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.
Coercion
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.
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:
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