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Myths That Dominate Substance Abuse and its Treatment in the 21st Century By Ann Dapice, Ph.D. (16th Annual Substance Abuse Conference, February 5, 2004, Tulsa, OK) When I was a young child I can remember going by car over Oklahoma hills and seeing the land end at the top of a hill with only sky ahead.  And when we drove through fog, roads, cars and houses seemed to disappear.  With time I learned that on reaching the top of the hill and looking down again, the land would reappear.  And, I learned that in fog, when I can see virtually nothing, the roads and cars and houses that I remembered are still there.  As children, we are all flat-earthers and we do magical thinking.  And, in fact, we enjoy much of our magical thinking,   wanting to believe, as in the Flintstones, that people once played with lovable dinosaurs.    As we grow and learn, our understanding changes.  Once upon a time all people were flat earthers, believing that ships would fall off the edge of the horizon. There was even a sign posted at the rock of Gibraltar that read, “Ne Plus Ultra” or “There is nothing beyond”—a warning that ships were not to go beyond that point. With experience and related theories, we became round-earthers, but it has only been in my lifetime that we could look back from space and see that the earth is, in truth, fully round.  Similarly, we teachers of psychology have taught Freud’s theory of repression for a century, but only in this last year have we had the brain imaging science to demonstrate that repression occurs anatomically and physiologically, and how this happens.    When Oklahoma Governor Brad Henry came to town last week to speak at a reception, sponsored by the Mental Health Association in Tulsa, Commissioner Terry Cline noted that in the area of mental health and substance abuse, we need “commitment, understanding and action.”  Now “understanding” can mean knowledge as well as compassion, both of which we need, but my immediate response was that we need “round earth,” not “flat-earth” understanding, or our commitment, compassion and action will be misplaced and plagued by actions which have devastating results. Round earth thinking requires continuous evaluation and openness to change.  (My working assumption is that if each of us went to a physician who prescribed leeches for most of our ills, we would look for someone else!)   Now not everything that is old or traditional is wrong.  In fact, we now know that while they lived in some ways a more uncertain existence, archaeological evidence shows that hunters and gatherers were physically healthier than their descendants have been since—the more civilized, agricultural, industrial and post-industrial peoples.  Hunters and gatherers, as more egalitarian peoples, didn’t have slavery, authoritarian regimes and human sacrifice.  Nor were they addicted to alcohol and other substances.  That has been the cost of civilization.  Unfortunately, our bodies are still geared to be hunters and gatherers—as our often inappropriate fight/flight responses remind us.   So the question is: What are the ethical and legal consequences of “doing the same thing and expecting different results?” (AA Big Book)  To continue to provide treatment for diseases based on past or incorrect knowledge is not only morally questionable but becomes a legal issue as well.  The cost is clear.  In 2001, the Robert Wood Johnson Foundation declared substance abuse the nation's number one health problem.  Stating that substance abuse causes more deaths, illnesses and disabilities than any other preventable health condition, the Foundation noted substance abuse costs the nation more than $410 billion a year according to health care and justice records.  Roughly half of all serious crimes are committed by people under the influence.  Physical, emotional, family, and societal suffering are beyond calculation.   Statement of biases.  All of us are flat-earthers to some extent, riddled by the limits of our own life experiences, our personal talents and preferences, as well as science that is by its nature always changing.  So let me do the scientific and ethical minimum and give a brief overview of my personal biases—and the experiences that have forced me to change, often against my will.   I’ll return to these “biasing” experiences later in the presentation as appropriate.  Clark Inkanish and Barbara Martin will do the same in their presentations.    I grew up in a tee-totaling, non-smoking family.  The church I attended as a child said it was a sin to smoke and drink. Unfortunately, the “sin” of gluttony did not appear to be as serious in this church—so that’s been my adult struggle.    I majored in nursing in college.  I later taught nursing at the diploma, associate, baccalaureate, masters and doctoral level.  But I confess that I hated what were to me, tedious facts of pathophysiology, and I disliked the authoritarian structure of nursing and hospitals.  The medical model was not one I especially appreciated either.  As soon as I could, I moved to the lovely broad concepts of the social sciences and philosophy for my graduate education.  I taught these courses with delight for many years.  In the ‘80s I also incorporated Scott Peck’s “community”—a group process he fashioned after AA meetings—into all my classes.    However, in my tee-totaling innocence, along the way I’d married into a family of alcoholism and would come to lose a husband through divorce and a son through death to the disease we call alcoholism. Attendance at Alanon meetings would be part of this experience.  My worldview has also been expanded by the reality of having two children suffer from cancer and a mother die of a rare cancer.  These experiences caused me, in both the disease of cancer and the disease of alcoholism, to look for better ways of treatment.  My daughter experienced cancer as a 16 year old and lived through terrible months of vomiting and other side effects, as well as total hair loss, never mind life threatening meningitis due to the destruction of immune responses.  She had a good prognosis for recovery so I forced myself to help literally “poison” my child so she could live.  Had I chosen for reasons of “faith healing” to not have her treated, the courts would have stepped in and forced her to have medical treatment.  What I did know, was that, having taken care of a college student who had the same cancer some 20 years earlier, his prognosis was death after graduation—and hers was life.  Treatment had improved over the 20 years.  When 12 years after my daughter’s cancer, my son became ill of the same cancer, his prognosis was better still and the treatments, while bad, were less horrific.  So I saw the benefits of improved treatment.  Meanwhile my mother had been diagnosed and died from a rare and unsuspected cancer.  Discovered too late for treatment, she did not have to go through the pain of chemotherapy.  She was given an honest prognosis and we were able to be with her as she died and to minimize her suffering.  In each case of cancer, we were given an accurate prognosis and the most up-to-date science to make educated decisions for treatment.  People need such knowledge.  This is a minimal ethical and legal expectation.  These are the experiences and biases I brought to substance abuse counseling.   Professional ethics.  As a long time teacher and researcher of ethics, I’ll begin with our ethical obligation to clients.  The oldest ethical imperative and the one we’re most familiar with is the “Golden Rule.” It has various forms (Runes 1959) from Confucianism, Buddhism and Hinduism  in the sixth, fifth and third centuries BC, as well as Christianity in the first century AD, where we hear the familiar, “Do unto others as you would have them do unto you.”  For those who don’t subscribe to any religion, there is a philosophical equivalent called the Kant Imperative.   There are two modern theories that also require our attention.  Frankena’s theory of obligation (1973) says that we must do good—the results must be good, not just that we want to or intend to do good.  Here, 1) we ought not inflict evil/harm, 2) we ought to prevent evil/harm, 3) we ought to remove evil/harm, and 4) we ought to do/promote good.   In Firth’s ideal observer theory (1970), we are:   1)      to make decisions and take actions with no ego/ethnocentric interests at stake (i.e., our personal likes or dislikes, what worked for us, what our friends say or think, etc.);   2)      to obtain all the information and knowledge we can—that includes updating our scientific knowledge and skills (one component of Terry Kline’s “understanding”);   3)      to see implications and consequences of actions as if we are one experiencing them ourselves (Terry’s other component of “understanding”);   4)      to react in the same manner with each individual regardless of race, religion, socio-economic status, etc.; and   5)      to refrain from making decisions and taking actions when we are too sick, hungry, tired, stressed, etc.  (Especially important for substance abuse counselors—see below.)     We have, and have for some time had, the scientific evidence, research, facts and figures to allow us to treat substance abuse successfully in an effective, ethical and legal way.  (Note: This information can be found in your handout or on our website at www.tkwolf.com) so you can listen without having to take notes.   Genetic differences in alcoholism have long been noted.  A number of researchers beginning in the 1980’s demonstrated that EEG patterns are different in alcoholics and non-alcoholics—see the pictures and your bibliography for articles (Propping, Kruger & Mark, 1981, Pollock et al., 1983, Begleiter and Porjesz, 1988, Tabakoff and Hoffman, 1988.)  It has been determined that the differences are not that of alcohol use but that these differences are present at birth in identical twins (Tabakoff and Hoffman, 1988).  Individuals at risk for alcoholism can be differentiated on the basis of their EEG alpha activity (Pollock et al., 1983). A reduced P300 wave is a good predictor of alcoholism.  According to a report from the NIDA, recent studies at University of Connecticut (Bauer) show that relapse to alcohol, cocaine, and opioid dependence can be predicted by brain waves.  The high frequency activity on EEGs was found to far outweigh other variables as a predictor of relapse (NIDA).  Alcoholics and addicts are said to use alcohol and other drugs including the common ones—sugar, nicotine, and caffeine in vain attempts to quiet their irritable brain waves.  Note: This requires treatment that normalizes and will maintain normal brain waves—cranial electrotherapy stimulation (CES) treatment has been researched through double and triple-blind studies for decades, is FDA sanctioned, inexpensive, and self administered by the client.   Diet and nutrition.  An elevated insulin response to carbohydrates exists in both the pre-diabetic and the alcoholic.  Most people are unaware that between 75% and 95% of alcoholics are hypoglycemic. Alcoholism may be partly related to a kind of allergic response.  American Indians and northern Europeans have not adapted to a number of foods and especially to grains (e.g., wheat, barley, oats, etc.)  Symptoms include fatigue, mental confusion, depression, physical aggression and suicide attempts. After repeated exposure, intense cravings for the food and physical addiction resulting in withdrawal symptoms are the maladaptive responses. Alcoholism is lowest in countries where these grains originated thousands of years ago (e.g., Northern Africa, Italy, Greece, etc.) and highest in countries that received these grains more recently (e.g., Russia and northern European countries.)  Indians in the US are a prime example of people most recently exposed to these grains and therefore most acutely affected.  Another part of treatment then is a diet that is high in protein and fiber, low in carbohydrates, grains and refined foods.    The need and effectiveness for addiction treatment that promotes physical healing and repair of physiologic damage has been studied for decades. Bill Wilson, the co-founder of Alcoholics Anonymous, first established the link between alcoholism and hypoglycemia and the need for biochemical treatment using niacin and B vitamins that regulate blood sugar.  His own experience suffering depression long after he'd been sober caused him to research the need for these vitamins in treating alcoholism.  However, he was advised by his medical board not to incorporate this information into AA practice.  Wilson's work has been supported (See bibliography and August 2002 Counselor Addiction) by considerable scientific research since the 1980’s demonstrating that the physiological effects of sugar, caffeine and tobacco (up to 75% sugar cured) are the major causes of alcoholic relapse. The NIAAA now states that alcoholics and drug users must stop smoking at the same time they are withdrawn from alcohol and other drugs.  Research has shown that smoking is the largest factor leading to relapse.   Even after sobriety, hypoglycemia and maladaptive allergic responses continue unless treated. New technologies enabling scientists to view changes inside the brain have shown alterations in brain pathways after prolonged exposure to alcohol. After years of sobriety many sober alcoholics not treated for hypoglycemia remain depressed, irritable and anxious, often hostile and paranoid as well.  These are what often have been referred to as "dry drunk" symptoms.  They are the symptoms of hypoglycemia as well.  This is related to a statistic showing that one in four deaths among sober alcoholics is due to suicide.  There is little improvement in the suicide rate of alcoholics after sobriety.  Without diet changes, maladaptive responses to grains and chemicals continue to cause intense cravings, trigger "addictive memory," and lead to relapse.    Nurture and environment.  More recently understood is the reality of what happens to the body and brain during high or chronic levels of stress. The adaptive mechanism known as “fight or flight” that allows people to protect themselves in emergency conditions becomes destructive when people are not allowed to fight or flee, or when the stress becomes chronic. Cortisol, produced during these times, becomes toxic to the body and the brain, killing brain cells and leaving depression in its wake. Post traumatic stress disorder (PTSD) resulting from traumatic events continues the effects of the stress over time, continuing a cycle of cortisol production with ongoing depression. After a long time of cortisol production, the supplies may become diminished.  PTSD patients typically continue to re-experience a trauma, avoid stimuli associated with the incident and feel numb. They demonstrate hyperarousal, irritability, insomnia and inability to concentrate. In his article, “Scars That Won’t Heal: The Neurobiology of Child Abuse,” Martin H. Teicher of Harvard Medical School writes that the after effects of childhood abuse can show in a variety of ways.  Internally, they take the form of depression, anxiety, suicidal thoughts or post traumatic stress.  Externally they are demonstrated through aggression, impulsiveness, delinquency, hyperactivity or substance abuse.   His colleague at Harvard, and speaker at the recent Zarrow Mental Health Symposium, Carl Anderson found (published in 2002—and also noted in Counselor Magazine, June 2002) that repeated emotional and sexual child abuse affects the blood flow and function of the cerebellar vermis. This a part of the brain implicated in the coordination of emotional behavior, which is strongly affected by alcohol, cocaine, and other drugs of abuse and may help regulate dopamine—a neurotransmitter critically involved in addiction.  It is “exquisitely sensitive to stress hormones,” develops slowly and, “damage to this area of the brain may cause an individual to be particularly irritable and to seek external means, such as drugs or alcohol, to quell this irritability.”   Recent research among primates by Michael Nader of Wake Forest University has demonstrated the impact of unequal power on the one with power—and the ones without.  Socially dominant male monkeys showed a brain chemistry change that encouraged resistance to using drugs such as cocaine.  This alteration actually increased the number of dopamine receptors.  While male monkeys at the bottom of the pecking order display no boost of the dopamine receptors and readily self-administered large amounts of cocaine.  As noted by the National Institute of Drug Abuse (NIDA) on their website, studies in the Journal Psychoneuroendocrinology indicate: 1) Stress and cortisol sensitize animals for drug-seeking behaviors and facilitate self-administration. 2) Animals that are under-aroused and have low levels of cortisol are more prone to develop drug-seeking behaviors. 3) Severe stress early in life induces a series of physiological, neurobiological, and hormonal events that result in dysregulation of biological reward pathways in the central nervous system and in stress response systems; these changes seem to prompt self-administration of drugs and alcohol later in life. 4) Prenatal exposure to stress and drugs predispose animals to drug-seeking behaviors in adulthood. 5) Post traumatic stress disorder is a risk factor for substance abuse. 6) The administration of cocaine to humans causes similar physiological reactions such as secretion of adrenalin and cortisol, and psychological reactions similar to arousal caused by stress. Researchers at the Scripps Research Institute in California observed a few years ago that heavy drinking not only depletes the brain’s supplies of substances necessary for feelings of wellbeing and pleasure (dopamine, seratonin, GABA, and opioid peptides), but it also promotes the release of cortisol. This release of cortisol causes tension and depression which in turn causes the individual to drink more which leads to an ongoing vicious cycle. In scientific terms, most substance abuse then is over-determined by both nature and nurture.  There are physiological components that must be addressed for successful treatment. Present treatment results.  Success rates from 12 Step and all but a few rehabilitation programs range between three and eight per cent after four years.  If you are diagnosed with cancer and given those odds, you write your Last Will and Testament and prepare to die.  In cancer treatment, as in other medical treatment, as noted above, it is ethically and legally required that such information be given to victims of disease. According to the largest survey of Americans’ drinking ever conducted (Dawson 1996) only about one in four alcohol dependent individuals enters treatment, including AA.  At one year, according to AA, one in ten of those who come to AA continues as long as a year.  In the largest trial of psychotherapy so far (Project Match, 1997), few alcoholics abstained for even as long as a year following treatment: 9 percent for outpatient treatment, and 35 percent for those who first had inpatient treatment.  Another study examining the benefits of Naltrexone for a “highly alcoholic population of veterans” found no difference in outcomes between those on “Naltrexone for one year, those on Naltrexone for three months with placebo afterwards, and placebo for one year.” Given the alcoholism active in ten percent of the population, the numbers that actually enter treatment, the numbers that relapse, and the death rates, addiction specialist, Hal Stecker (2003) notes that nineteen out of twenty “bottom out” through death. Past and present myths of substance abuse treatment. Myth One.  An addict has to “bottom out” first.   As noted, this advice is a death sentence, since nineteen out of twenty die first.  As the Wisconsin Bar Association notes, most alcoholics do not recover, ninety percent destroy their careers, lose their families, and die from the disease.  The Bar Association notes that there are two problems with the “bottom out” myth, 1) most die before recovering and 2) late-stage alcoholism is difficult to treat because there is more physical damage and there are more years of dependence.  This would be the same as telling cancer patients to wait for treatment until they had pain sufficient to motivate them to treatment.  Since pain is generally a late symptom in all cancers, this would insure death.  Having seen alcoholic clients go through drug withdrawal as well as chemotherapy for cancer, chemotherapy almost always entails more suffering by far.  One wonders why an addict would be able to go through chemotherapy willingly, but not drug withdrawal, if it was only the amount of suffering involved or the willpower to do it.  The Bar Association also notes that “enablers” allow the illness to progress to later stages.  This advice then makes enablers out of the professionals who are there to help, not hurt. To give this advice to addicts is nothing short of unethical and illegal.  We must begin giving clients the prognosis for addiction and the success rates for treatment in our facilities and those of others. (This information is generally nearly impossible to come by.) Myth Two.  Addiction is a relapsing disease.  Relapse results from inadequate treatment, just as relapse from cancer is from inadequate treatment. When people relapse from cancer, we blame the treatment, or lack of scientific knowledge, not the victim.  Why would we do otherwise for the disease of addiction? Myth Three.  Primary addictions should be addressed first.  Other addictions, such as to nicotine and foods, as well as to benzodiazapines and methadone (often used in treatment), may be addressed later.  As we noted earlier, substitute drugs, whether sugar, nicotine or even more addictive treatment drugs such as benzos and methadone, must be dealt with at the same time as the primary drug or relapse occurs.  Their use affects a number of neurotransmitters in the brain which lead to this relapse.  Caution: Of course, benzos and methadone are, in and of themselves highly addictive and are often then continued, and sadly, prescribed, on a permanent basis. To knowingly encourage continued use of foods, nicotine and prescription drugs that lead to relapse is unethical by every known principle.  Myth Four.  One is an alcoholic, a cocaine addict, etc., not one has a disease called addiction.    That is the same as one is a cancer, or a heart disease, not one has cancer and heart disease.  It is curious in health care, that there are preferred diseases.  Normally, one has cancer, heart disease, hypertension, one is not a cancer, a heart disease, a hypertensive.  Not liking to work with the addiction related aspects of food, most health professionals however, do call people “diabetics,” not clients with diabetes.  It is especially curious since Type II Diabetes and alcoholism are both related physiologically to problems of carbohydrate cravings.  Even then, we don’t tell a person with Type II diabetes to just go to a support group to get rid of the diabetes.  We do lab studies, adjust nutrition, and may have to temporarily administer medication.  Cancer, heart disease, hypertension and other diseases also have genetic as well as behavioral components.  Why is one a shame—the essence of who one is, while the other is a disease requiring appropriate treatment?   I understand that saying one is an alcoholic is meant to deal with the issue of denial.  However, denial is human.  In its positive aspects, it helps us drive down the road without imagining our death from an accident.  In its negative aspects, we use denial to war, rape and pillage in the name of religion, democracy and all matter of causes.  We do “Enron” behaviors thinking we won’t get caught and our actions really aren’t hurting anyone that much.  In its negative aspects it prevents us from getting appropriate treatment for all manner of diseases.  But let’s not just pick on people with addiction when it comes to denial.  One has to wonder why we do.   Myth Five.  If the treatment doesn’t work, it’s the client’s fault.   As I’ve said, with accurate, scientific treatment, the treatment does work.  (Our statistics over four years, and those of others who use these methods which address the physiological causes of addiction, show that anyone who uses cranial electrical stimulation as prescribed and reduces carbohydrates and caffeine, succeeds.  CES helps clients begin to feel better first and they then feel empowered to change their diets.  After change they feel well for the first time.  The problem is that clients have been given these other myths and believe them—the myths also give them excuses not to comply because “that’s not what other rehab programs said.”)    Compliance is a problem in the treatment of all disease.  Given that cancer treatment and treatment for other diseases can be enforced among minors even against a parent’s wishes, one has to wonder why the same doesn’t hold true in addiction. The courts can and do order treatment for adults once there has been a legal infraction, unfortunately, at present the treatment ordered by judges is not treatment that properly addresses the physical illness of addiction.   Myth Six.  Addiction is a symptom of an underlying problem, not a primary disease.   The Wisconsin Bar Association notes that alcoholism is a primary, not secondary disease.  To the extent that people have been abused, have PTSD, etc., there may be precipitating events other than genetics that are related.  However, only treating the past memories of abuse or treating stress through counseling, without treating the physiological damage, is to deny the physiological problem that must be treated as well.    Myth Seven.  The primary goal of addiction treatment is to no longer use the addictive substance.   This goal is necessary but not sufficient.  The statistics we’ve given on irritability, depression, anxiety, hostility, paranoia and suicide of sober alcoholics from Bill W. and Joan Larson, are more than enough to demonstrate the need for treating the entire physiology of the brain and body.  When we have an irritable or anxious no longer using addict in our office, we know that giving them nuts or protein in some form will immediately relieve these symptoms of hypoglycemia.   Myth Eight.  Substance abuse is a spiritual problem—as opposed to a disease that affects the mental, the emotional, the physical and the spiritual (from the American Indian medicine wheel).    If substance abuse is only a spiritual disease, then all diseases are only spiritual.  We are stuck in the old body-mind-spirit divisions.  We are mental-emotional-physical-spiritual beings and they are all connected.  Chemicals such as seratonin are distributed throughout the body.  When we’re physically ill, we can’t think as well, we become depressed, may be dispirited—even the most healthy of us.  The medicine wheel, and science, says these are all connected, we must work on all aspects at the same time.  To eliminate the physical leads to disaster.    Treatment implications.  At our organization we had to change and add to what we were doing.  I had to deal with pathophysiology and nutrition again. I still don’t deal with all those facts well.  (Fortunately, Barbara does pathophysiology and nutrition well.)  I had to read about physics and theory related to electrical treatment (Fortunately, Barbara began her college education as an electrical engineer before moving to health care.)  Clark, as a longtime addiction counselor, had to learn whole new bodies of knowledge as well.  It’s hard to change what we’ve done for a long time.  He’s been nothing short of heroic in doing so.   We still utilize counseling, classes, ceremonies, art therapy, and groups in our own practice, as we did before beginning the use of CES.  In a kind of accidental controlled study, we added CES after we’d been doing all these other therapies for more than a year and a half with the same terrible results that other facilities have.  Then after we’d used CES for a year with great success, we added nutritional elements as well and learned that the results were even better.  We often work with other counselors here and nationally to improve the results of their work.   CES and correct nutrition allow manageable withdrawal, prevent cravings, repairs damage to the brain and other organs, and prevent relapse.  Support groups, counseling and education may still be required to teach those whose lives have been dysfunctional, but these cannot and do not work when individuals have not received physical treatment as well.   The following story was read at an AA Conference in 2002.    “Hi! My name is Chuck and I’m—I was an alcoholic.  Sorry I couldn’t be here today.  Believe me, if I could, I would.  I went to AA meetings everywhere.   Eight years ago I had cancer treatment.  I was a good patient, did everything I was supposed to do, took all the chemotherapy—just like I worked my AA program, going to meetings, rehab, working the steps, doing what they said to do.  During cancer treatment, I worked at my job ten  days on, four days off for chemo, for nearly a year.  Strange, they knew how to treat the cancer, but not the alcoholism.  I died three weeks after finishing chemo, not from the cancer, but from the brain disease they call alcoholism.   It is a brain disease.  The pain in the brain that’s there at birth—the desperate need to quiet those brain waves—with sugar, alcohol, nicotine, coffee, anything to quiet the pain and the noise.  I had to go to the “other side” to learn that researchers had known about that for years, that they can measure how agitated those brain waves are and when you will relapse, and that they’ve known that all that sugar and coffee and smoking that seems to help for a while (like alcohol) just end up making you relapse.   I used to work on my cars. I’d have known that you don’t fix electrical problems with alcohol or nicotine, or caffeine or sugar or...pills.  You have to fix the wiring. But I had to go to the “other side” to learn that you can treat those brain waves yourself using small amounts of electrical current.  Decades of scientific studies have said so.  And I didn’t know—and no one told me while I was living—that success rates four years after typical treatments are less than 7 percent.  I thought it was just my failure.   I don’t know why they didn’t tell me, I can’t speak for the living.  But I can and must speak for the dead—all the millions of dead who thought the only way they could get rid of the disease was to die.  I must speak for those who will die unless they’re told—unless you tell them.   If you have this disease, or are related to someone with it, or treat people with addiction, please don’t rely on old methods that don’t work.  There was a modern treatment for cancer, why not for alcoholism?  Please listen!  My name is Chuck and I’m—I had a disease called alcoholism.  Thank you.”   My son, Chuck, would have been 40 years old today.  You can honor his life, and all the other addicts who have died needlessly, by:   1)      the commitment to change substance abuse treatment that is ineffective,   2)      using the understanding through science that now exists, and the compassion you have,   3)      acting in ways that will no longer lead to countless deaths.    We live on a round earth, we know what our religious and ethical obligations are, and there is “more beyond!” We are not hopeless.   Thank you.       Thank you to Active iNet Services for hosting this website.    visitors since March 9, 2006