punishment and the demands made of the child; in which society, its institutions, and its institutional representatives are regarded with suspicion and distrust; in which hopes for the future take the form of unrealistic dreams and in which there are no realistic aspirations for or expectations of the child. It is precisely from such families that chronic addicts tend to come. From this background they emerge into the larger world of the street and the school. In this larger world, they find the basic lessons of their earlier childhood reinforced in various ways. In school, they are misfits, taught frequently by inexperienced teachers who tend to look at them as incorrigible and unteachable. In the streets, they hang around aimlessly, dreaming of an affluent life achieved effortlessly, gravitating toward the delinquent subculture, but, as a rule, lacking the inner resources to become effective delinquents. Such boys are likely to have a favorable attitude toward the use of drugs. Abandoned at the threshold of a frightening adulthood by their more successful peers, narcotics offer them relief, an alibi, and a way out. In the deprived areas of a city there are sizable minorities of such youngsters. In some subgroups, this delinquent orientation is even more widespread, although not all delinquents become drug addicts. Not all delinquents become drug addicts, and not all young boys who grow up in slums, even in the most economically deprived families, become delinquent. It is not easy to escape the pull of the delinquent subculture. The child who succeeds is the one whose initial autonomy is great enough, or whose early family environment is wholesome enough, or who, in his early school years, encounters teachers who are sensitive and encouraging. Such a child is more likely than those in otherwise similar circumstances to pass successfully what Erikson (1950) has described as the developmental hurdle of establishing basic trust. Having done so, he is more likely to benefit from such favorable opportunities as may present themselves, to develop competencies and confidence, to become independent of the slum environment, and to establish relationships with wise and sympathetic adults who can help him through crises. In deprived areas, many youngsters with a delinquent attitude toward life become members of street gangs. However, none of the juvenile gangs we studied was organized to sell drugs. Since most of these gangs were the most troublesome ones to be found in the high drug use areas of the city and they engaged in many gang-sponsored illegal activities, this finding makes it most unlikely that juvenile street gangs operate on an organized basis to recruit users. Most gangs set limits on drug use by their members. The majority of the members of most of the gangs we studied were either opposed or ambivalent to the use of heroin. However, use of heroin among gangs is by no means rare, and the smoking of marijuana is extremely common. The general attitude seems to be that it's okay to use heroin "as long as you make sure you don't get hooked" (Research Center for Human Relations 1954c). The reasons why gangs seem to resist the spread of immoderate drug use in their midst are practical, not moral. An addict is thought to be "unreliable on the job," and, also, able to get the whole gang into trouble if they are all arrested together. Moreover, users tend to form little cliques that threaten the cohesiveness of the gang. For these reasons, a gang leader who starts to use drugs is likely to be demoted. To the gang members, the habitual use of drugs and their kind of "acting out" delinquency are incompatible. In line with this attitude, a pusher who is a member of a gang will not tempt a vulnerable fellow member, but will have no hesitation about tempting a nonmember or a member of another gang. Most boys who grow up in deprived areas are exposed to drugs. A great many experiment with their use. From whom do they get their first dose? Contrary to widespread belief, most addicts were not initiated into the habit by an adult narcotics peddler. Only ten percent of the addicts whom we interviewed received their first dose from an adult. The overwhelming majority of the boys took their first dose of heroin in the company of a single youngster in their own age group or while with group of teenagers. This first trial of narcotics was free to most of the boys (Research Center for Human Relations 1957a). Getting the first shot of narcotics on school property was the exception rather than the rule. In fact, most of the boys did not try heroin until their last year of school or later (Research Center for Human Relations 1957a). That first dose was most often taken in the home of one of the boys, although a large number first try heroin on the street, on a rooftop, or in a cellar. Frequently the first dose is taken shortly before going to a dance or party, presumably because the youngster thought it would be a bracer, giving him poise and courage. But not all juveniles who try heroin become habitual users, and not all habitual users become true addicts; that is, they are not hooked, not dependent on the drug. A juvenile drug user is by definition delinquent, since drugs are illegal. But among drug users, some were delinquent before they began using drugs, and others became delinquent in order to support their habit. We know that the typical user lives in a poor, disorganized neighborhood. But our research shows that the drug user who was not delinquent prior to becoming a user is likely to come from a family of slightly higher socioeconomic status than the users who were also otherwise delinquent. For the sake of convenience, we can speak of them as delinquent and nondelinquent users. It is probable that these two groups differ in certain aspects of their personalities, but all we can say at present is that the nondelinquent users appear to be somewhat more intelligent and more likely to remain in school beyond the tenth grade. They are also somewhat more oriented toward the future. But all juvenile addicts are severely disturbed individuals. Psychiatric research into the personality of juvenile opiate addicts indicates that adolescents who become addicts have major personality disorders (Gerard and Kornetsky 1955). These disorders were evident either in overt adjustment problems or in serious intrapsychic conflicts, usually both, prior to their involvement with drugs. Although there are marked individual differences, a certain set of symptoms appears to be common to most juvenile addicts: They are not able to establish prolonged, close, friendly relations with either peers or adults; they have difficulty in assuming a masculine role; they are frequently overcome by a sense of futility, expectation of failure, and general depression; and they are easily frustrated and made anxious, finding both frustration and anxiety intolerable. One may say that the potential addict suffers from a weak ego, an inadequately functioning superego, and inadequate masculine identification. One would expect that such serious personality problems would be acquired in the family setting. And as we stated earlier, this is indeed the case. Addicts are most likely to come from families which are not only economically deprived, but families in which relations between parents are seriously disturbed, as evidenced by separation, divorce, overt hostility, or lack of warmth and mutual interest. As children, the addicts were either overindulged or harshly frustrated. Moreover, the parents are either pessimistic about their own future or have the fatalistic attitude that life is a gamble (Research Center for Human Relations 1956). They are also distrustful of representatives of the society, such as teachers and social workers. This combination of attitudes toward themselves, toward society, and toward the boy are almost certain to undermine his confidence in himself and dampen whatever ambition and initiative he might otherwise have. With such a background, and without familial support at adolescence, it is not probable that the boy will have the strength necessary to stay away from the delinquent subculture by which he is surrounded. The potential addict is much like the delinquent gang member in his activities, interests, and attitudes. But many gang members, as they approach adulthood, make their peace with society, find jobs, steady girlfriends, and so on. But for the potential addict, with his weak self-confidence, the need to face adulthood creates the additional stress which often precipitates the onset of drug use. We know, for instance, that the age of 16 is of special importance in the process of addiction. Heroin reduces the pressure of the addict's personal difficulties. The positive reaction to a drug is not always immediate, but the addictionprone youngster will try again, hoping to capture the experience of feeling "high," of increased confidence, of the serenity and relaxation he can observe in the behavior of regular users. And the weaker the youngster's ego, the more likely he is to become an addict. While the less severely disturbed youngsters are satisfied with an occasional shot, the unhappy, anxious ones learn to use the drug as a means of relief from their everyday difficulties. In a less direct but more pervasive way, the use of the drug plays a malignantly adaptive function in their lives by making it easy for them to deny and to avoid facing their deep-seated personal problems. The drug habit is a way of life which takes the user outside real life. The habitual user of heroin spends a good deal of time procuring and taking his daily doses; he becomes less interested in sports, girls, parties. This picture of the addict, or the addiction-prone youngster, is rather a general one. There are, however, different kinds of narcotics users. These groups are not sharply differentiated, and little research has been done on them. One of my students, however, has found evidence of differences between two of the types. I believe that the consideration of what is involved in these differences is quite central to much of the discussion of treatment approaches. There is an amazing paradox in the English treatment system. The addict within the system is limited to maintenance doses. As a consequence of tolerance, he should be having no effects other than the prevention of withdrawal symptoms. Why not, then, get himself humanely detoxified and continue without the threat of sudden withdrawal? Obviously, the addict who stays in the system is getting something out of it that has nothing to do with the psychopharmacological effects of the drug. In America, too, severe withdrawal reactions among heroin addicts have become quite rare. Many boys, for instance, when deprived of drugs because of some sort of detention, go through so mild a reaction that the authorities do not recognize them as drug users. The cliche is that the real dosage levels in available heroin are so low that no severe physiological dependency develops. Most users, however, continue to take drugs, even if they seem to get little out of it. From the viewpoint of the abuser of drugs, there are three major kinds of motivations: the psychopharmacological effects of the drug, motivation that has to do with the taking of the drug rather than its effects per se, and motivation that has to do with the counternormative behavior involved. An individual addict may be responding to one, two, or all three of these motivations. The important psychopharmacological effect sought--especially with the opiate drugs--is, I believe, detachment, not oblivion nor the clouding of consciousness nor euphoria, and certainly not vivid hallucinatory experiences, but rather the relief from overwhelming distress that comes with detachment. To be able to get this kind of relief, the dosage levels must exceed the levels of physiological tolerance. Evidence indicates that for most contemporary, urban addicts, this effect of the drug is, at most, a relatively minor asset. Of the three possible motivations for drug use, the one I believe to be the major factor in chronic urban opiate users is that taking it provides social benefits that are an answer to emptiness. There are three interrelated benefits the addict acquires from his involvement with narcotics: He gains an identity, one posing little to live up to. He gains a place in a subsociety where he is unequivocally accepted as a peer, a not-too-demanding place among his fellow men. He acquires a career, at which he is reasonably competent, devoted to maintaining his supply, avoiding the police, and the rituals of taking the drug. If he is arrested, this provides an alternate phase of the identical career. In the institution, whether jail or hospital, he still has his identity and after a time may become a model and guide to newcomers. If, in the institution, he has no great need for the drug, it is because his other needs are being met. It is not he who has changed, but his situation, and only temporarily. The third motivation mentioned, that having to do with counternormative behavior, is seen in individuals who are deeply alienated from society, but who have sufficient inner resources left to want to hit back. For such persons, drugs, any drugs, are attractive precisely to the extent that their use is frowned upon, condemned, and persecuted by the representatives of the respectable society. Incomplete Mourning and Sandra B. Coleman, Ph.D. INTRODUCTION Recent developments in the drug abuse field suggest that drug-taking behavior is a function of certain variables that emerge from the psychosocial environment of the family. Rather than focusing on individual dynamics as the source of one's need for drugs, the family's interlocking, transactional patterns are considered essential elements of compulsive drug abuse. Theoretical explanations indicate that drugs play an important role in maintaining family homeostasis or equilibrium. As a subset of psychosocial theory, family systems theory explains how the family encourages, reinforces, and sustains drug-seeking behavior (Harbin and Maziar 1975; Klagsbrun and Davis 1977; Seldin 1972; Stanton 1979d). The theoretical perspective presented in this chapter is derived from family systems theory; it includes major constructs, such as homeostasis, role selection, intergenerational boundaries, etc., and their specific adaptations to the drug abuse field (Steinglass 1976; Stanton 1977a; Stanton and Coleman 1979; Coleman 1979a). This model focuses on death, separation, and loss as significant precursors of drug abuse, given the necessary addiction-producing elements of family behavior (Stanton 1977a; Stanton and Coleman 1979; Coleman 1979a). Because the family, rather than the individual, is the designated patient, the term "drug addict family" is used to refer to those families in which at least one member is engaged in compulsive drug use in a manner that suggests physical and psychological dependency. The general focus is on narcotics addiction--mainly heroin--and the distinguishing death-related family processes and properties that appear to be associated with it. Specifically, this theory of drug addiction suggests that the addictive behavior is a function of an unusual number of traumatic or premature |