contextual variation achieved was usually only a trivial representation of the possible larger contexts for drug use; for example, a different style of interviewer, or a different label on a questionnaire. In the real world, these simple differentiations are represented by major structural components of the legal, medical and social systems within which drug use and misuse take place. Within a given context, the reality of drug taking assumes a particular form or 'social reality' (Cohen 1990). Change the context, and the reality also changes.
Consequently, a society has the capacity to create a drug problem in whatever image it wishes. Surrounding drug use by tougher legislation, longer and more frequent prison sentences (see for example Haw 1988), unhelpful health messages based on fear arousal (see Davies and Coggans 1991 op cit) and alarm and outrage in the media (see Royal College of Psychiatrists Report 1987 op cit) creates a system characterised by fear, moral censure, crime, and an escalating black economy. Within such a system, particular forms of explanation have survival value. Attribution studies of drug users show, in a microcosm, how such a context produces a form of 'addicted explanation' which is inextricably intertwined with that context. The story does not stop there, however. Attributional research shows how forms of explanation can be related to future behaviour and expectancies. Consequently, having created the circumstances within which a particular form of explanation is adaptive, we can reasonably expect consequences to flow from that form of explanation. Since a climate has been created, with respect to drug problems, within which explanations that remove personal responsibility are strategically the best, we would expect that services might be provided on those terms; and we could anticipate that users would then require to present themselves to agencies in the same terms in order to receive whatever benefit was to be had.
This seems to be exactly what has happened. At the present time, the services on offer are generally geared to providing for helpless drug addicts who use drugs 'against their will' and who are trying to stop. As a result, people who encounter problems stemming from their use of drugs tend to present at agencies in accordance with that agenda. However, many people familiar with illicit drug use at the street level rather than in the hospital or clinic setting, will be impressed by the fact that most users appear to take drugs on purpose because they enjoy it, and their immediate problems frequently arise from their desire to keep using rather than their desire to stop.
It is thus possible to argue that service provision is required of a type that caters for the needs of drug users wishing to continue, with a correspondingly lesser role played by 'stopping' services; a suggestion which is however in opposition to the prevailing ethos. By and large, the services required to help the majority of continuing users to function as well as possible remain scarce and under-developed, or else the province of isolated and charismatic characters whose motives sometimes appear uncertain. This is unfortunate, since there are reasons for supposing that services of this latter type are now required with increasing urgency.
Drug Use and AIDS/HIV
The link between intravenous (IV) drug use and HIV infection, with transmission of the virus from user to user occurring as a consequence of the use of contaminated needles which are shared, is well established (though the different dynamics associated with borrowing as opposed to lending still require more investigation). Furthermore, a government review body (Advisory Council on the Misuse of Drugs 1988) has concluded that HIV/AIDS represents a more serious threat to society than does drug use per se, a view with which many would concur. Consequently, policy on drugs has to reflect the need to control and contain the spread of HIV as a matter of priority, notwithstanding the other health risks associated with intravenous injection and the use of non-sterile equipment. The need for a 'new paradigm' in dealing with drug problems has been emphasised in detail by Stimson (1990) and there is no need here for a lengthy exposition of those arguments. It remains to say, however, that the IV drug use/HIV link has given new urgency to the need for services for continuing drug users, in order to monitor and as far as possible guide drug users in the direction of safe use. Such services clearly need to be user-friendly, non-censorious, and free from the risk of prosecution, or they will simply not be used. This 'harm reduction' approach represents the best hope of limiting the spread of HIV into the general population via IV drug use, as well as controlling the other potential sources of harm that may arise. Services catering primarily for the needs of users who are trying to stop, and who are seen as helpless victims, clearly do not address the larger problem: namely, drug users wishing to continue with their use and consequently having no reason to contact existing agencies working to a drug stopping agenda. Something has to be done to draw this larger group into agency contact, where their drug-use can be monitored and their manner of use challenged if necessary, in the interests of personal and public health.
The basic agenda for such service provision requires users to take responsibility for the extent and manner of their use. But people can only be persuaded to use their drugs in a safer manner (e.g. smoke instead of inject) or a way that minimises the danger of infection (e.g. delay injecting until a clean needle is available) if in principle they are capable of implementing decisions about their drug use. If the prevailing view is one of helpless junkies driven by forces beyond their capacity to control, then any such attempt to alter drug use is rendered futile by the attributional style with which it is associated. Being 'addicted' is the antithesis of making and implementing decisions, and within such a framework people 'have to have' their drugs whatever the cost.
Addiction is therefore a specific subspecies of learned helplessness, a phenomenon which has been much researched in other contexts and has generally been found to hinder the individuals' attempts to take an active and constructive role in his/her own health-related behaviour. In particular, feelings of lack of control are associated with higher levels of experienced stress, and a general lowering in the ability to cope (see for example Fisher and Reason 1988; Fisher and Cooper 1990; Cooper and Payne 1988).
It is apparent that the increased responsibility expected from drug users in terms of making decisions about substances, sources of supply, routes of administration and lending/borrowing of needles, cannot take place within a framework which stresses a mechanistic view of the drug-taking process; that is, as an addictive process that happens to people, rather than something that people do. Such a view alienates people from their own behaviour and intentions. In order to cope with the decisions necessary to minimise the possible harmful consequences of drug use to self and to society, issues of volition and control, and thereby of competence, have to replace mechanistic conceptions. Progress can only be made along this route if the notion of addiction is seen for what it is; namely, a preferred style of explanation whose primary purpose is functional. It removes blame and responsibility in a climate of moral censure. However, that particular functionality is actually dysfunctional at another level. Whilst the addiction attribution minimises possible harm to the drug user deriving from the social and legal sanctions surrounding drug use, it does nothing to minimise the possible harm that might come from using drugs incompetently, and it reduces the likelihood of competent use. A new context for drug use is required within which a different set of attributions is functional, attributions that help the person to cope with the problems that may arise due to their drug use, rather than attributions whose function is to minimise the impact of the legal and social sanctions on drug use imposed by the society within which it takes place.
The involvement of HIV/AIDS with intravenous drug use now gives a particular impetus to the need for a drug-using context within which explanations in terms of volition and control are functional, types of explanation which have different implications for drug-using behaviour than currently-preferred explanations in terms of pharmacology and helplessness. People believing themselves to be helpless cannot guide or take responsibility for their actions; and the involvement of HIV with drug use now requires with some urgency that drug users do exactly that. In a society trying to limit the spread of HIV/AIDS via incompetent drug use, the addiction attribution is probably the single major obstacle to progress. It impairs the capacity to cope with the problems arising from unwise drug use per se and the ability to make and implement competent drug-taking decisions. The link between HIV and IV drug use now makes it imperative that if people decide to use drugs, and many people make that decision and will continue to do so, then they should use their drugs competently above all else.
Living with Drugs
Illicit drugs are probably not going to go away by themselves, and the possibility that a 'war on drugs' will succeed in eliminating them from our midst seems increasingly unlikely. History has shown us how prohibition can create more problems than it solves. At a time when borders are being dismantled and when international communication and travel are commonplace, the problems of trying to ensure that particular substances do not reach particular destinations are likely to increase rather than decrease. The problem is compounded by the fact that there are major economic incentives to overcoming whatever barriers are put in place; and the commodities themselves are easy to hide or disguise.
Consequently, the realistic option is the pragmatic one; learning to live with drugs whilst minimising the harm that some individuals may encounter with their use. Furthermore, in all probability drug use is going become more rather than less prevalent, a developing context within which harm reduction will make progressively more sense, whilst the drive to stamp out drugs will become increasingly out of touch and ostrich-like. In a world where experimentation with, and use of, illicit substances becomes more common, a framework is required which normalises this activity as far as possible, whilst providing users with the services they require in the interests of minimising harm, and controlling the spread of HIV and other infections. The alternative is a society in which an increasing number of people become sidelined in the 'helpless addict' role, unable to make decisions about their drugs or their manner of use, and unable to take part in that society on anything resembling normal terms; whilst the drive to eliminate the substances from our midst exacts an ever increasing toll in terms of societal disruption and the invasion of civil liberties.
It goes without saying that the approach being advocated requires some dynamic response; specifically it requires a step back from the worst excesses of the existing system, to a less punitive set of circumstances within which alternative forms of attribution may be encouraged to grow and eventually flourish. The two essential ingredients of any attempt to encourage drug use on terms which are controlled and manageable are, firstly, the belief that such control and management is possible; and secondly the belief that there are benefits to be had from adopting such an approach.
Addiction: A Systems Problem
Taken collectively, attribution theory and attributional research suggest that the current controls surrounding illicit drug use have had a determining influence on the way drug use is explained. In turn, the explanation has led to service provision of a type appropriate to the explanation itself, the explanation determining both the type of services offered and the terms on which drug users may present themselves. The last link in the chain occurs when drug users do in fact present themselves on those terms when they encounter problems, as the price of absolution. In other words, the functional attribution becomes the reality.
However, it is clear that in different circumstances, alternative forms of explanation could become functional; forms that would have different and more helpful implications for future behaviour. Given the extent to which drug use, and especially IV drug use, is now enmeshed with other critical health issues, the need for such a new reality could not be clearer. That alternative reality requires the development of a 'system' within which drug use is conceived of as an activity carried out for positive reasons, by people who make individual decisions about their substance use, and who may take drugs competently as well as incompetently. By contrast, the 'war on drugs' actually takes us in an opposite direction by repeatedly stressing that the only control possible over the use and misuse of illicit drugs is that imposed from outside.
It is clear that the problems created by the illicit use of mind-altering substances do not stand alone, but are part of a larger system. In the preceding paragraphs we have seen how the use and misuse of drugs is inextricably interwoven with other issues. Throughout this text it has also been repeatedly stressed that the explanations people offer for drug use are primarily functional in certain types of context, and consequently they change according to context. The problem of illicit drug use is thus basically a 'systems problem.' In describing addiction as a systems problem the word 'system' is used not in a general sense, but in the specific sense implied by systems theory (e.g. Ackoff and Emery 1972). Although a system may comprise most or all the elements of a set (in the sense that we all provide inputs to the addiction system), the focus is on the interrelationships between the different identifiable components of the system, rather than on what goes on at any particular level. Systems theory also seeks to understand the manner in which changes at a specific point within the system can change the properties of the system as a whole, in the extreme case modifying the way the system works so as to change its outputs radically.
In the real world, it is possible to become so enmeshed at one particular level that one loses sight of the system within which one is operating, and when this happens one becomes blinkered to the larger context of which one is a part, perhaps even failing to realise that the changes made at that level can produce greater and perhaps non-beneficial effects on the system as a whole. To solve this type of problem requires analysis of the various parts, their susceptibility to manipulation, and prediction of the consequences of change for the rest of the system. Unfortunately, such a systems analysis is lacking for drug use and misuse. Nonetheless, it is apparent that in recent times the major focus has been on a particular component, a component that lays stress on the medical perspective, takes as its premise the presumption that taking illicit drugs is essentially an illness or an inadequacy from which harm must inevitably flow, and leads to the conclusion that treatment and prevention in various guises are the two most appropriate and most fundamental responses. In fairness, it must be acknowledged that this approach has not completely ignored the non-medical aspects, but nonetheless they are not accorded equal status, being merely suborned to the medical perspective as and when they appear to complement that part of the system.
The attributions people make for drug use, and the functionality that may be discerned from the study of how these change in different contexts, is the key to a realisation that the addiction system is not operating in a coherent manner. Coherence can be restored by taking the first steps towards a more systems-based approach, within which inputs from drug users and treatment specialists play a role as a necessary and essential part, but which accords equal status to historical and geographical factors, to political and governmental agendas, to the role of newspapers and television, the law, the broader social and political climate within which drug use takes place, up to and including everyone living within that social system, and the attitudes and values they learn, and which they bring to the issue.
Understanding the addiction system, as distinct from the medical problems of drug use, now requires a concerted effort to obtain a broader perspective from all parts of the system, followed by an effort to understand how actions at any one level, and which may appear advantageous at that level, can cause the overall output of the system to change in non-advantageous ways. In the preceding pages it has been argued that the functional use of the addiction attribution is a real and identifiable output, and as such it clearly demonstrates that the system surrounding the use and misuse of illicit mind-altering substances is not working in a helpful and productive way.
Without a change in perspective, we lay the foundations for a continuation of the drug problem in the same terms. We run the risk of making the problem more and more extreme, and consequently of coming to view counter measures of a progressively more arbitrary and socially destructive type as desirable and necessary, as we add more and more energy to the system, until eventually we transform a problem involving individuals taking mind altering drugs into a problem of life-and-death on the streets. Something like this appears to be happening both here and in the U.S.A. as the economic rewards of trading in the illicit drug-economy escalate in a never-ending spiral.
Addiction: Exploding the Myth
It is essential to be clear on certain points. It is not the message behind this book that the illicit use of drugs never creates problems for people. It is abundantly clear that numbers of people encounter serious health problems due to the unwise or careless use of mind-altering substances. This is true of drugs like heroin and cocaine; and it is also true of drugs like alcohol, tobacco and benzodiazepines (minor tranquilisers). To the extent that the use of illicit drugs is a danger to individual health, there is a problem. The extent of this problem is, however, generally overestimated at the population level, in comparison with the harm caused by the use of licit substances; and also in comparison with major health problems such as accidents at home and at work, child-pedestrian fatalities, heart disease and so on.
It is also clear that the incompetent use of drugs can cause damage within the family, the work group, within broader social networks, and that in some localities these problems assume a greater seriousness than in others. Whether it be the neglected spouse, struggling to cope with a growing family on resources depleted by a partner's gambling; the businessman embezzling in order to keep himself in claret; the factory worker whose drink or drug use materially affects his/her work performance; or the talented musician whose performance moves from the sublime to the grotesque in response to increasing heroin use; all these instances demonstrate that the thing we refer to as 'addiction' can have serious repercussions at both the societal and the individual level. Again, however, we have to note that whatever the activity or the substance, such problems are far from inevitable and that controlled use in particular contexts need have no implications whatsoever beyond that context. It is becoming increasingly clear that large numbers of people use drugs in a controlled fashion, never encountering serious problems with their use, and never coming to the attention of police, health or other authorities (Cohen 1990 op cit; Ditton 1990 op cit).
Finally, although it has been suggested that the understanding of drug action at the level of the cell is peripheral to the understanding of drug-related molar behaviours, the pharmacological effects are real: the particular pharmacology of a substance gives that 'addiction' is own peculiar quality, and humans and animals are aware of and can even recognise that quality under certain conditions. Furthermore, such differences account for the fact that certain substances are intrinsically more pleasurable to use than others, and hence are employed by people for their pleasurable effects whilst other substances are not. However, it is also the case that people can and do become 'addicted' to things that involve no external pharmacology, in the sense that they pursue an activity single-mindedly to the detriment of their personal health and the disruption of their family and social relationships; and it is also true that other people seem able to use substances that are pharmacologically potent on an extended take-it-or-leave-it basis with no long-term health consequences. Consequently, an external pharmacological agent is neither a necessary nor a sufficient condition to bring about that state we describe as 'addiction' amongst humans.
If substances themselves are not the crucial issue in the explanation of why people display 'addicted' behaviour, then there is clear need. for a revision of basic strategy. We have to step back from the abyss towards which we are being beckoned not by users, but by those whose preferred solution to drug problems is to eliminate drugs and their use from our midst by whatever means appear necessary, no matter how socially disruptive this may be. Unless we seriously consider ways of reducing penalties, of producing more sensible media coverage, of reducing the political appeal of drugs, in other words of examining all aspects of the addiction system, the problem will metamorphose into something far more costly in societal terms. The response to the drug problem will come to have more serious, not to say lethal, consequences for society than the drugs themselves.
At the moment, the use of mind-altering substances serves as a springboard for responses to drug use that can eventually lead to death and chaos on the streets, where no such outcome is necessary. To avoid this outcome, it is necessary merely to take a more balanced perspective on the costs and benefits of illicit drug use; and in the light of that analysis, to arrive at the only sensible conclusion. Namely, it is time to abandon a response based on an escalating and ineffective tariff of legal sanctions against drug use; and switch to an approach which focuses on reducing the potential harm of certain incompetent drug-use practices, whilst handing personal control back to those who are involved. In other words, we need to rebuild our 'addiction system'; and in the process of doing so we may well discover that it was never in fact what we thought it was. We may discover that 'addiction' is not so much a thing that happens to people, as a functional set of cognitions surrounding the activity of taking drugs; a way of thinking made necessary only by the sanctions with which we surround the act of using substances to change our state of consciousness.
