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he now feels were evil and sinful ways. He finds needed strength in a new source of power (perhaps a counselor, a parent, a wife, a religious figure, or a rehabilitation program) and transfers all his devotion from the drug to that new entity. Obviously, the success of this form of change depends upon the success with which the new god-figure serves as an adequate symbol of selfhood and individuation.
Lennard and Allen (1973) have emphasized that, in order for drug abuse treatment to "take hold," the social context of the abuser must be changed. Applying drug abuse to its context in the family, one could assert, as have Bowen (1966), Haley (1962), and others, that in order for the symptom to change, the family system must change. Conversely, treatment which changes an individual also affects that person's interpersonal system. However, if broader system change (rather than change primarily in the individual) does not occur, the chances for prolonged cure are reduced, for there can be considerable pressure to revert to the old ways.
The often-referred to phenomenon of "maturing out" of drug abuse or addiction is relevant here. However, this concept does not go far enough. It is an individual-oriented concept and does not help to explain why some addicts mature out and others do not, and why some are much older than others when they do. It is more instructive to examine what is going on in the abuser's life when use ceases, i.e., what changes are taking place in the interpersonal systems--most notably the family. More explicitly, one could ask what family life cycle changes have occurred: Has either parent died? Has a sibling developed problems? (Stanton 1977b). Has the abuser recently had a first child? Has a new support system developed for the parent(s)? Some abusers have been known to "buy" freedom by substituting another person for themselves vis-a-vis their parents; they give the parent(s) a newborn or other child to raise as a replacement, thus taking pressure off themselves (Stanton et al. 1978). These and related questions about events in the abuser's intimate interpersonal system must be answered in order to gain a more meaningful understanding of the critical variables surrounding cessation of use.
In the framework of the self-esteem theory, we explain cessation on a basis of two sets of conditions, individual and situational. In the first instance, we postulate that if an individual's self-esteem were raised (through therapy), he or she would quit using drugs because they would no longer serve as a mechanism for coping with inferiority. In the second case, an individual may quit drug abuse as a result of a superimposed set of conditions, such as being forcefully detoxified in the Army, being arrested and jailed, or being socially pressured into
joining Alcoholics Anonymous or Synanon. Drug abuse may also cease if the social stress is removed or if interpersonal satisfactions are increased so that the abuser's fragile psychological balance does not require this primitive coping mechanism.
Cessation can take place on a microlevel or on a macrolevel. On a microlevel, self-esteem can be increased so the neurotic coping mechanism is not necessary--the person would be cured. On the macrolevel, it is the situation which is responsible for cessation, although the personal need might remain--the individual would be rehabilitated, not cured.
If it is accepted that conditioning factors (classical and operant) and protracted abstinence play an important role in relapse, then addiction must be regarded as a disease sui generis, and regardless of antecedent etiological variables (e.g., premorbid personality) its specific features must be eliminated by appropriate procedures. As Wikler (1965) pointed out, mere detoxification, with or without conventional psychotherapy and enforced abstention from self-administration of opioids, will not prevent relapse when the former addict returns to his home environment or other environments where the conditioned stimuli are present (drugs readily available; "pushers" and active addicts). What is needed in treatment after "detoxification" is active extinction of both classically conditioned abstinence and operantly conditioned opioid self-administration. This would require repeated elicitation of conditioned abstinence and repeated self-administration of opioids under conditions that prevent the reinforcing effects of opioids (production of "euphoria," reestablishment of physical dependence). Under such conditions, conditioned abstinence should eventually disappear and self-administration of opioids should eventually cease. With the introduction of the orally effective, long-acting opioid antagonist, cyclazocine, by Martin et al. (1966), it became possible to prevent the reinforcing effects of opioids by daily administration of cyclazocine. If former addicts are maintained on blocking doses of an antagonist for a sufficient length of time (e.g., over 30 weeks) to permit disappearance of protracted abstinence, and if active extinction procedures are carried out during this period (Wikler 1973d), then administration of the antagonist may be discontinued, with the expectation that relapse will be much less likely to recur.
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.
The narrow clustering of age at "maturing out" in different samples at different times (mean ages of 33, 34, and 35 in, respectively, Ball and Snarr 1969; Snow 1974; and Winick 1962a) suggests that there are underlying regularities in this process. Ethnicity, sex, residence, access to and salience of drugs, attitudes toward drugs in an area, and the extent to which nondrug-related 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.
Like other neurotic symptoms, compulsive drug use can recede or disappear--either "spontaneously" or under the impact of outside events (including treatment). Wherever the earlier described circle (figure 1, p. 356) is interrupted, drug use recedes. When there is a radical change in the "narcissistic equilibrium," i.e., when there is dramatic reason to feel proud, not ashamed, not guilty anymore, the wheel may be stopped. Not rarely, however, is it precisely apparent success that keeps it going, namely, when unconscious guilt is an important factor; then every triumph immediately has to be followed by an act of severe self-punishment and self-sabotage. In these frequent cases, actual suffering and punishment inflicted from the outside bring about sudden stopping of the drug use. With the great need to depend on outside ideals as protectors and givers, the strong intervention by a cause or person that can function as a meaning-giving ideal may make the dependency on a drug for increased self-esteem unnecessary. This is "cure" by displacement of idealization: conversion to a religion or sect; entrance to a powerful organization; joining Alcoholics Anonymous, a political cause, or following a charismatic leader; an intense love relationship; transference to a therapist--all are often observed to bring about cessation of drug abuse.
FIGURE 1.- Graphic representation of the psychodynamic
pattern of drug use
Repeated relapse is part of the picture in most addictive conditions, regardless of whether they are pharmacologically induced or of a nondrug type (gambling, obesity, etc.). If sentiments are reactivated through external stimuli and if dependent individuals consider the conditions for a relapse to be favorable, they may decide that they can permit themselves a relapse, particularly if they believe that they have now gained control over the addictive behavior (drinking, smoking, overeating, injections, etc.).
INCOMPLETE MOURNING THEORY
Family therapy offers a sense of "roots" and reinforces the continuity of the generations. It also provides an opportunity for individuation of each member. With optimal balance, future losses should be met with more creative responses. As Boszormenyi-Nagy and Spark (1973) suggest, "... death, loss and grief can be made into resources for significant relational gains." Unfortunately, for those families that do not successfully change their structural and functional relationships, some relapses can be expected, particularly when the system is threatened by additional loss or separations.
METABOLIC DEFICIENCY PERSPECTIVE
Implicit in methadone maintenance programs is an assumption that heroin addiction is a metabolic disease, rather than a psychological problem. Although the reasons for taking the initial doses of heroin may be considered psychological--adolescent curiosity or neurotic
anxiety--the drug, for whatever reason it is first taken, leaves its imprint on the nervous system. This phenomenon is clearly seen in animal studies: A rat, if addicted to morphine by repeated injections at one to two months of age and then detoxified, will show a residual tolerance and abnormalities in brain waves in response to challenge doses of morphine for months, perhaps for the rest of its life. Simply stopping the drug does not restore the nervous system of this animal to its normal, preaddictive condition. Since all studies to date have shown a close association between tolerance and physical dependence, and since the discomfort of physical dependence leads to drug-seeking activity, a persistence of physical dependence would explain why both animals and men tend to relapse to use of narcotics after detoxification. This metabolic theory of relapse obviously has different implications for treatment than the traditional theory that relapse is due to moral weakness.
The conditioned drug behavior which is strengthened through reinforcement is weakened through extinction in nonreinforcement, but recovery recurs through rest. Two additional concepts are central to an understanding of learning principles inherent in drug-related behavior. A different or newly conditioned stimulus, which has not been reinforced, can evoke a conditioned act upon its initial presentation. The likelihood that this will occur increases when it is similar to a previously conditioned, already reinforced, stimulus. Thus, the process of generalization becomes important in analyzing drug-taking behavior. When two acts or responses are alike but distinguishable, the individual can be taught to respond to one and not the other. This principle of conditioned discrimination can serve as a two-edged sword in careless hands, since it can possess both addictive and therapeutic aspects. Whatever is useful to assist the drug abuser in the clinic can be used to enhance and perpetuate a new addiction out on the street, so to speak. Personality (P), motivation (M), and habit (H) factors are particularly important in bringing about a relapse to drug usage, although most values clearly will have been altered over time with continued drug use. There is a spontaneous recovery of past learned addictive habits, when the motivation or drive to abstain is no longer superior to the motivation to engage in drug usage. While most destructive and constructive factors have been altered, due to reinforcement or nonreinforcement with time, the ratio is most affected by negative personality, motivational, and habit factors. Mathematically, as the equation shows, in principle, the proportional value now approaches 1, where drug usage unequivocally develops again: Pd x Md x Hd x Rd - 3 x 4 x 3 x 5 – 180
0.94 PC x MC x HC X RC4 x 4 x 2 x 6 19