Substance Use & Misuse, 42:421–439

Copyright © 2007 Informa Healthcare

ISSN: 1082-6084 (print); 1532-2491 (online)
DOI: 10.1080/10826080601142287

Addiction, Risk, and Resources

ALLAMAN ALLAMANI
Centro Alcologico, Azienda Sanitaria di Firenze, Villa Basilewsky, Firenze, Italy

Addiction is a contemporary social issue bound to the myth of self-control and control of
the other, which is typical of the contemporary “market ideology” society. In its broad
definition it includes not only the use and misuse of “substances” and addictive behav-
iors, but also the concept of risk. There is a continuum between “addicted behaviors”
and behaviors that are not “addicted” but may induce and/or be related to both physical
and psycho-social problems on a micro- to macrolevel.
Different studies have documented substantial changes in the consumption of to-
bacco, drugs, alcoholic beverages, as well as “junk foods” during the last decades in
various countries. All too often politicians, health administrators, and local providers
believe that consumption prevention programs are able, per se, to effect such changes. In
fact, the impact of factors such as international trade, globalization and societal values,
among many others, are considered relevant. On the other hand, sufficient place must
be given to national and community-based preventive initiatives.

Keywords addiction; control; dependency; failure inter-dependency; risk prevention;

shame; immorality; “the other” and the negative other

Addiction as a Contemporary Social Issue

Addiction, or dependency, is a contemporary social issue bound to the myth of self-control
and control of the other, typical of the contemporary market ideology society in which
there is a prevailing belief that any individual is endowed with free choice when faced with
different options.
Addiction, in its broad definition, includes not only the medical and psychiatric defi-
nition of the use and misuse of a broad range of substances (illicit and licit drugs, alcohol,
tobacco, food, caffeinated beverages, etc.) and addictive behaviors (gambling, sexual hy-
peractivity, obsessive buying, and excessive working, among others) but also the concept
of risk.1 In other words there is a continuum between addicted behaviors and behaviors
that are not “addicted” but may induce and/or be related to both physical and psycho-social
problems on a micro- to macrolevel. For example, an individual who is not an “alcoholic”—
however this label is defined and determined—but drinks alcoholic beverages in such an
amount and/or pattern that may cause her/him as well as others a problem.
The increasing dependencies on a variety of substances or behaviors should be included
in the list of diseases that have “sprung up” in our society over the last few decades. These
include AIDS, the effects of which, discovered not much more than 20 years ago, continue
Based on a presentation made at the Third Exhibit Planning Meeting, “For Whom Is It Permitted,
For Whom Is It Forbidden,” 2/23–3/3/06, Jerusalem Israel.
Address correspondence to Dr. Allaman Allamani, Centro Alcologico, Azienda Sanitaria
di Firenze, Villa Basilewsky—Via Lorenzo il Magnifico 104, 50129 Firenze, Italia. E-mail: all.
alcologico@asf.toscana.it

421
422 Allamani

to remain widespread; genetic diseases, representing an important area of development in

today’s research; chronic fatigue; mad cow disease, otherwise known as bovine spongiform
encephalopathy, and flu-type syndromes such as SARS and bird fu.
Generally, diseases owe their existence to medicine’s acknowledgment of them. The
task of medicine is to give them a place within the classing of nosography. Furthermore,
Western society today shows great interest in health issues and tends to reformulate in-
dividual or social problems in terms of pathology. In other words, it tends to medicalize
deviant social behavior. Alcoholism is a typical example: while just a few years ago (and
not infrequently still today) alcoholism was seen by professionals and the general public
as a vice or a defect in personal conduct, today it is a disease that has taken its place in
the prestigious Diagnostic Statistical Manual of Mental Disorders (DSM-IV-TR, American
Psychiatric Association [APA], 2000). The same thing is happening with drug addiction,
bulimia, obesity, and other compulsive behaviors.
From a sociological point of view, medical diagnoses are a function of the specific
culture of a given society within a given historical period. This process can and does
include the influences of individual and systemic stakeholder’s values, weltanschaung,
agendas, and goals. They are seen as the answers that each era provides to the collective
problems it faces. Some of these problems come to be defined as diseases2 according to
a diagnostic process that corresponds to the body of medical theory developed up to that
particular time and culture. This approach presupposes that as well as being concerned
with individual problems, medicine is also occupied with collective needs and that its
paradigms are periodically subject to change. According to the classic biomedical position
on the other hand, diagnoses, and new diagnoses in particular, constitute discoveries that
gradually deepen our insight into the nature of man, with the aim of amending our defects.
Such an approach is based on the biological concept of the individual: men and women,
viruses and bacteria are essentially the same in any place and time in as much as they
are subject to universal biological laws, and society must thus equip itself to allow for the
broadening of knowledge and therapy.
The list of diagnoses that have recently made their way into the nosography mentioned
above is made up of illnesses that have developed, above all, as forms of interaction with
the other (with the exception of genetic diseases, perhaps, that still, however, imply a
temporal chain of union among others, which forms the basis of our genetic inheritance).
At the origin of these pathological manifestations a “negative other” is depicted by both
biomedical and psychological theories. It is an other that attacks us, as a pathogen infecting
a body, or an other that “is not there” or that does not recognize us: the incompetent mother
or the conflictual family raising borderline offspring, the unfaithful partner that transmits a
sexual disease, the dishonest farmer putting contaminated food or animals on the market.
The negative other is also the environment that attracts us and that we ourselves infect,
thus acting as mirror to us, like the polluted air, water, and earth, which in turn propagate
ecological disease. The cities we live in are an everyday example of both a loved and
worrying context that well reflects our deep ambivalence towards life.
The question of the other comes fully into the history of the twentieth century, starting
with the Other “par excellence.” In a variation on the theme of Nietzsche’s famous “Death of
God,” Martin Buber, in the first decades of the century, affirmed that God has been eclipsed
from the human horizon, since the ego has interposed between us and Him the ego (Buber,
1952). What lies between the I-subject and the other-object is the stance that has brought the
I to investigate the mental objects that inhabit our sphere of consciousness and to subject
them to its particular form of reasoning: such a relationship widely informs the evolution
of human knowledge and science in modern history, contributing to the development of
 Addiction, Risk, and Resources 423

the concept of the I as “alone in face of the world.” This, says Buber, is not, however,
the central relation, because what we really long for, deep down, is based on the need of a
relationship with the other, qualified by the relationship between I and you. The relationship
or dialogue I–you thus implies the reciprocal recognition between two subjects or living
beings, stemming from the dialogue between “me” and God (Buber, 1953). Such a dialogue,
however, still seems to have only just begun.
In fact, the myth of modern man, as described brilliantly by the American historian
Ernst Kurtz, is made up of two kinds of relationship with the other. The first stems from
the romantic conception of the hero and represents a strong individual who overcomes
the trials of life to dominate the world, ending with its subjection. If he is touched by a
negative sentiment, it may be the fault of having committed deeds that do not respect the
others. The second is the representation of the asthenic man, that of existentialism, weak
by constitution, who fails in his projects and does not reach his objectives; the predominant
sense is one of shame in front of the world and its judgment (Kurtz, 1991). Given that social
expectations favor success, the first of the two types will obviously be the one adhered to,
to all extents and purposes, whereas the second will remain in the background, hidden from
sight as much as possible, and possibly denied.
The romantic myth of the individual who can make it on his own, that is, the image
of independence and ownership of oneself and the world, has achieved major consensus
all over the Western world, reaching its peak in North American culture. It pervades our
relationships with partners and family members, the organization of our work and our free
time, even our very thought processes. It supports the idea of dominating and subjecting
nature, with the consequences of deforestation, cementification, and the exploitation of
resources.
Such is its force that we wear it like a mask; even when faced with the experience of
failure, we prefer to try and maintain apparent positions of autonomy and independence
that is better described by the term pseudo-independence. Developmental psychology would
say that we are talking about adolescent behavior, oscillating between the affirmation of
independence and the need to depend upon parents and the adult world. The assertion of
pseudo-independence, however, does not resolve the lack of autonomy; the solution lies
in the acknowledgment of our limits and in opting for interdependency. In fact, we live
in a world that is ever more interdependent, with globalized markets, international travel,
political events, and geological phenomena that connect more and more areas of humanity,
with an increasing, experienced, dynamic anomie.
The predominant values of a culture highlight the forms of behavior that do not fit in
with those same values. Rather like a beach at low tide that exposes trunks, carcasses, and
rubble, our era exposes the behaviors of all those who remain outside of the consensual
“norm,” who are not able to conform to the predominant image of autonomy, self-control,
and victory over nature. This is the behavior of those who give in because they are not
able to reach the predominant ideals and who, at the same time, in one way or another,
reveal the inadequacies of those same ideals, demonstrating the importance of dependency.
Here I am referring to people dependent on mystified and empowered alcohol, drugs, or
other exogenous substances who need the substance in order to experience and/or accept
themselves. The force of the substance is such that it allows them to assume apparent control
over their relationship with the world, a control, however, that is only fully realized in the
compulsion to use the substance. So, in order to feel independent in relation to the other,
the alcoholic becomes dependent on the use of an alcoholic drink, which in turn makes him
dependent on the family member or friend who tries to limit his behavior. To then feel free
from the control of the family member who does not want to let him drink, he drinks and
424 Allamani

thus becomes even more subject to that “desire.” The battle against the bottle is a circular
one in which the other becomes an instrument; it is a losing game that no one can win
(Bateson, 1972). And in this process the boundaries between pharmacological actions and
“the drug experience” become blurred and myths about what “the drug does,” grow, are
transmitted, and become almost deified, and meaningless terms such as “drug treatment”
and “alcohol treatment” become misleading shibboleths.
We might then think that substance dependency is an illness that well represents the
condition of our society; it underlines its aspirations as much as it does its limits, right up
to its extreme pathologies.
The moral implications of contemporary dependency perhaps make us reflect on how
we might compare it to the horrors of present and past events such as the holocaust and
genocide. A real comparison is, of course, unacceptable in as much as the second party’s
intention to kill is a long way from the unconscious search for death that has been attributed
to and which perhaps is inherent in dependency. In other words, we are discussing different
kinds of responsibility and different moral questions. Furthermore, dependency is almost
always observed at an individual level rather than at a collective one. However, there are some
specific aspects that lead us to compare the two phenomena: on an anthropological level,
the sense of sacrifice and atonement that they both represent for society (see Sontag, 1978);
and on a psychological level, the feelings of blame and shame connected to the negative
judgment that surrounds the individual (Kaufman, 1985; Wiechelt, 2007). Lastly, figures
“invite” us to consider that the number of deaths associated with substance dependency
or to the effects of exposure to the risks of using “abusive substances”—another coded
misnomer—constitutes a massacre. For example, in the European Union alone (formally
made up in May 2004 with twenty-five states and a population of 452,869,000), there were
650,000 deaths in 2000 due to tobacco consumption (Peto, Lopex, Boreham, and Thun,
2004), 195,000 deaths in the 2000s due to alcohol consumption (Rehm et al., 2004), and
7,500 deaths in 2003 due to the use of illegal drugs (European Monitoring Centre for Drugs
and Drug Addiction [EMCDDA], 2005); on a whole, casualties from tobacco, alcohol, and
illicit drugs are about 850,000 per year.

Dependency as Immoral: The Case of the Woman Drinker

There are numerous examples of dependency considered as illness or as an existential
problem. A major example is the case of Alcoholics Anonymous and the movement that
has been advanced together with other associations that use the Twelve Steps method.
The condition of dependency, however, is still persistently judged, socially and indi-
vidually, as being immoral (evidenced, for example, by the idea that drinking too much is
a “vice”), matched with the addict’s sense of shame in being judged for his failure to live
up to social expectations (Wiechelt, 2006). In different ways the alcoholic, the drug addict,
the compulsive eater and other eating “disordered” people, and the compulsive gambler
have long been considered worthy of shame; now, after a few centuries it is the turn of
the tobacco smoker. The judgment of immorality,3 that is, informal social condemnation,
is often accompanied by formal judgment under the form of the penal responsibility of the
individual and the criminalization of addictive behavior. This happens in many countries
and is particularly true for certain substances in American society with all the contradic-
tions of the case related to the issues of care, treatment (their dimensions of parity–imparity,
availability, and accessibility), punishment, and formal control over clients (see Magura,
2006).
 Addiction, Risk, and Resources 425

The informal judgment of “immorality” and deviance that various societies have at-
tributed to the use of substances and to those who use them is particularly well represented
by the condition of the woman who drinks or gets drunk. In this case, judgments about drink-
ing are superimposed with judgments related to sexuality and power. This is particularly
clear if we take a look at the female condition throughout history (Plant, 1997; Allamani,
2003).
From ancient times, for ancient Greeks and Romans, the combination of women and
wine was automatically considered illicit, originating in the common idea that alcohol led
women to libertinism and therefore the consumption of alcoholic drinks, or the misuse
(most recently “abuse”) of alcohol, was considered a female vice.
The philosopher Seneca, in his Epistle 95 (Seneca, 1966), also deplored the women of
his time who indulged excessively in eating, drinking, and sexual activity just as men did,
reaching the conclusion that “their vices have led them to lose the privilege of their sex,
and since they are stripped of all their femininity, they are besieged by the same evils that
affect men.”
Johan Christian Goehrs of Halle, in his lauded medical thesis entitled De ebrietate
foeminarum [Inebriation in Women], discussed at Magdeburg in Germany in August 1737,
holds the moral opinion that women should be both angels of health and guardians of social
norms, while feminine faults associated with alcohol are interpreted as shame and absurdity
(Goehrs, 1737). This is not far from the description of Gipps, governor of New South Wales
in Australia, who wrote a century later in 1841 “there is no object of disgust or horror that
offends the eyes of God or man more horribly than the drunk woman” (as cited in Leigh,
1995).
At least up until the nineteenth century, if a woman from Western, bourgeois society
was seen drinking in public it was seen as a sign of sexual availability and immorality.
Later, judgment was shifted from drinking to excessive drinking (Leigh, 1995). According
to Leigh’s argument, women were usually seen as exercising negative control over the
occurrence and timing of sexual activity and thus were considered the source of major social
control over indiscriminate sexual activity. Therefore, inebriation in women, in contrast to
men, was seen as immoral because it led them to a lack of care for feminine responsibility.
Society was obviously more inclined to accept the contrary, which is that women were
the victims of excesses perpetrated by husbands and fathers under the influence of alcohol.
Married women needed to maintain their rights over their estate in order to allow themselves
and their children the possibility of escaping from their drunk husbands. This tendency gave
women the “more than moral” high ground in control over the damage produced by alcoholic
behavior in male society. Under this perspective, the birth in the United States in 1873 of the
Women’s Crusade movement, later to become the Women’s Christian Temperance Union,
legitimized women’s participation in national political life (Leigh, 1995).
During the last decades of the twentieth century the debate on the implications of
drinking during pregnancy was the first argument of modern research based on women;
nevertheless, attention rested more on the fetus than on the woman in her individuality.
More recent studies regarding the role that European and American women play in the
consumption of alcohol in comparison to men identified an increase in the consumption
of alcoholic drinks and the presence of certain alcohol consumption–related problems and
damage in women (Bloomfield et al., 1999; Bloomfield et al., 2005). It has been suggested
that drinking in women becomes the focal point of public attention and research in the very
moments when they begin to claim more social recognition and more power, like today,
(Heath, 1995). Further motivations for this kind of study can be found in the attention
that society gives to the special role that women play as instruments of reproduction and
426 Allamani

agents of socialization, as well as in the feminist directed research. In these cases, when
researchers try to investigate the cultural differences that influence the relationship between
women and alcohol consumption compared to men, they must find answers to questions
regarding categories of power, autonomy, and control (Ahlström, 1995). While they do not
adhere to the traditional model that regards the drinking woman’s behavior as immoral,
they do agree to a certain extent with the supposition that female responsibility differs from
male responsibility and that it might also carry more moral weight.

The Therapy of Dependency as an Improper Therapeutic Act

Another peculiarity/particularity of the phenomenon of dependency is that of questioning
the approaches and methods consolidated during medical and psychiatric treatment.
In fact, for illnesses related to the failure of control and the impossibility of being
self-sufficient, such as “dependency pathologies,” traditional medicine cannot be exhaustive
based as it is on the control of treatment and behavior and on the fact that the patient depends
on the indications of the doctor and the health system. Usually the patient’s compliance is
of crucial relevance in medicine since the assumption here is that problems are solved after
the doctor has given a prescription to a relatively passive patient; on the other hand, the
authority role of professionals is a potentially powerful force for healing, and “pervades
the consultation,” built as it is “into the fabric of healthcare” (Rollnick, Mason, and Butler,
1999, pp. 197–198). However, when a program is prescribed to a person to overcome
his/her substance addiction, the proposed treatment often ends up perpetuating the attitude
of dependency that is part of the illness itself, as it is usual to observe when an alcoholic
stops drinking thanks to an increasing amount of benzodiazepine intake, and even when
a drug addict is transformed into an alcoholic after (s)he quits heroin. This explains the
lack of success in treating dependency and the dissatisfaction with the efficiency of related
pharmaceutical treatment. There is also, of course, the complex issues of what are the
“demands” and dimensions of diagnosing and treating: (a) a medically delineated disease,
or (b) a total human being manifesting both illnesses and healths, strengths and limitations,
adaptations and maladaptations, functioning and dysfunctioning in a variety of roles and
contexts.
On the other hand,when the issue is behavioral change, as is the case in the field of
dependencies, high value has to be placed on the patient’s autonomy, and the professional
role is to encourage the patient to be a decision-maker, maintaining his congruence in
the consultation “with the patient’s feelings and attitude to change” (Rollnick, Mason, and
Butler 1999, pp. 197–198). Indeed addiction treatment is essentially a problem of motivation
to change (Miller, 2006).
Although it does not play a decisive role, medicine is nevertheless functional when it
is complementary to a larger program that takes into account the resources of mutual help
groups. Today the mutual help groups, which are widespread for many other chronic patholo-
gies including diabetes, bowel disease, breast cancer, kidney chronic diseases, chronic car-
diopathies, and others still, are a different way for the person to relate to himself, others and
to his problem, bringing him back to his own personal experience, shared with others who
have gone through similar experiences.
The difficulty of keeping those affected by the use and misuse of substances within a
standard therapeutic program and the length of follow-up programs related to the time it takes
for symptoms to develop has led experts to observe the emergence of a phenomenon that
seems less frequent in other diseases: the spontaneous or “natural recovery” (Klingemann
 Addiction, Risk, and Resources 427

et al., 2001; Shorkey, 2004). Moreover, some authors claim that, at least in the field of alcohol
misuser treatment, changes in alcohol consumption are brought about not by treatment
interventions per se, but rather by the individual’s choice to enter a treatment context
(Bergmark and Oscarsson, 2005).
The birth of Alcoholics Anonymous was one of the great events of the twentieth
century and gave rise to all mutual help movements4 by placing one’s own way of being
as central to the dialogical attitude. According to this association, the only way of winning
over dependency is to accept defeat; that is, to accept one’s own limits as an alcoholic
(Alcoholics Anonymous, 1976). The principles, which are summarized in the story that
brought Bill W. to found the Association in 1935, follow a process that can be summarized
in three stages:

r The first is the realization of defeat: all efforts toward winning, controlling oneself,
and stopping drinking are useless and instead bring one even further down to touch
the “rock bottom” of one’s condition; reaching independence with the help of a
substance, just as with a person, is impossible.
r The request for help that is generated can only be addressed to that which, incredibly,
makes change possible; a “higher power,” or rather, anything that we can conceive
of as being bigger than ourselves (God, the group, a superior belief).
r The third stage implies sharing with an other, an “alcoholic”5 in whom one’s own
experience and hope for change are mirrored.

It is difficult to reconcile the program’s first stage—the idea of admitting to impotency–

helplessness or of touching “rock bottom” (and not being able at the time to delineate
between I am . . . and I feel . . .)—with the medical principle of removing illness and doing
so as soon as possible. Nevertheless, two motivations are of central importance to both
the ill person and the professional, and they derive from the AA experience: the sense of
failure and the impossibility of change. The sense of failure is a feeling that the professional
may experience in the very treatment of the patient with alcohol-related problems if one
is capable of listening to oneself. And perhaps this sense of failure, in a culture that fears
failure and deifies success, matches the sense of failure that the “alcoholic patient” feels
when trying to “beat” what by now may be an empowered and mystified alcohol on his or
her own. In order to benefit as much as possible from a collaboration with A.A. (and the
other 12-stepsassociations like N.A., O.A., G.A., etc.) doctors, psychologists, and a range of
other health workers must identify their own willingness to become aware of, acknowledge,
and to touch their own limits, with the relative sense of possible defeat. A defeat that may
be perceived and related to as an opportunity for doing and not as a final judgment or an
end state.6
The second point is the idea that a change in behavior—giving up alcohol—is possible
even if, and when, it cannot be suggested. What can a professional do to suggest a reason
to the client for changing his/her behavior from that of drinking to abstinence, when this
is a difficult case? We think the professional can share his/her attitude toward asking for
help. In fact, one’s attitude in providing help to one’s client appears to be a function of
sharing one’s own experience and asking for help—both for professional colleagues and
mutual help groups. Furthermore, giving and asking for help is connected to the ability
of the professional to foresee the possibility of change: that the client will abandon his
dependency on alcohol—both as a substance as well as a metaphor for a range of other
parts in his/her life—even when this seems to be senseless or impossible in the context of
therapeutic practice.
428 Allamani

Experience teaches us that by living with and sharing failure and the impossible, it is
possible to find the road to recovery from alcohol dependency or other dependencies.

The Effect of Substance Use Risk Prevention as an Unpredictable Event.

The Case of Europe
While substance or behavioral dependency involves a relatively limited number of indi-
viduals, the risk of experiencing problems or damage from substance use and misuse and
behaviors extends to a much greater number of people. In Europe, for example, substance
misusers among the general population are estimated to represent between 1 and 30%
according to the different statistics and the different substance (either tobacco, or alco-
hol, or illicit drugs) (Hyland et al., 2003; Anderson, 2003; EMCDDA, 2005): In absolute
numbers, that would mean between 5,000,000 and 150,000,000 individuals in European
Union 25.
Cases of dependency are lived out personally in the dramas of our own everyday lives
or those of our family or our clients. Presumably we are normally faced with a sense of
pity or compassion for “us,” professionals, or family or friends, that we feel for “them,” the
addicts, when we try to help them or cure them, unless we have placed ourselves on the
level of judgment or condemnation. Instead, risk is defined by an approach that is guided
by the mind, that implies numbers, probabilities, averages, collective behavior and that sees
collectivity as one, that is, all of “us” as being exposed to risk. In other terms, risk is a
function of the relationships between, as an example, the amount of alcohol intake and
a range of physical and social consequences of drinking, and it has nothing to do with
inevitabilities, but with the assessment “of mounting probabilities of adverse outcome with
graded increase in consumption” (Edwards et al., 1994, p. 21). A caveat may be useful at this
point. Just as there is literacy and illiteracy, one needs to consider the impact of “numeracy”
as well as “innumeracy.” The place of honor given to numbers and statistical significance
and the minimal interest given to substantive significance colors much of the work done in
substance use intervention. The action to undertake in the case of dependency pathologies is
a more or less immediate program for that person or family. The results, positive, negative, or
mixed, can be seen at a distance of days, weeks, or months. Risk situations, however, imply
an intervention according to which one abstains—for example from alcohol or tobacco—
because (s)he is informed about the possible damages that are faced. In effect, risk seems less
urgent, present, or dramatic for the individual when compared with the evident medicalized
and pathologized illness of dependency. The results of an intervention can only be seen
from a collective perspective—the statistical curve in the reduction of chest diseases, for
example, where the individual is just a point on a line.
Consumption prevention policies and programs represent typical interventions related
to the risks of substance use and they are supposed to influence changes in consumption.
Indeed, different studies of trends of substance use during the last decades have doc-
umented substantial consumption changes in tobacco, drugs, and alcoholic beverages as
well as “junk foods” throughout the world. All too often, politicians, health administra-
tors, and local providers believe that consumption prevention programs are able, per se,
to effect such changes. However, it is not at all clear whether changes are due to the
implemented prevention programs. With the advent of artificial science and its theoreti-
cal underpinnings (chaos, complexity, uncertainty, and the more recent network theories),
it is now posited that much of human behavior is complex, dynamic, multi-dimensional,
level/phase structured, nonlinear, law driven, and bounded (culture, time, place, age, gender,
 Addiction, Risk, and Resources 429

ethnicity, etc.). Consumption-related “diseases,” however they are defined, would be such
behaviors/processes (Buscema, 1998), and it is reasonable to state that many, if not most,
substance use prevention programs operate as if what they are focusing on is linear, cause-
and-effect, and at most, complicated in its dimensions.
In fact, the impact of other factors such as international trade, globalization and societal
values, among many others, are considered as being relevant. We are still faced with the
challenge of how to evaluate the real impact of each factor, individually and in relation to
interacting with others, in terms of needed changes as well as ongoing de facto changes.
For example, recent international studies in alcohol drinking trends in Europe over the
last 40 years conclude that in this period there have been changes both in overall alcohol
consumption and in alcohol consumption–related harm, and that there is a relationship
between the two types of change (Norström, 2002). Such studies also assume that the
role of prevention policy is to control alcohol consumption. The gold standard prevention
model proposed by World Health Organization and other international bodies is the northern
European one; that is, one of relatively high taxes and state monopoly (Room, 2005).
However, the same studies report that over recent decades the consumption of alcoholic
beverages has increased in Northern countries, where greater alcohol consumption preven-
tion efforts have been implemented, while it has decreased, sometimes dramatically, in the
Mediterranean Latin countries such as Italy and France, where no or little prevention policy
has been implemented. This suggests that other factors, other than traditional prevention
policy, have to be taken into consideration in order to explain change. Unfortunately, it may
happen that the indications of international bodies are directly incorporated by the country
experts as a means to strengthen their preventive work in the face of administrators and
policy-makers. General ideologies and professional interests, including vested ones, may
concur in making preventive programs unsuccessful.7
A general oversimplified description of some cultural differences between northern and
southern Europe could help us to understand the context of change (Karlsson and Österberg,
2001). In Nordic countries: (a) laws and formal controls regarding alcoholic beverages are
common, (b) law enforcement is appropriate, and (c) informal control is weak. One might
suppose that this goes together with the issue of individual choice and freedom. On the
other hand, in Mediterranean countries, (a) laws and formal control regarding alcoholic
beverages are less numerous, and have certainly been endorsed more recently than in the
north; (b) such laws and formal measures are hardly or partially enforced; and (c) informal
control is strictly “enforced.” One might suppose that the collective opinion is stronger and
it may appear to the northern culture as a sort of intrusiveness within the other person’s life
that in the south is more acceptable.
Multiple causes have been claimed for the decrease of alcohol consumption in Mediter-
ranean Latin countries since the 1960s (Gual and Colom, 1997). A possible explanation
to the change in alcohol consumption over the years comes from an Italian study on the
decrease of consumption in the years 1970–2000 (Allamani, Cipriani, and Prina, 2006). It
uses a sort of time-series analysis of different factors, such as urbanization, industrialization,
internal country migration, and changes in family structure, health consciousness, and the
globalization of lifestyles among population subgroups. Food is a key factor here. In fact,
there is sociological and epidemiological evidence that traditionally wine is integrated into
eating habits, and that it has undergone changes that can be compared directly to changes of
traditional Italian food items such as eggs, bread, and sugar, and inversely to those ones of
the new types of food such as fish and cheese. Briefly during this period wine consumption
underwent a modification that can be interpreted as being due to urbanization as well as to
the awareness of food as a healthy nutrient.
430 Allamani

Certainly this is not to say that prevention policies are or were ineffective. Some
prevention programs as well as country-level measures have shown their effectiveness. As
an example, the rise in minimum legal drinking age in a U.S. state from 18 to 21 years
decreased single-vehicle nighttime crashes involving young drivers by 11–16% (Wagenaar,
1986). Also, community intervention projects or trials, operating in well-defined areas,
were able to document significant changes in terms of harm indicators and in community
awareness about the risks associated with alcohol consumption. Examples are found in
three communities in California and South Carolina, and in Lahati, Finland, and Florence,
Italy (Holder, 1988; Holmila, 1997; Allamani and Basetti Sani, 2003). However, more
studies about the actual as well as potential factors effecting changes in alcohol drinking,
preventative intervention policies being one of these factors, are mandatory.

Prevention as Resource: The Competence of the Local Community

Prevention assumes that society is characterized by both disease and illness, and by the risk
of being affected by it. In other words, there is an evil that can be avoided or eliminated.
Prevention is thus based on a negative assumption. Epidemiology experts look at health
statistics and make collective diagnoses. Experts are called in by politicians and adminis-
trators to correct what is labeled as being mistaken behavior through education. In terms
of substance use, prevention struggles against alcohol, licit and illicit drugs, tobacco, and
disproportionate amounts of food items and pathologized eating patterns. The concept of
morality, noted previously, may help to better understand the dynamics and the implications
of selected responses to selected behaviors.
Nevertheless, the opposite is also true to the extent that risk prevention from the use or
misuse of substances such as tobacco, alcohol, and legal or illegal drugs has as a consequence
a certain kind of depathologization of the individual or groups of individuals affected
by dependence. In fact, prevention underlines that the whole community is exposed to
problematical conduct, and not just those who carry its more visible signs. Thus, the idea
of the disease as affecting only certain individuals or groups is modified by an idea of risk
that, in less unequal terms, addresses the whole population of a given area. An easy “leap”
from this is the notion and belief that that there are “carriers of social infectious diseases”
to be contended with and to be controlled.
The positive side of prevention, that is, the promotion of healthy lifestyles, is endowed
with a more optimistic viewpoint. We believe that promotion can be carried out thanks to an
ecological approach. This means that if health awareness and behavior are more widespread
in a local community or in a society at large, they are able to decrease the frequency of
problematical behavior within that context. In turn, both behavior and awareness are best
increased when stakeholders and people agree on common, locally perceived problems
in order to find possible solutions. Facilitating needed community awareness also implies
that the community—however defined—is a potential partner for change and not just the
traditional funder for professional experts, or the other traditional role of being passive
recipients of the expert-consultant’s conclusions (Shiner, Thom, and MacGregor, 2004).
In any case, prevention intervention is based on the individual decision to change one’s
own behavior mediated by collective health messages. Nowadays it implies two conflicting
assumptions:
r the ego is free to decide, and
r collectivity tends to increase individual creativity.
 Addiction, Risk, and Resources 431

Such assumptions can be seductively deceptive as well as being misleading, during

the development of each intervention. And perhaps, paradoxically, there is the “risk” of
the wasting of limited intervention resources—human and non-human resources. Indeed,
when it decides in front of the different options that are apparently available, the ego
is not so free but also conditioned by a range of factors that has contributed to his/her
development, as family, neighborhood, history of the community, and cultural values. On
the other hand, collective efforts can clip the single person’s wings: any group created within
the local community, from root movement groups to sporting associations to municipality
institutions, tend to promote a sort of average series of needs and overlook the needs of any
single individual (Larsson, 1990).
Promotion or substance use preventative programs must be bound and sensitive to the
culture and values of a country and of a community. In order that they are accepted and
implemented, both nation-wide and international projects, if available, should be tailored
to the values and needs of the local population. For this to be a viable reality and not just
a politically correct statement, one needs to be as much aware as is possible about who
the actual and potential stakeholders are and their sources of influence—individuals as well
as systems—who are needed and who are ready to promote such interventions, as well
as those who have been, are and are likely to be, barriers and preventers of prevention
efforts.

Experiences
Programs designed to prevent the harms caused by and associated with alcohol and illicit
drugs consumption have existed for decades. They have consisted of hours of presentation of
“dissuasive” health information regarding risky behavior—including drugs, smoking, and
sexual activity—undertaken by health specialists within schools and directed at students,
or through campaigns including country-wide dissemination of informative “scare” posters
graphically showing the harm done by specific substances. This has resulted all too often
in the inadvertent mystification and empowering of selected substances and behaviors and
the disempowering, stigmatizing, and stereotyping of a selected other.
One of the limitations of traditional health education programs is that they can hardly
be evaluated. They also may render the behavior that they are trying to discourage attractive
to young adults who are challenged to taking risks. Also, their assumption overlooks the
local stakeholder’s competence in health issues, to the advantage of “experts.”
On the other hand, approaches such as community action, down-top initiatives, peer
approach, and children as adults’ educators are more promising in terms of their effect
and of the local mobilization of citizens. The system approach to the community appears
to be more satisfactory than other generalized approaches (Holder, 1988). The problems
that need to be prevented are considered as those problems expressed at an individual and
collective level within the community. Furthermore, community prevention gives adequate
competency to the people of a given area, favoring the presence of local stakeholders and
redefining the role of experts as consultant to projects that are realized through the activation
of local resources interested in prevention.
The change of direction toward the community prevention policy regarding alcohol
and other substances first appeared in the United States (OSAP, 1990), and successively in
Europe, at the end of the 1980s. One of the first and best known examples of community
programs in general was the cardiovascular prevention program of North Karelia in Finland
432 Allamani

(Puska, Nissinen, Tuomilehto, Salomen, Koskela et al., 1985). The first, most important,
community alcohol consumption prevention projects in Europe were carried out at Malmö
in Sweden and at Lahti in Finland (Hanson, Larsson, and Bracht, 1991; Holmila, 1997).
Furthermore, for some years the European office of the World Health Organization
has been preoccupied with launching initiatives for the prevention of harm from alcohol
consumption. In particular, the creation in 1992 of the European Alcohol Action Plan had the
primary aim of reducing alcohol consumption across the whole continent, also promoting
projects at a local community level. In 2000, WHO updated the European Alcohol Action
Plan (World Health Organization, 1992, 2000).

The Community
Community,9 among its various definitions, is defined as a geographical area, with a limited
number of people (5,000–100,000), that is a neighborhood, a village, or a town, where
relationships among people and forms of active participation exist to a greater or lesser
degree. The area can have a historical, economic, and social history. The community is also
a social system where, for example, different values are attributed to alcoholic beverages
according to individuals and groups and where alcohol drinking–related problems, among
others, are problems of the entire population, being considered the product of interactions
within the system. In accordance with the system’s model, alcohol consumption–related
problems are systemic problems, implying that alcohol consumption can be problematic
for any individual depending on the situation or the environment (Ryan and Reynolds,
1990).
Prevention projects at a community level are based on three principles (World Health
Organization, 1992):
1. Every community is capable of carrying out preventative interventions and can be in-
volved, through its residents, in identifying alcohol consumption–related problems and
establishing priorities. In other words, the approach is a down-top one that interacts with
the traditional hierarchical top-down method (Larsson, 1990).
2. Intervention programs work better if preventative action is integrated. That is, they
aim at influencing the entire area involved through contemporary or sequential actions
directed at different sectors or subgroups of the population. This is the multi-component
approach.
3. Interventions at a local level are capable of influencing health policy on a local level,
but also on regional, national, and even international level.
Preventative action carried out in various sectors, that is, intersectorial interventions,
allow the information that is disseminated in each sector to be consistent and to be recipro-
cally reinforced (Holder, 1988). Examples of sectors in which individuals or professionals
can be involved in various ways in the field of alcohol and drug use and misuse are:
r health (doctors and other professional categories);
r education and schools;
r agriculture;
r restaurant and consumption industry;
r traffic;
r judiciary system;
r work and trade unions;
r media and advertising;
 Addiction, Risk, and Resources 433

r non-governmental groups (such as self-help groups, voluntary groups, religious in-

stitutes, sporting associations, and women’s groups);
r local authority and politicians.

In simplistic terms the option and the challenge is that individual and systemic stake-
holders engage themselves as pro-social change agents.

The Skills of Community Professionals

Medical clinics are not generally particularly interested in prevention, inasmuch as that
preventive actions cannot be compared to consolidated clinical practice based on prompt
actions, which is easily verifiable with regard to the specific “patient” individual who is ill.
Instead, prevention dimensions, public mandates, goals, and processes go beyond the indi-
vidual to the collectivity. Interventions are more complex, the times needed for processing
as well as for the targeted outcomes are longer, evaluation instruments or indicators often
have to be built up case by case. The professional who works in area- or community-driven
prevention must be, in addition to his or her specific speciality, an expert in the ability to
communicate and motivate and must be able to:
r listen to the problems of the population and reformulate them in terms of prevention
intervention;
r favor interactions among people, particularly stakeholders, and among groups;
r coordinate the preventative actions with the program objectives; and
r be able to be part of a team of various types of “partners” and not function in the
tradition-based differential status-empowered hierarchy.

The Evaluation of a Community Project

Evaluation, both process and outcomes, is essential for the need to feed back to politicians,
authorities, funders, and other relevant stakeholders, for the reproducibility of the project
and finally in order to assess its short-term as well as long-term impact in the targeted area.
Evidence-based findings are necessary not only to facilitate continued, suitable intervention
and to engage needed individual and systemic “bridges” for change, but also to effectively
contend with the institutional and the institutionalized barriers to needed change.
Before beginning to plan preventative actions, the group responsible for the Project
must be responsible, in agreement with local stakeholders, to collect basic information
about:

1. alcohol consumption patterns and alcohol consumption–related problems, through local

estimates or epidemiological inquiries.
2. alcohol-related problems and their solutions as locally perceived by community mem-
bers, through the use of information supplied by key actors.
3. who and what are actual sources of help as well as of resistance and interference.
4. the types, levels, and qualities of community awareness about the targeted issue–
problem–topic–process–population.

At the end of the project, significant changes in alcoholic consumption are not to be
expected in the short term as they require several years to change.8 However, evaluation
can be carried out on the impact of the single components of the preventative intervention,
by means of relevant indicators. Examples of possible indicators are:
434 Allamani

r the percentage of reduction in “heavy” alcohol drinkers (amounts and/or frequencies

of drinking) observed by their family doctors;
r the number of citizens, generally, and, more specifically, the number of the posited
“at-risk” population(s) who are now informed about the interventions;
r how many reports appear in the local press, TV, and radio;
r the percentage of people involved in prevention initiatives; and
r the number of new educational programs introduced by community school teachers,
by community center staff, by religious groups in their sites of prayer and special cel-
ebrations, by secular and religious youth groups (i.e., boy scouts,), and by organized
labor groups.

More generally, in a community-based project it is essential to have an outcome eval-

uation, as well as the process evaluation (that is, analyzing the process of the development
of the project) and the formative evaluation (that is, how the project is organized from the
beginning and how it is actively altered during its course).
In reality, very few community-based alcohol consumption prevention projects have
been evaluated. Among those that have are:
r the Community Trial Project, a five-component community level intervention con-
ducted in three experimental communities (Northern California, Southern California,
and South Carolina) matched to three comparisons (1992–1996). The five interacting
components included community mobilization, drinking and driving, reduction of
underage drinking, responsible beverage service, and reduced access to alcohol or
beverage services. Overall results documented that alcohol consumption–related car
accidents dropped by about 10% annually, and severe assault cases requiring hos-
pitalization dropped by 43% in comparison to control communities (Holder et al.,
2000).
r two community projects in Rifredi, a neighborhood within the city of Florence, Italy
(1992–1996) and Scandicci, a 50,000-inhabitant town south of Florence (2000–2004)
demonstrated the mobilization of the community and induced opinion changes in
the perception of both alcoholic beverages and the problems related to their con-
sumption. In both cases, community opinion shifted from the more rigid idea at the
start of the project that only the “alcoholism” of a few addicted individuals is the
problem toward a more comprehensive understanding at the end of the project that
there is a “community risk” from alcohol consumption involving a larger number
of people (Allamani and Basetti Sani, 2003; Allamani, Basetti Sani, Centurioni, and
Ammannati, 2006).

Acknowledgment
Thanks to Shlomo Einstein who, being more a friendly consultant than an editor, has clarified
many aspects of this article for me, making my hours more difficult and more fruitful.

RESUMEN
Dependencia, Riesgo y Recursos

La dependencia es un aspecto de la sociedad contemporánea conectado al mito del

autocontrol y el control del otro, que es tı́pico de la moderna “ideologı́a del mercado.”
 Addiction, Risk, and Resources 435

En general incluye no sólo el empleo y el abuso de “sustancias” y de comportamientos

addicted (dependientes), pero también el concepto de “riesgo.” Existe un continuum entre
comportamientos addicted (dependientes) y comportamientos que no lo son pero que pueden
inducir o asociarse con problemas fı́sicos y psicosociales a nivel micro o macro.
Muchos estudios han documentado sustanciales variaciones en el consumo de tabaco,
alcohol y drogas en las últimas décadas. Pero demasiado a menudo polı́ticos, admin-
istradores sanitarios, y suministrador de intervenciones locales creen que los programas
preventivos sean capaz de influenciar tales variaciones. Se tienen efectivamente que con-
siderar tambièn, entre otros, factores como el comercio internacional, la globalización y los
valores sociales. De otro canto se tiene que dar un relieve mayor a las iniciativas preventivas
de comunidad.

RÉSUMÉ

Dépendance, Risque et Ressources

La dépendance est un aspect de la société contemporaine liée au mythe d’autocontrôle

et du contrôle de l’autre, qui est typique de la moderne “idéologie du marché”. Dans un sens
large il comprend non seulement l’usage et l’abus des “substances” et des comportements
“addicted” (dépendants), mais aussi le concept du “risque”. Il existe un “continuum” (con-
tinuité) entre les comportements “addicted” (dépendants) et comportements qui ne le sont
pas, mais qui peuvent induire ou s’associer aux problèmes physiques et psychosociaux au
niveau micro ou macro.
Diverses études ont documenté des variations substantielles en ce qui concerne la
consommation de tabac, d’alcool et de drogues au cours des dernières dizaines d’années.
Ce pendant très souvent les hommes politiques, les administrateurs sanitaires et les auteurs
d’interventions locales croient que les programmes de préventions sont capables seuls
d’influencés de telles variations. Effectivement, d’autres facteurs doivent être considérés
aussi, comme, parmi autres, le commerce international, la mondialisation et les valeurs
sociales. D’autre part, on doit donner plus d’importance aux initiatives préventives de
communauté.

THE AUTHOR

Allaman Allamani, M.D. (Italy), is a gastroenterolo-

gist, family therapist, psychiatrist; researcher; coordina-
tor, Centro Alcologico, Florence Health Agency; author or
co-author of 130 articles, editor or co-editor of 13 books.
He is also a member of the editorial board of Substance
Use & Misuse and a faculty member of the Middle Eastern
Summer Institute on Drug Use (MESIDU) in Israel, Spain,
and Italy; a member of the exhibit planning committee
For Whom Is It Permitted, For Whom Is It Forbidden. In
the 1980s, he contributed to a Regione Toscana project
on therapeutic communication for helping professions.
In the 1990s, he started a comprehensive alcohol prob-
lem treatment and prevention program in Florence, also
focused on eating problems, based on a low access threshold, family, and motivational
436 Allamani

approach and cooperation with mutual help groups. He developed the first community
action alcohol projects in Italy in the Florence area. He was the first non-alcoholic trustee
of Italian Alcoholics Anonymous from 1997 to 2003. He is trustee of the Psychosomatics
Training Institute, Florence, and member of the Kettil Bruun Society.

Glossary
Addiction: (a) in medical terms, is a dependency from or compulsion on a substance or
a behavior; (b) in psychological and sociological terms it is the need for the other
negatively associated with the failure of self-control and of the control of the other.
Community Action: a prevention initiative implemented in a community through the in-
volvement of its citizens.
Community Risk: the risk of a whole community in terms of, for example, smoking, alcoholic
beverage drinking, drug abuse, that is made evident through the extreme behavior of
some of its members.
Dependency Pathologies: this is a medical definition of a broader social and existential
dependency condition representing our society aspirations and limits. The medical
definition describes the extreme condition of dependency and allows society to treat
addicted people by means of medical or psychological programs.
Down-Top Initiatives: The down-top initiatives work with problems expressed at an indi-
vidual and collective level within the community. A down-top community prevention
program gives adequate competency to the people of a given area, favoring the presence
of local stakeholders.
The Other: (a) the object of control by a social authority or a therapeutic program and may
react against such control, perceived as negative; (b) one of the subjects within the
interaction between I and the other.
Risk Situations: defined by the relationships between the increasing amount of substance in-
take and a range of substance-related physical and social consequences. Risk situations
have to do with probabilities and not with inevitabilities.

Notes
1. This concept and posited process and status (“being at risk”), which is increasingly used
in the literature, is associated with selected individuals, groups, and networks, generally
implying the existence of a “vulnerability”—whatever its etiology. Unfortunately, at
the present time, its dimensions (linear–nonlinear; complicated–complex, etc.) and the
critical necessary conditions for it to operate (begin, continue, become anchored and/or
integrated, change as relevant de facto realities change, cease, etc.) or not to operate are
not known in an adequate generalizable way.
2. The reader is reminded that the medical model of disease is but one of numerous
other models. These include, among other models: biochemical-based models, actuar-
ial, functional, experiential, social, political, religious–spirit–animism, economic- and
consumer-based models. Secondly, each have their own critical definitions, criteria,
goals, and agendas; constituencies; indicated and contra-indicated techniques and ser-
vices; “healers” and change agents; preferred sites for intervention; temporal parameters;
and stakeholders.
3. A new concept and process, secular morality, has been posted in Morality and Health
(Brandt and Rozin, Routledge, 1997).
 Addiction, Risk, and Resources 437

4. Readers interested in an historical basis for “mutual help” can refer to Mutual Aid: A
Factor of Evolution (Kropotkin, New York University Press, 1921).
5. The reader is reminded that built-in limitations of concepts and the written word can
easily mislead one to “homogenize” heterogeneous groups of people as well as to fall into
the trap noted by the general semanticists that the map =//= the territory. “Alcoholics”
are not a homogeneous group of people.
6. The Buddhist saying expresses this “opportunity”: Fall down seven times, get up eight
times, that is the road to perfection.
7. Rittel’s thesis that failure may be built in to intervention when the targeted problems are
not usefully recognized and categorized into two types: “tame problems” and “wicked
problems.” The former are solved in a traditional known and tried “waterfall paradigm”;
gather data, analyze data, formulate solution, implement solution. The latter wicked
problems can only be responded to individually, each time anew, with no ultimate,
repeatable solution. (Rittel, Horst, and Douglas Noble. [1989]. Issue-based information
systems for design [Working Paper 492]. Berkeley, CA: The Institute of Urban and
Regional Development, University of California).
8. The term “community” has become something of a policy buzzword that has been at-
tached to a diverse range of ideas and initiatives. It means various things to a range of
individual and systemic stakeholders. “Shared geography,” as an often regarded simplis-
tic, common denominator minimizes the range of other “sharing” options, which range
from actual objects to beliefs, values, membership in, identification with, association
with from a micro- to a globalized macrolevel.
9. Whereas the ongoing research funding tradition is usually granted for 3 years (first
year is to “tool up”; second year is to collect data; third year is to analyze data and
to communicate findings [at conferences, publish, etc.]) individual–systemic–network–
community–cultural lifestyle changes have a pace and temporality whose dimensions
and “demands” differ from institutionalized, beauracratic needs and “habits.”

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