A few weeks after Paul and I met, Nancy herself came to see me at Paul's behest, and I tried to get her to look at her problem. She said, however, that she was quite comfortable in her analysis, and that it was offering her valuable insights. Further, she did not think it useful for me to speak directly with her doctor. When I pointed out that her continued drinking argued for additional intervention, or at least some visits to AA, she contended that her relationship in therapy should be enough to deal with her problems.
For many alcoholics, years of treatment have meant that they had achieved "insight" but that their drinking continues. Stories of therapy like hers abound at meetings of Alcoholics Anonymous. Ironically, though, these addicted people could have been treated effectively by those same therapists if the psychology of addiction were more widely understood and more effective care was implemented.
Substance abuse is as great a challenge as any clinical issue that has emerged in the past decades. Addictive illness is among the most prevalent psychiatric disorders.
A major study, the Epidemiologic Catchment Area Study, shows that the lifetime chance of an American developing an abuse or dependence disorder is 15 percent for alcohol and 6 percent for other drugs. These are the most prevalent disorders among men of all age groups and the most prevalent among women 18 to 24. The cost of alcohol and drug problems is greater than that of all other mental illnesses combined—144 billion versus $129 billion in a year.
Most mental health professionals are ill-prepared to help the alcoholic or drug abuser achieve recovery even though addicted people and their families regularly turn to them for help. Further, few alcoholics and addicts are willing to go to Alcoholics Anonymous until they've suffered very long, and most drop out before becoming involved. How can we engage and treat these people more effectively?
Most effective addiction treatment entails either self-help, peer support, or both, and these are hard to come by in office practice. To address this strategic deficit, I have developed an approach that engages the support of a small group, some family, some friends, to meet with a substance abuser and therapist at regular intervals to secure abstinence and help with the development of a drug-free life. The evolution of this new approach did not come easily, but through careful attempts to manage many patients over the course of their rehabilitation.
I call it network therapy. Family and peers become part of the therapist's working team, not subjects of treatment themselves. Such an approach is warranted by the unique characteristics of the substance dependence syndrome. Social supports are necessary for overcoming the denial and relapse that are so compromising to effective care for the substance abuser.
Nancy's resistance to seeking help for her alcoholism was typical of the way denial shows itself over the course of the disease. A few months after I saw her, she became annoyed at her psychiatrist for "pestering her" about going to AA, and dropped out of treatment. The drinking continued, and later that year she lost her job because of unreliability. Paul was ready to walk out as well, but he said he would give her one more chance if she saw me, "the doctor who said she had to stop drinking."
Nancy came in saying that her problem was that she needed "to get a handle on the depression" she had felt since losing her job. I was not about to let her ventilate her feelings in isolation, and fall into the same trap as her first therapist. I told her that since drinking played a role in her problem, it was important that we get some support for her, to help her look at her situation. I asked her to bring Paul and a friend to our next session to discuss the issue. So began her network therapy.
Two network members were certainly more revealing about the extent of Nancy's alcoholism than she had been. They described how it had often left her in awkward social situations, and feeling incapacitated in facing the next day. I encouraged Paul and the friend to voice their feelings and concerns, to soften her inclination to avoid the problem. The impact of this network session moved Nancy to acknowledge that she had a problem with alcohol. The network members helped me to prevail on her to accept the idea of abstinence.
Together, the four of us developed a regimen to support her recovery, one that included individual sessions as well as meetings with this network. To this we added AA meetings, and the network members supported her in attending the meetings during later sessions, when she expressed misgivings about them. Nancy and I continued to meet with her network while she focused on ways to protect her continued abstinence and on the psychological issues that would allow her to achieve full recovery.
She had a few slips back into drinking while in treatment and was once prepared to give it all up. Her network was behind her continued abstinence, though. We all consulted together at these times of crisis. With each slip we would work together to understand what certain drinking cues—situations and emotional states—led to the relapses. We would then plan together how Nancy could handle these cues when they came up again.
As time went on and Nancy's abstinence was secured, our network sessions were held less frequently, but were not called off, and her individual therapy continued. In network sessions, the three of us would act as a sounding board for her recovery. We also provided the assurance that if Nancy slipped again, even after treatment was over, there would be a resource to draw on to secure her return to sobriety.
The nature of network support is further evident in the way we drew on one particularly meaningful relationship to bolster Nancy's abstinence. We often spoke with her sister on my speaker phone during our network sessions. Although her sister lived in a remote city, Nancy had a trusting relationship with her, and the sister had been very distressed for years over her drinking problem. This relationship was one that added strength to the bonds of affiliation that supported Nancy's recovery.
I call on a variety of devices that enhance the effectiveness of the network, like introducing relapse prevention techniques into network sessions, using formal written agreements, and managing medication intake. There are many tortuous turns on the road toward recovery.
In 1972, I was appointed a career teacher in alcoholism and drug abuse by the National Institute on Mental Health. Expertise and competence at treating this problem was so uncommon then that the federal government was eager to support young medical school faculty members in the hope that their academic commitment would lead them to become involved. I took this mission seriously. In my searches of the literature, I found nothing on the technique of resolving a drinking or drug problem for a patient who came to the doctor's office. But soon my colleagues began to send me addicted patients to treat, and I felt obliged to do the best I could.
Since then, researchers in addiction have begun to develop a systematic understanding of how drug and alcohol dependence wreak their effects on thinking and behavior. But there are still very few descriptions of a comprehensive approach that the therapist can apply to addicted patients. Detoxification regimens, research approaches, and hospital programs are available, but they do little to clarify the day-to-day struggle that must be staged while recovery is achieved with a patient who is living in the community.
Few therapists venture beyond recommending to alcoholics that they attend AA or take a long break from job and family and go away to a rehabilitation hospital. Beyond this, psychiatrists, psychologists, and social workers simply apply their "usual" approaches to treatment and hope that they will be useful. And because "usual therapy" rarely solves these problems, it is assumed by many that hospitalization is the only safe treatment for addicted people. It is not. An astute application of what we now know about addiction can avert hospitalization for the large majority of substances abusers.
For relapse prevention, I draw on behavioral techniques that have emerged from psychology and physiology for managing impulses for drug-seeking, along with a supportive network for self-examination. Awareness of the relationship between addiction and symptoms of depression and anxiety is also essential; alcoholics are prone to depression and suicide. All these issues must be brought together for effective treatment.
How does network therapy fit into our evolving understanding of addiction? Addicted persons generate great conflict and resentment among their family and friends. On the one hand, persons close to the addict have long been angered by his lack of responsiveness and by a history of many disappointments that he has conferred on them. On the other, they are remorseful over his unhappiness and the losses that he has suffered. The tension between anger and guilt makes it all but impossible for individuals close to the addicted people to approach them in an objective way. They are likely to overreact at one time and castigate them, and at another time they may shrink from asserting their concerns and be overly permissive, even enabling their addictive behavior.
Professionals have begun to consider the orchestration of family dynamics to move the addicted person toward recovery. One important approach has been a technique for intervention with the reluctant substance abuser, which brings his family together to plan a confrontation designed to impress him with the immediate need for hospitalization. With aid from a professional, family members can thereby work together, spurring the patient into action. Multiple family therapy groups for substance abusers have also come into use to create a setting where a diversity of issues are melded together to neutralize individual resentments. The sense of community engendered can be supportive, and aid in achieving compliance with an expected norm of abstinence.
By themselves, therapists have only marginal potential for influencing patients outside the office. If a patient has a slip into drug abuse the therapist may not be apprised, and if he knows, he can bring little influence to bear. Therapists on their own are limited in the degree to which they can make demands on the patient's life, and the patient is free to walk away from the therapeutic situation if it is uncomfortable for him—that is to say, if it challenges a serious relapse to addiction. All these factors make the engagement and orchestration of family and friends into the therapy with a substance-abusing patient an invaluable resource, one which offers remarkable opportunity for the modification of traditional psychotherapeutic techniques to treat the substance abuser.
A social network is very important in altering addictive behavior. In the public alcoholism clinic I once directed, patients without families to support them had to be repeatedly confronted with the realities of the addiction in group therapy by their peers so as to assure that denial did not erode their capacity to deal with reality. A social network is apparently a necessary vehicle to stabilizing the cognitive components of patients' recovery, to allow them to deal with the reality they need to see, and to provide the support essential for accepting the new reality. I realized that because of the social ties in a cohesive network, a patient in a therapist's office might be reluctant to run out on his treatment.
Inpatient rehabilitation facilities, by contrast, often disrupt family and social ties while the patients are hospitalized. They also remove patients from the opportunity of learning to deal with the conditioned cues for drinking while treatment supports are greatest; the real temptations to drinking do not present themselves in the hospital.
A person's immediate network might draw on his spouse, some friends, or his family of origin. Components of the network are only parts of the natural support systems that usually operate without professional involvement. But, brought to act in concert, the strength of their social influence can serve as a therapeutic device.
A number of forces shape the network:
Social cohesiveness has been defined as the product of all forces that act to keep members engaged in a group, and it can be an important therapeutic instrument. It is generally evident and well-focused in indigenous mental healing rituals in preindustrial societies—and among members of groups like the Moonies and Hare Krishna. Colleagues and I have actually measured the emotional well-being experienced by members of these groups and found it to be directly proportional to the intensity of their respective feelings of cohesiveness toward the group. The relationship between emotional well-being and cohesiveness apparently served as an implicit motivation for persons to stay close to the group and promoted their compliance with its expectations.
Although community ties in our society are generally weak, the kinds of intimacy and social support that characterize traditional societies can potentially be generated by engaging a small network of persons close to the patient. If the relationship between cohesiveness and emotional being is harnessed within the therapeutic context, and the patient comes to experience closeness to the therapy network as a vehicle toward well-being, then the resulting social forces can move the patient toward accepting the group's expectations, as abstinence becomes the ticket to sustaining closeness.
The purpose of network therapy is then to create an atmosphere that will allow an alcohol or drug abuser to experience relief from distress by participating, and moving towards a drug-free outlook. After initial sobriety has been achieved, network sessions often acquire a social quality. The group becomes friendly and close-knit, and stories and even jokes may carry over from one session to the next.
In order to act out a pattern of behavior that is clearly self-destructive, addicts must adopt a pattern of denial. This denial is supported by a variety of distorted perceptions: persecution at the hands of employers, failings of his distraught spouse, a presumed ability to control the addiction if he wants. This cognitive set is not only unfounded, but it is also at variance with the common sense views of his drug-free family and friends. Because of this, intimate and positive encounters with them in the network produce an inherent conflict between addicts' views and the views of network members. The addict must resolve this conflict, or cognitive dissonance, in order to feel accepted in the group. The network therefore creates an ongoing pressure on the addict to relinquish the trappings of denial.
Typically, addicts deal with this conflict by defensive withdrawal, but if their network is properly managed, cohesive ties in the group will engage them and draw them into an alternative outlook. Gradually, they come to accept that their distress can be relieved by a change in attitude, as denial and rationalization are confronted in a supportive way. Over time, engagement in the network allows an addict to restructure the perspective in which the addiction has been couched.
For addicts, both healthy and faulted attitudes have long coexisted in conflict with each other, and the cognitive dissonance produced by these contradictions has driven them into a defensive stance, fending off any attack on this awkward balance. On the other hand, in a proper supportive context, a constructive view premised on abstinence and on acknowledgment of the harmful nature of drug use can emerge. Addicts can experience a "conversion" of sorts, perhaps gradual, but real nonetheless.
For one woman, four members of her network quickly made clear that she was much more likeable at social gatherings before she would begin drinking. Her inclination to present herself as a "happy drunk" could not sustain itself in the face of two siblings and two friends who attested to the contrary.
Attribution theory holds that under confusing circumstances, people are more open to the introduction of unfamiliar or previously unacceptable ideas from their social environments, so long as these ideas lend clarity to the context. They may attribute new meaning to an unfamiliar feeling when it is artfully introduced. Engagement into a new perspective is particularly effective when it is offered in a supportive group setting. In the case of the addict, the therapist promotes a new perspective: Abstinence may indeed be the best option for the relief of distress and reordering a disrupted life.
Every society has options for forcing reluctant members to comply with its norms of behavior. However, formal controls, such as legal restrictions, are less influential overall than the informal controls embodied in a community of mutual understanding, and mediated by family and friends. No society can codify the many proprieties it expects of its members.
Actions such as the withdrawal of affection, the expression of group disapproval, and the disruption of social interactions desirable to the patient can be highly coercive. More importantly, these steps need not be actually taken to enforce compliance. The implied threat of action may be enough, particularly when it is clear that the patient cannot avoid the network's judgment by being manipulative.
The network modality can convert idle threats into effective coercion. Standing alone, network members are generally ambivalent about taking action against a substance-abusing peer because they experience sorrow over his plight, as well as anger. But in the network, the therapist converts these motives into justified action, sanctioned by a professional; potentially coercive behavior is now understood to be for the patient's own good, rather than to relieve resentment.
Since network members act in concert, the impact of their interventions is much greater than if taken alone. They are now less hesitant to express disapproval over inappropriate behavior for fear that others will back off when confronted by the angry, defensive alcoholic. The cooperative tone set by the therapist encourages mutual support and conjoint action.
The natural response of disappointment alone has great coercive potential. Once a balanced network is properly established, the patient is reluctant to invoke its disapproval.
The Outcome of Treatment
Among the 60 addicted people whom I had treated for at least three sessions during the last 12 years, the average age was 37. Most (63 percent) were unmarried, employed (72 percent), and male (77 percent). They were dependent on a variety of substances, alcohol and cocaine the most common (42 percent).
Almost all the patients were treated with a network, rather than alone. A majority of these networks included mates (62 percent) and peers (51 percent). Parents, siblings, and children participated less often. The younger patients were more likely to have their parental families represented, although I never set up networks without someone the patient's age.
A variety of treatments was used in addition to networks. All were seen in individual therapy. Almost a third went to more than 10 Twelve-Step meetings, and this was a sizable number since alcohol was not the principal drug of abuse for most. Seven were treated with antidepressants; four of them were hospitalized because they could not maintain sobriety.
The results of treatment were gratifying. The large majority of patients (77 percent) achieved a major or full improvement. They were abstinent or had virtually eliminated substance use, and their life circumstances were materially improved and stable. Patients whose drug use was mild to moderate were more likely to achieve success (93 percent) than those with severe dependence (61 percent). Interestingly, a patient's drug of choice was not associated with relative success, nor was regular AA attendance.
The majority of patients whose primary drug was alcohol were offered disulfiram (Antabuse), observed by a network member (16 of 21), and this was associated with a major or full improvement in almost all cases (14 of the 16). On the other hand, refusal to take disulfiram was typically associated with only moderate improvement (4 of 6), probably due to the fact that these were patients who had rejected the initial proposed treatment option. In a sense, acceptance of the proposed treatment modality is, for the addicted person, a strong predictor of better outcome.
Some Myths About Addiction
We have witnessed careful scientific studies into the causes and treatment of addiction. Since many aspects of this problem defy conventional wisdom, myths have arisen in the absence of solid research. These myths have persisted among the lay public and professionals as well. Here are some examples:
- There is an addictive personality.
Most of the aberrations of personality and the poor adaptations we see among addicted people are the product of years of substance abuse, rather than problems that predated their reliance on drugs. No significant failings shared by them earlier in life have been found. This has been found in reviewing objective psychological tests that were done on college students decades ago. Students who developed alcoholism in later life were compared to those who did not, so that early personality factors could be evaluated. By and large, people are more likely to show dependent or sociopathic traits as a result of chronic substance abuse than they are likely to have been dependent people or sociopaths when they were young.
- Ethnic groups vary in their vulnerability to alcoholism.
In epidemiological studies, we find that certain groups, such as members of traditional Chinese or Jewish communities, are less likely to develop alcoholism. Whereas Native Americans are more likely. Nonetheless, as these groups assimilate into the mainstream, their patterns of drinking come to resemble those of other Americans. Interestingly, a fair portion of people of Japanese extraction actually develop a metabolically-grounded discomfort after drinking alcohol. Most of them, however, when acculturated into a society of heavy drinking, drink heavily nonetheless.
- A better understanding of oneself helps to overcome addiction.
While is always useful to have a handle on your own motives, such insights are usually no more than rationalizations in the addict's hands. All too commonly, one hears alcoholics at AA meetings speak of spending years in insight psychotherapy while they continued to drink. It is not that hard to hide a pattern of addictive behavior from a therapist, and one is just as likely to hide such a pattern from oneself. A well-structured program of abstinence is generally worth more than a thousand words of introspection.
- Psychologists and psychiatrists don't do much good for addicted people.
Although insight has limitations, mental health professionals can be very helpful to the addicted person, so long as they are conversant with basic principles of addiction treatment. It is essential that they secure abstinence from the outset of treatment, and organize a therapy around the active prevention of a relapse. If this is done, a very effective addiction treatment can be built around the professional psychotherapeutic encounter.
- The best way to start on recovery is to go away to a "rehab" for a month.
Inpatient hospitalization is sometimes necessary to the initiation of a stable recovery, as when patients are seriously psychiatrically disturbed, or when they have no stable residence. Otherwise, most alcoholics and drug abusers can achieve a stable abstinence with careful and expert outpatient management, supplemented by family supports and AA. This observation has led to declining support for inpatient care among insurance carriers. Unfortunately, though, most mental health professionals are not yet well versed in outpatient treatment of addiction, so the selection of a therapist must be made very carefully.
- AA is virtually a religious club for alcoholics.
In actuality, AA embodies highly systematic and well thought-out procedures for securing and stabilizing abstinence. Although it is oriented toward spiritual aspects of recovery, those who developed the program did so with implicit attention to social psychology, and considerable experience in stabilizing fellow alcoholics. In fact, many of AA's techniques have been adapted and applied in professional treatment settings.
- AA is the only way to achieve recovery.
Although AA is a valuable resource, it is not the only one. Many people secure abstinence by means of professional assistance alone. Community studies show that some do so by sheer will-power. Furthermore, some self-help groups, like "Rational Recovery", have emerged, offering alternative modes of self-help. Nonetheless, AA still is the most widely used resource for abstinence in the United States.
The causes of relapse to alcoholism and drug dependence are rarely obvious to the family of an addict, the therapist, or the addict himself. For an understanding of drug craving and relapse, we must examine the particular psychological vulnerability on which addictive drugs usually act. We also arrive at a model of motivation quite different from those used in most psychotherapies, and which explains why most therapies fare poorly in treating the substance abuser.
All addictive agents have two principal characteristics: they generate craving—a desire for repeated use—and they produce discomfort when they are withdrawn. With regard to the first trait, we say that an addicting drug is a reinforcer; it produces a reaction in the central nervous system that leads the exposed individual to take it more often. For example, drinking alcohol initially produces euphoria and a release of tension; caffeine produces a mild stimulation, perceived as positive. These responses lead to further consumption.
Alcohol, for example, can produce a reward of tension relief for a period of time, and can thereby lead a drinker to turn to it with regularity. Under the right circumstances, the drinker, perhaps by now an alcohol abuser, may begin to suffer its ill effects, with a life gravely compromised by consumption. Nonetheless, because of the reinforcing qualities of alcohol, the drinking continues, and the incipient alcoholic may crave alcohol in its absence.
This is an example of operant conditioning. An immediate response to the reinforcement is much more influential in deterring behavior than a later negative consequence. The hangovers or job loss that take place long after the immediate drug effect is felt do not effectively counter the immediate positive response to the drug.
What makes recovery from addictive drugs particularly problematic is their capacity to bring about a relapse to dependence long after the addicted person has been free from the drug. To understand this vulnerability, we must look at the withdrawal reaction, an unpleasant state engendered by the body when addictive drugs are withdrawn after long use. Withdrawal is most evident after a binge of drug taking, as in alcoholic shakes, cocaine crashes, and heroin sweats.
The substance abuser will forswear alcohol or drugs many times, but what foils a stable recovery is many slips back into alcohol or drug use. The problem of return to addiction is seen with all drugs of abuse, all social classes, and in many psychological circumstances. It is central to the problem of compulsive drug-taking. It demonstrates why addicts, family members, and caregivers are repeatedly frustrated in their attempts to avoid a return to drugs, and how traditional approaches to psychotherapy must be reconstructed to address the character of relapse.
Addicted people can differ markedly in the social problems they confront, the agents to which they are addicted, and the amount of ongoing emotional distress they experience. Nonetheless, they are all vulnerable to relapse to drug use with little forewarning, and they experience loss of control in a way that is almost mysterious. These are two clinical hallmarks of addiction. Exposure to certain subjective and environmental cues in fact precipitate these events, but the uncontrollable nature of the process cannot be explained without recourse to a model that weds the biological and psychological mechanisms that underlie addiction.
Conditioned Abstinence—Heart of the Problem
Conditioned abstinence (or conditioned withdrawal) takes place when an abstinent addict is exposed to drug-related stimuli. The addict develops feelings of drug withdrawal, which he subjectively experiences as drug craving. This leads him to seek out drugs.
Withdrawal reactions, such as the shakes that emerge after a drinking binge, and sedation and depression that follow use of the stimulant cocaine, reflect the body's ability to neutralize the direct effects of addictive drugs by producing an adaptive, physiologic response in a direction opposite to the drug's effect. Such a response assures that the body will not be overwhelmed by the drug itself. Drugs that can elicit an addiction apparently tap innate homeostatic stabilizing mechanisms in the body. These mechanisms operate through the actions of neurotransmitters.
These adaptive responses, which are clinically evident as withdrawal, are generally seen only when the direct effects of the drug have worn off and the body's adaptation response predominates. An alcoholic develops seizures after a long drinking binge; a cocaine addict "crashes" and sleeps after a day or two of cocaine use.
If an addict takes heroin enough times at a particular street corner, then his body generates its withdrawal response in association with the stimulus configuration of the street corner. The response is masked by the direct effect of heroin, at its brain receptor site. Ultimately, exposure to the street corner itself produces the withdrawal response. The heroin addict's innate homeostatic response becomes conditioned, unbeknownst to him, and leaves him vulnerable to conditioned withdrawal feelings whenever he is exposed to the associated stimulus of the street corner.
The conditioned cues that most commonly precipitate drug use are those immediately associated with ingestion of the drug itself. For the alcoholic, this is the taste of liquor, the handling of the glass, and the initial sensation of intoxication. For the heroin addict, these are the sight and manipulation of the 'works'—the needle, syringe, and spoon used to prepare and administer the drug—as well as the initial rush after ingestion. With each repeated administration, the addicted person becomes conditioned to experience the beginnings of the withdrawal response, subjectively felt as drug craving. The addict, however, may preempt the craving by immediately taking his next dose of the drug.
Because of this, each exposure to the drug of abuse, each drink, each shot of heroin, serves as a cue to further drug ingestion. Without a first drink—hence AA's insistence that "one drink and you're drunk"—the alcoholic may experience no immediate compelling cue to further drinking. After the first drink, the stirrings of conditioned withdrawal have been initiated, and vulnerability to the second and third is awakened.
The addicted person does not as a rule allow himself to experience the withdrawal that may emerge in the face of such conditioned cues. Instead, a chain of behavior unfolds in which drug-seeking and ingestion take place in order to avert an uncomfortable feeling of withdrawal. We have little empirical data allowing us to predict the course of this process in a given individual, so that it is hard to judge just who will become addicted.
Most psychotherapists operate on the assumption that patients will describe their symptoms in therapy in order to seek out relief from distress. Sadly, this assumption is of limited value in treating addicted people, and will fail on two accounts. The first is the outright denial that characterizes addiction. The second is that an addicted person is subjected to conditioned cues that lie outside of his awareness.
He may at times be aware of the circumstances that led him to slip, while being offered a drink or some cocaine. By the time of the next encounter with his therapist, however, the addict will have long since denied or lost touch with the cues that precipitated drug-taking. He will talk about the consequences of the slip, attributing them to some other available cause, perhaps blaming it on family or circumstance. Such misattribution is expected in the face of unexplained and unsettling experience. The addict in relapse will not spontaneously offer an understanding of how the slip came about, unless the cues precipitating it were so glaring that awareness breaks through a cloud of forgetfulness.
A therapist must elicit lost or forgotten information relating to a relapse, and encourage patients to become aware of the cues to which they are subject, so they can avert the consequences in the future. The therapist will have to enter areas that often have no compelling emotional content for the patient. Using an approach I call guided recall, a patient must be asked questions about locations, casual companions, seemingly unrelated events that were associated with the time when conditioned cues were first encountered.
If the street-corner context that precipitates heroin craving is consciously associated with some threat, the addict can recognize it better in the future and act to avoid that setting. If addicts are alerted to the fact that certain disappointments lead them to drink, they can become aware of the conditioned sequence and be forewarned. Therefore, the goal of therapy must include making addicted people aware of the conditioned cues to which they are subject and then labeling them in such a way that recovering addicts begin to find these cues aversive.
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Excerpted from Network Therapy for Alcohol and Drug Abuse, by Marc Galanter, M.D. Copyright 1993 by Marc Galanter. Reprinted by arrangement with Basic Books, a division of HarperCollins.