The strengthening of the addictive act is not merely a direct function of the number of reinforcements. Reinforcement of drug responses on an intermittent basis can lead to greater conditioning and more resistance to extinction than can reinforcement of every response. Anticipation of the receipt of a drug can stimulate further drug-seeking/receiving behavior. In extinguishing the drug response, the intermittent reinforcement principle holds for punishment as well as for reward. Once drug abuse/addiction has begun, it constitutes a punishing state of affairs when the person goes without the drug. Not receiving this strong reinforcer on each anticipated occasion contributes both to the drive to use it and to its suppression and extinction. Going "cold turkey" exemplifies this. The heightened drive state increases the likelihood of the addictive response when the strength of the habit remains constant or is even slightly reduced, depending upon the value of the drive state. Nonreinforcement of the habit, which is tantamount to punishment, causes it to weaken. After the drive reaches its peak, a decrement occurs in the strength of the habit, resulting in a diminution of the addictive response. General reinforcement principles are employed to account for the various facets of the development of drug usage for purposes of clarification, although it is evident that intermittent reward and punishment also operate in concert with the theory as outlined. The entire treatment spectrum, including administration of substituted medications, milieu therapy, and psychotherapy, is governed by these principles, as well.

Psychosocial Theory of
Drug Abuse

A Psychodynamic Approach

Herbert Hendin, M.D.

A psychodynamic approach to psychosocial problems seeks to explain the interrelation between social and psychological variables in producing adaptive and maladaptive behavior. It relies on psychodynamic study of a representative number of individuals to assess the meaning of these variables.

Psychosocial theory without a psychodynamic base has increasingly tended to reduce emotional illness to the consequences of such social factors as poverty, sex, and race. Economic determinism, sexism, and racism, however, cannot explain the great variations in the abilities of people to deal with the problems of class, sex, and race. The psychology of a considerable number of any group must be evaluated to understand the actual impact of caste or class on the character and adaptation of the rich or the poor. On the basis of work with Puerto Rican families, Oscar Lewis (1966) gave us an illuminating picture of the "culture of poverty." Yet anyone who works with poor Hispanic, poor white, and poor black families quickly becomes familiar with how different the culture of poverty is in each of these groups, let alone how varied the individual and family response is to the fact of poverty. In the case of the drug problem, social variables ranging from sexual activity to association with friends who use drugs have been shown to be related to drug use (Kandel 1973; Jessor and Jessor 1975). Friends, sexual activity, and drug use, however, are all part of an individual's total adaptation, and their interrelated significance for this adaptation must be understood in order to establish any meaningful psychosocial perspective.

Psychodynamic investigation employing unstructured interview sessions that rely on free associations, associative linkages, transference reactions, omissions, dreams, and fantasies provides a uniquely sensitive method for establishing individual and family dynamics (Hendin 1964; Hendin et al. 1965). Early psychodynamic studies of drug abuse, however, ignored social and even familial factors and viewed the abuser in a psychodynamic vacuum. All types of drug craving were seen as

representing a single disease (Rado 1933) characterized as an impulse disorder in which the "ego is subjugated" by an "archaic need for oral gratification" (Rado 1926, 1933; Fenichel 1945). In the past two decades we have become aware of the adaptive or defensive functions of drug use and abuse (Ausubel 1961; Allen and West 1968; Guarner 1966; Wieder and Kaplan 1969; Hendin 1975). We have also come to realize that heroin, marijuana, LSD, and amphetamines appeal to different kinds of people according to the specific psychopharmacological effects of each drug (Wieder and Kaplan 1969; Hendin 1973a,b, 1974a,b, 1975; Milkman and Frosch 1973). Mixed drug abuse also has its own particular effects and appeal (Hendin 1973b, 1974c). Psychodynamic emphasis, nevertheless, has been too often confined to determining the regressive state produced by each drug and establishing parallels between the regressive state and specific phases of childhood development (Wieder and Kaplan 1969).

We view drug use as part of the individual's attempt to deal with needs and conflicts, relations with others, and the social environment in which he or she lives. Since all of these vary with age and stage of life, one would expect drugs to be used and abused for different purposes at different points in the life cycle. A comparison of our study of adolescent drug abusers and their families with our study of college students who were drug abusers tends to support this conclusion.

COLLEGE STUDENTS

Our study of drug-abusing college students showed that conflicts over performance and competition were pervasive among college students who were marijuana abusers (Hendin 1973a). The same students who advocated a competition-free world saw their own success or failure in terms of murderous aggression or intolerable humiliation. Most retreated from activities that engaged them because they wished to be free of such painfully intense feelings, and they found relief in less challenging activities. No survey of drug incidence or evaluation of students' marks would reflect the numbers of students who withdrew from what they wanted most, to pursue activities with which they were less engaged and by which they were not challenged.

It

Amphetamine abuse was particularly common among college women. served the function of helping these women move in directions that they thought they should go but to which their actual inner feelings were opposed (Hendin 1974b). Most commonly, that direction was academic success which they felt was expected by their family and their own image of themselves; in some cases it was a marriage that they thought they should enter into but to which they were inwardly opposed. One of them dreamed of herself as a puppet. Another who dreamed of herself as a marionette saw amphetamines as necessary to move her strings and to keep her performing.

It is interesting to note that while college women were using amphetamines to help increase their achievement levels, college men were using marijuana to help ease or withdraw from competitive pressures. This difference appears to be consonant with the psychosocial changes we are witnessing in the roles of the sexes.

Heroin, too, served specific dynamic functions for the college men who used it. Most of them came to do so during the course of a relationship with a young woman, when heroin was used as a protection against the intensity of the involvement (Hendin 1974a). Pleasure remained under their control; they did not become close to the woman or let her be the major source of pleasure--they saw it as safer to be high on heroin. Because it provided a check on their involvement, heroin was often necessary for them to have a relationship with a woman at all. Psychedelics and indiscriminate drug abuse were favored by young people who wished to fragment themselves as a way of escaping the sense of constriction and entrapment they had developed in their relationships with their families. Two of them dreamed of themselves as jigsaw puzzles, reflecting their feeling that they could escape only by being torn apart or disassembled (Hendin 1973b, 1974c).

ADOLESCENTS

Most drug abuse begins in adolescence. Since a major adaptive task of adolescence is a change in the individual's relationship to his or her family, one would expect the family to be the arena in which the conflicts that center around drug abuse are expressed.

The parents' difficulties in accepting the changes in relationships with adolescent children have been shown to contribute to the problems (Zinner and Shapiro 1974, 1975). Families are most aware of the drug-abusing youngsters' anger, defiance, destructiveness and perhaps most infuriated by their provocativeness--agreements violated, promises broken, and the like. For some youngsters the anger they feel toward their families is open, often uncontrollable, and frequently frightening to the youngster. Marijuana in particular may be used by youngsters to help them subdue their rage (Allen and West 1968; Hendin 1973a; Hendin et al., in press).

Less accessible to the awareness of these youngsters and their families is their need for the parents' support and approval. The youngsters' defiance and provocativeness serve to force the parents to treat them like young children who have to be watched and controlled, locking them into an angry, dependent relationship. And despite all the anger of the drug abusers toward their families and despite their insistence on a desire for freedom, moving out of their homes and away from this dependent relationship with their parents is extremely difficult for them.

Ackerman's (1958) early family studies highlighted the contribution of the delinquent child (often the scapegoat) to the family situation. Stanton and his coworkers (1978) have developed and applied this concept to their work with drug-abusing youngsters and their families. Our own recent studies of adolescent drug abusers, in which their nondrug-abusing siblings were used as controls, show how family dynamics make it more or less likely for a particular youngster to express his or her difficulties through drug abuse (Hendin et al., in press).

Early childhood experiences play a critical role in determining later vulnerability to drug abuse (Hartmann 1969; Pittel et al. 1971). By the time a child reaches adolescence, parents may have resolved the

problems that troubled their marriage earlier or that interfered with their interaction with a particular child. Unfortunately, the youngster will have already suffered the consequences and may, in a sense, make the parents continue to pay for old injuries.

Parental response to the youngster's difficulties must be distinguished from the parent's contribution to the origin of those difficulties. Failure to make this distinction can lead to the mistaken assumption that the family's need for a drug-abusing youngster is responsible for the drug abuse. In some cases the drug abuser brings the family closer together; in others, the family does better when the child leaves home.

What drug abusers derive from their families becomes part of their own adaptation which they express both in and outside the family, and which they will continue to use after leaving the family. It is necessary to understand some of the features of this adaptation to be in a position to understand what role drug abuse serves for an individual.

Solely in terms of the difficulties they create for themselves at home, at school, and with the police, and the ways in which they damage their present and future prospects in life, the drug-abusing youngsters could be characterized as self-destructive. Many of the drug abusers are aware of some desire to harm themselves directly, if only through the use of drugs. Although most speak at first of their drug use as a conflict-free source of pleasure, in time they express somewhat more ambivalence. A young man who claimed to be joyfully high on marijuana whenever he could eventually indicated that he was wasting his life away being stoned, and that marijuana took away his ambition and drive and made him unable to express himself. A young woman indicated that she took drugs with a "let something happen to me" attitude. A young man who claimed his intermittent use of heroin was only a source of pleasure to him dreamed of it as a mixture of milk and poison.

Although virtually all of the drug-abusing young women we have seen had sexual relations, none of them took precautions to prevent pregnancy. All of them eventually revealed a great deal of conflict and guilt over sexual activity which, when combined with their failure to use contraception and a tendency to be involved in relationships that exposed them to abuse or danger, suggested a self-destructive quality to their sexual behavior.

If the chances taken with regard to pregnancy were a reflection of the self-destructiveness of the young women, the chances taken with cars and motor bikes were a comparable measure for the young men. Accidents were frequent; one of the young men we studied was killed when he crashed his motor bike into a truck. Sometimes being stoned or drunk when driving contributed to the accidents, but even in such cases, it only reinforced an already existing recklessness. Driving for these youngsters has an aggressive quality--going over the speed limit, cutting off cars--but the risks some took and the frequency with which they had accidents suggest a self-destructive quality as well. A grandiose illusion of invulnerability to injury often accompanies such behavior, and a grandiose self-image frequently serves to alleviate the depression and low self-esteem that accompany the self-destructive behavior of drug-abusing young men (Guarner 1966; Hendin et al., in press).