“Loose joints... blew... whar you need |. crack it up? — 1986 Street PusherJourney to Oblivion What are the conditions of « trip w oblivion? the voyage is destined for hardship and suf It can liegin anywhere in time and space The universe abounds with capsules fir transport, One blurs the senses with velocity Another erceps slowly leaving trails of combustion The passenger sleeps through much of the wa: while observers mark progress via symbols of change A robot pilot is strong at the heln ‘Only mutiny can adjust the shi A guard must be posted or the android returns. The traveler remains altered by this sojourn in hell. ae rs scattered Course. The Voyage of Hardship Of particular concern is the effect of the drug epidemic on youth. The only group in our society that has shown an increase in mortal- ity rate in the past two decades has been those s to twenty- four years old. Alcohol, drug-related accidents, homicides, and sui- cides are major factors in the accelerated death toll. At the time of this writing, crack—a widely available form of smokable cocaine— has taken the lead as the most devastating street drug on the market. Fast food of the drug scene, crack reaches the brain within ten sec- onds and produces an intense euphoria, which is followed in minutes by a crushing low. It can be purchased in most large U.S. cities in the form of chips that sell for as litte as $10 cach—yet within just a ic habit may escalate toa cost of , where erack is the most urgent law-enforcement problem, an [8-percent increase in robberies believed to be directly related to crack.162 Craving for Ecstasy Indeed, the metaphor of a hyped-up journey to nowhere thar produces incomprehensible hardship and suffering seems to de the sutcidal experience of addiction: He [the addict] had momentary visions as his mind floated in a sea of befogged escape. He felt a soothing warmth that expanded to fill the cavities of his shrinking torso . . . he was a maestro, a com- rable to the blades and knuckle-busters of a hos- tile and frightening world. He felt complete . . . needed nothing. [le dreamed that he was a hero; that he would be honored at majes- tic kingdoms on his route. Despite these reveries, he went nowhere. His ship was cap- tained by an android—programmed to mindlessly rotate through one drab circle after another, Slowly, the warmth that he once felt began to fade as his torso was besieged by dampness and chill Shivering, he sold his last bit of freedom for a moment of peace. mander—invul ‘The concept of addiction as a progressively incapacitating dis- es from a series of lectures presented by E. M. Jellinek at the Yale Summer School of Alcohol Studies in July 1951 and July 1952. On the basis of a questionnaire study of more than 2,000 male alcoholics, Jellinck formulated his four-phase concept of alcohol ad- diction, He distinguished between two categories of alcoholics: “al- cohol addicts” and “habitual symptomatic excessive drinkers.” The d : concept applies only to alcohol addicts who, after a variable period of problem drinking, lose control over their aleohol intake. essive drinkers, on the other hand, may pathologically use alco- hol to relieve conflict for many years, yet the phenomenon of loss of control never becomes part of their drinking history. In the first phase of alcohol addiction, ohEE Jellinek called the “pre-aleoholi .” the prospective alcoholic begins to experience an inordinate cae of tension reduction through drinking and drinking-relared activitics. Generally, within a period of six months to two years, Jellinek’s typical subject begins to use alcohol nearly every day to relieve stress. Although his tolerance for alcohol exceeds that of his peers, that is, he can drink a good deal more than they before reaching a desired level of intoxication, his excessive drinking remains relatively inconspicuous and undetected, The sudden emergence of alcohol-related blackouts marks the second, prodromal stage of alcohol addiction, A blackout may beJourney ta Oblivion 163 understood as a period of intermediate memory loss, whereby a per- son who imbibes as few as two ounces of absolute alcohol may carry: on a reasonable conversation or complex pattern of activity without a trace of memory the following day. The blackout pe iod is indeed intermediate in that the drinker experiences normal memory fune- tions before and after the lost interval. Soon after the onset of blackouts, the drinker begins to under- stand, in some very vague manner, that his pattern of drinking is different from that of others. He begins to sneak drinks at social gatherings and becomes preoccupied with when and how to get high. At this point, the prodromal drinker may be observed to gulp drinks, while increasing guilt leads to more obvious signs of covering up. The incipient alcohol addict may, for example, conspicuously avoid any reference to alcohol, pro or con, during conversation, De- pending on the drinker’s physical and psychological condition, as well as the nature of the social network, the prodromal period may persist for anywhere from six months to four or five years. ‘The next stage of alcohol addiction, which Jellinck referred to as the crucial phase, is marked by loss-of-control drinking. Che addict appears to lose the faculty of making rational choices about how much to consume, Any level of consumption, even the taste of one drink, seems to trigger an irresistible demand for alcohol that contin- ues until he is either too drunk or too ill to consume any more, Loss of control comes into play only when people respond to conflict or stress by succumbing to drink. Before drinking, the al- ecoholic may appear sensible, affable, and emotionally intact, During this phase he begins to rationalize his unseemly drinking by creating detected alibis, attempting to convince himself that he has good reason to become intoxicated. He minimizes the extent of disturbance by drawing attention to irresponsible actions among friends and associates. At this point alcoholism begins to bring about warnings and re- provals from family, friends, and business associates. The drinker, now thoroughly entrenched in the crucial phase of aleohol addiction, progressively withdraws from his usual social environment. He be- comes noticeably more aggressive, with more frequent and penetrat- ing feclings of desperation and remorse. He loses contact with most cof his “straight” friends. Mlurries of overcontrol (going on the wagon) alternate with episodes of alcoholic debauchery. The addict actempts to regain control by altering specific aspects of his behavior; he may164 Craving for Ecstasy change the times, past drinking. His entire behavioral repertoire becomes markedly al- cohol centered as drinking becomes his most salient need. Support from family and friends dwindles to a pittance, while sexual drive and nutritional prudence are negligible when compared to alcohol, ‘The drinker may now experience the first of a series of alcohol-re- lated hospitalizations resulting from accidents or physical illness. The crucial phase begins to terminate when the addict becomes so demoralized and confused by the conflict between outside pres- sures, inner needs, and his growing dependence on alcohol that he begins cach day by steadying I with a drink. Intoxication, however, usually remains restricted to the evening hours, The cru- cial-phase alcoholic may succeed in retaining his employment through many years of compulsive, less-of-control drinking, al- though family life usually deteriorates dramatically. The final, or chronic, phase that Jellinek identified is marked by prolonged periods of intoxication, colloquially referred to as binges. At this stage the alcohol addict may drink with characters who are morally and intellectually inferior to his customary clique. [is thinking and physical functioning begin to show dramatic signs of impairment. A relatively small percentage (approximately 10 percent of aleoholics experience full-blown psychotic symptoms, such as hal- lucinations, delusions, or bath, Tolerance for aleohol is dim (half the amount previously required may be suff r tion and stupor), while undefinable fears and physical tremors begin to emerge. These symptoms of withdrawal appear as soon as alcohol is'no longer present in the body. Consequently the drinker “controls” them through continuous consumption. Finally, the need for alcohol looms so large that the addict can intain any pretense that he has control aver his drink- W alcohol addicts (approximately 60 percent) develop vague spiritual desires as they begin to call upon a higher power to rescue them from the aleoholic abyss. At this point the addict has spontaneously become amenable to treatment for the dis beverages, or locations that have characterized his no longer r ing. According to Jellinek, mai Since Jellinek’s early formulation, the disease model for aleohol- ism has been embraced by Alcoholics Anonymous, the National Council on Alcoholism, the National Institute on Alcohol Abuse and Alcoha! and the American Medi ation. According toJourney to Oblivion 165 George Vaillant, regarded by many as the nation’s leading a on alcoholism: “Alcoholism becomes a disease when loss of voluntary control over aleohol ce umption becomes a necessary and suificie: cause for much of an individual’s social, chological and physi morbidity.” Im short, an alcoholic may be thought of as.a person who cannot always control when he or she starts or stops drinking, His or her life becomes unmanageable, with or without the bout Capsules for Transport In the past decade the disease concept of alcoholism has been en- larged by treatment practitioners to include gambling and the cur- rendy popular stimulant, cocaine. David Smith, founder and diree- tor of the Haight-Ashbury Free Medical Clinic of San Francisco, where thousands of addicts have been treated, finds that the disease model accurately describes addiction toa broad spectrum of mind- affecting drugs. Like cancer, add viewed asa potentially fatal discase that may be triggered by a varicty of causes. Among the many substances that Smith associates with addictive disease are: (1) alcohol; (2) the sedative hypnotics, including the barbiturates (for example, seco al and ad the benzodiazepines (for example, (3) the opiates and opioids (for example, heroin, morphine, codeine, pere dan, demerol, and methadone), (4) the cen- tral nervous system stimulants, including amphetamine and cocaine; and (3) the hallucinogens, including LSD, PCP, and marijuana. Ad- we substances may be used separately or in various comb ions. As in other disease processes, a person may have a gi predisposition for a particular disorder, yet may circumvent most of its complications by avoiding the substances or activities that trigger 's symptoms. For example, a person who has a genetic predispe tion to skin cancer can dodge most of its harmful consequences by avoiding undue exposure to the sun. Table 5-1 deseribes some of the emotional, behavioral, and: physic: quences associated with a wide spectrum of contemporary drugs. Michael’s escalating struggle with cocaine exemplifies how the disease model for aleoholism may be applied to millions of cocaine addicts in the United States today. According to Michael, he began to-enjoy “recreational” use of cocaine nearly four years ago. Although he seemed to enjoy coke somewhat more than his friends, he limited peric cotCraving for Festasy 166 osunxdsng mypUory poseaaop * ‘SsausTMosuE 9p prssaucdacy Sunk EIRIy unpsaiaey jaRLacyy weds ‘lumnonateny ‘siya sorroudiyy aapimpay ae 549d pau “pump asayy $9¢qN9 ‘adkop aaensinacy ddoaa ‘asa0y smrouny sucoydecny przathapyy yy, seaafley 3pq1en SOMA NG 1O0IS, JV MVAOdWALNOD ITS: SET SOpnpeeng> peuagog Teaeqwiany uO]167 Journey to Oblivion uouexepy jo asuss “uonendso *pooyy pelt aye yreay pasta.ooy (icp Wopaieq pasvaidap spd sdng g-urup axow yo asn Gliaua postaioun pafiuojeud) uors “apueanpita pasuvytia pastas ‘ss Xjpepadsa ounssaucl poogg par sops “aier uieay pidey, ounaftngy pur aureiq,*ssausnoxndsns “Buryoud-aony “aummesodaaion Spog uy asnsasun ‘aunssaud pooiy pareaagy peour SyunpRaUT SSaUApHTOD Pasearauy oooeqo) ‘suing sey ‘spaayy sonal rae “maar “pre ese] AF “sep ‘E24 ‘3390") auruunesngycligy udxosagy aones ‘azoog “aomf peyeopyaptaeyaq, saluiay tayouts, Maur ssmadde paseanap oad ‘ssea8 ‘ody p i P “Humes weil * suurgog *Sun00Igs pantodar 1x “sunouysnyyy e paireda ony 3 5 a, & = = S ‘panadde Joss aanssaud pooyd pasodas py daeuipae one ast Sserailiveen ey PEP ob ‘ 6 aan ay arouse jaseenp sainoseay [Rep sinadly agin Sonny aati poeurignce |<169 Journey to Obirvion saan “1 pue pie jo SIsOUALAS saci ataest amy ‘suaIsnjap pur st “Furry * pareduy id pacar aii 1 ssa “sN9q)1 poses pauods: wy pur aunssaud poojg paseassuy Md170 Craving for Ecstasy his use to parties and what he considered to be weekend treats. After several years, he began to rely on cocaine as a souree of energy for business and school obligations, About two years ago he found him- self working on three separate, yet highly demanding projects: com- pleting course requirements for a college degree tn creative writing: editing the advertising section of a commercial newsletter; and de- vising a business plan to open and operate a video store with several of hhis friends. He rationalized that he needed cocaine daily in order to muster sufficient energy to complete each task, Michael realized that his drug problem was becoming severe when he found thar he was using more cocaine even after his school obligatians were com- pleted. In what may be deseribed as the prodromal phase of cocaine addiction, he began to make up excuses for why he needed to get high. Each time there was any sort of business or advertising dead- line he would rationalize that he needed cocaine to help him get through. Michael agreed with his therapist that he was in the loss-of-con- trol or crucial phase of cocaine addiction when he spent $10,000 in three months solely to purchase the drug. He repeatedly experienced an irresistible urge to buy just a moderate amount, allegedly to help him cope with some temporary business stress. When the coke was gone, he would purchase more and more, until he either ran out of money or could find no more coke. Like the crucial-phase aleoholi Michael would alternate berween flurries of complete abstinence and cocaine debauche After a moment of reflecuion it becomes obvious that any stress~ wf activity—whether cleansing the body, ingesting a psy w for forgiveness—may be subject to compulsive overuse and the escalating consequences of loss of con- trol, We propose that the disease concept may be applied to the en- lire spectrum of compulsive problem behaviors. As we have shown throughout this book, the distinction between internally or exter nally induced alterations of mood, thought, or behavior is arbitrary and misleading. Activities that evoke sensations of arousal, satiation, or fantasy bring about alterations in brain chemistry and patterns of compulsive behavior that are similar to the symptoms traditionally ed with psychoactive substances. Arousal, satiation, and fan- tasy may be regarded as psychological organ systems that are vul- nerable to attack by multiple agents of addiction. As in viral andJourney to Oblivion 171 bacterial infections, the specific disease carriers may differ widely in origin and structure, and yet the consequences of foreign invasion may be virtually identical in terms of symptoms, prognosis, ane treatment. Each of the behaviors shown in the following list may become an agent of addiction, subject to compulsion, loss of control, and continuation despite harmful consequene Drug ingestion. Includes major psychoactive drugs; and mat juana, alcohol, and nicerine. Eating. Includes overuse of particular foods, for example, sugar. and varieties of sado- Sex. Includes autoerotic naasochistic activity, 1, pornography Gambling. includ numbers, horses, dogs, cards, and roulette. Activity, Includes work, exercise, and sports. Pursait of power. Includes spiritual, physical, and mate | power, Media fascination. Includes TV, mavies, and music. and drea Isolation. Includes sleep, fanta: s. Risk taking. Includes tement related to danger. Calts, Inchades groups using brainwashing or other technique of psychological restructuring. Crime and violence. Includes crimes against people and property. Bonding-socializing. Includes excessive dependence on_relation- ships or social gatherings. environmental Institationalization, Includes excessive need fc structure, such as prisons, mental hospitals, and tuaries, and institutional use of psychoactive medication, dure 5-1 shows degrees of probable risk between various agents of addictive disease. Five levels of risk are distinguished, with mul- tiple agents (capsules for transport) within cach level. Crime and drugs, for example, are viewed as very risky addictions because they usually bring about great harm to the individual and society, Insti- tutionalization, which is the compulsion to subject oneself to the del-173 Craving for Exstasy aos hsolation =-—--~ Promise ity, (S8AAI -—- _ Crime ws Gambling rags Huey ys Anieqo pow ~saer pee Bonding =_ ety ba [ setiiny ee ~~. (2 oe t re 5-1. LEVELS OF ADDICTION This impressionistic chart depicts levels of probable risk (loss of adaptive social functioning) between groups of problem behaviors. Fi distinguished with no diserin ion of relative danger wit Religion transverses all levels and may be used to short-cireuit the usual course of an addictive process, Dotted lines indicate the potential for overlap, substitution and Mux between ad ns. In thy lividual, a statistically low risk be! Ky Og, “ACLEV uilly occupy a space on the threshold of suicidal vortex. Suree: A, Milkinan, Aiddictive processes: An introductory formulatin, Fy Séreet Pharaiacolagise 4413 (1959)Journey to Ob 173 cterious effects of confinement in prisons, psychiatric hospitals, or other social-service facilities, is also considered a high-risk addictive behavior. The dimension of religion and cults transverses all levels and may be used toshort-cirenit the usual course of an addictive process. We have observed a multitude of recovering addicts who seem to strengthen their resolve by leaning on the pillars of religion. M bers of AA, for example, usually proclaim a renewed mate ina higher power, who aids them inn ‘ as signitied by the opposing arrows an figure $-1, may be a dleabhe edged sword. In the tragic example of Jonestown, bl nd deve ious cult burned a path straight to the suicidal vortex. ‘ldridge Cleaver is an example of a person who was able to ex- i f jon. Cleaver may have combined several addictive behaviors (power, crime, and drugs) during h t and accused criminal. He eventually found himself on the threshold of suicide with a loaded gun pointed to his head. Looking at the full moon, he saw the faces of his heroes, Marx and Engels, gradually fade ineo the cou ance of Christ. He renounced his former life-style and com- piritual journey, zealously: preaching the Gospel and love menced ‘ot God. The dotted lines in figure 5-1 indicate the potential for tution between the agents of addiction, and fluctuations in the rela- tive danger of a given problem dependency, In any particular case, a behavior that is usually low risk, for example, activity, may occupy a space close to the suicidal center, The addict may eventually risk life and limb as he attempts to recapture the cestatic moments of arousal that he once experienced through participation in a sport such as skiing. [thas been frequently observed that compulsive drug users often switch intoxicants only to find that the symptoms of their addiction resurface through another capsule for transport. Cocaine users often switch to heroin, while some heroin addicts abandon nar- coties only to find themselves hopelessly dependent on aleohol ibysti- ‘The Passenger Sleeps When children are asked if they would like to be addicts when ther grow up, invariably they respond with a combination of disdain and perplexity, There is no way that they want to be hooked on any-174 Craving for Kestasy thing. and besides, how could you have ever come up with sucha goofy question? Y cally, 3-10 percent of all grade school children will become addicted to alcohol or drugs; if we include food and other behavioral compulsions such as gambling or sex, the figure easily exceeds 20 percent Nobody wants to be dependent on any- thing, yer the number of people who develop pathological habits is huge. How do people reconcile the difference berween what they value in the morning of their life and what they actually do in the afternoon and twilight hours? ‘The key word is denial. Addicts insulate themselves from the glaring discrepancy between their natural inclination toward well- mindedness and the depraved life-style of addiction they have fallen into a deep sleep, space trippers become obli tude of observers imploring them to take heed of their compulsion and loss of control. In the face of massive evidence to the contrary, they continue to believe in their independence and self-determina- tion. Reverend Joseph L. Kellerman describes alcoholism as “a merry-go-round named denial,” on which the alcoholic, together with a regular cast of supporting actors, cnacts a predictable se nario: the group unintentionally protects the addict from the harsh ity of his or her desperate plight. Whatever the vehicle for trans- the addict’s support system usually includes three unwitting contributors to the avalanching predicame an Enabler, a Victim, and a Provocatice, ‘The Enabler is a character who is available to bail the addicted darling out of any crisis that might ensue from the demanding jour- ney. This supporting actor might be a professional, such as a phy- an or counselor, who helps the addict to “get by” with irrespon- sible behavior. He or she may also be a friend who fills in, on the job or at home, when the journey to oblivion takes a wild turn. The part of Vietim is played by the boss, employer, or super- pr who saves the addict’s job when he or she cannot perform the expected duties. The Victim picks up the tab for irresponsible con- duct because love or concern for the addict prevents the Victim from initiating proper disciplinary action at the work place. Finally, the Provoeatice—usually the girlfriend or wife of a male addict—is the person who dutifully compensates for everything that goes wrong within the home or the marriage, She alternates berween the roles of counselor, physician, mother, and wife as the addict vae- illates between needing to be forgiven, taken care of, and repri-fourney ta Oblivion 175 manded, on a cyclical basis. Although the Provocatice is deeply trou- bled by the addict’ life-style, she is always there to compensate for any action that might threaten to dissolve the tenuous family unit. According ta Reverend Kellerman, if recovery from addiction is to occur, it must start with the people who have unwittingly main- tained the addict’ system of denial. The Victim and Enabler should find a source of information and insight if they are to change their characteristic roles. The Provocatice should enter some form of on- going group program, possibly Al-Anon, to reevive the support th she will need to make a substantial change in her life. Finally, parents are asked to consider that they may be unintentionally playing sup- port roles on the “merry-go-round of denial” for addictive teenagers. w to Carla Lowe, a spokesperson for the Parents Movement, n of concerned parents that has gained momentum and. status worldwide, “denial is the teething biscuit of the E Movement,” Symbols of Change It is virtually impossible for af gauge the extent to which an addict depends on a neurochemical prop, After tolerance has developed, the addict may appear com- pletely normal during an extended voyage in his or her capsule for transport, By far the most reliable indication of continuing addiction is the person's apparent inability to integrate his or her goals and behaviors. The allegedly recovering addict is exposed by an obvious inability to coordinate stated objectives and actual performance. He or she may miss appointments with intimate friends or fail to appear fe ical work assignments. These inconsistencies, which might be dismissed among nonaddiets as faux pas, are the telltale signs of ishing addiction. Figure 5-2 shows the deterioration of a perso journey to ob! over time. The values closest to the center represent guiding principles in the addict's life. In the pread- diction (symptomatic) phase, a person’s behavior may reflect the en- tire spectrum of moral precepts that he or she has internalized from well-minded people y. However, as addiction progresses through prodromal, crucial, to function in accord with his or her own valucs dwindles to near 2ero. end or family member to accurately s values as the «i chronic phases, the addict’s abilityCraving for Ecstasy Awun jue adem say SUVIWACINY NOLLOIGY un “T-g aunty [ewoigeag wawang le song Ru OuOez=anee-Oz diyspuamay | eee rrererer aDIarysq paaUO-anye AJourney to Oblivion 177 With the onset of recovery, the principles thar guide one’s behav- ior may become reorganized. Those which formerly occupied posi- tions of highest priority, such as the experience of exeitement, may become peripheral and of minimal importance during the recovery phase of an addict’s career. When a person assumes the commitment to get well, the prelimi mast superticial aspect of the task is to stop the jor, whatever that may be: ‘The greater challenge Wy take years of self-discipline and support from treatment personnel, is to regain the full capacity to operate in accord with the values that one has chosen as guiding pninciples for his or her life. The Robot Pilot ‘ed hy an irresistible impulse, it bility to captain ces, services, oF Tf you have never been ensl: ficult to appreciate a perso! own ship. Whatever the seductive ager sweets—addicts repeat time and time aga ght there in front of me, | have no choice. I've never been able to turn downa.. .” This subordination of rational thought and valuc-based decision making te the lure of momentary pleasure is at once the most mystifying and destructive aspect of the addictive process. In order to understand the compulsion to be at craving’s beck and call, we must again consider the multifactorial basis of addiction. From the standpoint of biology, our formulation rests on the po- sition that we can become physically dependent on the experiences of arousal, satiation, or fantasy, independent of whether the cap for transport is a substance or an activity, Behavior in each sphere may be related to a particular kind of neurotransmission, possibly involving specific neural pathways and neurotransmitter comybina- tions. Arousal dependence may be compared to biochemical altcra- tions related to excessive amphetamine use, while satiation effects may be compared to those related to opiate use. Fantasy behaviors can be related to such neurotransmitters as dopamine, norepineph- rine, or serotonin, all of which are chemically similar to the main psychedelic drugs, LSI), mescaline, or psilocybin. Repetition of each type of activity sets up a compensatory biochemical reaction that restores neurochemical balance in the central nervous system. The individual must increase the level of addictive behavior, for ex- “Whenever its 1178 Craving for Kestasy experience of ample, risk taking, to continue to achieve a subject creasing discomfort from withdrawal effeets when they stop or reduce the need-satisfving ac- tivity. The tendency toward reinstatement (doing it aga aged hy a substratum of neurochemical instability. Alan Marlatt of the Universi ty of Washington in Seattle has udied the compulsion to repeat destructive behaviors from a com- bined psychological and social perspective. According to Marlatt, the irresistible urge to reenter the drab circle of progressive impair- ment is based on pressure from the following sources: is encour- ‘The addict's expectation that some positive effects might be ex- perienced through a brief interlude with the seductive agent. ‘The initial rush of pleasure produced by the object of craving Social pressures to be one of the group. The seasoned addict engages in a fierce battle for control over the object of his or her craving. Episodes of abstinence typically al- ate with nearly complete submission and loss of central. The ikelihood th addict will repeat the characteristic pattern of ex- cess and moral depravity is increased by an identified series of psy- chological reactions. According to Marlatt, the combined influence from a predictable set of internal messages convinces the addict to abandon control. ‘This process begins just alter the addict first tastes the forbidden fruit, When a person who tries to be straight, sober, controlled, or clean experiences a slip, that person becomes confused in self-con- cept: “I thought I had control over... but now it appears that I don’t.” Most often, the individual ateributes his or her failure or slip to personal weakness, These twe psychological factors—identity conflict and self-blame—are cumulative in effect. The internal dis- cord produced by the discrepant self-concept of “1 am in control” versus “I have failed” results in a regressive shift in self-image from responsible person to addict, By attributing the slip to personal weakness, the addict unwittingly creates the expectation for contin- ued failure i “he cumulative effect of role confusion and loss of confidence makes submission to the robot pilot an easier pos-Journey to Oblivion 179 ture to maintain than abstinence o1 “regulation. The intensity of this reaction depends on several factors: ‘The degree of personal commitment to maintain abstinence. ‘The period of sus greater the effect. ined abstinenee—the longer the duration, the The importance of the behavior to the individual involved. ‘The Mutiny ‘The course of addiction is remarkably resistant to change. Approx- nately 75 percent of all those who attempt abstinence from heroi alcohol, or cigarettes resume their habits between three and si months after begining a program for recovery, The statistics for attempted weight control are even more appalling. Recidivism rates for juvenile and adult criminals range from 70 to 80 percent, de- pending on how recidivism is defined. Relapse rates for sehizophre- nia are reported to be as high as 92 percent. Indeed, the entire range of émotional-behavioral disorders appears to be unyielding in repe- tition and progression. In consideration of the powerful influences from biological, psy- chological, and social sources, a continuing pattern of struggle and failure seems inevitable. To be sure, the traveler who survives must organize a powerful mutiny to overthrow the tyrannical Captain Ad- diction. The rebellious survival force must battle a sluc of weapons, massively deployed by a malevolent robot whose sophisticated ar- mament includes habitual psychological responses, biochemically based emotional and physical disturbances, intense social pressure, and the random stress of voidable negative circumstance. A suc- cessful rebellion must effectively counteract all of these forces. Fach be tailor-made to fit the special requirements of each journey, In the realm of substanee abuse, for example, the initial tactics for recovery are determined by the specific needs of the user and the unique qualities of his or her drug. Withdrawal from a single drug, drugs from the same group, or a combination of drugs from different groups requires diverse detoxification procedu Withdrawal from opiate dependence, for example, produces a well-defined abstinence1kO Craving for Eestasy syndrome, characterized by gastrointestinal distress, musele aches, anxiety, insomnia, and narcotics hunger—none of which are life threa ng. In contrast, withdrawal from barbiturates, or a baritu- rate-alcohol combination, may produce potentially fatal seizures, re- quiring vigorous medical intervention, often hospital-based care, Stopping cocaine or amphetamine ally involves only depression and lethargy. For these drugs, the symptoms of high-dose intoxication may become life threatening. i r sult in brain seizures, heart failure, delusions, hallucinations, and potentially violent behavior. Additionally, mixed addiction may re- sult from the alternating use of antagonistic substances as observed pper-downer evele. Some addicts use high doses of stimu- ‘has amphetamines or cocaine and then use a secondary drug alcohol, a short-acting barbiturate, er an opiate to calm the side effes ive stimulation. Occasionally dependence and tolerance may develop to the secondary depressant drug as well. During detoxification such an addict may experience a complex of symptoms h the withdrawal from drugs of different classe or nonsubstance add) s, the primary strategy for recover usually involves cither completely stopping the compulsive activity (as in gambling) or dramatically reducing the pattern of abuse (as in eating disorders). Although addicts take the first steps to recovery fora variety of reasons, including family pressure, the threat of being fired, health, or legal problems, the ensuing battle for control is al- ways decided according to one fundamental principle: The addict t discover alternative means to satisfy the needs that were pre- sly resolved through the addictive activity. An innovative client, whom we shall refer to as Max, developed a set of nonchemical alternatives that he successfully used to over- come his dependence on alcohol. With assistance from his therapist, Max realized that he used aleohol te cope with an identi psychological and physical needs. He and his therapist devised a program of behavioral alternatives, specifically designed to cope with the emotions and conflicts previously managed through the lure of alcohol. The program involved the use of sensory isolation, video movies, massage, and weekly psychotherapy sessions, After one year, was able to successfully terminate psychotherapy and continue to enjoy a comfortable and responsible life without using drugs or alcohol. ‘Table §-2 outlines the cognitive (insights gained =180 Craving for Eestasy syndrome, characterized by gastrointestinal distress, muscle aches, anxiety, insomnia, and narcotics hunger—none of which are life ening. In contrast, withdrawal from barbiturates, or a haritu- Icohol combination. produce potentially fatal scizures, re- ing vigorous medical intervention, often hospital-based care. Stopping cocaine or amphetamine depression and lethargy. For these dru! intoxication may become life threatening. Cocaine toxicity may re- sult in brain seizures, heart failure, delusions, hallucinations, and potentially violent behavior. Additionally, mixed addi sult from the alternating use of pao ic SDS LAnET as observed in the upper-downer eyele. lants such as amphetamines 0 or cocaine and ce sea secondary drug such as aleohol, a short-acting barbiturate, or an opiate to calm the side effects of exces imulatian, Occasionally dependence and tolerance may develop to the secondary depressant drag as well During detoxification such an addict may experience a complex of symptoms associated with the withdrawal from drugs of different se usually involves only ive ‘or nonsubstance addictions, the primary strategy for recovery usually involves either completely stopping the compulsive activi (as in gambling) or dramatically reducing the pattern of abuse (as in cating disorders). Although addicts take the first steps to recovery for a varicty of reasons, including family pressure, the threat of being fired, health, or legal problems, the ensuing battle for control is al- ded according to one fundan | principle: The addict must discover alternative means to satisfy the needs that were pre- viously resolved through the addictive activity. An innovativ ent, whom we shall refer to as Max, developed a set of nonchemical alternatives that he successfully used to over- come his dependence on aleohol, With assistance from his therapist, Max realized that he used alcohol to cope with an identifiable ser of psychological and phy needs. He and his therapist devised a program of behavioral alternatives, specifically designed to cope with the emotions and conflicts previously managed through the lure of aleohol. The program involved the use of sensory isolation, video movies, massage, and weekly psychotherapy: sessions. After one year, Max was able to successfully terminate psychotherapy and continue to enjoy a comfortable and responsible life without using drugs or alcohol. ‘Table 5-2 outlines the cognitive (insights gainedJourney to Oblivion 181 from psychotherapy) and behavioral (alternative behavior) tech- niques that Max used to regain control over his own life. \ Guard Must be Posted ‘The recovering addict must gain the upper hand over negative social or peer influences, internal and external states of conflict, and some- times excruciating phy discomfort. Often the challenge is too great, and the mindless robot returns. Those who avoid subjugation to the addictive process need to develop a mature set of emotional, intellectual, and behavioral skills that promote attainment of pleasure through internal re nd life-enhancing activities. may be accomplished through a variety of psychotherapy approaches, many of which we will discuss in the next chapter. ‘The vast majority of recovery programs—with the obvious ex- ception of those designed for cating disorders—stress the need for complete abstinence. George Vaillant has summarized the effective ingredients of programs for the treatment of alcohol dependence. ‘The same principles apply to the broad range of addictive behaviors: Offer the client or patient a nonharmful substitute dependency for the addictive agent. Remind him or her ritually that even one encounter with the addictive agent can lead to pain and relapse. Id Repair the social and med mage that has already occurred. Restore self-esteem. Depending on the personality and situation of the client, a covery-oriented self-help group, such as AA or an AA derivati such as Narcotics Anonymous or Sexaholics Anonymous, i required for suceessful treatment. The relief effect from participating in a group that offers empathy and belonging while continuously rewarding sobriety may be essential to the recovery process. In many cases group support can be bolstered by individual counseling. In other cases the only form of treatment that the addict will accept is one-to-one psychotherapy. Whether individual or group, effectiv mn bath sides (client and ther r intensive work,1s2 Craving for Ecstasy ‘Table 5-. DRUG-LIKE ALTERNATIVES $10: ALCOHOL. DEI (NDENCE isplavion Tank Massive Funtary Prychotberapy ; _— Device Rationale Gaals Float in water to alleviate the effects af gravity, As much as pos: eliminate all temperature difference while shutting out light and sound. ple Reduce external stimulation te Iigger fantasi power and immortality Results in altered state of coascinusness Fantasies of power help to compensate for feelings of helplessness and lack of selfworth, ‘These are examined during psychotheray and aca hy self- actualizing behaviors Soothing sensations to the skin and practitioner Reduee tension through internal chemicals released by touch. Dininish unresolved dependency needs rous massage is used ro dampen anxiety and aggressive dtive. The client graclually learns to subduc emotional discomfort through jxnitive interpersonal relationships. Video movies are selected from the complere range af fantasy productions available im the contemporary retail video inatket, Movies allow for passive means to achieve relaxation withenut the unwanted effects ‘of intoxication and hangovers Provide gratification for acsthet intellectual, and cmotional needs that have been mismanaged at home or at the bar. Gain insight into-origins af anxicty and fear. Individual psycherhery is delivered by a qualifie professional with a cognitive-behavioral orientation Therapist helps client understand the emotional, sensory, and. intellectual necds thar were previously met through alcohel. ‘The client learns to himself from needs previous! resolved ina self destructive fashion. ‘Through a safe, caring insight-oriented enlarges the scope af his coping skills,Journey to Oblivion 183 Although recovery-oriented treatment has helped millions of ad- s to reclaim their freedom, by far the humane solution to addiction problems would be to. prevent the life-corroding process from gaining even a foothold in the human psyche, As evidenced time and time again by the failure of our legal system to effectively bind the crippling hands of addiction, cducation—not legislation— ed values of berty, and the is the key to preserving our cheris s pursuit of happiness. Parents-as-educators are obliged to insure that their children are successfully inoculated against the false promise of external charms, ‘The strategy that we suggest is based on flexible use of a three- phase, addiction-inoculation approach that involves: Mental preparation Skill development Rehearsal The procedure can be modified to accommodate the specific needs of children, students, patients, or other high-risk community groups. The technique is based on Michenbaum’s cognitive-behay- ioral method for managing anxiety, depression, and pain. It has been successfully used by Howard Shaffer of Harvard Medical Sehool to prevent the onset of smoking, A similar technique has been sug- gested by Alan Marlatt of the University of Washington in Seattle to prevent relapse in alcoholics, smokers, and heroin addi Mental Prepararion In the mental-preparation phase, high-risk people are ta principles that explain addiction in terms of biochemistry, psychol- ogy, and sociology. In terms of biochemistry, students learn the neu- rological and physiological origins and consequences of suicidal plea- sure seeking. When a child vividly Lae the deleter effects of tampering with his own br stry, he or she is less likely to be duped by claims such as, “LSD ae you closer to God,” or “Cocaine will make you a better lover.” Psychologically, children are helped to form positive values, sound judgment, and clear thinking. We communicate our expectation that they will grow184 Craving for Ecstasy “quick fae On the sociological pine! chi iden learn to appreciate how society itself may promote a deviant earcer: from a child who enjoys little self-worth, to a marked or st nt, then fi sorrowful, depraved, and incapacitated adult. Young people are taught the effects of peer influence, parental role models, and learning through observation. Chikdren are imbued with a firm understanding of how advertising and street rumor may entice youngsters to experiment with short- term pleasure and long-term harm. As parents, educators, and com- munity members we can insist on responsible advertising while we develop our own slogans and symbols in the war against compulsive pleasure seeking. ily twa person who loses all self-respect as Skill Development ‘The process of skill acquisition involves learning to cope adaptively with stress, through behaviors that provide internal satisfaction through heightened perceptions of self-worth, On the interpersonal level, children learn to experience a sense of well-being when they master the ability to withstand negative peer pressure. This can be accomplished through programmatic exposure to positive role models. The National Institute on Drug Abuse, for example, has developed a variety of drug-prevention videotapes in which an at- tractive role madel, such as Brooke Shields or Mr. T., demonstrates assertiveness and sensibility in the face of drug temptation, Other media productions show a familiar-looking youngster who demon- strates the enormous personal value of being able to “just say no.” At the level of emotional control, subjects are taught how to use relax- n techniques to gai stery over their own internal states, Mus- relaxation, guided fantasy, and breathing, ex have all been shown to reduce tension and promote feelings of well-being. An ex- emplary program would accommodate individual differences in the ttainment of pleasure through the channels of arousal, satiation, or fantasy. Ideally, students could develop a large repertoire of coping skills, including wholesome activities from each plane of pleasurable experience—arousal, relaxation, or fanta clJourney ty Oblivion 185 Rebearsal In the rehearsal phase, which can overlap with mental preparation and skill development, the learner is encouraged to role play appro- priate verbal and behavioral responses to potentially harmful sedue- tions, Simulated encounters with addictive agents are created in fam- ily, classroom, or group-counseling situations, AIL phases of the inoculation procedure should be conducted by ‘dda free adults ho command respect and admiration from the student population. Phe effective inoculator net only has the intellectual and emotional ability te cope with masochism and denial from the preaddiet, but communicates a sense that he or she can “walk the talk” of an addic- tion-free life-style, The rehearsal stage should signify to every par- ent, therapist, and educator that one talk, one picture, or one story about addiction is not enough. We must go over and over th sage ina Variety of ways to overc! and get through to our kids. Finally, through the family, the school, and the culture, children should be inoculated to develop a healthy resistance to the seduction ofa plastic paradise. ‘To achieve this outcome, we must successfully promote the values of commitment, control, and challenge. These three C’s may be thought of as the antidote for the three C’s of com- pulsion, loss of control and continuation despite harmful conse- quences. We must demonstrate commitment to self, family and com- munity; believe in our individual strengths and abilities to exert a ignificant measure of contro! over personal destiny; and view life as a challenge, a grand adyenture, a mystery to be explored with the benefit of our full mental capacity, rather than as a riddle to be solved through artificial means, mes- «¢ the enormous wall of denialYou are here Pleasure6 Finding the Right Substitutes Let us assume that you or someone that you care about ers from addiction. This chapter is intended as a consumer's guide to sound and appropriate treatment, Tf you have an addiction, the first step toward recover ad- iting that your present substitutes aren't working. Granted, they have many alluri es—the soothing gush of cigarette smoke i s through your trachea; ice creams anesthetic sweetness as down your esophagus; the dose of aleoho! that loosens your libido; or the drug that finally affords sleep. But after all is said and done, you're really not up for suicide—in slow motion, as with to- bacco and food; or at high speed, as with alcohol or heroi It is critical that you recognize the long-term consequences of ure secking. As illustrated, initial experiences with the object or experience of your cravings have been extremely sa fving. In the course of time, however, rewards diminish and suffer- ing begins to surface. Perhaps you have become unattractively over- weight, developed a cigarette cough, or find that excessive drinking has caused a schism in your love relationship. Red flags may be dis- i clearly sce that present difficulties are minor ¢ consequences that he ahead. Creeping obesity may be an overture to heart disease; a mild cigarette cough na_or lung cancer; alcohol-induced ating memory, defective judg- ment, and deereased ability te learn. Acknowledge that your greatest source of pleasure has evolved into a etippling habit. Your brush with eestasy should be remem- bered with humility and respect, yet the days of unmitigated plea-188 Craving for Ecstasy sure are long gone, Continuing the present course will probably de- stroy the remaining quality of your life. Be thankful that you still have a chance. Reentering the world of sanity requires the develop- ment of alternative means of grat Restructuring ideas about the object of your craving is another positive move toward changmg a negative life-style. Replacing self-defeating thoughts like, “I can’t cope without for example, cigarettes),” with positive statements such as, “Tcare about maximizing my experience of life,” represents al shift in your self-image from loser to a person worthy of You might experiment with saying something like this to : “L love... (perhaps, the feeling af being intoxicared— especially: with my friends), but | value my health and the quality of my experience more.” If you earnestly bell ¢ that the importance of sound health and ndedness far exceeds temporary sustenance through sinking sof short-term pleasure, you have taken the most crucial stride toward genuine self-repair, When the values of comfortable and re- le living emerge as pillars of your new existence, you are ready for the next step toward finding the right substitutes—decid- ing whether you can manage your problem alone, Be open to the possibiliey thar you cannot. Most people who experience habitual problem dependencies have wasted years of their lives trying to convinee themselves and everyone around them that they were actually in control of their addiction. In reality, this was not the case, A humorous bue tr: example of a young cocaine addict's futile attempts at controlled use exemplifies the difficulty of exclusive self-reliance. The man worked traveling salesman in the San Francisco Bay area. He could e: cocaine at a number of locations on his daily route. In ed attempts to regulate his level of use, he would snort a few lines, then place the supply in a self-addressed letter and mail the leftover quantity to himself. By the time he reached the next desti- nation, he came dewn from the previous dose and was out of cocaine, He would then make another purchase and repeat the entire process of snorting and mailing all over again, An important indieation of your own abi stance or behavior is to face squarely the question of whether you can cease the activity, even for a brief period of time. Can you go without a drink for a month? For a week? Can you climinate snacks from your diet, even for a day? What is the longest period you have ty to control a sub-Finding the Right Substatites 189 endured without a cigarette? Addiction is very difficult to admit— sometimes it takes years before an addict will acknowledge the ex- istence of a problem, The enormous wall of denial is, by far, the greatest obstacle to recovery, Many people die without ever havi confessed, even to themselves, that they were unable to control cru- cial segments of their behavior. It is neither a sin nor a weakness to seck help, particularly when your future happiness and health are at stake. Some are especially good at assisting the wounded; others profit from their suffering. Beware of miracle cures. It took far more than several days or weeks to arrive at your present condition, and it is highly unlikely that a treatment angel will suddenly materialize and fix you up in just a few d; he vast majority of people who arrive in therapy for overeating, drug abuse, alcoholism, or smoking re- lapse w twelve months. The longer they remain in treatment, however, the better is their chance of recovery, When you have reached the junction of seriously secking help, you are especially vulnerable to charlatans, Those who proclaim fantastic success rates, in a short period of time, with minimal suffering or effort, are likely to be corrupt merchants of health. You have waited this long; don’t compromise your chances by jumping into a program that is funda- mentally unsound, By grasping for a miracle cure you mere! Jong self-deception. When it fails, it may take years before you build up the courage to try again, and you'll have only yourself to blame. Fortunately, many effective recovery programs exist, rum by practitioners who have a genuine concern for your well-being. You may wonder, of course, how to choose from a multitude of possibil- ities a treatment approach that is best suited to your personality and needs. Ideally, your selection should be based on a synthesis of four vital sources of dat ra pra- 1. Your personal philosophy of what causes seli-destructive behavior. 2. Your belief about what forms of psvchorherapy are most effective. 3, An awareness of the types of treatment program available in your community. 4. Recommendation of a s fied individual. able treatment program from a quali190 Craving for Ecstasy Before reading further, please complete the Cou ventory in table 6-1. This will help you to identify the psychother- apy systems thar are most likely to be compatible with your philos- ophy and beliefs. Treatment effectiveness has been shown to increase dramatically when clients feel comfortable and compatible with the methods and beliefs of their therapists. The Counseling Interest In- ventory is designed to orient you to counseling and psychotherapy systems that are consistent with your attitudes, biases, and beliefs. Table 6-1 COUNSELING INTEREST INVENTORY Read cach of the stavements thar follow, Mark the box next to the concept that best represents yor point of view. If you are unsure ur feel equally strong about both extremes, reread the question and try to chouse the phrase that is mast appealing. [gnore the letters below each bax, as they are for scoring purposes only. Take your time and remeniber that there ave no correct oF incorrect answers, Example: 1 pref 1. A person is most likely to bring co to discuss family problems: With one family (With all members of member at a time. F omy family present. ‘uctive change to his or her life (]_ Setting goals and making positive (1) First understanding, then B.C decisions, D resolving, internal conflicts. as alter a negative pautern an individual should: [5] Change his or her self-clefea Become aware of his or her c F.2D emotions. 3. When involved in a project or task, | prefer to: [] Work alone or with one other Work with several others. TP person. Ff 4. Which phrase best deseribes your view of humanity? Hhiimans are basically rational and Humatis are often irrational and fundamentally good, D basically programmed for their own survival. person may alter a maladaptive quality of his or her life by: ving his or her behavior [] Mod ig his or her t B expectations.Finding the Right Substitutes Table 6-1 contitued ‘6. [feel most comfortable when engaged in conversation with (] One person at a time Several people at a rime. 1 F 7. The most important cause of human suffering may be attributed to: (1 Spiritual cis ( Exvironmental stress that triggers: confusion about the meaning of ‘2 chemical imbalance resulting in life. mental illness 8. To help a person who is experiencing emotional probl it is most important te: Understand how he or she has oO Focus on the behavior ¢ D been influenced by the past. 8 causing current problems. 9. People are best able to experience more fulfillment in life when they: Change their thoughts and (Change the behaviors th feelings about themselves. causing problems. tare t (0. My life seems most fulfilled when: Tan able to jive according to my personal values and innermost feelings. (J L follow my religious conv G ‘The people who have been most able to help me with personal problems Prescribed medicine or suggested Spoke at length about my DF thoughts and feelings. A.B activ problem, ies to overcome the 2. When I'm with a group of people, I usually pay most attention te: (The person I'm talking to at the All people in the roomy including 1 moment. F the person Pn talking to. (3. The majority of people with moderate to severe emotional problems are most effecuvely helped by: A form of individual counseling or O A combination of effect A counseling and an appropriate ion, I level of preseriberd medi te from: (4. Most psychological problems origi [] Absence of purpose and fear of O Learned habits that have ne FG nonbeing. B consequences.192 ble 6—1 continencedd 15. An effective psychotherapist will focus most intensively on: (The elient’s behavior and belict oO client's relationship and BCL system, DF feelings within his or her family social group. the advice of 16. When something is wrong, I would be most likely to s (My personal physician or a (J A group af people who AI psychiatrist, GF understand my spirirual or religious values 17, With regard to problems in (2) Physicians or other scientists who [] People who have experienced \ have studied the origins and G similar problems and have al disarder, discovered the spiritual me: of their lives, ig. the people most equipped to be of help are: atment of men 18, ‘The opinions and ideas that seem to influence me the most arc: Highly confidential [] Observations about my behavior T communications from my most F which are substantiated by grouy intimate associates. consensus. 19. All things being equal, | would tend to seck help from: My personal phy: [1] A person qualified to afer A G spiritual guidance. 20, When I have been most anxious or upset the cause scems to have been: A physical problem. (C]_ Disharmony in my family. A ¥ Scoring: ‘Count the numbers of As, Ds, etc., that correspond to the answers you have given. Record the letters that occur four or more times in the adjacent bo! ‘These letters correspond to the counseling and psychotherapy approaches listed belo A—biomedical B—behavioral D—psychodynamic E—existential/humanistic G—spiritual I-individual ‘The letters that appear most frequently are li psychotherapy approaches that are compatible to represent counseling and h your personal philosophy and belielFinding the Right Substitutes 193 You may now wish to discover some of the fundamental ideas that are associated with the styles of mtervention that scem most attrac- tive to you. Brief descriptions of the basic philosophy that underlies each major psychotherapy system is provided in the rest of this chap- ter. Some guidelines for selecting group, family, or spiritually ori- ented approaches are discussed, Readers are encouraged to explore their interests further by obtaining relevant readings or contacting relevant organizations listed in the appendix, “Suggested Readir and Information Resources.” A number of selections have been ch sen on the basis of their superior quality and suitability for a non- professional readership. Addresses of treatm nformation or- ganizations are provided. at and ‘Treatment Philosophies ‘The Biomedical Approach Those who advocate the biomedical model treat addiction as a phy sician would treat a disease: first identifying the syndrome (recog- nizing patterns of diverse symptoms that tend to occur together); then searching for the cause of the syndro ally deciding on appropriate treatment for the illness. ‘The symptoms of addiction are those of any psychiatric syndrome, for which three physical causes can be considered: germs, genes, and biechemistry. In the case of addiction, it is unlikely that the disorder is linked to either bacterial or viral invaders. ‘Allan Collins of the Institute for Behav- ioral Geneties at the Unive! Mf Colorado has shown that for most behavioral disorders, alcoholism and cigarette smoking in particular, genetic factors are highly relevant. Stanley Sunderwirth has shown the relationship between self-induced alterations in neurotransmis- sion and the aad etn of Aes ible pee behaviors that may pel fii there is a posi considered to be of considerably bight Smith, director of the Haight-Ashbury ie Medical C) Francisco, is a renowned adyocate of this perspective. ing new field of research focuses on biochemical predisposi-194 Craving for Eestazy tions toward addiction, Robert Freedman of the University of Col- orado Tlealth Sciences Center examines the addict's biochemistry and anatomy for possible irregularities. Analysis of blood and urine samples may suggest b inical links between certain addictive be- haviors and malfunctioning neurotransmission, Richard Wurtman of MIT has discovered a possible link between low levels af serotonin and carbohydrate craving. When biochemical i larities are dis- covered, the patient’s symptoms may be treated through prescribed abstinence, as well as appropriate dictary changes, exercise sched- ation—ideally combined with effective psychotherapy. ules, or me The Bebavioral Approach Behavior therapists, irrespective of their specific approaches to treat- ment, agree on the importance of scientific methods in research sessment, and clinical practice. Behaviorists assume that addictive behaviors are to a considerable degree acquired through learning, and therefore they can be modified through additional learning. ‘Therapy is delivered with the assumption that specific problem be- haviors, for example, gambling, can be targeted for change without fear that unconscious causes will result in the substitution of new and equally severe symptom Clients procure the services of behavior therapists with the clear understanding that the focus of treatment will he on reducing or eliminating undesirable behaviors. Neither exploration of carly childhood experiences nor analysis of one’s feelings coward his or her parents is required for successful treatment outcomes. ‘The duration of treatment is ustially considerably shorter than other forms of psy- ehotherapeutic intervention. Behavioral therapies for the entire range of addictive disorders—from workaholism to heroin addic- tion—are very common among medical and nonmedical practition- in the Contemporary psychotherapy market. Howard Shaffer of the Department of Psychiatry, Harvard Medical School, at the Cam- I has recently reviewed current trends in the use of ioral psychology in treating addiction, Thomas Crowl Ladvoeate for a behavioral approach to the treatment ve disorders, Through a carefully managed program of ran-Finding the Right Substitutes 195 domly conducted urine analy punishment for continued drug management technique known as contingency ¢ dicted physician, for example, agrees to write a letter to Fi stare medical licensing board, admitting that he is adclicted and offering to surrender his I he letter is given to Crowley, and a con- tract is devised instructing Crowley to mail the letter if the patient returns to the use of drugs. In the ARTS treatment milieu, drug- incompatible behavior is modeled by therapists and former addicts, then prompuy rewarded as it becomes mirrored in the client population, Whereas unconditional absti cis the usual goal of most treat- ments for addiction, some behavior therapists may work with some chents toward learning the skills necessary for controlled use. Alan Marlatt of the University of Washington in Seattle, who has done extensive research on alcoholism-relapse prevention, has eloquently articulated the tremendous controversy, yet considerable promise, of a controlled-use approach to problem drinking. The Cognitive Approach As opposed to strict behaviorists, cognitive theorists believe that thoughts and expectations have great influence on human behavior. The major tenet of the cognitive perspective is that maladaptive thinking causes psychological distress. Such negative mental con- structs as self-devaluation, a negative view of life, and a pessimistic view of the future are viewed as irrational cognitions that lead to depression. Unnecessary clinging to false expectations or nonpro- ductive beliefs, memories, and so on is perceived as the psychologi- cal underpinning of self-defeating behavior. The therapist’ job is to help clients first to express their negative distortions of alley, and then to confront and accept evidence to the contrary, For example, a man who relies excessively on sexual con- quest to bolster his self-esteem may become aware of a deep-seated , counterproductive belief t in order to be successful, he must have several love affairs going on simultancously. [fis therapist might well confront him with his nonsensical expectation that his work, creativ- ity, and health will falter and perhaps dismregrate without novel sex- ual encounters. Rational-emotive psychotherapy, developed by Al-196 Craving for Kestary bert Ellis, is certainly the most popular and probably among the most effective of the cognitive approache: A promising development in the efforts toward addiction pre- mand treatment has been the recent synthesis of cognitive and ioral approaches. ¢ nrick, past president of the Society of Psychologists in Addictive Behavior and current director of Ab- stinenee Alternatives in Denver, extensively explores clients’ beliefs and expectations about substance use, in conjunction with behavior- modification techniques. Howard Shaffer has successfully used a three-component cognitive-behavioral strategy to reduce the fre- quency of onset and the extent of cigarette smoking among teenage students, The Psychodynamic Approach Psychodynamic treatment focuses on carly childhood experiences. This therapeutic technique places great emphasis on how the client copes with internal anc external conflict, Personality is viewed as a changeable system that represents an individual's unique reaction to psychological, biochemical, and environmental events. Anxiety is produced because biological impulses have been blocked from their natural expression. Excessive or addictive behaviors are perceived as necessary psychological props for the short-term management of in- ner distress, Edward Khantzian of the Department of Psychiatry, Harvard Medical School, at the Cambridge Hospital has conducted extensive clinical research on the considerable number of drug ad- dicts who appear to be using illicit substances as a form of self-med- cation to cope with their underlying feelings of anger and depres- sion, often rooted in early childhood frustrations and traumas. ‘The development of inner resources for effectively coping with misguided impulses is viewed as a vital aspect of successful therapy. Through candid and uncensored discussion with the psychothera- pist, carly conflicts with parents and intimate associates are discov- ered and explored. Forbidden wishes and fantasies become con- scious, thereby freeing energy that was formerly blocked from constructive use. Psyehad ing of old fantasies isted in separating previously important infantile needs and wishes from their currentFinding the Right Substitates 197 life situations. They develop internal means to effectively tole the inevitable frustrations of a more mature adult state. As copi strategies shift from dependence on drugs or other external suppor clients become more adept at work, love, and play. An Elementary Texibook of Psychoanalysis, by Charles Brenner, pro- vides an excellent overview of the enormous scope of psychodynamic thought. Tbe Prychodynamtics of Drug Dependence, published by the Na- tional Institute on Drug Abus ie collection of articles on the theory and management of drug addiction by major propenents cof the psychodynamic school, An important | applying a traditional psychodynamic approach to addiction is that treatment is short-circuited by intoxication. Fven the most orthodox practition- ers agree that they must first focus on stopping substance abuse be- fore any meaningful exploration of inner fantasies and wishes can Occur, Tbe Hamamsticl Existential Approach ‘The hallmark of the hu istic/existential perspective is the view thar what characterizes humans mo freedom to make respon~ sible choices and to anticipate the consequences of our actions. Hu- manistic thinkers have great respect for the fundamental goodness of humankind, and they believe that we are responsible for our own behavior. Although some aspects of our experience are undoubtedly determined by genetic, social, and cultural influences, in many im- portant situations people are the primary actors in determining their fate. Humans, more than any other species of life, form images, en- gaye in reflective thought, use symbols, and create novel solutions to problems in their midst. Most significant perhaps is the human ability to conceive of infinity and death. These unique abilities and sensitivities allow people to choose betw alternative courses of action rather than simply forming thoughtless responses to uncon- trollable stimu The humanisti¢/existential camp maint ins that human experi- ence is characterized by reciprocal determ we interpret our environment and plan our responses accord we affect the work just as much as it affects us. When people believe that they do not have the freedom of self-derermination, they react by becoming alicnated and depressed. Addiction becomes a means of coping ¥198 Craving far Festavy feelings of futility and unworthiness, ‘The diverse array of human- istic/existential approaches to psychotherapy share three philosoph- ical beliefs: (1) They actively seek to explore the client’s inner expe- riences with primary emphasis on the here and now; (2) They stress personal responsibility and freedom of choice and will, in regard to both psychorherapeutic growth and fulfillment during everyday life; (3) They believe thar humanistic/existential therapists should be ac- tive participants in the treatment process. On Becoming a Person, by Carl Rogers, the most renowned spokes- man for the humanistic/esistential camp, is a particularly important id easily read work in this area, Fredrick Perls, founder of Gestalt therapy, and Victor Frankl, who developed Logotherapy, have also made major contributions to humanistic/existential theory and practice. Styles of Deliv Group Approaches Group therapy ha: in ancient Gree ne: s sin the all-day dramas that were staged more than 2500 years ago. Greek citizens wit- d theatrical performances of w! hat we now regard as classic hu- yedies. In the drama of Oedipus, for example, a young war- rior named Ocdipus kills Lams, the king of Thebes, and marries the queen, Jocasta. Oedipus later discovers that the king was his father, and that he therefore married his mother. Horrified by the knowl- edge of his unintentional crime, Ocdipus gouges his eyes out, Hundreds of bemoaning onlookers are presumed to have derived great therapeutic benefits from the eniotional release triggered by ions such as these. Before the Middle Ages, Christianity is said to have achieved widespread popularity through open confe: partici- pants would publicly admit their sins and ask forgiveness am scores of entranced devotees. In the modern world, religious ins tunions form the backbone of informal psychological services. In temples, mosques, and churches, members receive group support, moral gui : puragement to express their most profound fears about life and death, unmarred by the stigma of mental illness. Moreno was the first to recognize that psychotherapy could ively delivered to groups of emotionally disturbed patients. man traFinding the Right Substinutes Loy Impressed by the therapeutic benefits that could be derived fror theatri dramatizations, he attempted to integrate role playing— the inclination and ability to make believe we are someone else— th the deeper possibilities of spontaneous acting. From this he founded the theory and practice of psychodrama, which was intro- duced in the United States in 1925, Moreno discovered when people are encouraged to play the roles of important people in their lives, they are likely to experience powerful emotions that are associated with these characters. Ie theorized that spontancous release of feel- ing was the first step toward improved psychological functioning. ‘Since Moreno’s pioncer efforts, the style of delivering psycho- therapy en masse has become widely used in the treatment of addic- tive disorders. Most current systems of individual psychotherapy, including behavioral and psychodynamic approaches, can be offered to clients in a group format. The most prominent group approaches are based on Transactional Analysis and Crestalt therapy. Despite the diversity of techniques that are associated with var- ious group treatments, several bi commonalities exist between them. Treatment groups usually consist of five to ten members, who meet with the same therapist, at least once a week, for ninety-minute to two-hour sessions. Group members are often seated in pattern so thar everyone can see and react to everyone else. } may share similar problems, such as obesity or alcoholi mogencous groups; or they may have a diverse array of identified problems in heterogeneous groups. Participants receive advice and guidance from other group members as well as from the primary therapist. lope is instilled early in treatment, as beginning clients observe others who have successfully grappled with problems simi- lar to their own. Group members experience relief in simply know- ing that they are not alone. Feelings of self-worth are enhanced as participants discover that they can be of value to other members of the group. Watching and listening to others often leads to improved interpersonal relationships and heightened social skills. As the group hegins to operate as a. cohesive family unit, members discover the opportunity to resolve and explore problems relared to their own fa . The negative effeets of childhood deprivation and stress can be dissolved by learning adaptive coping mechanisms in the current, growth-oriented family setting. Group therapy for substance abusers has become known for the powerful interpersonal confrontations that are promoted during the lies200 Craving for Ecstasy treatment process. Most current group treatments for substance abusers are modeled after the Synanon Game, which was developed to help recovering drag addicts to remain abstinent. The Game i type of group cneownter in which the open and direct expression of hostility and anger is quite prominent. Neither physical threats nor violence of any kind are allowed, and mind-altering drugs are not permitted, Group leaders are usually nonprofessional, recovering ad- dicts who have earned high status among fellow members of the treatment community. Each meeting lasts about three hours, and participants are en- couraged to ge at cach other in an uninhibited fashion. Screaming and yelling are common as individual participants are successively made the center of a series of verbal attacks. Group members are expected to be totally honest, as the conventions and restrict r normal interpersonal relationships are cast aside. ‘The us i sarcasm, and hostility is intended to rip away the defensive shields that have been used by addicts to avoid genuine human contact. It is assumed that the healthy release of anger creates a bond of mutual caring among group members. At the end of each Game, confron- tation and anger transform into warmth, support, and concern among participants. For many drug abusers, particularly heroin ad- dicts, the Game is an important veh! for personal growth, The vernacular and toughness of the street are preserved as vital aspects of the therapeutic encounter, where addicts can use their consider- able verbal and manipulative skills toward positive ends. Most con- temporary substance-abuse treatments use some variation of the Synanon Game as an integral part of the treatment process. Family Therapy Family therapists perceive addicted individuals as “identified pa- tients,” who are usually enmeshed in a network of disturbed fan embers. Addiction is viewed as a symptom of an overall family problem; drug dependence or other behavior disorders serve definite functions within the addict's family. If the addicted family member 10uld improve or abstain, other family members may act to under- mine or derail the success, returning the disturbed family to the prior state of equilibrium. Most authors who address this topic have noted the enormous difficulty of bringing family members of ad-Finding the Right Subssituzes 201 dicted individuals into treatment. Parents and siblings typically dis- place responsibility for the addict's problem to friends neighborhood, or other external systems, allegedly bey: ‘ence or control of the family. Family therapists have discovered that when relatives can be coaxed into entering family therapy, the probabilities for treatment success are greatly improved. When therapy is geared toward form- ing an alliance of family members who are mutually engaged in the Treatment process, family influences can be modified from factors that maintain addiction to forces that overcome problem dependen- Virginia Satir, author of Conjant Family Therapy, is the most -known advocate for the family therapy approach. She views disturbed functioning by a family member as symptomatic of w tions of love and trust within the family, Addiction is viewed as a primitive survival mechanism in a family that has somehow com- municated a need for mistrust and defensiveness to the disturbed family member. Claudia Black has achieved impressive results usi family therapy with children who have alcoholic parents. Duncan Stanton, director of the Addicts and Families Project at the Phila- delphia Child Guidance Clinic, has extensively written on the sub- ject of family therapy for herein addiction and other compuls' problem behaviors. ond the influ- Spiritual Orientation ‘There is widespread belief among both therapists and addicts that craving and addiction reflect a state of spiritual disharmony. By plac- ing their faith in a “higher power” addicts may be released from the influence of the substances or behaviors over which they lost control, Since the founding of Alcoholics Anonymous in 1935 the membership of recovering alcoholics in this spiritually oriented treat- ment approach may exceed one million people. Alcoholics are helped to stay sober through mutual support, self-examination, and spirit ual guidance, Alcoholics Anonymous groups exist throughout most of the world and are regarded by some renowned behavioral and social scientists as the most effective method for the treatment of alcoholism, In the past decade the AA model has needed only slight modification to address eftectively the needs of people who suffer from the entire range of addictive disturbances.202 Craving for Bestasy Many contemporary addicts are simultaneously addicted to more than one substance or behavior. Cocaine addicts, for example, often become dependent on a variety of “downers,” including aleohol, sed- atives, tranquilizers, or heroin, in order to cope with the jiteri ‘ and irritability that coke induces. Most contemporary aleoholic id to mix drugs and booze. The AA membership has aceordir shifted from a nearly exclusive focus on alcohol addiction to an in- creasing percentage of polydrug abusers. Irrespective of their chosen drags, AA members take comfort from what has become known throughout the world as the AA prayer: re GOD grant me the SERENITY to accept the things I cannot change, COURAGE to change the things | ean nd WISDOM to know the difference.Appendix Suggested Reading and Information Resources ‘The following resources are suggested for further understanding of treatment for compulsive behavior and addiction. References marked with asterisks are suggested for nonprofessional readers Treatment Philosophies Bromedical Approaches ins, A. C. {1985}: Inheriting addictions: A gevretic: perspective with emphasis ‘on alcohol and nicotine, In Addicsious: Multidiseiplivary perspectives aiad soeatmieis. edited by H. Milkman and H. Sbafier, Levington, Mass. Lexington Hooks, 2-10 Freedman, R. (1985). Biopharmacoligie factors in drug abuse, In Addicelins: Malt idicciplinary perspectives aud treaiments, edited by 11, Milkman and 1. Shaf- fer. Lexington, Mass.: Lexington Books, 21-28 *smith, D., Milkman, H., ane Sunderwinth, S$. (1985), Addictive disease: Concept and controversy. In Addictions: Multidicesplinary perspectives wind sreaiments, edited by H Milkman and 11, Shaffer. Lexington, Mass,; Lexington Books, 145-160), Sunderwarth, S$. (1985), T ical mechanisms: Neurotransmission and addiction. In Addictions: Multidisciplinary perspectives aud treatments, eslited by 11. Milkman and HH. Shatfer. Lexington, Mass.; Lexingron Books, 11-20. “Wortman, Ro (May 1985). ann. Cneni, $4) din Mind! nutrients, Behavioral Approaches . J. (1985). A biobehavioral approach to the origins and treatment of In Addictions: Multidinciplinary perspectives and treatments, exited by IL. Milkman and HL Shaffer. Lexington, Mass.: Lexington Books, 105-110. Marlatt, G. A. (1983). ‘The controlled drinking coftraversy: A commentary, Amer sea Prychalgisr 38: M7110.204 Craving for Bestasy Shaffer, H., Beck, J., arid Boothroyd, P. (1983). ‘The primary prevention of smokiig onset; An inoculation approach. formal of Prychoacrive Drugs 3; 177-184, Shaffer, H. (1985). Trends in behavioral psychology ane addictions. In Additions: AMfadtidiscrplinary perspections und trewtmends, edited by TH. Millman and H. Shaf- fer. Lexington, Mass.: Lexington Books, 36-36. Cognitive Approaches A. (1962), Reason wd cimotion in poychutherapy. New York: 1. Stuart. is. A., and Harper, R.A. (1975). A new guide to rational tring. Englewood Clits, NJ. Prentice: Hall C.D. Hansen, J. and Mayrag, J. (1985), Gagnitive behavioral treatment of problem drinking. In Addictions: Madtedisciplinary perspectives and treatments, edited by HL. Milkman and H, Shaffer. Lexington, Mass.: Lexington Books, 11-179. Eo Psychodynamic Approaches Blaine, J. and Julias, 1D., eas. (1977). Peyehadyatinies Release NIDA Re- search Monograph oS. Government Printing Offic Brenner, ©, (1973). An elementary teerbook of paythoanalysis, Garden Ci chor Books N.Y: Ane Humanistic! Existential Approaches Frankl, V. F. (1975). Paradoxical totention and ddereflectiont. Psychotherapy: Theory, Re- search and Practice 12:226-237. *Perls, FS. (1969). Genale tberapy verbatin. Lafayete, Calif. *Perls, FS. (1970). Gestalt therapy new. Palo Alto, Calif. Books, * Rogers, C. (1961), On becoming « persom: A prycbotberapist's views un peyeborberapy, Revs ton Houghton-Milflin, *Truax, C, B., and Carktuff, RR. (1967) Finsand effective counseling and psycbo- therapy: training and practice, Chicago: Aldine. Real Peuple Press, nce and Behavior Style of Delivery Family Approaches 2 (19RD). fr will mever Aappen 1 me, Denver, Colo.: MLALC, Printing and ation (1985), Repeat after me, Denver, Colo.: M.A.C. Printing and Publication. Satir, V. (1967), Conjoint family therapy: A guide to theary and tectmigue. 2nul. rev. ed, Palo Alto, Calif: § ener and Behavier Books,Appendix: Suggested Reading and Information Resources 205 Stanton, M.D. (1975). Psychology and family therapy. Professional Prychotagy 6: 45— 4. *“Weyscheider, S Alto, Cali 1981): Amother chance: Hope and bealth for the alcoblic fumity. Paley cience and Behavior Books. Group Approaches “Berne, E, (1961), Tramsactional analysis in prycborberapy, New York: Grove Press. *Berne, E. (1964). Gamer people play. New York: Grove Press. Casricl, D. (1963), Sa fare a Aorse, Englewood Cliffs, N J: Prentice-Hall. Casriel, D. (1971). The dynamics of Synanon. In Sensitivity training and group en- conuter: An introduction, edited by K. W. Siroka, E. k. Siroka, and G. A. Schloss. New York: Grosset and Dunlap. Frye, R., ed. (1984). Therapeutic community movement: Process and research. Journal of Psyeboactive Drags 1611); 1-99, ‘Treatment and Information Organizations The following organizations are suggested for treatment and infor- mation on various addictions, Alcoholics Anonymous and Narcotics Anonymous have a spiritual orientation. Alcobol Adiiction Alcohol 24 Hour Line National Clearing Honse for 1-800-242-6465 Alcohol Information Box 2345 Alcoholies Anonymous Rockville, MD 20852 P.O. Box 459 Grand Central Station National Council on Alcoholism: New York, NY 10017 733 Third Ave, New York, NY 10017 113 East 23nd § New wae NE end Women for Sobriety P.O. Box 618 Quakertown, PA 18951 (215) 536-9126 Drug Addiction Cocaine Hotline Haight-Ashbury Drug Detox 1-ROIKCOCAINE San Franciseo, CA 94117 4415) 621-2014206 Craving far Ecstasy Narcotics Anonymous National Institute on Drug Abuse World Service Office Prevention Branch, 36410 16155 Wyandotte Street Fishers Lane, Room WA—¥0 Van Nuys, CA 91406 Rockville, MID 20857 (818) 780-395 1 1-800-662-HELP Sexwal Addiction x Addicts Anonymous Twin Cities 8. A.A. P.O. Box 3038 Minneapolis, MN 55403 Gambling Addiction Gamblers Anonymous National Service Office PO, Box 17173 Los Angeles. CA 90017 (213) 3R6-87HY Food Addiction Overeaters Anonymous 2.0, Box 92870 Los Angeles, CA 90009 (213) 320-7941 Spending Addiction Spender Menders P.O. Box 1000-156 San Francisco, CA 94115 4415) 773-9754 Training Health Care Providers (public interest encoaraged) Center for Adkliction Studies Department of Psychiatry Harvard Medical School 1493 Cambridge Street ‘Cambridge, MA 02139 (617) 498-1148 the nbeidge HospitalReferences and Notes Introduction References Hughes, ]., Smith, 1. W., Kosterlit, H. W., Fotherwill, 1. and Morris, H.R. (1975). Identification of two relared pei ponies free thie brain with potent opiate agonist activity. Natare 258(5536). 5 Jellinek, E. M. (1952), Phases of alcohol addiction. Qamierty fournil of Biudies of Aleabol 13; 673-684, Jellinek, FE. M. (1960). The diseaie concype uf alcobuliom. New Brunswick, N.J.: house Press. Reagan undergoes surgery. (uly 22, 1985). Teme, 6-15. Zinberg, N. (Oct. 29, 1983). Personal communication with the author, Hill- Nate Figures on the extent of America’s drug problem are cited from: In the age of cocaine at is America’s drug problem? ffarpers (Dec. tatistics attributed to Arnold S. Trcbach, professor of justice at American University and director of its Institute on Drugs, Crime and Justice. Trebach is author of The Wur oa ws: The stary of the American anti-drug crusade and its victims. (New York: Macmi in press). Chapter 1 References Chein, 1. Gerard, D. L., Lee, R.S., and Rosenfeld, F Narcotics, delinquency and social policy. New York: Bh LOBED. The roaid in ft: Books, 227-250. Re-208 Craving for Kestacy printed in Cheute canribasions in the addictions, edined by H. Shatter and M. Bur- glass. (1981), New: Yo Collins, A. (1983), Inheriting addictions: A genetic perspective with emphasis oa alcohol and nicoune, In Addiction: Mudtidisrplinary perspecerces and teearuents, edited by H. Milkinan and H. Shaffer. Lexington, Mass: Lexington Books, 9 Donegan, N.. Rodin, ‘T., O'Brien, C., and Solomon, R. (1983). A learning’ theory approach to commonalities, In Communalities i satbsrance abuse and babewal be- ductor, odited by P. Levinson, D. Gerstein, and D. Mlolf. Lexington, Mass.: Lexington Books, 111-156, Goffman, E_ (1963), Stigma: Notes om ihe management of spoiled itentity. Englewood Clift: + Prentice-Hall. Kandel, D. al Malaff, (D. (1983). Commionalinies in drag use: A sociological per- spect In Commmuatities int substance abuse and Aabitwal bebavior, calited by P. Levinson, 19. Gerstein anel 9. Maloff, New York: Brunner/Mazel, 3-27. E. (1981). Selé-selection and progression of drug dependence, In Clantic contributions rm the addictions, edivet by H. Shaffer and M. Burglass. Lexington, Lexington Books, 154—140. (1983), Commonalities in substance abuse: A genetic perspec In Commenalirier in selstance abtse cud babicwal bebavior, edited by P. Lev D. Gerstein and D, Maloff, Lexington, Mass.; Lavington Books, 323-341. Milkman, H1., and Frosch, W. (1977). The ceug of choice, fowraal of Peycbetetic Drags Aly L3—04. Milkman, H_, and Sunderwirth, $. (Oct. 1983). The chemistry of craving. Prychal- ogy Tadiry, 3644. Schmeck, HL. M. (Mar. 22, 1988). Drug abuse in America: Widening array brings new perils. New Jank Times, CIC U) Sunderwirth, 5. (1985). Biological mechanismas: Neurotransmission and addicti In Adhticinons: Afuitidiseiplinary perspectives and treatmenes, edixedt by 11. MM and A Shaffer. Lexington, Mass. Lexington Books, 11-19, Wikler, A. (1973). Dynamics of drug dependence: Implications of a conditioning theory for research and treatment. Archiver of General Prychictry 28: 411-16. runner/Mazel, 95-116, Chapter 2 References Bruch; HL (1961), Conceptual confusion in eating disorders. Jourwal of Nervous aad Meritt! Disease 133: 46-54. Bruch, H., and Touraine, G. (1940). Obesity in cltildbood, ese children. Psyebeiamuatic Mtedicime 2: 141-20 Burns, M.. (1980), Aleohel abuse among wamen as indirect self-destructive behav~ jor. In The mary faces of swivide: Indirect self-destruction behavior, edited by NL. Farberow. New York: McGraw-Hill, 720-230. ‘he family frame ofReferences and Notes 209 Carnes, P, (1983). Tite sernal addiction, Minneapolis, Minn, Compare Publications. Coleman, D, (Oct. 16, 1984). Some sexual behavior viewed as an addiction. New York Times. Diaz del Castillo, B. (1963). Conguent of New Spain. New York: Penguin Books. Freud, S. (1962). Dbree essays om the theory of sexuality. New York: Basic Books, 47 Haley, |. (1973). The art of being schizophrenic. In Exploring madness, experience theory, and research, edited by J. Fadiman and D, Kewman. Monterey, Calif.: Brooks/Cole. Halmi, K. A, Palk, J. R.. and Schwartz, E. (1981). Binge-cating and vomiting: A survey of a college population, Pryeholagical Mediceue 24% 697-706, Hughes, J., Smith, T. W., Kosterlitz, [1 W., Fothergill, L. A.. Morgan, B.A., and Morris, H.R. (1975). Identification of two related pentapeptides from the lirain with potent opiste agonist activity. Narure 258(8536): 577-79. Jung, C.G., ed. (1964). Mam aad bts guabuls. New York: Dell Kagan, 1. (May 1985) Mind nutrients, Gmai, 3640. Khantzian, F. J. (1985). The sclf-medication hypothesis of addictive disorders: Fo- eus on heroin and cocaine dependence. American Journal of Povcbiatry 42:11: 1259-1264. Klein, D., and Liehowinz, M. (Dec. 1979). Af forms. Prychwtrie Clinics of North America, Liebsecitz, M.R. (1983). The chenustry of lve. Buston: Little, Brown. MacLennon, A., ed. (1976). Won ‘bei ture of alcabol tied other legal deags. “Toronto: Addiction Research Found: of Ontario, Mahoney, M. J., and Mahoney, K. (May 1976). Fight fac with behavior coneral, Prycholagy Today, 39-41. Mahoney, M. J.. and Mahoney, K. (1976), Permanent wetedr coral: A ronal salerion ta the dieter’ dilemma. Sew York: Norton, Marlatt, Gr. AL, and Gordon, J. R. (1979), Determinants of relapse; Implications for the maintenance af behavior change. In Behauioral meaficine: Changing health (yfe- styles. edited by P. Davidson. New York: Brunner/Mazel, 410-452, Masters, W. H., and Johnson, V. F, (1970). Hluman serual inadequacy. Boston; Little, Brown, Miller. P. (1985). Tbe chunge your wecaboliser diet, Landon: Panther Books. National Institute on Drug Abuse. (1979), Prcbolngical characteristics of drag-abusing women. NIDA Research ograph Series. DETEW Publication # (ADM) 80.917. Washingron, DC: U.S moment Printing Office Obrien, W. B., and Biase, V. (1984). The therapeutic community: A current per- spective. Tbe Journal of Psychoactive Drugs V6 1): 9-23 Peele, S., and Brousky, A. (1975). Love amd addiction. New Yor! Peterson, K. $. (May 16, 1984), Can a little aleohol be good for you? i, Rado, 5, (1933), The psychoanalysis of pharmacorhymia tdrug addiction). Tee Pry choanalytic Qnarterly 2-123. Ray, Oakley $. (1972), Drugs, society amd human bebavior. Saint Louis: C. V. Mosby. Rosenbaum, R, (1984). The chemistry of love, Exguere 1k 111. Rowland, ©. V., Jr. (1980). Hyperabesity as indirect selfalestructive behavior. In we disorders: special clinical210 Craving for Kestacy The mueny facts of siticide, edited by J. L, Farberow: New York: McGraw-Hill, Pera a Sehachter, S$. (1982), Recidivism and self-cure of smoking and obesit Payeboltgrist 47: 436-44. Schachter, $., and Gross, L., P. (1968). Manipulated time and eating behavior, Jaur- nal of Personality and Social Psychology WO: 98106. Shuckit, M. (1974). The alcoholic woman; A literature review. Peychiatry in Medicine Ht 37-43, Stunkurd, A. J. (1958). The management of obesity. New Fork Stare fonenal of Med- icine 5H; TORT American Vaillant € iggestions for would-be helpers. In Tbe aanival bistury of alen- bolisw.. Cambridge, Mass.: Harvard University: Press, 296-97 Wood, HL P., and Daffy, E. L- (1966). Psychological factors in alcoholic women, Ammericea: Jorrtial of Peycbivtry 124: 341-48 Vankelovitch, Skelly, & White, Inc, (May 20, 198%). Poll of drinking patterns in America, Time, $6-61 Notes The SCIENCE method of weight control is adapted fram Mahoney, M, J., and Mahoney, K., Fight fat with behavior control, Psyebolagy Today (May 1976): 39-41. Information for the case of Peter was adapted from “Free at Last,” distributed by: Sexaholics Anonymous, P.O. Box 300, Simi Valley, CA, 93062 An excellent review article by Ron Rosenbaum, “The Chemistry of Love" leak in Esguire (June 1984): 100-110. Research findings by psychopharmacologists Lewis Seiden and Charles Schuster of the University of Chicago and Ronald Siegel at UCLA on the toxicity of MDMA (Kestasy) were cited by Marjory Roberts in “MDMA: Madness, not ecstasy.” Prychalagy Today (June 1986): 14-15 The following information from our section, “Eating vourselt sick,” was adapted from “Slimming down; what works, what won't, awhat’s new,” cover story by Anastasis Toufenis, Time (January 20, 1986); 46-52. ‘The studies by Daniel Porte at the University of Washington and Martin Cohen at the National Institute on Mental Health, on the relationships between eating and endorphins.References and Nates 2u1 Remarks by George Bray of the Los Angeles County University of California Medical Center. Percentage estimates of people in the United States who bel they are overweight. Serotonin deficieney theory of obesity, studied by nutritional biechenust Judith Wurtman and neuroendocrinologist Richard Wurtman, both of MIT, Studies of premenstrual gorging at the University of Toronto, Studies of the relationship between childs body weight and bio- logical versus adoptive parents, by Claude Bouchard, the Physical Activity Sciences Laboratory at Quebec's Laval University. Prognosis for obese people by Amed ki Jolin McCall. Remarks by nutrition: Nestle, of the Medical School at the University of California at San Francisco, on foods that predispose people to obesity. schah, Jules Hirsch, and Chapter 3 References Clechley, HL (1964). Tbe mash of samety, St. 1. : Mosby Delh, J. L. (1980). I igh-risk sports as indirect self-destructive behavior, In Tbe many faces of suicide, edived by N. L. Farberow. New York: McGraw-Hill, 393469, Dietz, PF. (1983). Recurrent discovery of autoerotic asphyxia. In Agvoerneie farit- wie, edited hy R.R. Hazelwood, PE. Dieta, and A.W. Burgess. Lexington, Mass.: Lexington Books, 1344, Farley, F, (May 1986). The thrill-sccking personality. Psyedalogy Taday, 44-52. Glassman, A. (1984), Cited in Craving may be at the root af several drug addictions, hy BE Bower (184). Se Newer, 126: 310. Goldstein, 4., and Goldstein, D. B. (1968). Enzyme expansion theory of drug tal crance and physical dependence. Asswiation for Research én Neroors awd Adena Disease, 46: 265-167. Greengard, P. (1975), Cyelic nucleotides, protein phosporylation and neuronal fine- Tn Adsunces of Celie Nacleoride Research, edited by G1. Drummond, P, Greengard, anc G. Robinson, Vol 5, Proceedings of the 2nd International Con- ference on Cyclic AMP. New York: Raven Press, 985601.213 Craving for Ecstasy Litrnan, R. E., and Swearingen, GC. (1972). Bondage and suicide, Arebives of General Prycbiatry 27, 80-85. Lutfullah. (1857), Autobiography of Lutfullah, 2 Mohammedan gentleman. Lei vig, 112, Cited in Varieties of Religious Experience, by W. James (1988). Mentor Books, 133-39. ae D.T. (September 1982), Fearlessness: Its carefree charm and deadly risks. ley Today, 20-28. uae M Rosny, Journal of the Aimerican Pryohnanalytic Association 15; 740-760. Milkinan, H., and Frosch, W, (1973), On the preferential aluise of heroin and am- phetamine, Journal of Nervous and Mentat Disease 136; 4, 242-48. Milkman, H., and Frosch, W. (1977). The user's drug of choice. Jamrnal of Prichedelic Drugs 41% 11-24. an, H., and Sunde sive Drugs 4G). 177 Murphy, M. R., Bowie, D. L., and Pert, ©. B. (1979). Copulation clevates plasma B-endorphin in the male hamster. Society of Nerureiences, Alacka, 470. Reich, A. (160). Povchudatatyric stay of the child V5: 215-232 Rosenblum, S., and Faber, M. M. (1979). The adolescent sexual asphyxia syn- drome. Journal of the American Acadenry of Child Prychistry 18: 456-538. Rupp, J. C. (1980). Sexerelated deaths. In Moder degal medicine, prychiatry and forensic science, edited by W. J. Curran, A. L. MoGarry, and C. 8. Petty. Philadelphia: FA. Davis, 575-587. Selve, H. (1969). Stress: It's a G.A.S. Prychology Today 44): 25-26, 56. Solomon, R. L., and Corbit, J. D. (1974). An opponent-process theary of motiva- tion, Part 1. ‘Temporal dynanaics of affect. Prycbnlagical Reviews #1(2): 119-148. Tyhurst, |. $. (1951). Individual reactions eo community disaster, American Jornal of Psychiatry Wh; 746-769, Wallis, C, June 6, 1983), Stress; Can we cope? Time, 48-54, Wolfe, T. (1980). Tbe night suff. New York: Bantam Books. Zuckerman, M. (1979). Sensution seeking: Beyaad the optimal level of arousal Hillsdale, NJ: Lawrence Erlhaum, Zuckerman, M., cd. (1983), Biological bases of sensation secking, impulsivity, and anxiety. Hillsdale, N_J.: Lawrence Fribaum, 229-232, 255. inth, 5. (1982). Addictive processes. Journal af Poycbmac- 2 Chapter + References Bellack, L., ed. (1979). Disorders of the scbizapbrenic syirdrame. New York: Basic Books. Bettetheim, B. (1976). The ases of eachantmnent: The meaning and importance of fasry tales. New York: wee Biculer, E. (1911). tia Praceox oder die Gruppe der Schizophrenien. In Handbook der Paine edited by G. Aschaffenburg. Leipzig: Deuiticke. Crick, F., and Mitchison, G. (July 14, 1983), The function of dream sleep. Narn 304: 111 Fron, L. 1D. (1982), Parent-child interaction; televised violence and aggression ofReferences and Notes 213 children, Awerican Prychologist $702), 19 Fleming, C. B. (june 1983). Maidens of the sea can be alluring but sailor beware. ‘be Smurheuntan, 8-95 Goldman-Rakic, P. (1982), Postnatal development af monoamine content and syn- thesis in the cerebral cortex of Rhesus monkeys. journal of Brutn Rematch 43). 339-149, Greenberg, H.R. (1975). The mevies om your mined: Bilin classiey om the couch frum Petlins to Frankenstein, New York: EP Dutton, 4, Gygax, G. E. (1978), Gfficitl advanced dungennt & dragons players handbook. Lake Ge- neva, Wis.: TSR Hobbies. Hartman, E. (1973). be fictions of steep, New Haven, Conn.; Yale Univer Press, Hebb, D. 0, (1958), Brain cell assemblies. Pryctulagical Brain Aéscraces Humphrey, N. (1981). Four minutes to midnight, ind annual Jacob Bronowski Lec- ture, B.B.C, Television, BHC. Radio Timer Jaffe, A. (1964). Symbolism in the visual arts. In Alaw and bir symbols, edined by ©. G. Jung. Ganden City, S_Y-; Doubleday, 242-271 Laing, R. 1, (1960), The divided self New York: Pantheon Books. Lindner, . (1985). The jer-propelfed couch, and other trne peycboanalytic sales. Lanuton: Secker and Warburg. Lindsey, 1. (1976), Phe lave greai planet curt. Grand Rapids, Mich Mander, J. (1978). Four arguments fir the elimination of television. New York: Murrow. Mare, D. (Aug. 1984). Understanding telev n. Tbe Atlantic Monthly, 33-44, Meltzer, HY. (1979). Biochemical studies in schizophrenta. In Disorders of the schizo- phrenic sindrime, edited by L. Bellak. New York: Basic Books, 45-135. Rado, 8. (1981). Psychoanalysis of pharmace a. In Classic comeribessons in the addictions, edited by H. Shaffer and M. Burgliss. New York: Brunner/Mazel, 17-04. Rossel, R. 1D. (May 1983). Addictive video games, Prehofagy Today, Ryan, PB, and Clifford, G, (Dec, 26, 1983—Jan, 2, 1984) Ronald Reagan: No way to make it easy. Peapte, Singer, J. L. (981-82), Towards the sicentific stitdy of iinagination, Jmiaginacinns, Cognition and Personality Wy: 5-28. sr, T. §. (1961). Thy myth of mental illneys: Foendativns of a theory of persanal eurduet New York: Hocher-Harper Wanner, D. (Oct. 1982). The electronic bogeyman. Prycbobagy Fiiey, 5 Finberg, N., and Shaffer, 1. (1985). The social psychology of intosieant use. Tn Adiliciions: multidisciplinury perspectives and treatment, edited by H. Milkman and Hi. Shaffer, Lexington, Mass.: Lexmgton Books, 37-74, Zondervan. Chapter 5 References Diagmuctic and statistical manual of mental disorder. (198). Washington, 1D.C.: Ameri- can Psychiatric Association ‘The deng crtsis: crack and crime. (june 16, 1986). Newstreek, 16—22-314 Craving for Festasy Jelinek, EM. (1952). Phases of aleohol addiction, Quarterly Jornal of Studies of colo! 13; 673-684, Jelinek, E. M. (1960). The disease concept of alcobolion, New Haven, Cann.: Hillhouse Press. Kellerman, J. L. (1960), Atcululiom: A. merry-go-roend named deneal, Sew York: Ale Anon Family Group Headquarters. Lowe, C. (Oct. 26, 1985). The parents mavement.. Paper read at the National Anti- Drug Conference, Kuala Lumpur, Malaysia. Marlatt, G. A.,and Gordon, J. R (1980). Determinants of relapse: implications for In Bedwvinral aneslicioe: churning beslth life styles, edited by P.O. Davidson. New York: Brusner!Mazel. Meichenbaum, D., and Turk. D. (1976). ‘The cognitive-bchavioral management of anxiety, anger and pain, In The bebaviaral management of auxiery, depression and pain, edited by P.O, Davidson. New York: Benner! Maz Milkman, H, (1979), Addictive processes; An introductory formulation, Servet Phar nacologiot 24): 1~5, Shaffer, H., Beck, J., and Boothroyd, P.(1983). ‘The primary prevention of smoking onset; An inoculition approach, fouraal wf Psychaaceive Lruges §: 177-184, Smith, D., Milkman, H1., and Sunderwirth, $. (1985). Addictive disease; Concept and controwersy, In Mulriadisciplinary perspectives and treatments, edited ty H. Milkman and HH. Shaffer. Lesingron, Mass.: Lexington Books, 144-159. C (1983), The nateral bistory of alenbaliom Cambridge, Mass.; Harvard wersity Press, 44, 190 Vaill: Chapter 6 Notes 1. References for Chapter 6 are mm Resources. seling Toterest Iiventory was adapted from H1, Milfunan and N. Hal- Iiday, Counseling: A self-insteuctioeal programmed course, inv the Idaho Instructional Programs, developed by Barbee Associates, 1976, under grant no. 750608, West- ern Arca Alcohal Education and ‘Training Program, the National Instirute an Alcohol Abuse and Alcoholism, and the National Tnstirute on Deng Abuse, 9, 3. A review of drag and alcohol treatment facilities in-the United States may be found in the article, Getting straight, Newsweek (June 4, 1984}: 62-69. 4. Anescellent selection of current Titeratur amultidisciplinary nature, relevant to all aspects of substances, their use and abuse, may be obtained through: The Journal of Psychoactive Drags 409 Clayton Street, San Pranciseo, CA O4117 (415) 626-2810 5. The auchars wish so thank Eveline Vang of the Awraria Library, Denver, Colo- rada, for her referencing assistance, cl in the appendix, Suggested Reading and In-