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I I I I I I I I I I I I I I I I I I The Journal of Drug Issues 23(3), 463-4 i 8 1993 - 'I'HE DISEASE CONTROVERSY REVISITED: AN ONTOLOGIC PERSPECTIVE Charles Neuhaus, Jr. The current debate over the disease model of addictive behaviors is brie1Zy reviewed, and the ill-will between some advocates and opponents of disease conceptions is noted. The recognition that language distinguishes humans from other living beings is introduced, in which one's reality is generated lingu.istically. This is fundamentally divergent from the rationalistic view that there is an objective world, free of observer bias, that language seeks to describe. Consequently, diseases are seen as interpretations, or attempts to ascribe meaning to a set of observations. Since meaning happens only in language, diseases are necessarily linguistic distinctions, and not physical entities. The author recommends efforts be directed toward developing innovative treatment approaches, rather than quarreling over the veracity of addiction as disease. Listening for the explicit and implicit rules that patients live by and assisting them to invent new realities and practices in language that permit more productive moves is advocated. Introduction Whether or not alcoholism and other addictive behaviors can be attributed to a primary disease process has attracted the attention of clinicians and theorists, with more heat generated than light, in the attempt to prove one position more correct than another. Authors such as Jellinek (1960), Johnson (1973), Peters (1984), Talbot (1983), Vaillant (1983), Wallace (1985), and many others have advanced the argument for the disease model. In this view, alcoholism and other drug addictions are understood to be caused by a primary disease process. Individuals are said to lose the capacity to control or li:nit the amount they ingest and to continue to use the substance despite aegative consequences associated with that use, and the disease is considered progressive and terminal. Some proponents of this model claim that alcoholics inherit the disease, and that they (and other addicts) differ physiologically from nonalcoholics. They point to currently incomplete evidence suggesting biological (Blum et a1. 1990) or genetic (Bohman, Sigvarrdsson, and Cloninger 1981; Hrubec and Omenn 1981; Schuckit 1987) influences, and anticipate that alcoholics may someday be identified even before drinking problems are manifest. Others have challenged the concept of addictive disease and dismiss it as Charles Neuhaur, Jr., M.Ed., C.A.S., is a substance abuss clinician at the Miner Street Treatment Center of Harvard Community Health P1an. and sarves on the faculty of the Norman E. Zinberg Center for Addietion Studie., Department of Psychiatry, Harvard Medical School at The Cambridge Hospital. Requests for reprints should be addressed to Charles Neuhaus, Jr., M.Ed., C.A.S. at Harvard Community Health Plan. 23 Miner St.. Boston, MA 02216. O Journal of Drug Issues, Inc. 0022-442fjSW$/463-478 $1.00 463

I I I I I I I I I I I I I I I I I I NEUHAL'S fol+dlore, superstition, and unsupported by research findings (Faulkner. Sandage, and Maguire 1988; Fingarette 1988; Peele 1984, 1988, 1990a; Szasz 1974). Peele has been especially pugnacious in his attempts to discredit the disease model. He has charged that treatment interventiona,grounded in addiction as disease conceptions are actually counterproductive (Peele 1988, 1990a, 1990b, 1991). Unfortunately, these theoretical and philosophical disagreements have been superseded by polemics and personal attacks, including accusing disease advocates of self•serving and persecutory motives (Peele 1988, 1990a, 1990b), and counter charges of professional irresponsibility, inadequate scholarship, and implications of quackery (Wallace 1987, 1989, 1990, 1992). In an apparent attempt to heal the rifts, as well as to further our understanding of these behaviors, Shaffer (1985, 1987) proposed that the disease concept be understood as a metaphor, or as a map of the territory. Later, he demonstrated that all clinical perspectives represent 'manufactured meanings" (Shaffer and Robbins 1991). This was not intended pejoratively, but rather as a recognition that different points of view of the same phenomena can, and do, coeast. There need be no implication that other positions are less valid to support or employ a particular vantage point. For example, a psychodynamically-oriented psychologist might understand a patient's difficulties as a consequence of maternal deprivation and childhood trauma. Few would be surprised if that clinician requested a medication evaluation from a psychiatrist who prescribed tricyclic medication. Although the same symptoms were observed, a distinctly different explanatory framework would be used to diagnose a biological depression. More recently, influenced by the work of Martin Heidegger (1962, 1971) and Fernando Flores (Winograd and Flores 1986), Neuhaus (1991) posited that the term disease is a linguistic distinction, and not an entity with objective properties. In this view, diseases are not inherent, universal realities or things that can be proved or disproved. The tradition of rationalistic inquiry suggests that the goal of science is to discover the truth of an objective world by somehow escaping observer bias. An ontologic perspective recognizes that objectivity is impossible and that organisms are constrained by their biologic structure. Humans attribute meaning to events, and are distinguished from other living beings by the capacity to design the future. The purpose of the present article is to examine the phenomenon known as addictive behaviors from this perspective to illustrate the futility of the addictive disease controversy, and to further cliniciann' ability to prescriptively provide effective treatment even to patients who do not share their point of view. Cartesian and Newtonian Science and Language While DesCartes believed that scientific inquiries could best examine matter in its smallest constituent parts, Newton attempted to ascertain the laws of nature, as if they were preordained by the creator. Each discovery or technological innovation would thus allow scientists to more closely approach the essence, or truth, about the nature of the world in which we live. Over time, science was no longer imbued with religious significance. Nevertheless, the historic consequence of these pioneers endures in the unezamined assumptions of both our present common sense, and the classical scientific model that suggests there is an objective world, independent of the 464 JOURNAL OF DRUG ISSUES

I I I I I I I I I I I I I I I I I I THE DISEASE CON"I'ROVERSY observer. Eventually, Kant ((1"87] 1975) introduced the notion that the 'mind" is not a passive spectator, but organizes experience so that the individual can understand, or make sense of it (Budd and Zimmerman 1986).986). The biologists Maturana and Varela (1980, 1987) have demonstrated, in a scientifically-grounded argument, that living beings are structurally determined. To briefly summarize their thesis, living beings are closed systems, with information neither leaving nor entering the system. The organism can only respond to perturbations of the environment as its structure allows. When the structure of the organism is modified so as to permit new behavior, it can be said that learning has happened. Maturana (Maturana and Varela 1980) coined the term (objectiuity), in which the parentheses reflect that our worlds of perception are defined by the structure of the nervous system, rather than the traditional and automatic (i.e., without reflection) assumption that the nervous system provides a representation or map of reality. Observers can never really know the world, only that the structure of their nervous system is being triggered in some way (Maturana and Varela 1987). To illustrate, in Pavlov's famous experiment, the nervous systems of dogs were recurrently perturbed by the presence of food accompanied by a ringing bell. When the dogs salivated in response to the bell without food, an observer could say that their nervous systems have been modified, permitting a new behavior to appear. However, the dogs could not learn behavior not allowed by their biologic structure (e.g., flying or whistling), nor could they be triggered by stimuli not recognized by their structure (e.g., printed words). We can say that, for dogs, such stimuli do not exist, no matter how obvious or real to human observers. According to Winograd and Flores (1986:68), 'Nothing exists except through language.' For a given observer, there are events (e.g., objects, actions, and phenomena) that his or her biology (physical structure) and history (personal, familial, cultural, professional traditions, etc.) allow to appear. The same phenomenon will not exist for another observer if their biology and history do not allow them to make certain distinctions. Observers not familiar with the structure of a cell on a microscope slide will be `blind' to the systems known as cell wall, nucleus, and so on. Of course, the physical "stuff" or matter is present, but the entities do not exist in the reality of these naive observers. With training in the biological sciences, one is able to make sense of what was previously incomprehensible, while the slide itself remains unchanged (Budd and Zimmerman 1986). Language both conceals and reveals, as it invents rather than describes reality. Living in these distinctions generates a different world. What Is A Disease? To the extent that the medical/scientific model influences substance abuse clinicians, they seem to think that the truth can be known, and the clinician's task is to discover that truth in order to effectively treat the patient. In other words, clinicians practice as if objects existed independently of the observer. In this unarticulated, but pervasive paradigm, diseases are seen as entities, somehow existing within the individual, and which doctors are scientifically trained to find (Budd 1992). Clinicians generally do not recognize that a diagnosis is always an assessment, not a statement of truth. Diagnoses do not exist independently of the observer, but represent judgments, rooted in the cultural and historical Summer 1993 465

I I I I I I I I I I I I 1 I I I I I :vEUHAt'S context, that an individual's functioning is impaired, and which has implications for their future well-being (Colasanti 1991; Eisenberg 1977). Furthermore, clinicians rarely distinguish between disease and illness, often using the terms interchangeably. Eisenberg (1977) proposed that diseases represent disruptions in the structure and function of the body organs and systems, while illness refers to diminished social function or states of being. Doctors interpret test results as proof of the presence or absence of disease. Patients are interested in whether or not they experience limitations in their family, social, and vocational spheres, notwithstanding the doctor's devotion to, and reverence for, tests that cannot measure pain, assess work performance, or evaluate family dynamics (Colasanti 1991). To illustrate, assembly line workers have complained of pain and discomfort after recurrently performing certain motions. They often have been dismissed as malingerers or described as psychosomatic. Physicians now have introduced the term repetitive motion injur.ies and validated the discomfort that their patients were reporting. We can surmise that the diagnosis "repetitive motion injury~ lay quietly awaiting discovery for decades or that it did not exist until recently, and has been invented as a social phenomenon, which only happens in language. Paradigias and Standard Practice If doctors interpret patient complaints according to the prevailing cultural standards, then they are not purveyors of truth. The concept of paradigm, articulated by Kuhn (1962), has been applied to clinical situations in general and specifically to addictions treatment. An operating paradigm serves as a template through which the clinician views patients and their problems; this template organizes information and suggests which questions to ask and which data are important (Shaffer and Neuhaus 1986: 88). In addition, paradigms operate so automatically that clinicians seldom challenge their limitations. This has been referred to as the blinding function of paradigms (Shaffer and Gambino 1979). Health care providers, like all practitioners, make observations and take actions consistent with the standard practices of their professional discipline. A physician might visually examine and palpate the patient's body, take a medical history, and review the records. The clinician then attempts to assign meaning to observations of, for example, blood pressure readings that could be coupled, by the clinician, to the patient's report of headaches and prescribe antihypertensive medication. Alternatively, a psychologist might interview the same patient and administer psychological tests before recommending psychotherapy to relieve stress. The diagnoses "hypertension" and "stress" are interpretations that cannot be seen or touched; they happen purely in language, not in the physical world. Interpretations are influenced by, and reveal more about, the historical and cultural context of the observer than the subject itself. They are never right or wrong, but can be supported by evidence, including test scores and blood pressure readings. While these also are invented in language (and not truths awaiting discovery), observers can see, measure, or define them with certain "acts of distinction" (Maturana and Varela 1987: 40). 466 JOURNAL OF DRUG ISSUES I

I I I I I I I I I I I I I I I I I I THE DISEASE CON"IROVERSY In the examples above, both providers act according to historically- determined discourses, and generate diagnoses that make sense within that discourse. However, observations and actions can be irrelevant or even contradictory when considered from within another discourse. When a doctor recommends vaccination to sorneone immersed in the discourse of voodoo, referring to invisible microbes and antibodies is apt to sound like superstitious nonsense. Similarly, the explanations of acupuncture treatment offered by Chinese practitioners make no sense in a Western paradigm, nor can they be transposed to more familiar terms. By recognizing that we are blinded, as well as informed, by our point of view (Neuhaus 1991), we can begin to see more. In order for disciplines to flourish and be recognized as valid, they must provide practitioners with actions that produce results judged as effective by the community. However, health care providers within a given tradition may produce results for some conditions, and subsequently be assigned responsibility for treating other conditions. If they have few or no useful distinctions, they will be unable to respond effectively. Perhaps because of earlier successes, both the community and the profession may be slow to recognize the poor results. In some cases, patients are assessed as resistant and uncooperative. For example, traditional Western medicine has produced spectacular results in treating bacterial infections and innovating surgical procedures, but has been less successful in responding to complaints now commonly heard by general medicine practitioners such as fatigue, chronic pain, and stress (Budd 1992). It is now widely recognized that, despite early attempts, the addictive behaviors did not respond to psychoanalytic methods, and other techniques have been developed. Whether the health care professions (rather than family, clergy, educators, the criminal justice system, social policy administrators, etc.) should have responsibility for these conditions has seldom been questioned (Shaffer 1982, 1984). Reification and Reductionism Nevertheless, addiction treatment providers continue to practice as though concepts, interpretations, and metaphors invented to facilitate speaking about and understanding observable phenomena were themselves actual entities, things to be observed. To compound the confusion, the interpretations are then spoken as explanations. To illustrate, when individuals are assessed by the community as drinking more than acceptable amounts, they may be considered to be addicted. To neutralize the guilt and social stigma associated with the behavior, addiction is often understood as a disease. The linguistic distinction "disease," which is neither a truth nor an entity, but only a way of speaking about behavior(s), is then used to explain the behavior. In other words, people are said to be alcoholic because they drink too much, and then said to drink too much because they have the disease of alcoholism. Other potentially useful terms for making sense out of chaos have been similarly reified and then used as quasi-explanations. For example, the observation has been made that many, whose use of a substance is assessed to be excessive, frequently use increasing amounts of the chemical and tend to precipitate ever greater social consequences. Some observers have found it useful to refer to this tendency as "progression," which is simpler than saying "people tend to use more and more, and tend to experience more and more Summer 1993 467 ~ ~ ~ ~ I

I I I I I I I I I I I I I I I I I NEUHAUS problems. ^ However, the term progression is often spoken as if it were a force that actually exists, rather than way of talking about what we see. Furthermore, this attempt to 'pathologize' behavior is more likely to occur with activities clinicians consider undesirable (Efran aad Heffner 1991). If a student develops an interest in reading, it is seldom seen as an alarming case of progression, even when meals are missed and homework assignments are ignored for the sake of an engrossing novel. Instead, the student will likely be encouraged to cultivate preferences and explore the work of a favorite author or research a topic of interest. The problem is not that we speak in interpretations and metaphors, but that we have forgotten that we are speaking them, and not describing reality. Referring to a behavior as a disease can be an effective way of speaking, which we can assess by comparing the results to accepted community standards. When we do not produce the desired actions, it is reasonable to search for another ontology, or set of distinctions. Just as a car represents transportation to some drivers, others will derive status and prestige from their automobile. Similarly, Efran, Heffner, and Lukens (1987a, 1987b) have shown that a circus may be experienced as a financial event. Even though evidence can be marshalled to support this perspective, such as box office receipts, payrolls, accounts payable, and so on, it can not speak the whole truth about circuses. Another observer, possibly including an accountant sitting in the grandstand as spectator, could enjoy the animal acts and acrobats. In that moment, the event becomes primarily about entertainment, rather than finances. Both interpretations can coexist without conflict, each with their respective merits. Neither ontology tells the whole story of what a car or a circus is for once and for all. Explanations in terms of brain chemistry often seem more "real~ to us than those that focus on, say, patterns of communal living, reinforcement schedules, or personal gain. This is, of course, the reductionistic error to which our culture is prone. Virtually any pattern of human activity - from falling in love to falling down the back stairs -can legitimately (and sometimes usefully) be described in the language of biochemistry. However, positing an explanation in one linguistic domain - the biochemical - does not replace nor invalidate explanations proffered in other domains, such as the sociological, psychological, religious, economic, and so on (Efran and Heffner 1991: 57-58). The available sets of distinctions have direct consequences in the actions seen as possible and relevant by practitioners (Efran, Heffner, and Lukens 1987). When a culture or tradition and its language can provide a rich panoply of distinctions in a given domain, its members or adherents can act more effectively than those whose heritage supplies a spare and limited taxonomy for expression. U,rdu offers many more ways to articulate unrequited love than does English (Kapur 1987). The precision available in the English language is said to lend itself to scientific and mathematic pursuits, while emotions and poetry are better expressed in Italian. For example, if physicians were unable to distinguish between viral and bacterial infections, their effectiveness in prescribing suitable treatment and 468 JOURNAL OF DRUG ISSUES I

I I I I I I I I I I I I I I I I THE DISEASE C0YTROVERSY medication would be lessened. Calling a set of distincti .ns a disease is neither true nor untrue - never a complete depiction. Constructivism and Language Shaffer's (1985) characterization of addictive disease as 'metaphor' may have been inferred by some (Wallace 1989) as diminishing the validity or realness of the term disease. While I do not disagree with Shaffer (1985, 1987; Shaffer and Robbins 1991), what he and some other constructivists (Bateson 1972; Watzlawick 1984, 1990) fail to show is that these social constructions (e.g., realities, metaphors, heuristics, meanings, abstractiona), happen in language (Winograd and Flores 1986). While some (White and Epston 1990) argue that people give meaning to the events of their life through the stories or narratives they tell, this view seems to imply that some intention is exercised in the authoring of these stories. For an ontologic observer, individuals are their stories. In other words, they embody the interpretations, meanings, beliefs, and so on of their personal history and cultural and professional traditions. Individuals do not consciously choose them. Instead, these narratives and discourses are historically generated and transmitted from one member of a community to another through the social acts of living together. Rather than choosing their clothing, foods, jobs, family interactions, social practices, and so on from all of the possibilities available, people act within their historically-determined traditions and discourses. These constructions operate as if they were scripts that dictate the likely actions, beliefs, and emotions. The criticism that the role of emotion is underestimated by conatructivists (Nichols 1990) misses the point. In the contemporary discourse of psychological explanations, cognitions and emotions are regarded as discrete and concrete entities that reside in the mind. Absent from this understanding is a rigorous investigation of the phenomena we call moods and emotions. From an ontologic perspective, emotions are not independent and autonomous entities. They happen within the personal, familial, and cultural narratives by which one experiences life, and are manifested in a biological response. Emotions cannot be isolated from cognitions (language) nor can they exist separate from a physical body. Not only are clinical perspectives manufactured (Shaffer and Robbins 1991), but so are the concepts pervasive and fundamental to living with others in a social community (Efran, Heffner, and Lukens 1987); trust, compassion, contracts, marriage, nations, science, and the mind are constructs invented in, and made possible by, language. They facilitate our relating and interacting with other people, and happen in a linguistic space, not in the physical world. There are whole domains, such as those in financial markets involving "shares," "options,- and "futures,' whose existence is purely linguistic - based on expressions of commitment from one individual to another (Winograd and Flores 1986: 174). Although a full exposition of their thesis is beyond the scope of this article, Winograd and Flores (1986) argue even things directly experienced through the senses (e.g., water, rocks, automobiles, eta) exist in the world of an observer only by being articulated in language. This is a counter-intuitive, and possibly Summer 1993 469

I I I I I I I I I I I I I I I I I I I NEUHALi S disturbing, notion to some observers. Nevertheless, for nonlanguaging species. including human infants, objects can not be distinguished from the background. even when a sensorimotor response is stimulated. Helen Keller chronicled her transformation from the nothingness of her prelanguage existence to the emergence of entities, events, circumstances, and her personhood, which all became possible when she recegnized the motion of her teacher's hand on hers as the symbol for water (Keller 1903, 1908). Accordingly, which substances are considered drugs is a function of linguistically determined, but usually implicit, mores and values, referred to as social setting by Zinberg (1974, 1984). For example, at different times, cigarette smoking has been considered evidence of moral weakness, a sophisticated mannerism, and, more recently, a disgusting and dangerous addiction. In addition, Shaffer and Neuhaua (1985:87-88) argue that an individual's "prior experience, social circumstance, and/or profession" influence how one appraises that individual's drug use. Evidence of a single episode of illicit substance use would likely result in different consequences for a paroled felon than for a respected and otherwise law-abiding community leader (Neuhaus and Caplan 1992). Moreover, Zinberg (1974, 1984) showed that "set," referring to an individual's expectations, beliefs, and attitudes, influences the effect of a chemical agent. Whether one expects to become intoxicated, or perceives social license for drunkenness will affect behavior (Chiauzzi 1991; Efran and Heffner 1991; Marlatt and Rohsenhow 1980). Drug effects are determined by linguistic as well as biological factors. Social-Linguistic Coordirations While "saving a marriage," or "going to a wedding" are familiar and convenient expressions, marriages are not objects to be examined. Although animals coordinate behavior (e.g., mate, reproduce, share a home, and hunt and eat together), language, which Maturana (Maturana and Varela 1987) calls the coordination of coordination of behavior, permits actions for designing the future. Thus, a wedding is a ritual for making the explicit and formal requests and promises that differentiate being married from other relationships. Language makes both marrying and reflecting upon it possible. Similarly, a disease cannot be observed. Doctors refer to a set of observations (i.e., signs and symptoms) as diabetes, coronary heart disease, or cancer. Speaking in such a way facilitates the doctor-to-patient and doctor-to-doctor conversations. However, the same symptoms observed by another practitioner could be judged as insufficient to make the diagnosis, or indicative of another condition. Diseases are always interpretations made by an observer. Even when there is widespread agreement and the interpretations lead to useful interventions, they do not represent truth or certainty. For a patient who has suddenly gone mute, it makes sense to accept a diagnosis of "spirit possession" if one were interested in knowing what the phenomenon means to the patient and others in the culture. It would make even more sense if the only therapist available is a traditional healer specializing in exorcism. On the other hand, a psychodynamic theorist might prefer to see this as a hysterical phenomenon. ... Each way is valid but only to an extent - each way 470 JOURNAL OF DRUG ISSUES

I I I I I I I I I I I I I I THE DISEASE COti'TROVERSY adds and d-rtracts information, each categorization is useful in some way but not in another. The classification of psychiatric disorder should allow itself to be open to all these expressions and meanings, and the users should remain open to the realization that there is no absolute truth to any of these (Kapur 1987: 47-48). Debating whether or not addictive behaviors are a disease is divisive and distracting. It is no more productive than attempting to resolve whether television viewing is good or bad. The answer depends upon when and of whom it is asked, and for what purpose one watches. While some will say that television is a convenient and inexpensive source of entertainment and education, others will maintain that it encourages passivity or promotes violence. Each premise has its merits, but assigns different weight or value to the evidence, is measured by separate standards, and cannot be used to discredit the other. History, Innovation, and Design It is tempting to dismiss beliefs and rituals of an earlier time as unenlightened folly. Bloodletters practiced for centuries within the explanatory framework of balancing humours. Given the distinctions available, (e.g., black and red bile, etc.), the practice must have seemed utterly reasonable and responsible to observers of the era. The deaths of some patients were likely dismissed as acceptable and unavoidable losses, not as evidence of a misguided practice. The current discourses or traditions in which we live and practice transparently (without reflection) both reveal and obscure the actions possible. How will history judge present day addictions treatments, given the large numbers of patients who do not improve, or worsen after treatment? In a recent study (Walsh et al. 1991), employed heavy drinkers treated in hospital programs were compared with those who only attended Alcoholics Anonymous. Forty-two percent of all subjects required subsequent hospitalization within two years. Of the group treated in hospitals, which showed the most improvement, 23% reported continuous sobriety over two years. This means that about three-quarters of hospitalized patients experienced some degree of relapse. Although the data have been widely interpreted as an endorsement of hospital treatment, the evidence simultaneously reveals the importance of developing innovative and more effective treatment approaches. Some drinkers avoid engaging with treatment when they do not wish to participate in the disease conversation. Others eagerly speak the language of disease and recovery. However, they are unable to change as they maintain old and familiar, but ineffective or destructive behavior. Our failure to help these patients should be at least as instructive as our successes in assessing efficacy. There is little room for innovation and creativity in clinical situations when providers are committed to a predetermined, unitary model. Having defined their function as converting patients to their point of view even before someone walks in the door, clinicians deny themselves the opportunity to explore and invent conversations that open up new and unforseen possibilities. The recognition that language does not describe, but generates reality, empowers clinicians to rigorously "listen" to patients (Budd and Zimmerman 1986). According to Budd (1992), distinguishing pain from suffering is critical to understand the nature of patient problems. Pain is biologic, and happens in the present time when a body is perturbed in certain ways that are assessed as Summer 1993 471 I ~ I ~ ~ ~ I O O C.D C3T

I I I I I I I I I I I I I I I I .NEUHAliS negative. Suffering exists in the narrative or sto-y that a patient embodies. When disappointed or betrayed, different observers will make sense of the event according to their historic traditions, beliefs, or values. Resentment, for example, is the automatic assessment that one has been harmed with no willingness to generate a conversation that would allow the other to make amends. Resentment is manifested in the body, but keeps one trapped in the past. The sometimes implicit rules and related strategies that patients live by determine what actions are permitted, required, and prohibited. Clinicians can help clients renegotiate their own rules, allowing different behaviors and inventing new identities. For example, instead of suffering in resentment in accordance with the arbitrary rule of -not giving in," one can decide to inform the perceived offender of the hurt and disappointment engendered by their behavior, and request corrective actions. Alternatively, forgiveness can be declared unconditionally. Similarly, one might discover a patient's belief that saying no to another's request is impolite or uncaring, with diminished autonomy and self-respect as a consequence. Clinicians can show that politeness and caring are only characterizations (in language), for which the standards vary from observer to observer, and concurrently use exercises to strengthen the ability to respectfully decline requests. Furthermore, stress can be reinterpreted as a function of the inability to make and decline requests (Budd 1992). When patients express concerns about trusting and being trusted, the clinician can show that the phenomenon of trust is related to the promises one makes and receives. Reflecting upon what specific promises have or have not been made, and evaluating the promisor's competence and sincerity, will help patients determine when to exercise prudence, rather than oscillating from mistrust to naiveti. These distinctions, constituting a language set or system, indicate different actions to take. This is more fruitful than simply reiterating that the patient has ~trust issues," as if trust were an entity possessed by some fortunate individuals, and lacking in others. The disease model per se only explains the loss of trust as a symptom of the disease, without recommending specific corrective action to take and skills to learn. These are strategies that can be employed whether or not one embraces a disease philosophy if one recognizes that individuals invent their identities in language (Budd 1992). The possibilites suggested here are linguistic in nature. Although one usually defines action as movement in time and space, speech acts have the potential to profoundly alter moods and relationships. Effective living with others is a function of one's ability to coordinate actions by making requests, promises and declines, declarations and assessments, and assertions. Furthermore, knowledge is demonstrated by the ability to perform certain actions. Individuals behave without reflection in historically and socially determined ways, and learning requires a structural alteration of the nervous system (Maturana and Varela 1987). This understanding permits a compassionate and effective explanation for the persistence of unwanted behaviors. Americans drive on the right side of the road, not by divine edict, but social (i.e., linguistic) agreement. Motorists appropriately attempting to stay on the left in a foreign country will notice the tendency to veer right whenever strict concentration is relaxed. This happens in spite of intellectual awareness of the danger and social disapproval that the old behavior engenders. However, 472 JOURNAL OF DRUG ISSUES