“Candy is dandy, but liquor is quicker.”
Ogden Nash
Introduction
When talking about substance abuse, the most common pictures brought to mind are those of alcoholics and drug users. In reality, however, the field includes food, caffeine, and nicotine. The distinctions among these five basic categories is their accessibility. Food and caffeine are both legal and extremely easy for anyone to have access to. Nicotine and alcohol, while different in their affects, are both regulated to some degree … usually by age. Drug usage is heavily regulated at best, and the use of many drugs is completely illegal.
By separating the five substances into these different levels, one can readily see that the person with an abuse problem with food is not of necessity thrown into the company of the same type of people as a person with a drug abuse problem, or even a minor with a nicotine or alcohol abuse problem. This theory is supported by the fact that prior to the Harrison Narcotics Act of 1914, users of heroin and cocaine (including Sigmund Freud) were tolerated, and allowed to exist peaceably alongside the rest of society. Today, the drugs are the same as they were in 1914, but society’s perception of the users of those drugs has changed markedly.
The focus of this paper will be primarily on alcohol and drug abuse: alcohol because of its widespread and devastating effects, and drugs because of its many close ties to alcohol abuse. Kaufman (1985), has point out that “(i)t is easier to describe the common aspects of drug abusers and alcoholics that it is to tease out those that are unique.” For the purposes of this paper, therefore, I will use the term “substance abuse” to refer to either alcoholism or drug abuse, although in many cases it could apply to other abusive behaviors, as well (Donegan, et al, 1983).
Definitions
The DSM III definition of substance abuse will suffice for this discussion. Briefly, the three points mentioned in the DSM III that must be present for a diagnosis of substance abuse are:
- a pathological pattern of use
- social or occupational complications related to this use
- a consistent pattern of use lasting at least one month.
The DSM III further defines substance dependence as occurring when the three criterion above are joined by tolerance and/or withdrawal. Tolerance means that as time goes on, the user requires greater and greater doses of the substance to get high or, as in the case of heroin, just to feel right. Substance dependence is also the diagnosis when withdrawal symptoms occur upon cessation of substance intake.
Current Status
Alcoholism ranks as the second most prevalent public health problem in our society behind cancer (Milam and Ketcham, 1981). The number of alcoholics and alcohol abusers in this country has been repeatedly estimated at nine to ten million. Alcohol-related highway crashes kill over 25,000 people a year, including 10,000 youths between ages 16 and 24 (National Institute of Alcohol and Alcohol Abuse, 1982) and seriously injure 300,000 others yearly. Adding to these numbers are alcohol-related diseases. Alcoholism is the fifth leading cause of death in the United States (Cohen, 1978).
Alcohol has been implicated in 67 percent of all child abuse cases, 39 percent of forcible rapes, 51 percent of felonies, 41 percent of all assaults, 52 percent of traffic deaths, 40 percent of industrial accidents, 83 percent of fire fatalities, 50 percent of all homicides, 64 percent of criminal homicides, and 33 percent of all suicides (Milan and Ketcham, 1981).
The estimates of the visible economic losses to the nation from alcohol problems range to $50 billion yearly, including costs for prisons, mental institutions, hospitals, welfare, lost production, motor vehicle losses, violent crime, and fire. The hidden costs are even higher (Milam and Ketcham, 1981).
On top of this, alcohol seems to be the stepping stone to drug abuse. At least 20 percent of alcoholics use at least one other dependence-prone drug (Freed, 1973). 52 percent of young alcoholics and 16 percent of older alcoholics tend to abuse multiple drugs (Rosenberger, 1969). Illicit drug abuse is much higher in heavy alcohol users than in light drinkers (Wechsler and Thum, 1973). In a study of clients in alcohol treatment programs, it was noted that 30 to 60 percent of all clients were using drugs in addition to alcohol at the time of admission, and about half of these were abusing these drugs.
Although there are no easy solutions to a problem this massive, the one clear fact is that mental health professionals must be prepared to deal with substance abuse in all of its many forms.
Etiology
In general, substance abuse is to be expected of those who look outside of themselves for validation or completion. Because everything that is really important to them is outside of themselves, these people also look outside of themselves to feed, fill, or obliterate feelings of pleasure or low self-esteem.
Specifically, there are many models available to explain substance abuse. Schuckit and Haglund (1977) developed a framework for viewing models of alcoholism that provides for three major categories: biological theories, psychological theories, and socio-cultural theories.
In addition, substance abuse can be diagnosed in two major ways: binary and multivariate (Kissin, 1977). The binary approach is based on the idea that one clearly is or is not a substance abuser. Substance abuse can also be construed as a multivariate syndrome. That is, there are multiple patterns of dysfunctional use that occur in various types of personalities, with multiple combinations of adverse consequences, with multiple prognoses, that may require different types of treatment interventions (Pattison and Kaufman, 1982). The preponderance of mental health professionals now believe that substance abuse is a multivariate syndrome.
Biological theories
Biological theories can be broken into three sub-categories: the medical model, the genetic model, and the biological model.
The Medical Model. This model forms the basis for the Alcoholics Anonymous treatment program (discussed below). It is grounded in the observation that substance abuse seems to follow the same course as a disease, albeit in a body with a weak immune system. The physician is therefore the primary therapist (Brown, 1985). Although the disease model avoids value judgements on the morals of the abuser, it also provides the abuser with the “excuse” that they cannot stop substance abuse because they are “sick.”
The Genetic Model. This model postulates that substance abuse is inherited. This is supported by a study conducted by Drew, et al (1981), among others (Winokur, et al. 1970). This is not to say that there are other studies with less concrete results. Cotton (1979), for example, found that in reviewing the literature, between 50 and 80 percent of alcoholics do not come from families in which one or both parents were also alcoholics. This theory also ignores societal factors.
The Biological Model. This model claims that there is an chemical imbalance in the body of substance abusers that causes them to act the way they do. This model has different facets to it. For example, some researchers believe that the body produces a chemical that is responsible for alcohol addiction (Davis and Walsch, 1970). Other researchers believe that inherited metabolic patterns produce nutritional deficiencies that result in substance abuse (Williams, 1959). Yet a third group believes that substance abuse is related to dysfunctions in the endocrine system (Milam and Ketcham, 1981).
Psychological theories
Psychological theories can be broken down into four sub-categories: the personality model, the psychodynamic model, the transactional model, and the learned-response model.
The Personality Model. This model holds that there is an addictive personality. Research on this model has come up with mixed results, however, and to date it is unclear whether the addictive personality causes the substance abuse, or whether the substance abuse causes the personality characteristics (Lang, 1983).
The Psychodynamic Model. This model theorizes that substance abuse is the result of the abuser’s need to satisfy unfulfilled childhood needs, or as a means of supporting power fantasies.
The Transactional Model. This model states that the abuser uses substances to promulgate the scripting he received as a child. Transactionalists see the abuser involving others in “games” as a means to this end. Transactional therapists therefore include the abuser’s family and friends in the treatment.
The Learned-Response Model. Proponents of this behavioral model claim that people become substance abusers because they see rewards in abusive behavior. These rewards might include euphoria, relaxation, peer acceptance, better self-image, or even the avoidance of withdrawal symptoms (Brown, 1985).
Socio-cultural theories
Socio-cultural theorists examine both the society’s attitude toward substance abuse, as well as cultural biases for or against substance abuse. In spite of studies that show a high degree of correlation between substance abuse and socio-cultural influences, the socio-cultural theory is of limited use to the therapist who must deal with individual differences in substance abuse within the culture or society, except to say that the more difference there is between the individual’s behavior and his socio-cultural heritage, the better the probability that the individual has a severe psychopathology.
Treatment
There are several different types of treatment modalities, each of which has a different thrust. Some, however, can be used in collaboration with each other to good effect.
Therapeutic community
This has historically been one of the most effective treatments for substance abuse (Kaufman, 1985). The origins of the therapeutic community started in the early 1930s with Alcoholics Anonymous, and later spread to other similar groups. Currently, most of the therapeutic community groups utilize principles based on the Twelve Steps developed by AA in 1938, no matter what substance abuse they specialize in. AA itself has also spawned Al-Anon, an organization where spouses and relatives of alcoholics can discuss common problems related to living with an alcoholic, and Alateen, an organization where the children of alcoholics can share experiences and provide each other with support. Although AA has been criticized for its “religious” overtones, its greatest downfall in terms of the mental health professional is its procrustean view of alcoholism as a disease, which by its very nature discourages therapy for its members.
Hospital treatment
Since the first drug detoxification center opened in 1935, hospitals have periodically provided legal detoxification for substance abusers. Studies have shown, however, that rates of recidivism are high, probably due to the difficulty in treating unmotivated people (Kaufman, 1985).
Maintenance programs
These programs, which include methadone maintenance, have traditionally been thought of as working best in conjunction with family therapy. For best results, the family therapist should work closely in concert with the physician in setting and reducing dosages.
Group therapy
Group therapy should be started immediately after the client quits substance abuse. At this point, the client should agree to a contract that allows his involvement with the group only so long as he stays “clean.” After the client stops substance abuse, the typical pattern is to expect to be rewarded for his sobriety. Such rewards are not to be had, however, and the client must become involved in therapy before this realization takes place, but after detoxification, while his resistance to group therapy is low.
Biological treatment
Some researchers (Milam and Ketcham, 1981; Phelps and Nourse, 1986) have noted that substance abusers have common dietary problems, and thus have incorporated eating regimens into their treatment of substance abusers. Whether or nor the dietary deficiencies are the cause or effect of the substance abuse, the fact remains that substance abuse can be very damaging to the body, and a high-vitamin, high-protein diet can be valuable in helping to repair damage. Family systems therapy can be greatly augmented by following this principle. A more traditional biological technique is the use of the drug Antabuse, which causes an unpleasant reaction when combined with alcohol in the body.
Behavioral techniques
One of the earliest and most widely used forms of treatment was the behavioral technique. Behavioral techniques range from aversion therapy to assertiveness training. The basis of aversion therapy is to get the client to mentally associate a negative image with the thought of taking a drink, smoking a cigarette, etc. Behavioral techniques have been criticized for ignoring the factors that cause substance abuse in the first place.
Psychotherapy
Both of the two major classes of psychotherapists (insight-oriented and here-and-now oriented) view substance abuse as a symptom of underlying psychological pathologies. Clients in insight-orient therapies verbally work through their motivation for substance abuse. Clients in here-and-now oriented therapies are helped to work through their problems via the use of confrontative techniques, in addition to receiving directives from the therapist.
Family systems therapy
Family systems therapists are particularly well equipped to deal with substance abuse. The United States Congress on Alcohol and Health has referred to family therapy as “the most notable current advance concerning alcoholism in the area of psychotherapy” (Keller, 1974). Family systems therapy combines aspects of the therapeutic community, group therapy, and behavioral techniques, while adding its own powerful techniques of viewing the family as a system, homeostasis, equifinality, wholeness, communications theory, and boundaries. Family therapy can also make good use of dietary regimens to counteract and repair the damage done to the body due to substance abuse.
Because family systems therapy deals so heavily with the verbal and non-verbal communication among the members of the family, the family therapist’s first step is to redefine the “identified patient” as just another member of the “identified family.” The significance of this can be seen in the study by Leon and Phesan (1985) that showed a significant number of the parents of anorexics exhibited a deterioration in their relationship with each other as their daughter improved in treatment. The anorexic daughter was thus serving an important function as a distraction from underlying relationship difficulties between the parents.
In cases like this, the substance abuser is the homeostatic mechanism that helps the family maintain the “status quo” sense of balance. As one family member gets better, at least one other family member must get worse. A non-abusing family member may also consciously or unconsciously sabotage the improvement in the substance abuser; throwing a big party when the abuser is on the wagon, making use of the abused substance a reward for abstinence, etc.
By using communications techniques, the family therapist can explore family messages that perpetuate the behavior of the substance abuser. These might take the form of double-bind messages or contextual messages that encourage the substance abuser to continue his self-destructive behavior, or limit his range of options.
The family therapist also is able to use the family boundaries as a diagnostic tool. Families that lack cohesiveness often have loose boundaries. Families that cling to the status quo and have a more difficult time attaining homeostasis after a period of change often have rigid boundaries. Families with enmeshed boundaries may present a united front against any attempts to cure the patient.
Summary
The ever-increasing awareness of the problems of alcoholism and the recent emphasis on drug testing at all levels of society foreshadows what may be the most intense concentration of efforts on finding solutions to substance abuse problems. The costs involved in substance abuse of all kinds has mushroomed, and now they are no longer acceptable in or compatible with civilized society. The spate of new laws and restrictions have done nothing to slow the abuse of illegal drugs, and legislation covering other controlled substances is moving even slower. Clearly, the solution does not lie solely in legal sanctions. It is up to mental health professionals to discover and implement the treatment modalities that will help the current user. With further work, perhaps methodologies can even be found to help prevent substance abuse in the first place.
For the time being, I find myself most comfortable with the family systems approach, combined with community service programs (such as Alcoholics Anonymous, when possible) and changes of eating patterns to repair the damage of substance abuse and to help reduce pathological cravings. Because this subject can be so complex, however, I will continue to limit my therapy to substance abusers who have not yet become substance dependent.
Professional Insights
One of the most common threads I see in substance abuse is the compulsive behavior of the substance abuser. Philips and Nouse (1986) suggest that the compulsive disorder is of a biochemical nature. I personally feel that there is something to this point, but psychological explanations, family systems perpetuating factors, are also a part of this disorder.
No matter what etiological factors there are, I feel that therapists need to be better trained in diagnostic skills to understand the signs of substance abuse, including family patterns, personality types, and the variety of abuses. Another important point is the training therapists need to have in knowing what kind of questions can be helpful to give you clues as to which people are substance abusers. This is critical not only for the obvious reason of helping the client overcome the substance abuse, but also because you don’t want to unintentionally give the substance abuser the wrong message about his problem. I feel that if you don’t get the substance abuser to deal with his problem, you are in effect colluding with the abuser, by giving the him message that it is not a critical issue.
In my clinical experience, I have found that the hardest substance abusers to work with are those who seem to be doing well, on the surface. They are successful at work, and their personal relationships seem fine. In these cases, diagnostic skills are extremely important in helping the abuser identify the reasons for the abuse, and in getting him to understand the eventual negative aspects of continued abuse. Another facet of this situation occurs when family members cover up for the abuser, saying things like “he only drinks like that at parties (Steinglass, 1979).”
Finally, I would suggest that the therapist who doesn’t have a great deal of background in substance abuse should refer his clients to an appropriate community program that specializes in the type of abuse the therapist is facing. My belief is that any therapist who treats substance abuse without working with the family, community resources, behavioral approaches, and all adjunctive resources such as AA, NA, hospital settings, etc., is not seeing the gravity of this problem. In other words, I feel that unless therapists have a strong background in substance abuse, they need to get consultation from programs that work closely with substance abusers before evaluating if they can realistically treat the problem on their own.
Personal Insights
In my family and small social circle no one used drugs, cigarettes, or alcohol, and use of these substances was frowned upon. My only insights into substance abuse came later in life in the area of compulsive eating (in the form of excessive sugar intake), after I began to deal with my frustrations in an abusive manner. Still, this has helped me personally relate to the feelings of low self-esteem that accompany substance abuse. I know how hard it can be to think of anything else when the feeling comes over you, and I have gained insight into how extremely difficult it must be for someone who has a more severe problem, possibly including dependency.
Because of this experience with my own eating disorder, I have become especially interested in the subject of substance abuse. I must be aware, however, that I have the tendency to over-identify with the client’s feelings, and the potential exists for me to become concerned about their pain and ignore the seriousness of the substance abuse. I must also be very self-aware to avoid becoming caught up in the manipulative behavior that some substance abusers are capable of. My dynamics also make me a prime target for abusers who attempt to make the therapist the rescuer. With this type of client, it is important for me to distinguish between the pain and the manipulation.
Also in my clinical experience, a few of the substance abusers I have seen form a very dependent relationship with me, characteristic of people with that problem. When I stopped this process from occurring in therapy, they had the tendency to leave treatment, either to seek therapy with someone else who would not confront them, or to engage in self-damage acts. In all cases, there was a great deal of anger. These experiences are referred to by Kaufman (1977) when he discusses abusers who form dependent relationships, then readily shift this dependency from person to person when their needs are not being met. Because of this, I believe that both my clients and I benefit from plugging the client into a community program to help provide some of the support system these types of substance abusers need.
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