Despite millions of dollars being poured into trying to stop the
influx of drugs at their source, barely 10% is effectively being
intercepted. It is evident that interfering with drug abuse
will have to focus more at the demand level in the form of
treatment and prevention. While this is hardly a novel idea,
I believe the lack of specificity of practical details has
thus far thwarted attempts to make a significant dent on
this problem. Thus there is an urgent need to derive new
approaches. It is the purpose of this letter to do so.
With respect to treatment, an article in The New York Times
Attention is shifting to a more fundamental issue, the
shortage of treatment programs for those who want to shed
their addiction. In New York and other locals, experts said,
treatment programs are saturated and callers seeking help
are put on the waiting list.
With respect to prevention through education: appeals to the
risks and dangers of drugs are often presented in off putting
moralistic ways, and in unrealistically optimisitic one shot
doses that only touch surface issues. I believe there is a major
deficiency in this approach. This deficiency is a lack of an
adequate understanding of the core problem underlying the
symptom of drug abuse.
Assuming the above, it is clear that bold, innovative
programs for both treatment and prevention need to be
conceptualized and implemented on a massive scale.
The following suggestions for the structure and focus
of such a program has grown out of my experience as an
Assistant Director of
Odyssey House (a therapeutic community
treatment center for drug abusers).
along with other therapeutic communities,
derived its treatment program based on the Ramirez Theory
of drug addiction. The Ramirez model assumes that drug
abuse is a symptom of an underlying set of psychological
problems in addition to cultural, familial and sociological
variables. Ramirez agrees with Chein, a noted addiction expert
who states in his classic book, The Road To H.
Chein says: ''The evidence indicates that all addicts suffer
from deep-rooted, major personality disorders. Although psychiatric
diagnoses will vary, a a particular set of symptoms seems to
be most common in cases of juvenile addicts. They are not
able to enter prolonged close, friendly relations with either
peers or adults; they have difficulties in assuming a masculine
(or feminine) role; they are frequently overcome by a sense
of futility, expectation of failure and a general depression,
they are easily frustrated and made anxious, and they find both
frustration and anxiety intolerable.''
Central to these findings is the inability of the addict to
tolerate psychological pain. This finding is supported repeatedly
in the literature. It follows that effective treatment and prevention
must address itself to this central issue. In clinical terms, the
research indicates that the core psychological issue underlying the
symptom of drug addiction is the abusers inability to tolerate
frustration and associated painful feelings. Therapeutic community
programs were designed to effectively confront this core issue.
Therapeutic Communities implicitly or explicitly appreciate
that frustration tolerance or frustration intolerance is a
learned response to too much or too little gratification in
childhood. The child who is a by-product of excessive negation
of his wants and/or needs grows up feeling deprived. This
feeling of deprivation prevents the person from tolerating
the inevitable limitations of life. This is so because
under-gratified people feel beaten before they act,
resulting (beyond a fail safe point) in their collapsing under
the weight of internal or external pressures experienced by them
as too stressful.
This contrasts with the overly-gratified person
who grows up with an attitude of unrealistically expected ease.
When such pain averse people have no choice but to confront
inevitable limitations stirring painful dissappointment, they
often cave into pressure at best or are paralyzed at worst.
This inability to tolerate frustration has major implications
for developing individuals. Without this ability there is no
way for a person to effectively summon his/her whole self to
cope with increasingly more complex problems of daily living.
The structure of the
Odyssey House treatment program is geared to promoting
graded, systematic difficulties for teaching patients to tolerate
increasing doses of frustration. Initially there is an acceptance
of the incoming addict with all of his/her self-defeating attitudes.
An invitation is extended to each addict to take a chance with the
program held out to be a better alternative than their present
lifestyle. Motivated addicts are able to distinguish themselves
with productive work, attaining increased rank, privileges, and
responsibilities. Finally, as the 'more productive citizens'
of the community work through their problems, they in turn become
co-counselors who along with professional helpers aid those below
themselves. The last task is for the mature ex- addict to leave
the program re-entering society as a 'whole person.'
A planned structure for each day is the vehicle for meaningful work and
relatedness. Part of the day consists of maintaining the up-keep of 'the
house' including such tasks as cooking, cleaning, and repairing. The
afternoon consists of individual therapy, group therapy, and
classes in a school setting. Night time is for play and socializing.
Experience demonstrates that it takes approximately one year for the
new addict to develop into a productive citizen of the house.
There is no question that programs such
Odyssey House have been successful in re-educating the
attitudes and behavior of a large number of drug abusers. However,
it is also true, that scarcely a dent has been made in the overall
drug problem with respect to treatment and prevention. The
reasons behind these low ratings are to be found in the history
of past failures.
In the early 196O’s the Federal Government sponsored a
comprehensive rehabilitation program called the Riverside
Program that had high hopes but failed to reach its expectations
and closed in 1963. Jeffee (1966) accounts for the reasons of
this failure in his book, Narcotics - An American Plan.
(failure was due to) a lack of trained
personnel with the abilities to cope with the nuances and
intricacies of the addict and his/her problems; a lack of
sufficient hospital beds and funds; inadequate follow-up programs,
psychotherapy, and after-care and rehabilitation.
Jeffee implies that the failure of such programs is due not to
a lack of knowledge ;but, rather due to an attitude that
fails to provide adequate training, supervision, funding, and
careful follow-up. Most likely for the same reasons, the
Rockefeller Program (1973) attempting to control narcotics
addiction in New York State became an admitted failure in
the same vein as the Riverside Program which preceded it
ten years earlier. Some called it "a billion dollar failure."
If the corrections Jeffee outlines in his book would be
implemented it seems reasonable that such program structures
should be extended in scope.
One attempt to extend the scope of such 'corrected' programs was
experienced by me while working at
Odyssey House in 1968. The
year, 1968, was parallel to 1986 when, like now, drug addiction
was spreading at an alarming rate. Heroin was the crack of it's day.
was one of approximately ten such programs attempting to stem the
epidemic of heroin addiction. Intake figures indicated that many
of the incoming addicts were from Harlem. An idea was proposed
to take the program to this problem area. A plan was conceived
to find a "slum lord" who would lease a broken-down house for
a small monthly rent. In return, we would promise a complete
renovation and maintenance of the building. Our reasoning was that a
broken-down house is a perfect vehicle for generating meaningful
work by appealing to a person's pride of possession. In New York
City there were and are no lack of sites to satisfy this need.
The same conditions are probably true for many other areas of
That very afternoon the plan was put into motion. In one week
a building was found, rented, and filled with 35 raw addicts
and their supervisors. I dubbed it ''the pressure cooker.''
The structure of the treatment program was the same as that of
''the mother house.''
The central attitude conveyed in the program philosophy is that
there is no magic cure. You get back what you put into the program.
The program structure is guided by two basic assumptions:
(l) Struggle is an inevitable fact of this life ( there no free lunch);
(2) addicts suffer from an aversion to sustained struggling
The core attitude conveyed in the program philosophy is that there is no
magic cure. Success is proportional to the degree of hard work undertaken by
a given patient.
Thus, such programs as Odyssey House
provide a systematic opportunity for the addict to be challenged,
aided, and encouraged to struggle with struggle. In so doing the
addict gradually learns how to tolerate increasing dosages of
frustration. This is brought about as the addict learns to cope
with the associated problems of daily living in a structured setting.
In a short time, the house was humming with constructive activity
and positive feelings. In a positive atmosphere, the best in people
is brought out contrasted with the opposite. Expect little, provide
little, and you cultivate self - defeating attitudes and behavior
leading to cynicism, emotional and spiritual impoverishment and
despair. In encouraging atmospheres, hopeful attitudes are as
contagious as cynical ones are in discouraging atmospheres. Boredom,
meaninglessness, and passivity, trademarks of street addicts, are,
in positive atmospheres, converted into kinetic energy, hope and
purposeful activity. Previously lost souls begin to come alive.
I firmly believe with careful planning, training, supervision,
follow-up and adequate funding this model satellite program
might be adopted on a larger scale in New York and elsewhere.
A question of funding and obtaining professional personnel
may be raised. In 1968 it was allowable for addicts in treatment
programs to receive Medicaid monies which were turned over to
the programs to pay for the costs of care. As for counselors,
some came from the ranks of ex-addicts. As for trained
professionals, it is to be noted, that at the time, there was an
over supply of social workers, rehabilitation counselors, and
psychologists. Additionally, there might be individuals
recruited from a domestic peace-corps. Other innovations for
competent staff members might be to invite capable and interested
older workers to lend their expertise, wisdom, and years of
experience to serve as role models and guides. Companies such
as IBM might donate computers; Kodak, photography equipment, and
With respect to prevention, I believe there needs to be a clear
delineation of the underlying core problem of drug abuse; namely,
the inability of the addict to tolerate frustration. There must
be an attitude that appreciates the fact that neither power
nor faith alone, or in combination are enough to solve the assumed
core problem of addiction. In this view, addicts suffer not so
much from an unwillingness to control themselves, but from a lack
of psychological know how based on an inadequate psychological
structure. Psychological structure (a cohesive self and a
strong ego) spontaneously develop as a direct result of people
purposefully learning to tolerate increasing acceptance of the
inevitable pain and conflicts of normal living.
In summary, the intent of this proposal is not to present itself
as the definitive solution for the drug abuse problem, but does
intend to serve as a catalyst for bold, innovative, practical
initiatives of proven workable ideas. Evidence exists that drug
addiction is best viewed as a symptom of an underlying psychological
problem. It is proposed that the core psychological problem is an
inability of the addict to tolerate increasing dosages of frustration.
Applying this assertion to the idea that in an accurate description
of a problem lies an embedded solution it follows that effective
treatment of drug abuse is primarily directed to working on this
core issue. Proven treatment models already exist which might
be implemented on a large scale provided there is adequate knowledge,
attention, resolve, funding, training, supervision, and appropriate
follow up of these proposed mini-therapeutic communities.
If and not until there is an all-out-commitment to turn the tide of substance
abuse, by focusing on the demand side of the problem (at least equal to the
supply side), is there likely to be a truly significant reduction in the
overall numbers of actual and potential substance abusers.
Reducing the demand for drugs will come about only when we
have an indepth understanding of the basic needs met by
compulsive drug users. In my professional experience the
psychological craving for drugs is an attempt to induce an
altered state of consciousness. Its purpose is to reinforce
two basic illusions concerning the addict's relationship to
(1) there are no limitations, and
(2) there should be no psychic pain.
Until and unless the grown-ups among us challenge these infantile
illusions we may well look back to our time as the beginning of the
disintegration of civilized society. Mature adults know that realistic
limitations and the need to cope with psychic pain is inevitable.
What is needed is a systematic educational program which teaches
addicts and pre-addicts how to tolerate increasing dosages of
frustration (i.e., learning how to struggle with struggle).
Such a program would utilize the 'how' underlying Mrs. Reagan's formula
of "Just Say No."
We must, as caretakers of organized society, confront our lost and
potentially lost generations; exposing the myths that quick money,
material goods and power over others appears to fill the emptiness,
reduces the sense of meaninglessness and raise the low self esteem
that motivates addicts to ever more desperate attempts to blot out
ordinary complicated experience.
Gibbs A. Williams, Ph.D. © 1999-2000