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moving along a life cycle (Benedict 1938). Americans have increasingly been deprived of significant role-related ritual experiences that help in the achievement of an emotional state that could bridge the gap between old and new. The role-related ritual helped to give meaning to the conclusion of one phase of the life cycle and the commencement of another, providing a sense of community and publicly affirming the subject's social and personal identity and the move from one age and status group to another. As modern American rites of passage have become more subdued, people have had a lesser role identity and less opportunity to develop a sense of self. Insufficiently graded sequences of role positions through which people move may be dysfunctional and could be related to the onset of drug dependence (Winick 1968).

STUDIES OF SPECIAL GROUPS

It is possible to apply our theory to a variety of special groups which have had a high incidence of drug dependence: Native Americans, soldiers in Vietnam, college students, jazz musicians, physicians, and

nurses.

NATIVE AMERICANS

A study of Menomini Indians concluded that the members of a tribe most drawn to peyote had difficulty in developing role relationships either with the tribe or the world outside (Spindler 1952).

SOLDIERS IN VIETNAM

Another situation providing data relevant for our theory can be derived by analysis of the experience of the American troops in Vietnam. A study of Army enlisted men in Vietnam concluded that approximately 35 percent of this group tried heroin at least once during their "hitch." Fully 20 percent of the troops were "strung out," or dependent on the drug during their year of service (Robins 1973). While serving in Vietnam, the soldiers had (1) access to heroin, which was cheap and freely available; (2) disengagement from negative proscriptions about its use because many of the natives as well as other soldiers were already using it; and (3) severe role strain because of boredom, homesickness, uneasiness, the ambiguity of our role in Vietnam, the lack of a clearly defined "front," and the enormous opposition to the war in the United States, all of which combined to make the strain so severe that tours of duty there were limited to one year.

COLLEGE STUDENTS

There are a number of studies of drug use among college students which, although they were conducted for other purposes, lend themselves to interpretation in terms of our theory. Certainly at many colleges there is a high degree of access to drugs and emancipated attitudes toward their use, which means that two of our three conditions are met. Drug use is favored by those students, we would argue, who are experiencing role strain and/or role deprivation. Among the contributors to role strain among the young are the current confusion over the masculine and feminine roles, the decline in clothing as an

indicator of age-graded role expectations, the role competitiveness induced by the large numbers of young people seeking similar goals, disillusion about conventional roles, loss of positive role models in mass media, and consideration of the notion that many of our role models in public life are less than admirable (Winick 1973).

Suchman (1968), in a survey of a large West Coast university, found that marijuana use was correlated positively with reading underground newspapers, negative reactions to education, respect for the "hippie" way of life, approval of "getting around" the law, and other dimensions of a "hang loose" ethic, which we can interpret as a special case of the larger phenomenon of role strain.

In a survey of almost 8,000 college students throughout the country, Groves (1974) found a positive correlation between marijuana, psychedelics, opium, and methamphetamine use and counterculture attitudes. The latter may be interpreted as reflections of what we would consider role strain.

The recurrent finding that the incidence of drug dependence and use is higher among liberal arts than engineering students and higher among undergraduates than graduate students can be interpreted in terms of role theory (Marra 1967). The liberal arts and undergraduate students are less explicitly role oriented and experience more role strain than the engineer-to-be or graduate student, who has made a career commitment which she or he is pursuing with a certain degree of awareness of what lies ahead.

Similarly, the finding that drug use is more common among students living off campus and not with their families than among dormitory residents or students living with their families can be understood in terms of the greater role strain to which the off-campus students are subjected (McKenzie 1969).

MUSICIANS

The theory has helped to explain the genesis and continuation of drug dependence among jazz musicians (Winick 1960, 1961b, 1962b). Jazz musicians tend to have liberated attitudes toward drugs, and they often perform in places where drugs are freely available. The occupation involves massive role strain, because of uncertainty over employment, the need for improvisation, and continually changing musical styles. Drug dependence among jazz musicians has consistently peaked at times when role deprivation threatened performers, such as the transition from Dixieland to swing (1930-35), from swing to bop (194549), and from jazz to rock (1954-58). Musicians who became drug users tended to be those who felt threatened by the shift from one kind of music to another. The same kind of phenomenon could be found among rock musicians as they moved from rhythm and blues (1955-57) to the British sound in the early 1960s to folk rock (1965-67) to hard rock (1970-71) and "crossover" music (1977-78).

PHYSICIANS

Physicians have long been identified as an occupational group with a high rate of drug dependence (Winick 1961a). Physicians have access to drugs of dependence and tend to have emancipated attitudes toward

their use. Physicians who become dependent may even have magical or omnipotent attitudes toward drugs. ("Because I am a doctor, I will know when to stop.")

Interview studies with 315 drug-dependent physicians concluded that medical specialties which traditionally involve considerable role strain, such as psychiatry and surgery, have a disproportionately high rate of drug dependence. Also overrepresented among addicted physicians are those in career contingencies that are likely to produce role strain: last year of residency, year before taking board examinations, inability to handle overwork, conflict between a humanitarian and entrepreneurship view of medicine, ambivalence about being a physician, and conflict between demands of the profession and of a spouse. Role deprivation figures in another group of addict physicians, those who are moving from one type of practice to another, failing specialty boards, moving their office, leaving one specialty for another, facing retirement, or are concerned about the effect of illness or their ability to practice.

NURSES

About one percent of the approximately 650,000 American nurses are drug dependent. Nurses have access to drugs because they administer them to patients and control their use in hospitals. They are relatively emancipated in terms of attitudes toward their use because of familiarity with their analgesic properties. In an interview study of 195 drugdependent nurses, role strain and deprivation were significant contributors to the beginning of the dependence (Winick 1974a). Among the role strain factors which emerged were extreme fatigue, physical ailments making for work difficulties, quarrels with coworkers, disagreements between the nurse's conception of her job and urgencies of the work situation, conflict between demands of a family situation and the job, and pressures arising from conflicting demands of the nurse's role. Among the role deprivation factors found in the drug-dependent nurses were uneasiness about leaving bedside nursing for a promotion to supervisor, the loss of a significant personal relationship (via death, a child moving out, or divorce), facing retirement, or leaving a familiar situation.

FOREIGN EPIDEMICS

The theory has been successfully used to clarify the reasons for a huge increase in drug dependence in the three countries which have experienced the most thoroughly documented post-World War II epidemics: Japan, Switzerland, and Sweden.

The amphetamine epidemic which swept Japan between 1945 and 1955 and involved more than 2,000,000 people centered on groups such as artists, Korean emigres, young male delinquents, and economically marginal persons who had been dislocated from their jobs and other moorings by post-War social change (Brill and Hirose 1969). We suggest that such persons were responding to role strain and/or deprivation. In Japan, methamphetamine was available without prescription in 1945 in large quantities. The drugs were promoted actively for their moodelevating properties by manufacturers. The situation in Japan meets the three criteria of access, freedom from negative proscriptions, and role strain and/or deprivation. The groups that did become drug dependent were usually vulnerable to role strain and/or deprivation.

Soon after World War II, drug dependence to analgesic compounds containing phenacetin, caffeine, and a hypnotic drug became a severe problem in the German-speaking part of Switzerland (Kielholz and Battegay 1963). Some 80 percent of these cases were women who tended to fall into two groups: working housewives experiencing role strain because of the multiple demands posed by their jobs, housework, and raising children, and single women who experienced role deprivation as a result of moving into urban areas from the country in order to become piecework employees of the watch and textile factories. In communities with such factories, about one percent of the population was dependent on these substances. Because Switzerland is the home of some of the world's largest pharmaceutical manufacturers, the analgesic substances were not only easily available but were advertised as harmless. All three elements of our theory are relevant to the Swiss situation.

A third foreign example is provided by Sweden, which had some 200,000 amphetamine users around 1959, when widespread nonmedical use of various amphetamines began (Goldberg 1968). The users tended to be single or divorced adults, from homes where the parents were divorced (41 percent as against three percent in the normal population); nomadic and disaffected youths; and others whose life situations posed problems of role strain or deprivation. There was relative acceptance of amphetamines, which were easily available. All three prongs of our theory are relevant to the Swedish epidemic.

CESSATION OF DRUG DEPENDENCE

The theory suggests that a population or subgroup will tend to cease drug dependence when (1) access to the substances declines, (2) negative attitudes to their use become salient, and (3) role strain and/or deprivation are less prevalent. If all three of these trends are operative, the rate of drug dependence will decline more rapidly than if only one or two trends are relevant.

Several examples illustrate the dynamics of cessation. Of the large number of soldiers who were addicted in Vietnam, only seven percent have been addicted at any time since their return to America (Robins 1973).

If we explain the genesis of the relatively high rate of Vietnam heroin use in terms of our theory, can we use the same theory to explain its relative nonresumption by the soliders? Yes, because when they returned to this country, the soldiers came to a situation in which (1) a major law enforcement effort had made drugs relatively inaccessible and expensive, (2) there was a strong feeling of disapproval of heroin and growing acceptance of the negative proscriptions about it, and (3) less role strain because the soldiers were out of Vietnam and usually no longer in uniform.

Perhaps the single most successful treatment program for drug addicts, in terms of recovery rates, was the Musicians' Clinic (Winick and Nyswander 1961). One reason that it was so successful is that it faced and dealt with the musicians' role conflicts about their work. The very existence of the clinic, which was widely publicized, also contributed to an atmosphere in which musicians' attitudes toward drug use became less accepting.

In Japan, the drug epidemic ended in a few years because when the dangers of the situation became clear, Japanese authorities acted decisively to control the availiability of amphetamines, change attitudes toward their use, and assist those users who needed treatment. The enormous boom in the Japanese economy and the stabilization of the society further helped to minimize role dislocations and, thus, in terms of our hypothesis, proneness to drug dependence.

Similarly, in Switzerland, the drug epidemic ended in the 1960s because the Swiss acted to educate the public on the possible hazards of these substances, made access to them more difficult, and provided treatment for those already afflicted. The education and treatment effort was quite successful for a number of reasons, one of which was that the role conflicts of the high-risk population were faced.

Because the Swedish Government has done little to deal with the availability of drugs, favorable attitudes toward their use, or role conflicts among its population, drug dependence still continues there as a severe problem.

RELAPSE

Here or abroad, a person may, of course, cease drug dependence, stop using for some period of time, and then relapse. The reasons for relapse, in terms of this theory, would reflect the person's inability to sustain the role of the nonuser. Each period of abstinence may represent a trying out of the nonuser's role. It is likely that the most common pattern of cessation of drug dependence involves experimentation with the nonuser's role until it is consonant with other aspects of the person's life.

An earlier formulation of the theory argued that drug-dependent persons "matured out" when there was a lessening of the role pressures which had led to the beginning of regular drug use (Winick 1962a). The process of "maturing out" was slow and typically involved a stopstart pattern of drug use until the person felt comfortable with the role of the nonuser. This was the most frequently found manner of cessation of drug dependence, and there is reason to believe that it is still the most prevalent form of termination of regular drug use. In the original study which led to the formulation of the "maturing out" theory, based on a national sample, the mean age of "maturing out" was 35 (Winick 1962a). A study of Puerto Ricans who were dependent on opiates concluded that those who "matured out" did so at the mean age of 33 (Ball and Snarr 1969). An analysis of the phenomenon in New York City concluded that persons listed in the Narcotics Register who "matured out" did so at a mean age of 34 (Snow 1974). This narrow clustering of age at "maturing out" in different samples at different times suggests that there are underlying regularities in the process. Ethnicity, sex, residence, access to and salience of drugs, attitudes toward drugs in an area, and the extent to which nondrugrelated roles are plausible and reinforced, contribute to cessation of drug use, as does the extent to which the user experiences less role strain and/or deprivation.

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