I had an long and interesting discussion yesterday with Maia Szalavitz about public health approaches to addiction (Her full article is here). One question we kicked around is why extremely troubled street drug users sometimes make dramatic positive changes in their behavior when they come into contact with a needle exchange site or a mobile methadone van or a Salvation Army treatment program.

Mark Kleiman and I have gone back and forth on this many times, with each of us leaning toward different explanations.

Mark emphasizes the role of self-command in behavior change. His hypothesis: People who feel defeated by life at every turn gain confidence when they are taught a masterable skill (e.g., how to clean a needle to prevent HIV infection). When they thereby come to understand that they are not utterly hopeless and incompetent, they feel more confident that they can engage in other positive behaviors that have previously intimidated them (e.g., finding a place to live, enrolling in a methadone maintenance program).

Mark’s theory is entirely plausible, but I tend to lean towards a different view. People are more prone to take care of themselves if they think that others care about them. If you are using drugs and sleeping rough, you can go through long periods where no one expresses any feelings toward you other than contempt, disgust or hostility. In contrast, when a stranger stretches an open hand into the cold night and offers to help you, it communicates something markedly different: You have worth. Knowing that you are not worthless after all provides a motivation to try to make changes that will improve your health and well-being.

Mark’s theory focuses on how people change (the mechanism), mine focuses on why they do (the motivation). Both explanations could be true, or more or less true for different sorts of people. They could also of course both be wrong, but that would in no way diminish my admiration for those people who, night after chilly night, extend their hand to those in dire need.