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reduced by 90 percent by the use of a restrictive and consistent drug policy (Harney and Cross 1961). Between 1951 and 1953, about 20 million opium addicts in China were rehabilitated by means of strong social pressure. When I visited Peking in 1978, I was told that about 90 percent stopped on their own, without interference from society. Shortly afterward (1954-1958), Japan eliminated a widespread epidemic of drug abuse in a similar way. Of the 600,000 estimated intravenous amphetamine abusers, it was only necessary to take action against about 20 percent; the rest stopped as a result of social pressure (Brill and Hirose 1969).
Fear of medical complications is a common reason for discontinuing addictive intoxicant behavior. The addict may have been frightened by a paranoid intoxication psychosis (cocaine, amphetamine), a death from overdose among friends, a severe abstinence experience (delirium tremens), the threat of liver cirrhosis, etc.
Inability to go on any longer with a far-too-expensive and hazardous lifestyle, when many relationships have become strained and complications of all kinds pile up, is usually called "maturing out of addiction." This is not a general phenomenon but is associated with epidemic addiction and seems to require a restrictive policy in society in regard to illicit drugs. The phenomenon is seldom seen in therapeutic or cultural addiction. If a society wages a prolonged and intensive campaign against the use of drugs, results may sometimes be achieved (the reduction in tobacco smoking among physicians and upper class people during the last ten years, the fall in abuse of alcohol to oneseventh in Sweden during the second half of the nineteenth century, etc.).
Reduction in pleasure stimulation and rising discomfort should lead to an interruption. This phenomenon is sometimes seen among elderly alcoholics. The situation is reminiscent of the failing interest in sexual activity on declining potency. Possibly both phenomena are the result of a neurophysiological decline in the effect of pleasure stimulation with rising age.
The introduction of another strong pleasurable experience to compensate for the loss of drug stimulation should lead to the discontinuation of addictive behavior. Religious salvation is a typical example. Only exceptionally can other events fill the same function. This is not surprising since the drug experience is often more pleasurable than sexual satisfaction.
Systematic treatment should be mentioned, even if in practice it still plays a very small part, since ineffective treatment techniques, based on inadequate analyses and models of the nature of dependence, are usually employed. A prolonged and thorough reconditioning of values is one possible method (e.g., Daytop model), as are simpler forms of behavior modification. Unconscious reconditioning (for instance, disulfiram medication to alcoholics without their knowledge) is unethical and unsuitable in practice, but it is theoretically possible. Consciously accepted aversion therapy of various types usually has only temporary effects but may act as a support in a wider program.
DISRUPTIVE ENVIRONMENT THEORY
in areas where drug taking is widespread, a certain number of comparatively healthy and normal persons will, through incontinent use of the drug, develop physical dependence. Such users might be expected to be capable of breaking the dependence. Indeed, this happens in some cases. But while some users manage to free themselves of the habit, most do not. In our investigation of heroin use, both in delinquent gangs and in other cases we studied, there was some evidence that a minority of habitual users manage to discontinue drug use (in our gang sample, there were 14 such cases out of 94 present or former heroin users) (Research Center for Human Relations 1954c). But many more--about one-half--make the effort and fail (Research Center for Human Relations 1957a).
Given the multiple motives of drug abuse, cessation of drug use without effective outside help is impossible for the majority of addicts, and little help is available. Users who are arrested sometimes receive some medical attention, usually limited to easing the pains of withdrawal. In our sample of 94 users who were members of gangs, more than one-half were arrested at one time or another, but only one in ten received any medical attention related to their use of drugs (Research Center for Human Relations 1954c).
Nor are parents of much help. Most do nothing. Those who do try, usually take drastic, punitive action, ordering the boy out of the house, taking him to court, or beating him. Or they remonstrate, giving expression to their hurt, dismay, and unhappiness. In general, few parents seem aware that anything effective can be done to help their children help themselves (Research Center for Human Relations 1954a).
In spite of the lack of help, about one-half of the boys in our sample made more than one effort to stop using drugs. This was especially true of those users who had not previously been delinquent and who came from relatively cohesive families (Research Center for Human Relations 1954a).
Sometimes the most genuine help comes from the user's own friends. Group workers report that gang members sometimes try to dissuade other members who are increasing their intake of heroin (Research Center for Human Relations 1954c). The nature of the support they give indicates that they sense the basic oral needs and the uncontrollable anxiety of the users: They treat them to food, wine, or marijuana, and they try to be with them all the time and watch over them to help at times of stress. The other boys intuitively feel that the user's need for support and his intolerance of anxiety are crucial factors in the process of giving up the habit.
Users do not take easily to psychotherapy. The experience of therapists working with juvenile users points to several common difficulties in treatment: resistance to insight into inner problems, difficulty in establishing rapport with and trust in the therapists, and ease of relapse. Apparently, having discovered an effective palliative in the form of the drug, the user finds it extremely difficult to give it up without at the same time getting some compensatory palliative. Many,
if not most, users who have been hospitalized for a period of three to six months relapse immediately upon release (Research Center for Human Relations 1957b; Riverside Hospital 1954). Most users must experience repeated failure in order to realize that they have been overestimating their powers of self-control, that the trouble is not simply an external "monkey on your back," but that they have inherent personality problems that must be dealt with if they are to be cured. The motivation to be cured must be strong. Also, recurrent opportunities for therapy must be so structured that each successive cycle can begin at a more advanced level so that repeated failures do not lead to the conviction that the struggle is hopeless. It is therefore not surprising that even after a number of such cycles, very few ex-users can be said to be cured of the habit.
Drug users need sustained help over a long period of time. Therapists who have had some experience with youthful users and are searching for more effective ways of cure and rehabilitation differ among themselves as to which of several patterns of treatment is likely to prove most successful. There is general concurrence, however, concerning the need to provide supportive and protective services for the addict in the community.
The main kind of support needed for the addict or postaddict is, of course, a sustained therapeutically oriented relationship. Successful cures are, as a rule, with those youngsters who succeeded in establishing genuine contact with a therapist in an institution and who, upon release, continue to see the same person in an aftercare clinic. It would obviously be desirable for the therapist to be able to command services which would help to cushion the addict or postaddict from unduly frustrating or anxiety-producing situations. Vocational guidance and placement is one such service. A "transition home" for those whose family situation is too damaging and impedes their efforts at better adjustment is also advisable (Riverside Hospital 1954). Planning of leisure time and social contacts with nondelinquent peers who are not involved with drugs is also of prime importance: Addicts usually agree that rehabilitation is hopeless if one returns to the same community, the same crowd of "junkies."
INCOMPLETE MOURNING THEORY
The resolution of the heroin problem is increasingly being sought by treating the family. A national survey of drug abuse and family treatment (Coleman 1976; Coleman and Davis 1978) reported that 93 percent of the respondent clinics (N=2,012) were providing some form of treatment to families. Stanton's (1979d) review of the literature on family treatment of drug problems indicates that this approach and its variations, e.g., multiple family therapy, marital therapy, etc., are both "beneficial and effective."
The incomplete loss theory is indeed dependent on family therapy in order for delayed bereavement to be mastered. Some of the clinical interventions for directly dealing with unresolved loss have previously been described by Coleman and Stanton (1978).
The extent to which heroin abuse is discontinued depends also on the degree to which families are able to restructure their relationship patterns, their power and control systems, their roles, and their feedback mechanisms. In terms of the circumplex model, those drugdependent families that are able to shift and rebalance their cohesion and adaptability, according to life's stress and change, will undoubtedly be less apt to have a relapse of heroin abuse. As a consequence of severing the connection with the loss and grief, families generally develop a renewed sense of meaning, both individually and together.
Without some change in virtually every factor in the drug abuse/addictive equation, even from a logical point of view, it is difficult to conceive of the cessation of such strongly reinforced behavior, both physiologically and psychologically. Once deeply engrained into the psyche and body of the abuser/addict, major changes are necessary in order to diminish the behavior appreciably. to say nothing of its cessation. Because an alteration in personality is less likely to occur, that factor has been left unaffected in our illustrations as one of the crucial links in the chain of events required for drug cessation. In point of fact, psychotherapy alone is often insufficient to bring lasting changes in ridding the individual of serious drug-taking behavior. An essential component in cessation is the nonreinforcement of key ingredients in order to bring about extinction of the previously conditioned behavior.
The ceasing of drug abuse or addiction primarily involves changes in three factors: destructive motivation (Md), constructive habit formation (HC), and destructive risk factors (Rd). In such a case, there is a diminution in the motivation to engage in drug-related behavior and an increase in habits that constructively counteract stress. Simultaneously, there is a decrease in the risk factor which no longer tempts the individual to partake in drug use. By substitution of the appropriate values, as the formula shows, the proportion has now reached 0.09 and is thereby approaching zero, where all drug usage terminates. Ba - Pd x Md x Hd x Rd = 2 x 2 x 1 x 4 = 16 = 0.09
PC x Mc x HC x RC | 3 x 5 x 2 x 6 T80
Effective treatment of the drug abuser requires a multimodal therapy approach. A therapeutic strategy must be developed to help the abuser cope with anxiety, modify faulty cognitive beliefs, learn appropriate interpersonal skills, and interfere with intrusive and unpleasant imagery. Drug abuse affects all aspects of the abuser's thinking, emotions, and behavior, and any therapy that has a narrow focus is likely to fail. The overall strategy is, therefore, to eliminate old
patterns and develop new ones that help the individual see himself or herself as competent and in control. To this end, a variety of therapeutic strategies must be employed. Systematic desensitization may be used to help the abuser cope with anxiety. cognitive restructuring or new "self-talk" may be needed to combat the individual's expectation of failure or rejection, and training in the use of imagery and fantasy may help the individual see himself or herself in a more positive light and provide a means to rehearse new interpersonal skills.
The use of drugs described in part 1 produces massive reinforcement based on the combination of genetic vulnerability and classical conditioning. It produces a "bad habit" that is singularly difficult to extinguish. Cessation of use occurs (if at all) when the overall longterm ill effects from drug use greatly outweigh the short-term positive effects. The addict stops, in my experience, because of fear of losing health or life, of losing a spouse and family, of losing a valued job, and, finally, of losing the respect of peers. Permanent cessation occurs when the addict fails to respond to the multitude of conditioned stimuli associated with drug use. Surrounded by temptation--drinking cues--the conditioned response of drinking can be extinguished only if one fails consistently to respond to the cues. After a time, following the laws of Pavlovian conditioning, the habit will cease, although this may take a very long time.
How continued illicit drug use can be prevented after the initial drug experience or disrupted after it has begun is a function of the model most appropriate for the initial drug experience. Since individuals entered into drug experiences by different paths and since at least the early stages of continued drug use are an extension of those paths, those paths must be disrupted for cessation to occur. Treatment immediately after an initial drug experience would therefore be contingent upon diagnosis of which path was involved.
The nonsocialized individual would be identified by appropriate personality tests showing low scores on conformity and responsibility scales. In addition, descriptions of the initial drug experience would--insofar as they avoided rationalization and self-justification of the "they made me do it" type--show that availability and lack of perception of social constraining factors were prime features in the initial drug experience. Prevention of further drug involvement and continued drug use would be possible either by developing the person into a more responsible member of traditional society or by reducing drug availability. Do note that the nonsocialized individual does not have high levels of motivation for continued drug use, and so social control techniques which prevent access to the drugs through, for example, limiting