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An Interactional Approach to Narcotic Addiction

David P. Ausubel, M.D., Ph.D.

As in other fields of medicine and the behavioral sciences, an interactional approach to the etiology, epidemiology, psychopathology, and treatment of narcotic addiction implies the operation of multiple causality within the person, in the environment, and in the interaction between them. One must consider both long-term predisposing factors and more immediate precipitating factors.

The most important precipitating factor in narcotic addiction is degree of access to narcotic drugs. This factor, for example, explains in part why narcotic addiction rates are higher in the urban slums than in middle-class suburbs and why the incidence of narcotic addiction approached the zero level during World War ll when normal commercial channels in the illicit narcotics trade were disrupted. Thus, no matter how great the cultural attitudinal tolerance for addictive practices is, or how strong individual personality predispositions are, nobody can become addicted to narcotic drugs without access to them. Hence the logic of a law enforcement component in prevention.

The second most important predisposing factor in the etiology of narcotic addiction is the prevailing degree of attitudinal tolerance toward the practice in the individual's cultural, subcultural, racial, ethnic, and social class milieu. This factor explains differences in incidence rates between lower class and middle-class groups, between Europeans, Americans, and Orientals (except the Japanese), and between members of the medical and allied health professions and other occupational groups (Ausubel 1961 , 1962, 1966).

The crucial and determinative predisposing factor, which, therefore, constitutes the most acceptable basis for the nosological categorizing of narcotic addicts, is the possession of those idiosyncratic or developmental personality traits for which narcotic drugs have adjustive properties. Thus it is obvious that narcotic drugs are more addictive than, say, milk of magnesia, because their greater psychotropic effects have adjustive value for these personality traits. Chief among these effects is euphoria, which is highly adjustive for inadequate personalities, i.e., motivationally immature individuals lacking in such criteria of ego maturity as long-range goals, a sense of responsibility,

self-reliance and initiative, volitional and executive independence, frustration tolerance, and the ability to defer the gratification of immediate hedonistic needs for the sake of achieving long-term goals (Ausubel 1947, 1948, 1952a,b, 1958,a,b, 1961, 1962, 1966, 1980a,b; Ausubel and Ausubel 1963; Ausubel and Spalding 1956). Several clinical studies of hard-core addict populations (e.g., Ausubel 1947; Dai 1937; Pescor 1939; Research Center for Human Relations 1957a; Zimmering et al. 1951 , 1952) have shown that most chronic narcotic addicts fall in this diagnostic category. Other studies (Ausubel 1947; Chein et al. 1964; Dai 1937; Research Center for Human Relations 1957a) have uncovered in the life histories of such addicts those types of parent-child relationships, i.e., overpermissive (underdominating), overprotecting, and overdominating parents, that tend to foster the development of the inadequate personality syndrome.

Contributory factors in the development of this syndrome are probably genic (polygenic) in origin and are undoubtedly fostered by lower social-class membership, particularly in families that have been on welfare for one or more generations. Most of such latter youth, of course, are not motivationally inadequate and tend to be sporadic narcotic users who do not become either physiologically or psychologically dependent upon the drugs in question. Epidemiological studies by the New York University Research Center for Human Relations (1957a) have developed various behavioral, familial, and socioeconomic criteria for differentiating between these two groups.

Because of these euphoric properties of narcotic drugs effected through depression of the self-critical faculty and the positive pleasure of the "rush," addicts receive an immediate, unearned form of gratification and ego enhancement. These same euphoric properties are also obviously adjustive for persons with histories of recurrent reactive depression. Recent studies with endogenously produced opiates, i.e., endorphins and enkephalins (Costa and Trabucchi 1978; Goldstein 1976c; Snyder 1977), suggest that in some instances deficiencies in the production of the substances that contribute to normal optimism in the face of life's vicissitudes (and hence have evolutionary survival value for the species) contribute toward the incidence of narcotic addiction. A recent study of psychiatrically disabled, treated narcotic addicts (Ausubel 1980a) shows that lower middle- and working-class addicts tend almost exclusively to develop severe anxiety states and reactive depressions when under psychological or environmental stress, whereas addicts from urban slum welfare backgrounds almost invariably develop schizophrenic symptoms under similar circumstances. This difference in pathological outcome probably reflects some insidious internalization of mature motivational traits by the lower middle- and working-class addicts despite the overt domination of the personality traits of the inadequate personality.

Another psychopharmacological effect of opiates, namely, sedation or relief of anxiety, probably accounts for the small minority of narcotic addicts who suffer from disabling neurotic anxiety. Such individuals, particularly members of the medical and allied health professions, typically take small, well-controlled doses of morphine subcutaneously (rather than large doses of heroin intravenously) for their sedative rather than their euphoric properties. Typically their addiction is well disguised and seldom recognizable (Jaffe 1970a,b).

Widespread sporadic use of heroin in adolescents with relatively normal personality structures is generally reflective of the aggressive, antiadult orientation characterizing adolescents in our culture. Here the personality predisposition is developmental rather than idiosyncratic.

Apart from the aforementioned affirmative clinical evidence supporting the existence of personality predispositions for which narcotic drugs have adjustive value, the very logic of this proposition itself is compelling. How else could one explain why, in a given urban slum neighborhood with uniform access to narcotic drugs and uniform subcultural or ethnic attitudinal tolerance for narcotic addiction, the vast majority of adolescents become only sporadic, nonaddicted drug users, whereas a relatively small minority become chronically addicted?

A separate nosological category of addiction can probably be made to include minority-group youths with normal or even better-than-average motivational maturity who use narcotic drugs chronically for limited periods of time because they perceive the odds of achieving any ordinary degree of academic or vocational success as so overwhelmingly stacked against them.

Finally, a very small minority of narcotic addicts may be classified as psychopathic or sociopathic personalities (Kolb 1925a,b). Drug addiction, insofar as it is regarded as a disreputable or socially disapproved habit, obviously has nonspecific adjustive value for such persons; however, it provides only one of many available nonspecific outlets for aggression or "acting out" behavior against society. Such addicts tend to commit the violent, remorseless crimes that are popularly and erroneously associated in the public mind with drug addicts generally. Actually, of course, the sedative action of narcotics tends to inhibit violence of any kind unless addicts are particularly desperate for their next "fix."

For the most part, except for the relatively rare psychopathic addict, most chronic addicts engage in nonviolent, remunerative crimes primarily to support their habits, e.g., "pushing," "con" games, shoplifting, check forgery, "paperhanging," fraudulent magazine subscriptions, etc. (Chein et al. 1964; Kolb 1925a). The percentage of addicts involved in preaddiction delinquency is generally lower than that of nonaddict narcotic users who are members of delinquent gangs in urban slum areas (Ausubel 1958a,b; Research Center for Human Relations 1957a). ln any case, delinquent addicts tend to be involved in more remunerative delinquencies directed toward satisfying their drug habits than in the more violent, predatory gang activities and "rumbles" (or gang warfare) (Research Center for Human Relations 1957a).

SPECIAL POPULATIONS

ALCOHOLlSM AND OTHER DRUG
ABUSE lN NARCOTlC ADDlCTS

Addicts in methadone maintenance programs, when deprived of their heroin-induced euphoria, turn to the euphoria-inducing properties of alcohol, large doses of barbiturates, amphetamines, benzodiazepines, and amitriptyline. Sometimes overdosage of these drugs leads to accidental or, in reactive depressives, to deliberate suicide. Reference has already been made to the relationship between addiction, on the one hand, and psychopathology and criminality, on the other.

lt is generally agreed that most addicts have a preferred drug that is most adjustive for their particular idiosyncratic or developmental personality defects and that they use other drugs only when deprived of access to their drug of choice. Heroin and marijuana, for example, each have their own separate constituencies based on their distinctive psychopharmacological effects. The use of marijuana does not predispose an individual to heroin use except insofar as it may "break the ice" for more dangerous drug use. Narcotic addicts tend in general to have a history of prior marijuana use because the latter drug is more accessible, cheaper, and considered less dangerous and less socially disapproved. The connection between the two types of drugs is not causal: The converse of this proposition is not true, i.e., the vast majority of marijuana users exhibit no later history of heroin abuse (Robins et al. 1970).

PHYSlClAN ADDlCTS

Clinical experience with large numbers of physician addicts at the Lexington Hospital indicates that there are essentially two different kinds of underlying predispositions: (1) the intelligent, overdominated inadequate personality who was forced into the profession by parents seeking vicarious ego enhancement, and who later rejects the goals of adult maturity as a measure of revenge against parental overdomination as soon as the parent dies or ceases to be autocratic, and (2) the anxiety neurotic who uses small, controlled doses of morphine subcutaneously to relieve anxiety rather than to obtain euphoria. These are typically highly achievement-oriented persons who seek in unusual accomplishment the ego enhancement and sense of intrinsic self-esteem never possessed because their parents either rejected them or failed to accept them for themselves (perceiving them solely as sources for vicarious ego enhancement).

The CAP Control Theory of Drug Abuse

Steven R. Gold, Ph.D.

With our current incomplete understanding of drug use and abuse, the appropriate function of any theoretical model may be to stimulate new work in the area. The aim of this paper is to describe a theory of drug abuse that can be empirically evaluated and to encourage additional research and theory development.

The CAP control theory emphasizes the interaction of the individual's style and the affective experience of drug use with the drug's pharmacogenic effect. These are the basic ingredients of the cognitiveaffective-pharmacogenic (CAP) control theory of addiction (Coghlan et al. 1973; Gold and Coghlan 1976). The cognitive style of the drug abuser is viewed as the pivotal factor in an individual's moving from drug experimentation to drug abuse. The cognitive dimension will therefore be discussed first.

There is a current trend in behavior therapy emphasizing cognitive approaches (Lazarus 1976; Mahoney 1977; Meichenbaum 1977). The major tenets of cognitive behavior therapy are that human behavior is mediated by unobservables that intervene between a stimulus and the response to that stimulus. Beliefs, sets, strategies, attributions, and expectancies are examples of the types of mediating constructs currently considered crucial to an understanding of emotion and behavior. Second, the way an individual labels or evaluates a situation determines his or her emotional and behavioral response to it. A third basic assumption is that thoughts, feelings, and behaviors are causally interactive (Mahoney 1977).

To tie the cognitive approach to drug abusers, the CAP control theory posits that the abuse process begins with conflict as a predisposing factor. People who are having difficulty in meeting demands or expectations placed upon them by society or by themselves are in conflict, and a consequence of the stress of conflict is anxiety. Anxiety is a universal feeling, something most of us experience to some degree each day. lt is not the experience of anxiety but the individual's interpretation of the anxiety that is crucial to the theory. Underlying the anxiety of drug abusers is a belief that they cannot alter or control the situation; that they are powerless to affect their environment and

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