Adv. Behav. Res. Thu. Vol. 9, pp. 59-72, 1987. 0146-6402/87 so.oot.5o hinted in Great Britain. All rights reserved. Copyright @ 1987 Pergamon Journals Ltd.

BEHAVIORAL RESEARCH: THE PARTICULARLY UNWANTED CHILD OF CONVENTIONAL WISDOM IN

THE ALCOHOL FIELD

Mark B. Sobell Addiction Research Foundation, Toronto, Ontario, Canada and University of Toronto,

Canada

Abstract - The alcohol field and the field of behavioral research and therapy both developed over the past two decades to become major domains of scientific and clinical activity. While this concurrent development was coincidental, a result of the alcohol constituency’s successful lobbying for an alcohol research priority was the attraction of behavioral and other researchers to the alcohol field. In several areas the findings of scientific research have conflicted with conventional wisdom. The conflicts involving behavioral research have been especially severe, however, because the behavioral findings represent not just an academic but also a practical threat to the dominance of conventional wisdom. Behavioral researchers have an obligation to continue contributing to the prevention and remediation of alcohol problems, even when those efforts are viewed disfavorably by defenders of conventional wisdom.

OVERVIEW

This article briefly traces the concurrent development of the alcohol field and of the field of behavioral research and therapy over the past few decades. Interactions that occurred between these emergent domains are discussed. In particular, the effectiveness of the grassroots constituency in the alcohol field in making alcohol research a national priority helped attract behavioral researchers to the field. Behavioral research is only one of several fields of study where empirical findings have conflicted with conventional wisdom in the alcohol field; the example of longitudinal and epidemiological research bearing on the notion of progressivity is discussed in support of this point. The conflicts in the case of behavioral research, however, are notable for their acrimony and for the widespread attention they have received from the media. It is suggested that the ‘special’ attention which behavioral research has received from traditionalists in the alcohol field has occurred because behavioral findings represent both an academic and a very practical threat to the dominance of conventional wisdom. Confronted with these circumstances, the direction of behavioral research is now approaching a crossroad offering a choice between following a safe but innocuous course, or following where the data lead and challenging the dominance of conventional practices when those practices fly in the face of scientific evidence. If, as behavioral

Requests for reprints should be directed to: Mark B. Sobell, Clinical Institute, Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, Canada M5S 2Sl.

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60 M. B. Sobell

researchers and clinicians, we fail to take the latter path, we will be deserting our scientific roots and, immeasurably worse, forsaking the population which can benefit most from our work. The article concludes with a discussion of some ways that behavioral research can be of service in the remediation of alcohol problems.

THE CONTEMPORANEOUS MATURING OF TWO FIELDS

The use of alcohol, and problems associated with drinking, have been noted since the advent of recorded history (Keller, 1976). Thus, it would be quite natural to think that serious study of the drug, its effects on human behavior, and of methods of counteracting undesirable effects, has a similarly long history. This, however, is not the case. The field of alcohol studies only started to become the target of serious scientific research during the 194Os, and it was not until the late 1960s that a serious interest in and commitment to the study of alcohol problems developed.

In the United States, federal funding specifically targeted at alcohol research only began in 1966 when the National Center for Prevention and Control of Alcoholism was established as part of the National Institute of Mental Health. Writing in 1970, Mello and Mendelson from the Center stated, “Our heritage from the years of scientific neglect is ignorance concerning even the basic phenomenology of alcoholism” (p. vi). The provision of federal funding was largely the result of lobbying by an alcoholism constituency fueled by the success and rapid expansion of Alcoholics Anonymous, which started in the 193Os, and by a small group of physicians and scientists who lobbied their colleagues to become involved in the treatment of the disorder. Remarking on this latter interest group, and on the acceptance of the disease concept of alcoholism by the American Medical Association in the 195Os, Bacon noted:

The ‘disease’ notion was an alien view to the profession. It was ‘inserted’ or ‘foisted upon’ or ‘sold to’ the medical professions chiefly by outsiders (who were significantly helped by a handful of rebellious insiders). (Bacon, 1976, p. 94).

The impact of this lobbying reached its pinnacle in 1971, with the establishment of the National Institute on Alcohol Abuse and Alcoholism as an agency freestanding from the National Institute of Mental Health and charged to deal with alcoholism and problems of alcohol abuse. Such events were very important in helping the alcohol field become established as a worthy area of research and clinical service.

To understand the alcohol field’s current status, it is important to view the field from a historical perspective. Although alcohol problems have been recognized for millennia, only recently, and especially during the past two decades, has serious attention been given to research and treatment in this area. Historically, despite the absence of substantive scientific knowledge,

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there developed a guiding ideology in the alcohol field that predominates to this day (Pattison et al., 1977; Heather and Robertson, 1983; Sobell, 1981). This ideology, frequently referred to as conventional wisdom, was not scientifically grounded, but it was not without a basis. It reflected the phenomenological experiences of persons who had alcohol problems, and the clinical experiences of those who had to deal with the pervasive consequences of drinking problems. A curious aspect of conventional wisdom in the alcohol field is that despite its enjoying the unquestioning allegiance of many service providers and scientists, its basic elements have never been well defined except by its critics (e.g. Pattison et al., 1977; Heather and Robertson, 1983).

For the purposes of this article, conventional wisdom can be said to have the following primary features: 1. While acknowledging general problems of alcohol abuse, in practice there

is a predominant focus on individuals who chronically consume very large doses of alcohol.

2. It is postulated that these persons are biologically, and perhaps genetically, different from those who drink in moderation.

3. These heavy drinkers are thought to suffer from a distinct disorder that impairs their ability to regulate their drinking and to resist drinking despite their having suffered adverse consequences from drinking.

4. The natural history of the disorder is thought to be that it progressively worsens unless the individual ceases drinking.

5. The disorder is held to be irreversible, in that individuals so afflicted can never regain control over drinking.

Although some of the above features may be supported by future research, it must be emphasized that the above concepts were developed in the relative absence of scientific study. This has led to an increasing gulf between science and practice as research has increasingly exposed problems with conventional wisdom. The process by which this disparity has developed is summarized in Fig. 1.

One can easily draw a temporal analogy between the way the alcohol field has developed, and the development of the field of behavior therapy. While learning processes had long been considered important, only in recent decades has learning became a matter for serious scientific study. There is no need to review here the conflicts that developed between schools of thought on learning theory during the 193Os, or how the application of learning principles to changing problem behaviors developed in the late 1950s and eventually became a major force in the clinical service arena (Kazdin, 1978). It is important to note, however, that the fields of alcohol studies and behavior therapy came of age at approximately the same time. Those who witnessed what occurred, who were energized by the seemingly limitless horizons of both fields, would find it almost unremarkable that a natural cross-fertilization of the fields occurred.

62 M. B. Sobell

CONVENTIONAL WISDOM (Phenomenologlcally Based)

t INCREASING IMPETUS TO

REVISE CONVENTIONAL WISDOM TO BE CONSISTENT

WITH RESEARCH EVIDENCE (Scientifically Based)

t FURTHER STRENGTHENS

ADVOCACY OF CONVENTIONAL WISDOM

ADVOCACY OF ALCOHOL PROBLEMS AS PUBLIC

HEALTH AND SOCIETAL CONCERNS

CONVENTIONAL WISDOM REIFIED AS “TREATMENT OF

CHOICE’

t TO SUPPORT

CLINICAL SERVICE + ALLOCATION OF FUNDING

AND RESOURCES BY DEVELOPMENT GOVERNMENT

ACCUMULATING BODY OF TO SUPPORT

SCIENTIFIC KNOWLEDGE SCIENTIFIC RESEARCH - (Includtng Behaworal)

FIG. 1. Diagrammatic illustration of how advocacy of conventional wisdom in the alcohol field has led to a conflict between the scientific and phenomenological orientations.

At a general level, therefore, behavioral research in the alcohol field was greatly facilitated, if not indirectly spawned, as a result of lobbying by advocates of conventional wisdom (see Fig. 1). But it was not alone in this regard; many types of scientific research on alcohol use and problems were encouraged and facilitated by the elevation of alcohol studies as an important social concern. In many ways, however, the establishment of alcohol studies as a legitimate domain for scientific inquiry gave birth to a collection of ‘unwanted children’ for conventional wisdom. This occurred because research findings have frequently contradicted essential elements of that wisdom. To underscore this point, the following section describes just one example of the multiple present conflicts, many of which are not entrenched in behavioral research, between scientific findings and conventional wisdom in the alcohol field.

Progressivity: An Example of the Gurf between Science and Conventional Wisdom

Epidemiological and longitudinal research have virtually destroyed the utility of the classical notion that alcohol problems inevitably worsen unless the individual stops drinking. Consider, for instance, the conclusion reached by Mandell (1983) upon reviewing the research in this area:

Behavioral Research in Alcohol 63

The retrospective studies consistently support the view that there is a consistent sequence of symptoms in the development of alcohol dependence illness. This sequence can be reliably divided into phases or stages, each of which has major markers. The phases are psychological dependence, physiological dependence, and central nervous system disorganization or damage. Individuals are able to stop or control consumption of alcohol at any stage and arrest the progression of symptoms. (p. 443).

Upon cursory inspection, this conclusion and similar ones that can be found in the literature may appear to support the concept of alcoholism as a progressive disease. A closer examination leads to a quite different conclusion, however. Whether or not a disorder is progressive is evaluated by examining the natural history of the disorder. For a disorder to be considered progressive, it should be the case that those individuals who manifest symptoms proceed to develop increasingly severe symptoms unless the natural course of the disorder is altered (i.e. by cessation of drinking). Some instances of spontaneous remission of symptoms are expected, but such cases should be rarities. Research, however, has shown that only a minority of cases (e.g. 25-30% by some estimates) evidence a progressive increase in severity of symptoms over time. In contrast to the progressivity notion, the majority of cases are characterized by individuals moving into and out of periods of alcohol problems of varying severity, separated by periods of either abstinence 01 nonproblem drinking (Cahalan and Room, 1974).

There are several ways that one can attempt to reconcile the research findings regarding progressivity. Mandell’s (1983) carefully phrased conclusion retains a not very surprising ordering of symptoms (i.e. that brain damage typically occurs after a person has been drinking very heavily and has become aware that his/her drinking is abnormal), but it does so by forfeiting predictability: people can stop or moderate their drinking at any stage and avoid further symptoms! In essence, Mandell’s (1983) conclusion limits the value of the progressivity notion to an after-the-fact description, which endows it with negligible utility. It would be important to know whether someone who has developed a pattern of heavy drinking will progress to suffer brain damage unless they stop drinking, but research has shown that such an outcome cannot be reliably predicted.

Taylor and Helzer (1983), in reviewing the literature on the natural history of alcoholism, concluded that:

[Alcoholism] is characterized, more often than not, by frequent relapses and remissions rather than by a progressive or relentless deterioration. Admittedly, some alcoholics do suffer such an outcome, but this type of malignant course is probably not the case for the majority. (p. 59).

Importantly, they went on to explain why this slight variation on a theme, “conceptualizing alcoholism as an illness with a chronic, relapsing, and remitting course is important for more than theoretical reasons” (p. 59). Their

64 M. B. Sobell

concern was with the translation of conventional wisdom into practice by clinical service providers: “One cannot help but wonder how much the negative attitudes that some clinicians have had toward the treatment of alcoholics is due to expectations that, given the nature of the illness, may be unrealistic” (p. 59).

While Taylor and Helzer (1983) suggested replacing the progressivity concept with a more generally applicable characterization, this is not the only way of dealing with the research evidence. An alternative strategy is to delimit progressivity to a subset of the population of all individuals with alcohol problems. Kissin (1983) has probably produced the most compelling case for distinguishing ‘alcoholics’ from what he refers to as ‘problem drinkers’. This tactic has its problems, however (Sobell and Sobell, 1987).

First, with regard to progressivity, the only way that individuals can presently be reliably classified as real alcoholics is after-the-fact. If an individual proceeds to develop increasingly severe symptoms, then that individual is a ‘real’ alcoholic. If instead the individual begins to drink in moderation or shows a pattern of decreasing symptomatology, then the person is shown not to be a ‘real’ alcoholic after all. Until the features that predict membership in a distinct subset of real alcoholics can be specified, the distinction between alcoholics and problem drinkers is tautological and alcoholism will remain simply a label applied to the most serious cases of alcohol problems. While I am not contending that a distinction between real alcoholics and other individuals with alcohol problems will never receive research support, at the present time the distinction is mainly useful for explaining and ignoring research findings that are anomalies for conventional wisdom.

Drawing a distinction between hypothetical groups of real alcoholics and persons who merely suffer alcohol problems also has a second serious drawback. Even if a subset of real alcoholics could be accurately predicted, this subset would still represent only a minority of the total population with alcohol problems. This, of course, has serious implications both for concepts of alcohol problems and for the nature of prevention and treatment efforts. This is especially the case because public perceptions and most treatment programs are largely based on a conventional wisdom that assumes that all persons with alcohol problems are real alcoholics. To relegate this view to a minority position would be no small undertaking.

A ‘PARTICULARLY’ UNWANTED CHILD

While the foregoing discussion of problems with the progressivity notion poses serious problems for the alcohol field, it has only been described here as an example in support of the proposition that conventional wisdom in the

Behavioral Research in Alcohol 65

alcohol field has spawned several ‘unwanted children’. These other unwanted children have not evoked the ferocity of debate, however, that has been precipitated by behavioral research. Gottheil(l983) has well summarized the alcohol field’s reaction to behavioral research:

Behavioral techniques and principles have been intimately involved in, if not central to, many of the controversies of the past decade and a half in the field of alcoholism. One need only mention nonabstinent outcome criteria, experimentally induced inebriation, controlled drinking, the medical model, or the Rand Report to bring to mind the intensity, and sometimes the bitterness, of the arguments concerning these issues. (p. 73; note - the authors of the Rand Report would presumably object to their work being categorized as behavioral research).

What has made behavioral research ‘particularly’ unwanted? Put differently, why have other areas of conflict between research and conventional wisdom not been fraught with similarly intense levels of controversy? As Moore (1983) has noted in a different context: “The literature emanates primarily from academic centers or programs located in academic centers. . . . Much of this literature is unknown to the treatment staffs of the majority of treatment programs or, if known, is often rejected.. . the most important reason is the deprofessionalization of the alcoholism treatment field.” (pp. 250-251). He further notes that, “An outside observer dropping in once a decade would chide us for our lack of movement” (p. 251). This describes the typical reaction by the field to ideological threats, but it still does not explain why behavioral research has elicited such controversy.

A parsimonious explanation of the reaction to behavioral research, I suggest, is that behavioral research, and especially its component of clinical practice, has posed not just an ideological, but also a practical threat to conventional wisdom. Behavioral research has had immediate implications for service delivery, and it has greatly complicated life for people who are guided by conventional wisdom. As favorable outcomes of behavioral treatments were reported (see Emrick, 1982; Miller and Hester, 1986), such treatments increasingly became a threat to the dominance of conventional wisdom. The following are a few examples of some of the more obvious ways in which behavioral research has complicated the job of those who would defend conventional wisdom. 1. Empirical studies have complicated the notion of loss of control, by

repeatedly demonstrating that control over amount consumed and control over intoxicated behavior are greatly influenced by environmental and cognitive factors (see Pattison et& 1977; Orford, 1985; Marlatt and Gordon, 1985). This means that rather than being an acquired characteristic of the alcohol abuser, the key to impaired control resides substantially in the nature of the drinking environment.

2. The willingness to entertain the possibility that some individuals might recover without being totally abstinent led not only to the exploration of

66 M. B. Sobell

alternative treatment goals to abstinence (see M. Sobell, 1978; Heather and Robertson, 1983; Miller, 1986; Sanchez-Craig and Wilkinson, 1987), but also to the development of improved assessment and outcome evaluation methods (see L. Sobell, 1978; Sobell et al., in press; Sobell and Sobell, 1983). Since the logical yardstick against which to measure the effects of alternative treatments was the effects of treatments based on conventional wisdom, this focused attention on the relative ineffectiveness of treatments based on conventional wisdom (Sobell and Sobell, 1987). Interestingly, it appears as though the field is finally beginning to come to grips with this problem. For example, in what was characterized as “his first major appearance since assuming office” (The Akoholism Report, Dec. 16, 1986, p. 3), the newly appointed Director of the National Institute on Alcohol Abuse and Alcoholism, Dr. Enoch Gordis, was reported to have drawn an analogy between the problems of schizophrenia and alcoholism, stating: “for the bulk of the [schizophrenic] patients, there is no cure; and therapy is only of moderate effective- ness. . . . It’s the same thing in alcoholism. . . . It is nothing to be ashamed of, but that message has to be gotten out.” (p. 3).

3. Behavioral research has substantially focused on persons whose drinking problems are not extremely serious. Such so-called problem drinkers constitute a majority of those with drinking problems (Cahalan, 1970; Cahalan and Room, 1974; Edwards, 1973; Fillmore and Midanik, 1984; Lloyd et al., 1986; Polich, 1981; Vaillant, 1983), but they have been given short shrift by conventional wisdom. The conventional approach is consistent with the progressivity notion, as discussed earlier (i.e. problem drinkers are simply in the early stages of the progressive development of alcoholism, and thus they require the same sort of treatment as more severe cases). However, as also discussed earlier, the research evidence has shown that the majority of problem drinkers will not progress to more severe types of consequences. Service providers steeped in conventional wisdom may not be able to provide the types of clinical services from which the less seriously afflicted have been found to benefit - mainly services oriented toward helping them re-establish control over their drinking (see Hill, 1985; Babor et al., 1986; Sanchez-Craig and Wilkinson, 1987; Sobell and Sobell, 1987).

THE FUTURE ROLE OF BEHAVIORAL RESEARCH IN THE ALCOHOL FIELD

Clearly, behavioral research has done its share of hell raising in the alcohol field. What the future holds for the relationship between behavioral research and the alcohol field is less easily discerned. The remainder of this article

Behavioral Research in Alcohol 67

provides some speculation about the role that I hope behavioral research will play over the next two decades. My suggestions reflect a bias which can be summarized as follows: the question is not whether we should go on raising hell, but rather, in what ways can we most meaningfully raise hell?

McCrady (1986) recently characterized behavioral research as David and the alcoholism treatment community as Goliath, and this seems consistent with political happenings in the United States. I believe, however, that we have an essential role to play in the alcohol field, and particularly in how that field continues to evolve in the United States where many behavioral researchers and practitioners work. We have an obligation to defend the principles that have served to guide our work, and to bring our expertise to bear on alleviating human suffering, even if such efforts evoke controversy. It would be unconscionable to allow ourselves to be intimidated by the current political strength of conventional wisdom in the United States. Moreover, we would do well to keep in perspective that the real dispute is not between behavioral research and the alcohol field, but rather between science and conventional wisdom in the alcoholfield. Behavioral research is only one of many fields of research whose results have had an ill fit with traditional ideas about alcohol problems. Debates over behavioral research, therefore, should be viewed as part of a maelstrom of continuing conflicts that will plague the alcohol field until popular notions are rationalized with the scientific evidence.

The role of behavioral research in the continuing evolution of the alcohol field should be twofold. First, we must continue making substantive contributions to the prevention and remediation of alcohol problems. The second and related role has been well described by Moore (1983): “to keep the field from stagnation and to encourage its receptivity to new ideas” (pp. 252-253). The following is a brief description of four lines of research that I propose warrant emphasis over the next several years. 1. Behavioral researchers should continue to play a critical role as advocates

for the provision of services for problem drinkers (alcohol abusers who are not severely dependent on alcohol), and to develop treatments appropriate for that population. Such individuals are accustomed to controlling their fate, and they favor treatment approaches that are consistent with respect for their self-determination (Miller, 1987; Sanchez-Craig and Wilkinson, 1987; Sobell and Sobell, 1987). As stated by Hill (1985): “To prescribe abstinence or mandatory AA attendance for these individuals may mean that the individual feels that the treatment system or its providers lack credibility” (p. 212). Our ability to serve the field in this way, however, is seriously jeopardized by events such as recent attempts to establish program accreditation standards and clinical licensing standards that require a commitment to a specific treatment ideology. Such efforts, as described by McCrady (1986) in her recent article, should not be taken lightly; their widespread adoption would

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68 M. B. Sobell

impact not only on behavior therapists, but also on a population that needs the services that we can provide. The stakes for society are high.

2. Another area where behavioral research is likely to be of significant value is continued research to clarify the appropriate use of treatment goals and the relationships between goals and outcomes. Research conducted during the 1970s suggested that severity of alcohol dependence was the most critical determinant of whether individuals who have recovered from alcohol problems did so by adopting a mode of abstinence or by moderating their drinking to nonproblem levels (M. Sobell, 1978). Orford and Keddie (1986) have defined this relationship as the severity of dependence hypothesis, which states that: “The more an individual is dependent upon alcohol, the poorer are his/her chances of being able to control alcohol intake (as distinct from being able to abstain totally) in the future” (p. 495). However, several recent studies, reviewed elsewhere (Sobell and Sobell, 1987), have suggested that a cognitive factor, beliefs, might be more important than severity of dependence as a determinant of the type of successful outcome achieved (abstinence or moderation). Some of these studies have also found there to be benefits to letting clients select their own treatment goals, unless medically contraindicated. Behavioral researchers have led the way in exploring these areas, and the new data present exciting research prospects.

3. Although politically unpopular in the United States, there is also a serious need for experimental intoxication research using clinical populations. Early research of this sort settled decades of old controversies about the reality of withdrawal symptoms, and it revealed the tremendous influence of environmental factors on how alcohol abusers regulate their drinking (reviewed in Sobell and Sobell, 1983; Pattison et al., 1977). Such demonstrations opened the door to very different ways of thinking about how drinking behavior is regulated and how it might be changed. Except for medical sequelae, alcohol problems remain one of the few disorders studied primarily in the distinct absence of its manifestations. It is indefensible that present knowledge about alcohol problems includes scant information about the acute effects of alcohol on clinical populations, and particularly about the effects of intoxication on important abilities, such as decision making. At present, even the main behavioral features of the state of ethanol intoxication cannot be reliably described. Also, since most experimental intoxication research was conducted with severe alcoholics in the late 1960s and early 197Os, there is a virtual lack of information about how ethanol affects less severely debilitated alcohol abusers. While experimental intoxication studies using alcohol abusers as subjects continue occasionally to be reported from Great Britain (Stockwell et al., 1982) and Scandinavia (Laberg, 1986), such research has not been reported from laboratories in the

Behavioral Research in Alcohol 69

United States for several years, despite the fact that the United States provides far more financial support for alcohol research than do other countrieh. In this regard, one cannot help but wonder whether an objective observer might not conclude that a requirement of conducting alcohol research in the United States is abstinence from acquiring systematic knowledge about the nature of ethanol intoxication. Finally, over the past several years there has been a resurgence of interest in the role of conditioning in alcohol and drug use. Based on a large and increasing amount of research, several theories regarding the relationship between conditioning and alcohol use have been advanced (Baker et al., in press; Baker et al., 1987; Solomon, 1977; Siegel, 1983; Hodgson and Stockwell, 1985). While the competing explanations differ in many of their specifics, they all propose that conditioning processes must be central components of any comprehensive theory of alcohol problems. They also have in common the hypothesis that extinction (cue-exposure) procedures will be an effective treatment approach, especially for more dependent alcohol abusers. However, despite the advances in basic research and the formulation of clearly testable theories, only two minor tests of such treatment have been published (Blakey and Baker, 1980; Rankin et al., 1983), and both were conducted in Great Britain. While both studies reported positive effects, albeit with small sample sizes and short or no follow-up, no further studies of this sort have been published throughout 1986. If ever an idea stood in need of test, the efficacy of cue-exposure treatments, and of such treatments in combination with other treatment procedures, is such a case. It would seem only a matter of time until more data are forthcoming.

4.

THE NEED FOR PERSPECTIVE AND PATIENCE

Besides the four directions discussed above, there are other ways in which behavioral research can continue to make contributions to the alcohol field and to society. For example, we need to look for areas where we have interests compatible with conventional wisdom (McCrady, 1986), and we must bear in mind that not all nonbehaviorists in the alcohol field are wed to a traditional viewpoint.

The view of the alcohol field presented in this article has focused on the United States. In other countries, a large profit-making treatment industry has not developed and the American treatment model is not universally embraced (Miller, 1986). Also, in other countries, one does not find the same degree of overzealous devotion to unsupported beliefs about the nature of alcohol problems as exists in the United States. This international perspective is important, because viewed in this way Goliath is far less menacing.

70 M. B. Sobell

By way of conclusion, it is important to stress the need to adopt a temporal perspective on the alcohol field. The fields of behavior research and therapy and of alcohol studies are both extremely young compared to many other areas of science. In terms of understanding how to change behavior, or understanding the complex nature of alcohol problems, the opera has only begun. It would serve us well to sit back and remember that the best parts may be yet to come. We need to bepatient. The only clear mistake would be to leave the performance while the fat lady is still singing.

Acknowledgement - Portions of this article were presented as part of a symposium at the annual meeting of the Association for Advancement of Behavior Therapy, Chicago, 1986. The views expressed in this paper are those of the author and do not necessarily reflect those of the Addiction Research Foundation.

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