By Norman E. Zinberg, M.D.

An individual’s decision to use an intoxicant, the effects it has on the user, and the ongoing psychological and social implications of that use depend not only on the pharmaceutical properties of the intoxicant (the drug) and the attitudes and personality of the user (the set), but also on the physical and social setting in which such use takes place (Huxley 1970; Weil 1972; Zinberg and Robertson 1972).

This theoretical position has been so widely accepted in the last two years as to become almost a truism, but, though lip service is paid to the importance of all three variables (drug, set, and setting), the influence of the setting on intoxicant use and on the user is still little understood (Zinberg and DeLong 1974; Zinberg et al. 1975).

Even those who make use of this theoretical construct in analyzing the patterns of drug use and treating users fail to realize the important role played by the setting (both physical and social) as an independent variable in determining the impact of use.

When a drug is administered in a hospital setting, for example, the effect is very different from that experienced by a few people sitting around in a living room listening to records.

Not only is there a vast difference between the actual physical locations, but different social attitudes are involved. In the hospital, the administration of opiates subsumes the concepts of institutional structure of therapy and licitness.

In the living room, there is a flavor of dangerous adventure, antisocial activity, illicit pleasure, and the considerable anxiety that accompanies all three. Considering these differences, it is not surprising that few patients in hospital settings experience continued drug involvement after its therapeutic necessity is past (O’Brien 1978; Zinberg 1974a), while many of the living-room users express an intense and continued interest in the drug experience.

The role of the setting continues to be minimized because of the greater preoccupation either with the pharmaceutical properties, with the personal health hazards of the drug itself, or with the personality deterioration of those who have not been able to control their use (Zinberg 1975; Zinberg and Harding 1979).

These preoccupations obscure from the scientific community, as well as from the public, the precise ways in which the setting influences both use itself and the effects of use, acting either in a positive way to help to regulate use or in a negative way to weaken control.

This paper defines the mechanisms of control developed within the social setting, which I call social sanctions and rituals, and the theory behind their operation. Then it discusses and gives illustrations of the process of social learning by which these mechanisms become active in controlling use.

SOCIAL CONTROLS--SANCTIONS AND RITUALS

Social sanctions are the norms defining whether and how a particular drug should be used. They include both the informal (and often unspoken) values and rules of conduct shared by a group and the formal laws and policies regulating drug use (Zinberg et al. 1977; Maloff et al. 1979).

For example, two of the sanctions or basic rules of conduct that regulate the use of our culture’s favorite drug, alcohol, are “Know your limit” and “Don’t drive when you’re drunk.”

Social rituals are the stylized, prescribed behavior patterns surrounding the use of a drug. These patterns of behavior may apply to the methods of procuring and administering the drug, the selection of the physical and social setting for use, the activities undertaken after the drug has been administered, and the ways of preventing untoward drug effects.

Rituals thus serve to buttress, reinforce, and symbolize the sanctions. In the case of alcohol, for example, the statement “Let’s have a drink,” by using the singular term “a drink,” automatically exerts control. Social controls (rituals and sanctions), which apply to all drugs, not just alcohol, operate in different social contexts, ranging all the way from very large social groups, representative of the culture as a whole, down to small, discrete groups (Harding and Zinberg 1977).

Certain types of special-occasion use involving large groups of people-- beer at ball games, drugs at rock concerts, wine with meals, cocktails at six--despite their cultural diversity, have become so generally accepted that few, if any, legal strictures are applied even if such uses technically break the law.

For example, a policeman will usually tell young people with beer cans at an open-air concert “to knock it off” but will rarely arrest them, and in many States the police reaction would be the same even if the drug were marijuana (Newmeyer and Johnson 1979).

The culture as a whole can inculcate a widespread social ritual so thoroughly that it is eventually written into law, just as the socially developed mechanism of the morning coffee break has been legally incorporated into union contracts.

The T.G.I.F. (Thank Goodness It’s Friday) drink may not be far from acquiring a similar status. Small-group sanctions and rituals tend to be more diverse and more closely related to circumstances. Nonetheless, some caveats may be just as firmly upheld, such as: “Never smoke marijuana until after the children are asleep,” “Only drink on weekends,” “Don’t shoot up until the last person has arrived and the doors are locked.”

The existence of social sanctions or rituals does not necessarily mean that they will be effective, nor does it mean that all sanctions or rituals were devised as mechanisms to aid control.

“Booting” (the drawing of blood into and out of a syringe) by heroin addicts seemingly lends enchantment to the use of the needle and therefore opposes control.

But it may once have served as a control mechanism which gradually became perverted or debased. Some old-time users, at least, have claimed that booting originated in the (erroneous) belief that by drawing blood in and out of the syringe, the user could tell the strength of the drug that was being injected.

More important than the question of whether the sanction or ritual was originally intended as a control mechanism is the way in which the user handles conflicts between sanctions. With illicit drugs, the most obvious conflict is that between formal and informal social controls, that is, between the law against use and the social group’s condoning of use.

The teenager attending a rock concert is often pressured into trying marijuana by his or her peers, who insist that smoking is acceptable at that particular time and place and will enhance the musical enjoyment. The push to use may include a control device, such as, “Since Joey won’t smoke because he has a cold, he can drive,” thereby honoring the “Don’t drive after smoking” sanction.

Nevertheless, the decision to use, so rationally presented, conflicts with the law and may make the user wonder whether the police will be benign in this instance.

Such anxiety interferes with control. In order to deal with the conflict the user will probably come forth with more bravado, exhibitionism, paranoia, or antisocial feeling than would be the case if he or she had patronized one of the little bars set up alongside the concert hall for the selling of alcohol during intermission.

It is this kind of mental conflict that makes control of illicit drugs more complex and difficult than the control of licit drugs across a wide range of personality types. The existence and application of social controls, particularly in the case of illicit drugs, does not always lead to moderate, decorous use, and yet it is the reigning cultural belief that controlled use is or should be always moderate and decorous.

This requirement of decorum is perhaps the chief reason why the power of the social setting to regulate intoxicant use has not been more fully recognized and exploited. The cultural view that the users of intoxicants should always behave properly stems from the moralistic attitudes toward such behavior that pervade our culture, attitudes that are almost as marked in the case of licit drugs as in the case of illicit drugs.

Yet on some occasions--at a wedding celebration or during an adolescent’s first experiment with drunkenness--less-than-decorous behavior is culturally acceptable. Though we should never condone the excessive use of intoxicants, it has to be recognized that when such boundary breaking occurs, it does not signify a breakdown of overall control.

Unfortunately, these occasions of impropriety, particularly following the use of illicit drugs, are often taken by moralists to prove what they see as the ultimate truth: that in the area of drug use there are only two possible types of behavior--abstinence or unchecked excess leading to addiction. Despite massive evidence to the contrary, many people continue unshaken in this belief.

Such a stolid stance affects negatively the development of a rational understanding of controlled use. Two facts in particular are overlooked. First, the most severe alcoholics and addicts, who cluster at one end of the spectrum of drug use, do not use as much of the intoxicating substance as they could. Some aspects of control always operate.

Remarkably few people--particularly some personality theorists who think inhibition against control stems from an actual defect in some aspect of personality (Zinberg 1975)--recognize this fact, however, because it is obscured by the appearance of great excess. Second, at the other end of the spectrum of drug use, as the careful interviewing of ordinary citizens has shown, highly controlled users and even abstainers express much more interest in and preoccupation with the use of intoxicants than is generally acknowledged.

Whether to use, when, with whom, how much, how to explain why one does not use-- these questions occupy an important place in the emotional life of almost every citizen. Yet hidden in the American culture lies a deepseated aversion to acknowledge this preoccuption. As a result, our culture plays down the importance of the many social mores--sanctions and rituals--that enhance our capacity to control use. Thus the whole issue becomes muddled.

Both the existence of control on the part of the most compulsive users and the interest in drugs and the quality of drug use (the questions of with whom, when, and how much to use) on the part of the most controlled users are ignored. We are left with longings for that utopian society where no one would need drugs either for their pleasant or for their unpleasant effects, either for relaxation and good fellowship or for escape and torpor.

But since such idealized abstinence is socially unacceptable and impossible, the culture’s reigning model of extreme decorum overemphasizes the pharmaceutical powers of the drug or the personality of the user. It inculcates the view that only a disordered person would not live up to the cultural standard, or that the quantity or power of the drug is so great that the standard cannot be upheld.

To think this way and thus to ignore the social setting requires considerable psychological legerdemain, for, as in most other areas of living, people can rarely remain indefinitely on so decorous a course. Intoxicant use tends to vary with one’s time of life, status, and even geographical location.

Many adolescents who have made heavy use of intoxicants slow down appreciably as they reach adulthood and change their social setting (their friends and circumstances), while some adults, as they become more successful, may increase their intoxicant use.

A man born and bred in a dry part of Kansas may change his use significantly after a move to New York City. The effects on intoxicant use of such variations in social circumstances have certainly been perceived, but they are not usually incorporated into a sound theoretical understanding of how the social setting influences the use and control of intoxicants.