Drug and Alcohol Review (r99o) 9, ~59 -266

Spirituality: the silent dimension in addiction research. The I99o Leonard Ball oration

WILLIAM R. MILLER

University of New Mexico, Albuquerque, New Mexico, America

United States of

Abstract

Researchers currently recognize and incorporate psychological, biomedical, and social determinants in the study of addictive behaviors. Yet spiritual aspects of addiction and recovery remain virtually unstudied, despite the fact that spirituality is given central importance in Aleoholics Anonymous and in the lives of many individuals. Traditional spiritual eoncepts have been relabelled to remove their transcendent dimension, and addiction researchers have acted as though spirituality plays no role in the lives of those they study. Consequently an entire elass of potentially important variables is being overlooked. A majority of variance in addictive behaviors and treatment outcomes remains unexplained, a portion of which might be accounted for through the study of spiritual dependent, moderator, and independent variables. Behavioural scientists have begun to aeknowledge the role of complex spiritual, moral, and decisional processes in the addictive behaviours. Though uncomfortable in some ways for both believers and unbelievers, the seientlfle study of spiritual processes may improve our understanding of the addictive behaviours, and our ability to prevent and treat these enduring problems.

To the psychologist the religious propensities of man must be at least as interesting as any other of the facts pertaining to his mental constitution.

William James

Introduction

The study and treatment of addictive behaviours have entered the 'multi' age. We employ multivariate statistics to analyze multiple measures assessing multi- modal treatments delivered by multidisciplinary teams. Territorial chauvinism is giving way to a view of

addic t ive behaviours as multifaceted problems, influ- enced by multiple determinants, expressed in a multipli- city of types rather than a single uniform condition. Any model worth its salt today has to be 'biopsychosocial'.

This insight is not exactly new. Jellinek's r960 treatise on The Disease Concept of Alcoholism discussed biological, psychological, and social determinants, and proposed a typology to distinguish among different

types of alcoholism [i]. The r939 edition of.,41coholics Anonymous described alcoholism as a disease with "medical, psychiatric, social, and religious" dimensions [2, p. I9].

Religious? Whatever happened to this fourth dimen- sion? Biological, psychological, and social factors are all well represented in modern scientific theory and research on addictions, but the spiritual dimension has been curiously ignored. The degree of researchers' inattention to spiritual aspects is remarkable and, I think, unlikely to have occurred by chance (p <0.05). Modern studies have explored alcohol's effects on the permeability of cell membranes, addicts' responses to specific items of personality questionnaires, and the influence of country music tempo on drinking rate. We research expectancies, self-image, and defence mecha- nisms, DNA, enzymes, neurochemicals, and immune functions, the influence of gender, culture, and advertis- ing. A few recent voices have called for acknowledg- ment and exploration of the moral side of addictive

William Miller, PhD, Professor of Psychology and Psychiatry, University of New Mexico, Albuquerque; New Mexico 87x3i , United States of America. Correspondence and requests for reprints to Professor Miller.

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260 I~illiara R. Miller

behaviours [3-5], but serious scientific research on the spiritual side of addictions is rare indeed. Why have we maintained such a peculiar research silence on this topic?

The divorce of body, mind, and spirit

In part, our fragmentation of people and their problems may have arisen from the increasing specialization of professionals. We have spent four decades, for example, debating whether the addictions are primarily biomedi- cal or psychosocial phenomena, when it is abundantly clear that both classes of determinants are important. This polemic is one reflection of the dualistic isolation of professionals treating 'physical' problems (e.g. physi- cians and nurses) from those addressing 'mental' disorders (e.g. psychologists and counsellors).

Whilst biomedical and psychosocial knights have been jousting, few have championed spiritual factors as predominant, or even significant determinants of addic- tive behaviours. The spiritual domain has been further isolated and separated from both biomedical and psychosocial professions. As Mansell Pattison observed, all of these healing functions were once integrated within a single social role, and are still so united in some cultures and subcultures [6]. The holistic approach is not a new, but a very old tradition. It is rather recently that the domain of spiritual guidance has been socially and economically isolated from the practice of healing. Many people, in fact, still seek first the counsel of their clergy when encountering life problems.

Intersection

The disciplines of psychology and psychiatry are themselves developmentally intertwined with philos- ophy and theology. William James, Karl Menninger, Carl Jung, Gordon Allport, Erik Eriksen, Viktor Frankl, Lois Barclay Murphy, Lawrence Kohlberg, and Erich Fromm were all much interested in and con- cerned with the role of spiritual and religious processes in human life. Other pioneers of the field were significantly influenced by religion and seminary educa- tion, including Carl Rogers, Rollo May, and O. Hobart Mowrer. More recently, these ties have been explored in the writings of Scott Peck [7], Allen Bergin [8], Alan Watts [9], Herbert Benson [xo], and Norman Cousins [ix], among others.

In pursuit of hegemony, however, the psychological and medical professions have established a certain territorial imperative in the healing field, marking their boundaries not only with licensing statutes but also with vocabularies. Longstanding spiritual concepts remain in use, but are recast in new jargon. 'Sin' is rejected in

favor of concepts such as 'alienation' and 'rebellion'. 'Faith' and 'hope' are discussed in terms of 'expectancy' and 'placebo effects' [i2]. The old Methodist concern with 'backsliding' has been born again as 'relapsed prevention' [i3]. The healing power of 'grace' and 'forgiveness' is encapsulated in 'acceptance'. Modern professionals are concerned with 'personality', not 'character', though a few character constructs such as 'self-control' have escaped renaming [I4]. We live in a post-Babel era, in which professionals speak in a confusion of different tongues.

What is missing in these new biopsychosocial definitions is a sense of transcendence. In every culture through all of recorded history, at least large segments of humankind have assumed the reality of a spiritual dimension that transcends material existence. This unseen domain is usually but not always personalized, and the deities worshipped through the ages have varied greatly in their form and nature. Many people have described, and continue to describe, direct personal experiences of God and of transcendence, a topic that was of great interest to William James [i5] , hut such experiences are seldom included in modern scientific conceptions of human problems and their healing. A key difference between spiritual constructs and their psychological or biomedical counterparts is the removal of this transcendent dimension. Modern grace has no suprahuman source, and faith no transcendent object. Character and sin must be redefined if there is no absolute, external standard against which to judge behaviour as virtuous or wanting.

And this, many may say, is exactly how it should be. Science and religion do not mix. Since the persecution of Galileo, scientists have recognized the wisdom of separating themselves from religion. As Descartes divorced the body from the soul, thereby clearing the way for medical progress through the scientific study of bodies living and dead, so--one might assert--the behavioural sciences must separate themselves from matters spiritual. In this way, scientists can proceed with greater objectivity, unhindered by the blinders of belief systems.

The fallacy of this perspective has been addressed in detail elsewhere [8,I6-I7] , and is not a central focus here. Suffice it to say that whatever the abstract merits of this argument, scientists (and therapists) do not and cannot proceed in a vacuum free of values and beliefs. The canons of science require no suspen- sion of one's belief system, only a willingness to question and test it. The perception that one is operating with total objectivity, unbiased by personal beliefs, is a dangerous assumption, both in science and in therapy. My purpose here, however, is not to attack the rejection of spiritual factors in science, but to commend their relevance in the study and treat- ment of addictive behaviours.

Spiritual variables

Reasons for interest

My central thesis here is that an entire class of potentially important variables is being overlooked in current research and (to a lesser extent) practice in the area of addictive behaviours. These are spiritual variables. By 'spiritual', I refer to transcendent processes that supercede ordinary, material existence. This in- cludes, but is not limited to, systems of religion. The easiest examples are those which involve relationship to a God, deity, divine presence, or higher power. Certain religious and existential questions [i8], however, also involve this transcendent dimension without necessarily assuming the existence of a personal deity (e.g. Why am I here? What meaning or purpose is there to my life? What happens to me after I die?). James discussed spirituality in terms of this more general search for discernment of meaning [i5]. It is important to note that a scientist (or therapist) need not personally affirm transcendent reality in order to consider the relevance of spiritual variables in addictive behaviours and their treatment. Neither does the measurement of such variables assert transcendent reality. The scientific concern is whether a person's disposition on such variables can account for variance in behaviour.

Herein is one reason for openness to spiritual variables in the study of addictions. At our present state of understanding, we are accounting for only a minority of variance in addictive behaviours and treatment outcomes through psychological, biological, and social variables combined. That is, most of the variability in the onset, process, and outcome of addictions remains unexplained at present, and we can ill afford to ignore any class of variables with potential explanatory power. Although we may yet identify that single elusive psychological, biological, or social variable which drives the preponderance of variance, our best minds and measures have not yet unearthed it. In this light, the existence of an entire measurement domain, largely untapped in prior research, should at least evoke curiosity. In the quotation opening this paper, William James argued that human spiritual processes should be "at least as interesting" to psychologists as other determinants of behaviour [i5].

A second reason for interest is that both our clients and our colleagues have pointed to the importance of spiritual processes in addictions. The essence of Alco- holics Anonymous (AA) is unambiguously spiritual [2]. Alcoholism is described in AA as a fundamentally spiritual problem (e.g. self-centeredness and resent- ment), which is also influenced by psychological and physical factors. The official account of 'how it works', manifested in the familiar 'twelve steps', emphasizes acts such as turning to God, taking a personal moral inventory, confessing and making amends for past

Spirituality 26x

wrongs, praying, living by spiritual precepts, and reaching out to others. That is, spiritual variables are described as lying at the core of addiction and recovery, within a movement that boasts more than a million members in tens of thousands of groups spread over a hundred countries. It seems, in fact, that the question in the minds of the founders of AA was not whether spiritual factors are important in recovery, but rather whether it is ever possible for alcoholics to recover on a non-spiritual basis, without the help of a higher power [2]. Despite the current lack of objective scientific proof for AA's efficacy [i9] , one cannot discount its social success and influence. The tenets of this major movement clearly assign central importance to spiritual processes, and could yield testable hypotheses in this regard.

Interest in essentially spiritual processes within addictions has not been limited to believers and proselytizers, but has extended to distinguished behav- ioural scientists of the field. Orford has called for "a consideration of the role of higher-order attitudes and values, and hence of 'spiritual' factors in behaviour change," and asserted that, "The moral aspects of the appetitive behaviour change process have been insuffici- ently acknowledged" [-20, p. 29i j. In discussing addic- tions, David Premack asserted "that the individual has a conscience--a set of beliefs that prohibit certain acts--and further, that the discovery that one is engaged in behaviour that makes one a member of a prohibited class can be acutely humuliating" [2I, p. Izz]. Hunt & Matarazzo similarly discussed the role in addictive behaviours of volitional and wilful decisions, impacted by larger value systems. "The phenomena are there. We would rather avoid the issues involved, but we will accept the risk rather than brush the behavioural phenomena under the rug" [22, p. 84]. The constructs being discussed by these scientists are moral processes, which may or may not involve a transcendent dimen- sion. Morality, in this sense, involves a higher-order value system of right and wrong, which guides behav- iour and affects social contingencies. Spiritual perspec- tives typically include such a system of morality, and may further perceive a higher transcendent source or authority behind these values.

The expressed views of these behavioural scientists point to yet a third reason for interest in processes that are usually regarded as 'spiritual'. The kinds of change sometimes reported by members of Alcoholics Anony- mous do not resemble the familiar successive approxi- mations of learning theory. The experience of Bill Wilson, co-founder of AA, was sudden, dramatic, and life-changing. In his personal account he reported that he was "catapaulted into what I like to call the fourth dimension of existence. I was to know happiness, peace, and usefulness, in a way of life that is incredibly more wonderful as time passes [2, p. 8]. Dr Silkworth, a key

262 lP'illiam R. Miller

physician in the early history of AA, described similar "vital spiritual experiences" in the lives of other alcoholics before the founding of AA: "To me these occurrences are phenomena. They appear to be in the nature of huge emotional displacements and rearrange- ments. Ideas, emotions, and attitudes which were once the guiding forces of the lives of these men are suddenly cast to one side, and a completely new set of conceptions and motives begin to dominate them" [2, p. ZT]. Such stories are common, though not the experi- ence of a majority, among the members of Alcoholics Anonymous. They stand in sharp contrast to the gradual change model that typically guides psychological theory and practice.

One could, of course, discount such stories as anomalies or fabrications, though there is no scientific reason for doing so. An alternative is to consider the possibility that there is another type of transformation that can occur in the lives of addicted persons, which does not seem to obey the ordinary rules of behaviour change as we understand them. Such change looks more like an abrupt about-face than a learning curve. It seems more decisional than habitual, relatively sudden and discrete, and it often (though not always) is manifested in an apparent and broad reorganization of behaviours, attitudes, and values. Such changes are not unknown in behavioural science. They have been described by psychologists [2o-221, and occasionally documented in considerable detail [23]. Indeed, current theory and research are consistent with a view that there are at least two systems of behavioural control that are relatively, though not wholly separable [I43. At present, we seem to have a good understanding of some of the determi- nants of the more gradual, habitual, automatic control system. Some advances have been made in describing a separate memory system that is more controlled, effortful, and intentional. But in comprehending the kind of abrupt behaviour change described earlier, we are kindergarteners.

In the spiritual domain, by contrast, such about-face change models are familiar and ancient. The Greek word epistrepho was an everyday word meaning to turn around, and metanoia conveyed a more cognitive shift--to change one's mind. Early Christian writers appropriated these terms for a new purpose, not captured in their original Greek usage, to describe a total, dramatic turnabout in a person's life, usually based on a wilful personal decision [241. The resemblance of this construct of conversion or repentance to the kind of transformational change described earlier is noteworthy. Perhaps in spiritual processes we can find better models and hypotheses for understanding transformational change [251"

The study of spiritual variables, then, may reveal important determinants of addictive behaviors, and shed light on change processes by which people escape from

them. A better understanding of spiritual influences in etiology and remission could be helpful in conceptualiz- ing approaches for both prevention and treatment. If religious commitment, for example, is related to lower risk for addictive behaviors or more stable remission, what are the factors that mediate this relationship? How do these dramatic transformations happen, and what affects their occurrence and endurance? How are clients' spiritual understandings (e.g. conceptions of God) and religious practices (e.g. personal prayer) related to the course of their problems? To answer such questions, researchers must venture into the realm of spiritual variables.

One hypothesis is that there is a reciprocal relation- ship between spiritual vitality and drug dependence, so that each inhibits the other. This idea was expressed by the early Christian writer, Paul [261, and 19 centuries later by Dr Carl Jung, in a letter to Bill Wilson [27]. Jung wrote, "You see, alcohol in Latin is spiritus and you use the same word for the highest religious experience... The helpful formula therefore is: spiritus contra spiritum" (p. 625). This view suggests that spiritual variables are not only correlates, but causal agents of the addictive behaviours.

Types of spiritual variables

Spiritual processes could be incorporated into current addictions research as three different classes of variables: (i) dependent variables, (2) moderator or predictor variables, and (3) independent variables. In each case, testable hypotheses could be generated regarding these variables.

Spiritual dependent variables are behaviours that covary with other conditions or responses. It might be predicted, for example, that successful treatment of addictions would be associated with improvement in spiritual functioning as well as medical status and psychological adjustment. This might be reflected in measures of perceived purpose or meaning in life [I8,28], changes in the structure of values and beliefs [291 , or shifts in religious practices and involvement. A further hypothesis would be that status or change on such measures would predict stability of sobriety.

The inclusion of a transcendent dimension might also require some rethinking of traditional dependent mea- sures of constructs such as attribution, locus of control, and self-esteem. Attribution of change to God, for example--a common view in AA--is neither internal (self-generated) nor purely external (beyond one's influence), and depends upon one's conception of God (e.g. as alo0f versus within the person). Individuals with strong spiritual and religious belief systems sometimes have difficulty responding to questionnaires that do not take the spiritual dimension into account. Consider a

classic Christian conception of God as responsive to human concerns and actions, and as residing partially within each person. How does a person with this belief system respond to questions about self-efficacy, or to forced-choice items describing the future as either self- controlled or beyond personal control? The point I wish to make here is that consideration of clients' spiritual perspectives may improve our understanding of indivi- dual differences, and reduce the noise in measuring other constructs.

This is relevant to a second class of variables where spiritual constructs could be considered: moderator or predictor variables. In experimental design, a moderator variable is one on which the client's status alters the rdationship between dependent and independent vari- ables. In addictions research, this is now discussed in terms of client/treatment matching [30]. The relative effectiveness of two different treatments for alcoholism, for example, may depend upon where a client stands along a predictor dimension. Those with severe alcohol dependence may respond better to treatment X than to treatment Y, whereas for those with little or no dependence the opposite may be true. This yields a statistical interaction effect on outcome measures between treatment and predictor variables. This is a more sophisticated way to study treatment outcome than the comparative 'horse race' design, pitting treatments against each other on overall effectiveness with heterogeneous populations. New emphasis is being given to such matching effects in addictions treatment research [3i].

In this light, spiritual moderator variables may be of value in predicting differential courses of outcome from alternative treatment approaches. It has been predicted, for example, that individuals who are more familiar and comfortable with spirituality would be more likely to affiliate (and succeed) with AA [32]. Ninety years ago, William James postulated individual difference charac- teristics that would mark a person's susceptibility to rapid, transformational change as opposed to gradual adjustment [i5]. Clients' religious value systems and practices may affect the acceptance of particular treatment goals and strategies.

Spiritually relevant variables may also be simple predictors of outcome, without regard to treatment type. The course of change may be affected by a person's value hierarchy, such as the priority given to personal pleasure and freedom relative to other values [29]. Religious adherence has often been found to be related to lower levels of addictive behaviours, and those with no religious affiliation have been reported to be overrepresented in treatment [33,34]. Religious involve- ment, then, might be expected to be predictive of better post-treatment adjustment. The opposite hypothesis has been proposed by Albert Ellis, who asserted that "the less religious [people] are, the more emotionally healthy

Spirituality 263

they will tend to be" [35, P. 637]. Such rival hypotheses are testable [8].

Independent variables are those which can be experi- mentally manipulated to study their effect on measur- able outcomes. Spiritual independent variables, then, represent a third way in which the role of spiritual processes in addictions could be conceptualized and investigated. The hypothesis to be tested in this case is that a particular spiritual process itself impacts the course of addictive behaviours and their treatment. Intentional interventions impacting these spiritual pro- cesses, then, would be expected to alter outcomes.

Both behavioural and biomedical scientists have been chary of investigating the impact of the spiritual interventions. Such interventions may lie beyond the expertise and comfort zone of many researchers, but clearly they are not beyond investigation. Byrd reported a medical trial of one of the oldest forms of healing intervention, Judeo-Christian intercessory prayer [36]. Coronary care patients were randomized to receive or not receive intensive intercession, in a double-blind design wherein neither patient nor physician knew group assignment. Though the groups were identical in medical status before the experiment, those in the prayed-for group showed significantly better recovery in hospital, had fewer complications, and required less medical support in the form of antibiotics, diuretics, and ventilation.

Rebecca Propst studied the impact of incorporating clients' spiritual imagery into cognitive-behaviour therapy for depression [37]. Clients in her study were religiously-oriented individuals, who were randomly assigned to receive cognitive therapy with or without spiritual imagery. She found that therapy was signifi- cantly more effective when it incorporated spiritual content. Interestingly, the religious orientation of the therapist had no effect~ non-religious therapists were equally successful in incorporating the client's own spiritual imagery. Apparently it is not only possible, but can be advantageous to include clients' spiritual per- spectives in behaviour therapy [38].

These experimental studies indicate that spiritually- oriented interventions can impact treatment outcomes. Neither was analyzed for matching effects, and it may be possible to identify subpopulations who are particu- larly responsive to such interventions. Spiritual ap- proaches have a long history in the addictions field, through the efforts of Alcoholics Anonymous and the Salvation Army. It is puzzling that these approaches, which represent some of the oldest and most prevalent forms of intervention for addictive behaviours, have been the subject of so little empirical study. In a report recommending US priorities for alcohol treatment research in the i99os , the Institute of Medicine of the National Academy of Sciences has called for studies of the long-term impact of AA [39] and of the mecha-

264 tFilliam R. Miller

nisms underlying effective change for those involved in such groups.

It would be possible to test spiritual approaches as a 'black box', examining their overall efficacy relative to alternative interventions. More informative results would likely result from studies examining the processes of change within such approaches, and their interaction with individual difference characteristics. One reason- able approach would be to test the importance of variables that are assumed within the approach to be crucial to recovery. Within AA, these are largely spiritual constructs, which could be operationally de- fined. To my knowledge, it has never been empirically verified, for example, that recovery within AA is dependent upon or promoted by the specific processes prescribed in the twelve steps. A wealth of testable hypotheses could be derived from this source alone. One could predict, from the twelve steps, that recovery would be enhanced by admitt ing powerlessness over alcohol (step ~), believing in and commit t ing to a higher power (steps 2 and 3), making a moral inventory (steps 4 and to), confessing past wrongs (step 5), making amends (steps 8 and 9), praying (steps 7 and ~x), and reaching out to other alcoholics (step i2).

The big book of AA also points to certain character- istics of individuals that promote recovery [2]. These are, interestingly, constructs of character. While psy- chologists have myriads of measures for personality traits, we have no established methods for assessing character constructs such as honesty, humility, patience, forgiveness, or unselfishness. Such concepts are recog- nized and employed in everyday human discourse, and represent key components of recovery within the framework of AA. At present, behavioural scientists are ill-prepared to study the spiritual processes, character shifts, and transformational changes that are regarded as normative in AA.

Yet nowhere is there a field more ready for harvest, if one wishes to understand the relationship between spirituality and addictive behaviours. A A is a mature and ubiquitous organization. It was founded and continues to focus on spiritual precepts, which are specified and empirically verifiable. The personal ac- counts of some members bespeak a type and magnitude of change uncommon in many treatment settings. Membership is open and free of charge. There are substantial obstacles of design and practicality, to be sure, but the t ime has come for such research.

Bel ief and unbe l ie f

Studies of this kind pose different challenges and threats depending upon one's personal belief or unbelief. Although a majority of clients profess religions belief, many therapists and researchers do not [8]. Propst's findings suggest that at least some therapists can

integrate clients' spiritual imagery regardless of their own belief system [37], and the same is likely true of researchers. Yet extremes of belief or unbelief may involve a dogmatism that precludes either good therapy or good research where spiritual issues are concerned.

For unbelievers, there is the question of why one should bother with immaterial constructs. But though they are immaterial in one sense (i.e. spiritual), it is an empirical question whether they are immaterial in the other sense (i.e. of no consequence). Most clients who present for t reatment have some history of religious belief [8,34], and spiritual concerns and practices remain important for many. At present, we lack adequate knowledge of whether and how spiritual variables impact the onset, course, and treatment of addictive behaviours. There is, I believe, more than enough evidence to warrant curiosity and investigation, regardless of one's personal beliefs.

For believers, rather the opposite question emerges: Why bother to try to prove, through relatively weak and t ime-consuming methods, what we already know to be true? This obstacle can be a substantial one, whether the belief be in a particular religious system or in a specific t reatment approach. A response here is that human belief is always fallible, and none of us is beyond error or new learning. The advance of medicine through scientific investigation has been a progressive unfolding of mysteries, a discovery of elements that contribute to illness and of processes that promote healing. I f we believe that spiritual processes are crucial and powerful, we should lift them up confidently and gratefully to the kind of scientific study that will permit them to be shared more widely.

At a deeper level, both believers and unbelievers may fear the consequences of such research. One cannot contemplate studies of spiritual processes without asking oneself, 'What would it mean to me if I did find an effect?' or 'What would it mean if I did not?" Anxiety over such questions may be one reason for the apparent consensus between believers and unbelievers that spiri- tual processes are best left unexamined. Yet can it be best not to know? Unbelievers may protest that we are trying to measure the immeasurable, while believers may liken such investigations to a testing of God, a biting of the forbidden fruit. Similar obstacles once impeded scientific progress in many scientific fields, including astronomy, medicine, and aerodynamics. Bill Wilson observed that: "Some of the contemporaries of Colum- bus thought a round earth preposterous. Others came near putting Galileo to death for his astronomical heresies . . . Are not some of us just as biased and unreasonable about the realm of the spirit as were the ancients about the realm of the material?" [2, p. 5x].

For me, this seems a field that is fitting, fascinating, and likely to be fruitful. It is impossible to say, at the outset, what the harvest will yield. I suspect, on

reflection, that like many couples, psychology and religion have been divorced because they are so alike. Psychological researchers and spiritual seekers are both on quests for understanding and change. Both infer unseen dimensions. Both realize that there are processes well beyond our present comprehension, and both push forward in the hunger to know more. To me, it is a natural confluence, to bring together our rational faculties and our spiritual yearnings. In the words of William James, "We and God have business with each other; and in opening ourselves to his influence our deepest destiny is fulfilled" [i5, p. 4o6]. Perhaps, in the process, we will also discover important new pieces of the puzzle of addictive behaviours, and new tools to help those who look to us for healing.

Acknowledgments

The author wishes to express his gratitude to Professor Nick Heather and the staff of the National Drug and Alcohol Research Centre (NDARC) in Sydney, Australia, where this paper was prepared during sabbatical leave, and also to Mr Malcolm Edwards and Essington Ltd, for their generous grant to NDARC which made his Visiting Professorship possible.

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