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.
       

The history of the use of alcohol in America provides a striking example of the variability of intoxicant use and its control (Ade 1931; Bacon 1969). First, it illustrates the social prescriptions that define the social concept of control and, second, it shows that the time span of these control variations can be as long as a major historical epoch.

Five social prescriptions that define controlled or moderate use of alcohol--and these may apply to other intoxicants as well--have been derived from a study of alcohol use in many different cultures.

All five of these conditions encourage moderation and discourage excess (Zinberg and Fraser 1979).

1. Group drinking is clearly differentiated from drunkenness and is associated with ritualistic or religious celebrations.

2. Drinking is associated with eating or ritualistic feasting.

3. Both of the sexes, as well as different generations, are included in the drinking situation, whether they drink or not.

4. Drinking is divorced from the individual effort to escape personal anxiety or difficult (even intolerable) social situations. Further, alcohol is not considered medicinally valuable.

5. Inappropriate behavior when drinking (violence, aggression, overt sexuality) is absolutely disapproved, and protection against such behavior is offered by the sober or the less intoxicated.

This general acceptance of a concept of restraint usually indicates that drinking is only one of many activities and thus carries a low level of emotionalism. It also shows that drinking is not associated with a male or female “rite de passage” or sense of superiority.

The enormous changes in alcohol use that have occurred since the colonial period in America illustrate the importance of these social prescriptions in controlling the use of alcohol. Pre-Revolutionary America, though veritably steeped in alcohol, strongly and effectively prohibited drunkenness.

Families drank and ate together in taverns, and drinking was associated with celebrations and rituals. Tavernkeepers were people of status; keeping the peace and preventing excesses stemming from drunkenness were grave duties.

Manliness or strength was measured neither by the extent of consumption nor by violent acts resulting from it. Pre-Revolutionary society, however, did not abide by all the prescriptions, for certain alcoholic beverages were viewed as medicines: “Groaning beer” was consumed in large quantities by pregnant and lactating women.

With the Revolutionary War, the industrial revolution, and the expansion of the frontier, an era of excess dawned. Men were separated from their families, which left them to drink together and with prostitutes. Alcohol was served without food, was not limited to special occasions, and violence resulting from drunkenness grew.

In the face of increasing drunkenness and alcoholism, people began to believe (as is the case with some illicit drugs today) that it was the powerful, harmful pharmaceutical properties of the intoxicant itself that made controlled use remote or impossible. The increase in moderation that appeared at the end of the nineteenth century was interrupted in the early 1900s by the Volstead Act, which ushered in another era of excess.

We are still recovering from the speakeasy ambience of Prohibition in which men again drank together and often with prostitutes, food was replaced with alcohol, and the drinking experience was colored with illicitness and potential violence.

Although repeal provided relief from excessive and unpopular legal control, the society was left floundering without an inherited set of social sanctions and rituals to control use.

SOCIAL LEARNING

Today this vacuum has been largely filled. In most sectors of our society, informal alcohol education is readily available. Few children grow up without an awareness of a wide range of behaviors associated with the use of alcohol, learned from that most pervasive of media, television.

They see cocktail parties, wine at meals, beer at ball games, homes broken by drink, drunks whose lives are wrecked, and all the advertisements in which alcohol lends glamor to every occasion.

Buttressed by movies, the print! media, observation of families and family friends, and often by a sip or watered-down taste of the grownups’ portion, young people gain an early familiarity with alcohol. When, in a peer group, they begin to drink and even, as a rite of passage, to overdo it; they know what they are about and what the sanctions are.

The process of finding a “limit” is a direct expression of “Know your limit.” Once that sanction has been experientially internalized--and our culture provides mores of greater latitude for adolescents than for adults--they can move on to such sanctions as “It is unseemly to be drunk” and “It is all right to have a drink at the end of the day or a few beers on the way home from work, or in front of the television, but don’t drink on the job” (Zinberg et al. 1977).

This general description of the learning or internalization of social sanctions, while neat and precise, does not take account of the variations from individual to individual that result from differences in personality, cultural background, and group affinity. Specific sanctions and rituals are developed and integrated in varying degrees with different qroups (Edwards 1974).

Certainly a New York child from a rich, sophisticated family, brought up on Saturday lunch with a divorced oarent at The “21” Club, will use drinks in a different way from the small-town child who vividly remembers accompanying a parent to a sporting event where alcohol intake acted as fuel for the excitement of unambivalent partisanship.

Yet one common denominator shared by young people from these very different social backgrounds is the sense that alcohol is used at special events and belongs to special places.

This kind of education about drug use is social learning, absorbed inchoately and unconsciously as part of the living experience (Zinberg 1974b). The learning process is impelled by an unstated and often unconscious recognition by young people that this is an area of emotional importance in American society, and, therefore, knowledge about it may be quite important in future social and personal development. Attempts to translate this informal process into the formal drug education courses, chiefly intended to discourage any use, of the late 1960s and early 1970s have failed.

Formal education, paradoxically, has stimulated drug use on the part of many young people who were previously undecided, while confirming the fears of those who were already excessively concerned. Is it possible, one might ask, for formal education to codify social sanctions and rituals in a reasonable way for those who have somehow been bypassed by the informal process?

Or, does the reigning cultural moralism, which has pervaded all such courses, preclude the possibility of discussing reasonable informal social controls that may, of course, condone use? So far, these questions remain unanswered.

It will be impossible even to guess at the answers until our culture has accepted the use not only of alcohol but of other intoxicants sufficiently to allow teachers to explain how they can be used safely and well.

Teaching safety is not intended to encourage use; its main focus is the prevention of abuse. Similarly, the primary purpose of the few good sex education courses in existence today is to teach the avoidance of unwanted pregnancy and venereal disease, not the encouragement or the avoidance of sexual activity per se.

Whatever happens to formal education in these areas, the natural process of social learning will inevitably go on, for better or worse. The power of this process is illustrated by two recent and extremely important social events: the use of psychedelics in the United States in the 1960s and the use of heroin during the Vietnam War.

Following the Timothy Leary “Tune In, Turn On, and Drop Out” slogan of 1963, the use of psychedelics became a subject of national hysteria--the “drug revolution.”

These drugs, known then as psychotomimetics (imitators of psychosis), were widely believed to be the cause of psychosis, suicide, and even murder (Mogar and Savage 1954; Robbins et al. 1967).

Equally well publicized were the contentions that they could bring about spiritual rebirth, mystical oneness with the universe, and the like (Huxley 1970; Weil 1972). Certainly there were numerous cases of not merely transient but prolonged psychoses following the use of psychedelics. In the mid-sixties, psychiatric hospitals like the Massachusetts Mental Health Center and Bellevue were reporting as many as one-third of their admissions resulting from the ingestion of these drugs (Robbins et al. 1967).

By the late sixties, however, the rate of such admissions had declined dramatically. Initially, many observers concluded that this decline was due to fear tactics--the warning about the various health hazards, the chromosome breaks and birth defects, which were reported in the newspapers.

These stories proved later to be false. In fact, although psychedelic use continued to be the fastest growing drug use in American through 1973, the dysfunctional sequelae virtually disappeared (National Commission on Marihuana and Drug Abuse 1973).

What then had changed? It has been found that neither the drugs themselves nor the personalities of the users were the most prominent factors in those painful cases of the sixties.

A retrospective study of the use of such drugs before the early sixties has revealed that although responses to the drugs varied widely, they included none of the horrible, highly publicized consequences of the mid-sixties.

Another book, entitled LSD: Personality and Experience (Barr et al. 1972), describes a study of the influence of personality on psychedelic drug experience that was made before the drug revolution. It found typologies of response to the drugs but no one-to-one relationship between untoward reaction and emotional disturbance.

And Howard S. Becker in his prophetic article of 1967 compared the then current anxiety about psychedelics to anxiety about marijuana in the late 1920s when several psychoses were reported. Becker hypothesized that the psychoses came not from the drug reactions themselves but from the secondary anxiety generated by unfamiliarity with the drug’s effects and ballooned by media publicity.

He suggested that such unpleasant reactions had disappeared when the effects of marijuana became more widely known, and he correctly predicted that the same things would happen with the psychedelics. The power of social learning also brought about a change in the reactions of those who expected to gain insight and enlightenment from the use of psychedelics.

Interviews have shown that the user of the early 1960s, with great hopes and fears and a sense of total unfamiliarity with what might happen, had a far more extreme experience than the user of the 1970s. who had been exposed to a decade of interest in psychedelic colors, music, and sensations.

The later user, who might remark, “Oh, so that is what a psychedelic color looks like,” had been thoroughly prepared, albeit unconsciously, for the experience and responded accordingly, within a middle range.

The second example of the enormous influence of the social setting and of social learning in determining the consequences of drug use comes from Vietnam. Current estimates indicate that at least 35 percent of enlisted men used heroin, and 54 percent of these became adicted to it (Robins et al. 1977).

Statistics from the U.S. Public Health Service hospitals active in detoxifying and treating addicts showed a recidivism rate of 97 percent, and some observers thought it was even higher. Once the extent of the use of heroin in Vietnam became apparent, the great fear of Army and Government officials was that the maxim “Once an addict, always an addict” would operate, and most of the experts agreed that this fear was entirely justified.

Treatment and rehabilitation centers were set up in Vietnam, and the Army’s slogan that heroin addiction stopped “at the shore of the South China Sea” was heard everywhere. As virtually all observers agree, however, those programs were total failures.

Often people in the rehabilitation programs used more heroin than when they were on active duty (Zinberg 1972). Nevertheless, as the study by Robins et al. (1977) has shown, most addiction did indeed stop at the South China Sea.

For addicts who left Vietnam, recidivism was approximately 10 percent after they got back home to the United States--virtually the reverse of the previous U.S. Public Health Service figures. Apparently it was the abhorrent social setting of Vietnam that led men who ordinarily would not have considered using heroin to use it and often to become addicted to it.

But evidently they associated its use with Vietnam, much as hospital patients who are receiving large amounts of opiates for painful medical conditions associate the drug with the condition. The returnees were like those patients (mentioned earlier) who, having taken opiates to relieve a physiological disturbance, usually do not crave the drug after the condition has been alleviated and they have left the hospital.

Returning to the first example--psychedelic drug use in the 1960s--it is my contention that control over use of these drugs was established by the development in the counterculture of social sanctions and rituals very like those surrounding alcohol use in the culture at large.

“Only use the first time with a guru” was a sanction or rule that told neophytes to use the drug the first time with an experienced user who could reduce their secondary anxiety about what was happening by interpreting it as a drug effect. “Only use at a good time, in a good place, with good people” was a sanction that gave sound advice to those taking a drug that would sensitize them so intensely to their inner and outer surroundings.

In addition, it conveyed the message that the drug experience could be simply a pleasant consciousness change, a good experience. The specific rituals that developed to express these sanctions--just when it was best to take the drug, how, with whom, what was the best way to come down, and so on--varied from group to group, though some spread from one group to another.

It is harder to document the development of social sanctions and rituals in Vietnam. Most of the early evidence indicated that the drug was used heavily in order to obscure the actualities of the war, with little thought of control. Yet later studies showed that many enlisted men used heroin in Vietnam without becoming addicted (Robins and Helzer 1975).

More important, although 95 percent of heroin-addicted Vietnam returnees did not become readdicted in the United States, 88 percent did use heroin occasionally, indicating that they had developed some capacity to take the drug in a controlled way (Robins et al. 1977). Some rudimentary rituals, however, do seem to have been followed by the men who used heroin in Vietnam.

The act of gently rolling the tobacco out of an ordinary cigarette, tamping the fine white powder into the opening, and then replacing a little tobacco to hold the powder in before lighting up the opium joint seemed to be followed all over the country, even though the units in the north or in the highlands had no direct contact with those in the Delta (Zinberg 1971).

To what extent this ritual aided control is, of course, impossible to determine. Having observed it many times, however, I can say that it was almost always done in a group and thus formed part of the social experience of heroin use. While one person was performing the ritual, the others sat quietly and watched in anticipation.

It would be my guess that the degree of socialization achieved through this ritual could have had important implications for control. Still, the development of social sanctions and rituals probably occurs more slowly in the secretive world of illicit drug use than with the use of a licit drug like alcohol, and it is hard to imagine that any coherent social development occurred in the incredible pressure cooker of Vietnam.

Now the whole experience has receded so far into history that it is impossible to nail down what specific social learning might have taken place to be passed on. But certainly Vietnam illustrates the power of the social setting to influence large numbers of apparently ordinary people to engage in drug activity that was viewed as extremely deviant and to limit that activity to that setting.

Vietnam also showed that heroin, too, despite its tremendous pharmaceutically addictive potential, is not universally or inevitably addictive. Further study of various patterns of heroin use, including controlled use, in the United States confirms the lessons taught by the history of alcohol use in America, the use of psychedelics in the 1960s. and the use of heroin during the Vietnam War.

The social setting, with its formal and informal controls, its capacity to develop new informal social sanctions and rituals, and its transmission of information in numerous informal ways, is a crucial factor in the controlled use of any intoxicant. This does not mean, however, that the pharmaceutical properties of the drug or the attitudes and personality of the user count for little or nothing.

As I stated at the beginning of this essay, all three variables--drug, set, and setting--must be included in any valid theory of drug use.

In every case of use it is necessary to understand how the specific characteristics of the drug and the personality of the user interact and are modified by the social setting and its controls.

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From N.I.D.A. Monograph 30 - Theories on Drug Abuse: Selected Contemporary Perspectives.  [Page for pdf download, which includes diagrams and reference list.]