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 (6/17/86) states:
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).

Odyssey House, 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.

Odyssey House 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 as 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.

Jeffee states:
(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. Odyssey House 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 this country.

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 the like.

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 reality:

(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