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Drug addiction : the role of social work in its recognition and treatment Tobin, Joseph 1952

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DRUG ADDICTION: The Role of Social Work in its Recognition and Treatment. by JOSEPH TOBIK Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of " MASTER OF SOCIAL WORK . in the School of Social Work Accepted a s conforming to the standard required for the degree of Master of Social Work School of Social Work 1952 The University of British Columbia ABSTRACT For s o c i a l workers, the entire problem of drug a d d i c t i o n i s a challenge. On the one hand, i t i s widespread and t h r e a t -ening; on the other, i t i s dealt with much ineptness and prejudice. Because addiction involves i n d i v i d u a l s , and because-problems of an emotional nature e i t h e r cause or i n t e n s i f y the a d d i c t i o n , the s o c i a l work profession c a n — o r s h o u l d — p l a y a leading p a r t i n i t ' s treatment and prevention. The t h e s i s s t r i v e s to show the addict as an i n d i v i d u a l , what his pro-blems are, and how he can. be aided by caseworkers, as w e l l as by p s y c h i a t r i s t s , psychologists, e t c . In p a r t i c u l a r , i t s t r i v e s to c l a r i f y the s o c i a l worker's r o l e i n a therapeutic approach,.' Data f o r the study came from many sources: from texts and reports made by various a u t h o r i t i e s i n the f i e l d , p a r t i c u l a r l y , studies made at the Lexington narcotics farm. Personal v i s i t s were made to prisons, c l i n i c s , and hospitals handling addicts, and discussions were held with doctors engaged i n t h i s work. Correspondence waS' c a r r i e d on with people i n various regions who are i n a p o s i t i o n to study the problem at f i r s t hand. And f i n a l l y , interviews were held with many addi c t s , both treated and untreated. F i n a l impressions rendered are a product drawn and based on the composite f i n d i n g s . . The plan of the thesis i s to review f i r s t the a v a i l a b l e information on the general incidence of addiction; then to focus what i s known of the t y p i c a l addict as a person, i n d i v -i d u a l l y and s o c i a l l y . Treatment p l a n s — c u r r e n t , discarded, and u n t r i e d — a r e then discussed; and the f i n a l chapter attempts to describe the work that caseworkers can perform with treatable addicts. -The conclusion of the t h e s i s i s that present methods can be improved considerably, with the help of s o c i a l workers among others, f o r work with treatable a d d i c t s , and that the number of "cured" addicts can be r a i s e d by such improvement. At the same time, the " u n t r e a t a b i l i t y " of many addicts has been examined, with the conclusion that a very large group of addicts cannot at present expect any r e a l p s y c h i a t r i c help. V i r t u a l l y no w r i t t e n material e x i s t s on the subject of casework with the t r e a t a b l e a d d i c t s , and i t i s hoped that t h i s study points the way to such a development. TABLE OF CONTENTS '; page Introduction .. i Chapter 1. The Nature and Prevalence of Narcotics Addiction Historical background. Incidence of addiction. The drug addict and his adjustment in work, marriage, etc. Criminality and drug addiction. Its relation to alchoholism. Theories on drug addiction. The penal approach. The place for social casework .........1 Chapter 2. The Addict as a Person The l i f e he leads, his argot, and his self-estimation. Drugs employed, and their effects. Classification of addicts according to treatment, and results with each group ....21 Chapter 3. Social Aspects Social histories of the addicts, their backgrounds and present circumstances. Social, psychological, and medical factors in addiction. Deterioration and recidivism. Social implications. 35 Chapter U> Treatment Reasons for treatment at a narcotics farm. Types of addicts who can benefit by treatment there. The Lexington narcotics farm. Suggestions regarding the farm. The caseworkers role 47 Chapter 5* Community Implications Treatment on the community level. Clinics, hospitals, public and private welfare agencies and their potential use for such work. Narcotics Anonymous. Conclusions 65 Appendix: Bibiliography 85 DRUB ADDICTION: The Role of Social Work i n its Recognition and Treatment. 1 INTRODUCTION The problem of drug addiction has, in the past few years, received a great deal of attention in the press and on the radio; this publicity has, i f nothing else, brought to the attention of the public the gravity of the whole matter. The almost daily recordings in the newspapers of individuals apprehended for-possession or sale of drugs i s indicative of the persistence of the problem; and the pleas of addicts occasionally included i n these items — pleas to have some rem-edial attention given them — provides some insight into the need that exists to attempt at least some form of therapeutic approach to the problem. That this entire matter i s or should be — of wide commun-ity concern i s indicated by both the widespread prevalence of narcotics addiction and by the deteriorating effect that this addiction has on the social structure. Narcotics addiction is not only a symptom of personal and social disorganization, but i t is also, in turn, an additional stress that may cause s t i l l further disorganization in the individual and in society. Alleviation of the problem, to be consistent, would therefore rest upon correction of weaknesses in both these areas. Just what the nature of this problem "is, and how i t can be approached in a positive, correctional way w i l l remain the central purpose of these chapters. Chapter I NATURE AND PREVALENCE OF NARCOTICS ADDICTION The narcotics addict is often referred to in a manner which suggests that he belongs to an undifferentiated entity in society, and as part of this entity, he leads a l i f e quite unique in most social respects. It would be helpful i f the conduct of the addict, as a mem-ber of the community, could be examined more closely, so that any conclusions that may be drawn about him would be based upon observation rather than on prejudice. Specifically, i t would be enlightening to know, first of a l l , just how many there are today, and how this total compares with, say, the number of addicts, twenty years ago; i t would be helpful to know how these people actually do get along in the community; are they a l l criminals; what sort of marital and sex l i f e do they lead; can they manage to work, even though addicted; which group in society is most affected by drug addiction, etc. These are pertinent questions which call for substantiated answers if one is to understand, with some authority, the many ramifications of this entire problem. HISTORICAL BACKGROUND The use of narcotic drugs is nothing new; i t is as old as recorded history itself. The Sumerians spoke of their poppy some seven to eight thousand years ago; around 4000 BC, the Assyrians had their word for the 'joy' associated with the use of the poppy. The Egyptians, Greeks, and then the Romans were a l l acquainted with the drug. Through - 2 -the spread of Mohammedanism by the Arabs, opium fi r s t reached Persia, and later India; and because the poppy then grew mostly in the East, addiction there became most prevalent. In the West, the renowned physician, Dr. Sydenham, in 1680, in speaking of the value of opium, made this interesting observation: "Among the remedies which i t has pleased Almighty God to give to man to relieve his sufferings, none is 1 so universal and so efficacious as opium." For more than two thousand years, the use of opium was employed as the major means for the allevia-tion of pain in human i l l s . In 1804, a German chemist, Dr. Serturner, isolated morphium, and with this discovery the means was provided whereby usage, and then addiction, became,prevalent in the West. In the United States, the Civil War saw the popularization in medical circles of the hypodermic needle, and also saw the almost indiscriminate use of narcotics among the wounded to reduce pain. The years following were years in which addiction in the United States reached major proportions; this, primarily as a result of the inordinate use of the drug. Both the Spanish-American War and the f i r s t World War had a similar effect, although the latter to a much lesser degree. Opiates were again used extensively for the wounded during the second World War, and because of the sharp drop in available drugs as a result of the war, prices for these drugs rose extravagantly in the i l l i c i t market. The high profits thus realizable on available 1 E. Terry and A. Pellens, The Opium Problem Today, N. Y. C, Bureau of Social Hygiene, Inc., 1928, pp. 53-57. - 3 -drugs — as high as 3000$ in some cases — became encouragement for the underworld to enter the market on a large scale, pushing the use of drugs 2 wherever possible. Significantly, drug addiction during the nineteenth century, when narcotics were available at pharmacies, was not especially linked with crime, as i t is today. Rather, addicts at that time were viewed much as alcoholics are at present. Before passage of the Harrison Act in the United States in 1914, which dealt with narcotic control, i t was estimated that females addicted to drugs outnumbered males addicted by 3 three to one; today, males are clearly the majority group. The passage of the Harrison Act changed completely the narcotics picture. The Act was intended as a revenue and control scheme, and required a l l who dealt in opiates or cocaine to register with the Collector of Inter-nal Revenue and to pay special taxes. Because the Act was not so interpreted as to allow doctors to treat addicts as patients, chronic users of drugs had to turn to surreptitious sources for their supply, and so the i l l i c i t t r a f f i c had f e r t i l e grounds in which to flourish. 4 INCIDENCE Because of the psychological and sociological complexity of-narcotics addiction, i t is v i r t u a l l y impossible to determine accurately 2 A. R. Lindesmith, Opiate Addiction, Bloomington, Indiana, Principia Press, 1947, pp. 196-198. 3 Ibid., p. 182. 4 J. D. Reichard, "The Narcotics Addict as a Custodial Problem." Prison World, Vol. 5, No. 2, 1943, p. 19. - 4 -just how extensive the problem i s today; users of drugs can — and do-include doctors and nurses who have f u l l access to the drugs and so are rarely reported; they can include many who are apprehended and put in prisons, but for offenses other than addiction. On-the other hand, vio-lators of narcotics laws include 'peddlers', contacts, handlers, etc., many of whom never touch their products, but who are nevertheless often l i s t e d together with addicts on the police blotters. Again, there are the habitual users and the casual users, though from the s t a t i s t i c a l viewpoint, failure to distinguish between the two is the rule rather than the .exception. I t can be seen from this how d i f f i c u l t i t would be to obtain any really accurate count of 'addicts'. The Secretary of the Treasury, i n 1918, reported over one million narcotics drug "addicts" in 5 the United States. The methods in arriving at that figure are open to question, but the t o t a l l i s t e d does indicate dramatically the seriousness of the problem at that time. In the years immediately following, addic-tion i s believed to have decreased appreciably. In a not untypical year, 1937, the United States reported 5,386 convictions for violations of state and federal narcotic laws; this figure i s more or less indica-tive of the extent of violations during the period between the f i r s t World War and the start of the second. It has been estimated that in this period, drug addiction was four times as prevalent in urban areas 7 as in rural. In New York City, where recent investigations have spot-lighted the intensity of the problem, f i f t y - s i x deaths were reported i n 5 Terry and Pellens, op. c i t . , p. 32. 6 L. Kolb, "The Narcotic Addict; His treatment" Federal Probation, Vol. 3, No. s,'.Washington, D. C. p. 20. < 7* A Systematic Source Book in Rural Sociology, Minneapolis, P. Sorokin and C. Zimmerman, ed., Univ. of Minn. Press, Vol. 3, 1932, p. 75. - 5 -1950 as a result of i l l e g a l use of drugs; nine of these were among youths under twenty-one years of age. Among teen-agers, known addicts 8 9 in that city rose from 329 in 1947 to 1,031 in 1950, a rise of 700$* ' The potential threat of drug addiction to the youth ofaany metropolis i s made evident by these figures. There has been a corresponding rise in addiction i n other areas ( i . e . among adults, females, etc.,) as shown , _ i ... 10,11 by recent surveys in Eastern c i t i e s . The picture in Canada is not so alarming, but is none the less serious. The Health Department at Ottawa reported 9,500 addicts in the 12 country in 1924, with a steady decline to about 4,000 in 1943; in the number of convictions for narcotics offenses, there has been a sharp rise 13 since 1943. There has similarly been a sharp rise in the number of females involved in this latter period. About one thousand cases are annually admitted to mental or penal institutions for drug offenses. 1 4 For the year 1951, i t is estimated that there were about three to four thousand addicts, one third of whom could be found in the Vancouver area alone. The rate of increase i n the past ten years i s considered to be 8 "Mayor's Committee Reports on Drug Addiction Among Teen-agers." N.Y.C..Spring 3100, Police Department, 1951. j 9 J. Dumpson, "The Menace of Narcotics to the Children of New York.", Report of the Welfare Council of New York City, Aug. 1951. 10 "Drug Addiction Spreading"* the B r i t i s h Columbian, Jan 9. 1951. 11 D. Carlsen, "Facts about Narcotics", Narcotics Anonymous, N. Y . 12 St a t i s t i c s of Criminals and Other Offenses, Ottawa, Dominion Bureau of Statistics, 1949, King 1s Printer, p. 20. 13 Ibid, p. 92. 14 G. Josie, A Report on Drug Addiction in Canada, Department of Health and Welfare, 1948, pp. 9-10. - 6 -about four to one. There i s at present no significant,addiction problem among the school children of Vancouver; and among the non-school adolescents, the reported incidence is extremely small. -This is the record as known to police authorities at present. However, in a study made by H. F. Price for the Royal Canadian Mounted Police, of forty-five known addiction cases, i t was determined that over half of this group, 54.5^, began using drugs at an average age of 17.4 years; , 1 65.8J& of the group were f i r s t arrested at an average age of 16.9 years. It becomes apparent from these figures that, though addiction i s not a major, overt problem among the youth of Vancouver (or Canada) today, i t does nevertheless exist as a beginning pattern likely to be followed by many-young delinquents in the years to come unless fundamental changes soon take place. DRUG ADDICTION AND WORK ADJUSTMENT - Narcotics addiction i s no respecter of race or education; there is an exceptionally high percentage of individuals in the medical 1 7 profession involved as addicts, and i t is peculiarly prevalent among 1 8 those groups having sufficient theoretical knowledge of the drugs. 15 H. F. Price, "The Criminal Addict", Royal Canadian Mounted Police  Quarterly, Oct. 1946> pp. 150-154. (The author considers the rate to be the same for the years since 1946.).. 16 Los, c i t . 17 A. R. Lindesmith, Opiate Addiction, p. 156. 18 A. R. Lindesmith, "A Sociological Theory of Drug Addiction", American Journal of Sociology (hereafter referred to as AJS.) Jan. 1938, p - r s o i — : ~ .. . 19 G. Josie, op. c i t . , p. 21. - 7 -Convictions under the Opium and Narcotics Act, however, are most often confined to those i n the laboring, domestic service, and commercial work, i n that order. 1 9 Among addicts studied at the 'Harcotics Farm' operated by the U. S. Public Health Service at Lexington, Kentucky, i t was discovered that a high percentage had f a i r l y good job records: t h e i r work was sa t i s f a c t o r y , and t h e i r employment was reasonably long. In 172 cases studied, 88 had a good-to-fair job record;; 84 had irregu-20 l a r or unsatisfactory records. In most addicts, as a r u l e , a s u f f i c -ient amount of the drugs produces lethargy and decreased ambition; pre-occupation with obtaining the drug and association with the underworld to achieve t h i s results i n a personal and s o c i a l deterioration, the 21,22,23 outcome of which i s an increasingly poor work record. The;! addict's development of tolerance for the drug, which thus necessitates increasingly larger amounts for his comfort, plus the other harmful mental effects, decreases his productive a b i l i t y s i g n i f i c a n t l y ; a slave to the drug, always needing more, the addict soon finds himself unable to report 24-to work.** I t would appear from these studies that those addicts who 20 L. Kolb, "Pleasure and Deterioration from Narcotic Addiction", Mental.Hygiene, Oct. 1925, pp. 699-724. 21 L. Kolb, "Drug Addiction Among Women", United States Public Health  Service B u l l e t i n (hereafter referred to as USPHS), Wash. D.C. 22 A. P f e f f e r and D. Ruble, "Chronic Psychosis and Addiction to Morphine", Archives of Neurology,and Psychiatry, Dec. 1946, p. 670. 23 M. Pescor, "A s t a t i s t i c a l Analysis of the C l i n i c Records of Hospit-alized Drug Addicts", USPHS Report, Supplement 143, 1943, p.2. 24 Spring 3100, (1951). - 8 -must obtain their drugs i l l i c i t l y generally reveal unsatisfactory work records, particularly where procurement i s quite d i f f i c u l t ; the good work record of so many addicts — even though this group included pro-fessional people capable of obtaining drugs without d i f f i c u l t y — i s surprising, in view of both the lethargic effect of the drugs and the deteriorating social effect of usage. One can only conjecture at this point, lacking intensive research into case backgrounds, as to why this significant difference exists. It would seem that, asbborne out by these studies, a majority of addicts can make f a i r l y good adjustments i n employment in spite of their addiction.' MARRIAGE The narcotics offender i n Canada, in his marital relation-ships, has been found to be quite similar to his non-addicted, non-criminal neighbour; this is in interesting contrast to a l l other 25 convicted offenders who, maritally, are quite different, The addicts studied at Lexington however, show a high percentage of un-successful marriages as compared to the general population in the U. S.; half of a l l the married cases examined there can be described as uncongenial marriages, with separation or divorce a frequent consequence (39$ of a l l cases studied f i t t e d into this latter group)'. Divorced 26 addicts frequently re-marry females who are themselves addicts. 25 G. Josie, op. c i t . , p. 20. 26 M. Pescor, op. c i t . , p. 11 - 9 -This rather tenuous relationship which addicts show in this area of marriage can be traced to several factors: (a) the use of the drugs causes sexual disinterest and disintegration; (b) money needed for drugs reduces, often seriously, the amount available for family main-tenance; and (c) the neurotic or psychopathic behavior which so often leads to addiction also creates the uneasy relationship between marital partners which then results in separation or divorce. • The apparent difference ran rates of divorce and separation among addicts between Canada and the United States can perhaps best be explained in cultural terms: the provinces of Canada, and particularly because of the inclusion of the Province of Quebec where family ties are very strong, have as a whole a more" clearly defined and stronger social and family control than does the United States, such control quite l i k e l y having a more restraining influence even among addicts. SEX Contrary to most lay impressions regarding drugs .and sexual behavior, i t is an observed fact that the use of drugs curbs sex desires, 27 and, in the male, delays the appearance of' orgasm. Indeed, medical authorities are convinced that i t is actually physically impossible for 28 the narcotic addict to commit violent sex crimes. There is some stimulation of sexual phantasies resulting from the use of marijuana, at 27 M. J. Pescor, op. c i t . , p. 11 28 D« Carlsen, op. c i t . - 10 least for those who expect such actions, but the degree of such 29 stimulation i s very small. Among females, there is a high correlation between prosti-tution and drug usage, ( a l l but one of the female addicts studied O A by H. F. Price were prostitutes; the exception was a nurse. u) but the explanation for this correlation i s debatable. Most female addicts, perhaps as rationalizations, insist that they have had to resort to this profession to pay for the drugs. Price has found that a great many of the prostitute-addicts use the drugs in the hope of blotting out of their minds their daily experiences, particularly because of the many perversions which they are expected to perform in their profession. For most prostitutes using drugs, i t would appear that their addiction i s merely another manifestation of their already disordered and anomalous l i v e s . CRIME AND DRUG ADDICTION Perhaps the most controversial area in the entire narcotics addiction problem is that portion dealing with crime. In the popular mind, the drug addict i s generally assumed to be somewhat of the "criminal type". Police authorities tend to regard the use of drugs as offshoots, by the addicts, of their other criminal tendencies. 3 1 29 J . Reichard, "Some myths about Marijuana", Federal Probation, Oct. - Dec, 1946, p. 19. " " 30 H. F. Price, op. c i t . , p. 151 31 H. F. Price, op. c i t . , p. 154. For purposes of cl a r i f i c a t i o n , "criminal.tendency" w i l l be used here to imply anti-social behavior and attitudes; thus, the one who violates the Opium and Narcotics Act, but who would not be described psychologically as anti-social w i l l not, in this section, be described as criminal. - 11 It would be convenient, for the purposes of analysis,iif a sharp line could be drawn between criminals who later in their careers took to drugs, and addict3 who, taking drugs, became offenders in the process. At the British Columbia Penitentiary, for example, in 1951, some twenty-five per cent of the inmates were adjudged to be users of drugs, but the most careful examination of records thus far fails to bring out the desired distinctions; the two are too closely intertwined. Price, in his studies, has found that every addict has had a previous record of criminal behavior; Sandoz, studying sixty morphine addicts, finds that forty-two of them never had been arrested prior to addiction, and that 32 after addiction, his group showed 8.2 arrests per case; at the Lexington farm, three-fourths of the patients studied had no delinquency record prior to addiction, and the biggest majority of patients were not 33 anti-social prior to addiction. 0 The evidence, in these apparently contradictory observations, would seem to favor the latter studies i f v. for no other reason than that the R.C.M.P. studies would'quite naturally embrace those who are in sharpest contact with law enforcement (and hence with the observer), while the latter studies were made in areas where treatment of both voluntary and involuntary patients was the emphasis. A'<'non-criminal' addicted nurse or lawyer, e.g., would be found in the Lexington study, but probably not in the R.C.M.P. study unless otherwise engaged in crime. 32 E. Sutherland, Principles of Criminology, 4th. ed. N.Y. J. B. Lippincott Co., 1947, p. 115. 33 M. J. Peseor, USPHS Report (1943), pp. 7-8. - 12 -For the individual who starts taking drugs (the one having no previous delinquency record), the pattern is generally that of his becoming enslaved by the drugs, getting less efficient, becoming care-less in his appearance, job, and sense of responsibility; he feels driven by psychological and physical needs to get more drugs, feels indifferent to a l l else, and slides rapidly down the social ladder. Lacking ambition, industriousness, the addict seeks the easy money 34 found in gambling, larceny, etc. It is very doubtful i f the drug i t s e l f ever induces the user to engage i n crime. ^ Narcotics addicts are not prone to crimes of violence; their crimes are assoc-36 iated with the obtaining of the drugs. As opposed to this group of addicts who engage in crime prim-a r i l y to get their drugs, there is the large class of criminals to whom drug addiction i s just another of their anomalies. For treatment pur-, poses, the distinction may be important, as w i l l be indicated later. > Criminal addicts can here be regarded as anti-social and of such neurotic or psychopathic bent that, under the circumstances, treatment preferably f a l l s , together with the anti-social criminal addict, under the aegis of penal authorities. Addicts-who-become-criminals, on the other hand, may (with important reservations) more logically be suited for treatment such as that offered in certain mental hospitals and narcotic farms. It is d i f f i c u l t to draw any hard, sharp line between these two groups because, as indicated earlier, addiction and criminality so often grow together as part of the same process; i n the f i n a l analysis, one can only take 34 G. K. Himmelsbach, "Comments on Drug Addiction", Hygeia, May 1947 p. 353. 35 J. D. Reichard, Fed. Probation, Vol.X (1946, pp.17-18. 36 6. Josie, op. c i t . , p.,39 - 13 -each case on its~own merits, and decide whether i t is properly a penal or a treatment case, in the hospital-versus-prison sense of these terms. Where the case reveals a persistent record of criminality prior to addiction, then a hospital setting would ordinarily not be advisable; but where i l l e g a l activity follows as a result of addiction, then a hospital may be indicated. However, as w i l l be discussed further i n a later chapter, selection for treatment, can not be arbitrarily based on a division into 'criminal versus npn-criminal types'. The problem i s far too complex to allow for such clear-cut and simple demarcations. "Big time" criminals rarely use drugs themselves; they may handle i t for re-sale, but among themselves they realize i t is too risky 37 for their profession. The use of opium tends to make the user serene," lethargic; morphine and heroin produce mental and physical lethargy, loss of ambition, a l l of which i s incompatible with the production of an 38 aggressive thief. The thief who takes cocaine is temporarily more efficient as a thief (this same drug w i l l not enhance the criminal impulse in anyone not so predisposed); but taking i t beyond a certain point 39 brings on in him a state of fear or paranoia. Among other effects, heroin and morphine in large doses w i l l change drunken, fighting psycho-40 paths into sober, non-aggresive idlers. In general, male addicts 4 resort to crimes against property; female addicts resort to prostitution. Reference i s of course being made here to those addicts convicted of 37 D. W. Maurer, "The Argot of the Underworld Narcotic Addict", Part I, American Speech, Ap r i l 1936, pp. 116-117. 38 L. Kolb, "Drug Addiction in i t s Relation to Crime", Mental Hygiene,. Jan. 1925. p. 78. 39 Ibid., p. 88. 40 Loc. c i t . 41 Spring 3100 (1951) - 14 -offenses other .than narcotic violations. •ALCH0H0L35M MD NARCOTICS ADDICTION The two forms of addiction, alchoholism and narcotics, have one major feature in common: both can be -interpreted as symbolic methods of flight. The use of both forms of addiction for the same not uncommonj in the United States, the inebriates form a very large addict group. One-third of the patients at Lexington were AO /J.O chronic alchoholics prior to addiction. ' The substitution of drugs for alchohol is a common occurrence, and has its basis in the same psych-ological motivation. (Cocaine and Marijuana, e. g., act to release depressed tendencies and to create disturbing and anti-social activity in those who are basically anti-social} the action resembles that of 44 alchohol. ) There is , however, one very important difference between these two forms of addiction: one can drink steadily without becoming an alcholic, but the evidence suggests that i t is virtually impossible 45 to take 'shots' steadily without becoming addicted. CONFLICTING THEORIES ON DRUG ADDICTION Existing theories that attempt to explain narcotics addiction are varied and many, and are, quite often, very much in direct conflict 42 M. Pescoe, USFHS #143 (1943), p. 12. 43 G. Josie, op. cit.', p. 25. 44 J. D. Reichard, "Narcotic Drug Addiction", Diseases of the Nervous  System • "(hereafter referred to as DNS) Vol. IV, (Sept 1943), p. 278'. 45 M. Moore, "The Management of the Alchoholic Probationers'* N.Y.C. 1941, p. 317. Probation and Parole Progress, ed., E. M. Bell. -15 -with one another. One leading authority in the field, Dr. Orgel, states categorically that " ... stable, well-integrated people do not become 46 addicts, even when the drug is administered for any length of time". But against this there is this statement by Lindesmith; "The 'Psycho-pathic basis'' theory implies that personality disturbance is at the basis of almost a l l cases. Yet i t appears that a l l 'normal' persons who have experimented upon themselves taking the drug, and who had, because of their stability, considered themselves immune, have, after 47 taking the narcotics for a length of time, become addicted themselves." This is but one illustration of the contradictory observations and con-clusions found in studies of drug addiction. The following theories, with some brief criticisms, may be set out as among the outstanding explanations given today in the field: A. The "psychopathic basis" which applies to the big majority of cases. It is.the nervous and mental instability in these people which pre-disposes them to addiction. (It has been shown, however, that 'normal* people can become"addicts. Exponents of this theory have never used control groups, so that scientific proofs of this view are lacking.) B. Bingham Dai theory of maladjusted personality. Drug addiction is, at bottom, a symptom of a maladjusted personality. iThe condition has definite connections with the childhood of those concerned, -especially with the maternal relationship. Their defective attitudes towards people cause the addict to shun the demands of the culture, and so makes permanent cure almost impossible. 46 S. Z. Orgel, Psychiatry Today and Tomorrow, N. Y. International Univ. Press, 1946, p. 206. 47 A. R. Lindesmith A J S (Jan. 1938), p. 598. - 16 -The addict's craving f o r opium i s due to h i s psycho-l o g i c a l desire to re-enter the state of Nirvana. (Once addicted, the addict i s not seeking Nirvana so,rmuch as he i s seeking only r e l i e f of his distress caused by the addiction.) C. Hereditary basis of addiction. In going over family, backgrounds" of a large number of cases studied, i t revealed that a s i g n i f i c a n t l y high per-centage of them have h i s t o r i e s of mental i l l n e s s e s among t h e i r forbear?. This theory does not pretend to cover a l l cases. D. Pleasure Theory. The common b e l i e f that opiate addiction i s based upon the happiness or pleasure which the drug i s supposed to produce. (The very fact that addicts always appear tmhappy would rule out such a hedonistic explanation. As suggested e a r l i e r , the addict, though he w i l l get some g r a t i f i c a t i o n from the 48 drug, also complains of the numerous e v i l upon himself.) E. Narcotic addiction i s fundamentally a physio-genic phenomena. Dr. Spragg, working with chimpanzees, gave them repeated doses of morphine, and found evidence in t h e i r behavior of a desire f o r morphine.49 (This projection of human attributes — the "desire" - r i s open to much debate.) ; F. The criminological theory. Addiction i s only another manifestation of the o v e r - a l l a n t i - s o c i a l pattern of the user. (But i t has already been indicated how many addicts show no record of a n t i - s o c i a l behavior, p r i o r to t h e i r addiction.) I t i s extremely d i f f i c u l t to 'prove' any of these — o r other — theories on the subject. For one thing, control groups are extremely d i f f i c u l t to use f o r such purposes; and f o r another, only a s l i g h t percentage of the entire population has been exposed to drugs, so that 48 A. R. Lindesmith, Opiate Addiction, pp. 145-155. 49 3. D. Spragg, "Morphine Addiction i n Chimpanzees", Baltimore, Comparative Psychology Monographs, -Baltimore, XV, No. 7. - 17 -those exposed and thenceforth addicted cannot f a i r l y be regarded as representative of this entire population. Therapeutic work with addicts, nevertheless, has been going on for years, a l l of these doubts notwithstanding. The treatment d i f f i c u l t i e s encountered — perhaps a direct reflection of this doubt and confusion — i s graphically portrayed by the following examples: (1) In Germany, 799 addicts who had been treated were studied for long term effects; i n five years, 96.7^ of 50 them had relapsed; (2) i n India, Dr. Chapra remarks how "... we have treated in our hospitals a number of (opium) addicts ... and our efforts ... have been miserable failures." A' The picture at'the Lexing-ton farm, where patients are treated for psychopathic and neurotic dis-orders, is fortunately, not nearly so discouraging. Because social work theory and practices f i t in most closely with this latter approach, i t is intended that they should receive the bulk of attention in the following pages. THE RENAL APPROACH TO NARCOTICS. ADDICTION. The Opium and Narcotics Act of Canada is a control and revenue measure, and does not concern i t s e l f with treatment. B r i t i s h Columbia has no legislation dealing with treatment of narcotic addicts, but only laws dealing with the mentally defective and insane. As a result, in 50 A". R, Lindesmith, A J S (Jan. 1938), p. 594. 51 R.'N. Chapra, "The Present Position of the Opium Habit in India", Indian Journal of Medical Research, XVI, p. 389. - 18 -a l l of Canada in recent years, only twenty-one addicts per annum, on an 52 average, have been admitted to mental hospitals for treatment. Gener-ally, only addicts who are psychotic cases are admitted. Most convicted addicts are sent to jails for periods of one year or less; a great many are sent to penitentiaries for iwo years or more. About one thousand annually are sent to penal institutions in Canada for drug offenses. That present penal methods do l i t t l e good in helping addicts towards recovery is readily admitted by most penal authorities. Recidivism among addicts is very common. In recent years, about 50% of those convicted under the drugs Act had previously been convicted, usually of other offenses. 5 4 At the B.C. Penitentiary, as of Nov. 1951, 125 inmates were serving there for drug offenses. Of 44 cases studied in this group, at least 34 used the drugs themselves; 42 of this group of 44 were recidivists. The pattern seems to be monotonously the same: arrest for drug or other offense, prison, release, and re-arre3t. It seems clear that the present techniques leave much to be desired; how-ever, to view the cases studied as essentially narcotic cases would be equally faulty, for every one of the thirty-four addicts mentioned had delinquent records antedating their addiction. Although to be relieved of their drug habit would undoubtedly aid in their general rehabilitation, i t can be suggested with good reason that, with such cases, rehabilitation might more appropriately f a l l under enlightened penal programs rather 52" G. Josie, op. cit., p. 52 53 Ibid., p. 69 54 G. Josie, op. cit., p. 69 -19 -than in a hospital setting where their presence may have serious deleterious effects among the non-criminal patient populations. The great amount of time needed for these people would again militate against their being sent to hospitals for treatment when one considers the existing paucity of resources for such work. It does seem possible to take some positive therapeutic steps even for these hardened criminal addicts; relief of their addiction may help considerably as part of treatment for their entire difficulty. For this group, a hospital setting in a maximum security arearcompletely separate from a treat-ment center for the other treatable addicts, and having at their disposal the necessary staff of trained personnel in psychiatric work, may be beneficial in eliminating or reducing the habit. That such efforts may be long and costly, and may actually do l i t t l e to re-orient the criminal addict so far as his other deviancies are concerned, needs to be carefully considered^ the light of available resources. SOCIAL WORK AS RELATED TO THE PROBLEM • ' ' D. Carlsen, head of Narcotics Anonymous, speaks of addicts as maladjusted people who have fallen out of step with the rest of the 55 world. Taking the drug away from the addict is relatively simple, once he is in an institutional setting (hospital, prison, etc.); but only when he, the addict, learns to understand himBelf and his condition can 55 D. Carlsen, op. cit., p. 2 56 L. Kolb, Fed. Probation, Vo. I l l , p. 23 - 20 -he hope to permanently arrest the disorder. This i s c l e a r l y an area i n which s o c i a l work i s applicable. Regardless of what theory one follows regarding addiction, i t does become evident that personality maladjustment i s a complicating and intensifying factor i n the huge majority of cases. Removal of t h i s factor w i l l most l i k e l y be of tremendous help i n the road to being cured. The explanation f o r addiction based upon personality disorders may be only coincidentally correct — as measured by i t s r e l a t i v e success i n treatments, contrasted with other methods — yet i t i s , f o r the present, pragmatically l o g i c a l . A former U. S. Assistant Surgeon-General recently stated that 11 ... the addict deserves more attention from physicians and s o c i a l workers, and less attention from the police.*;." This i n b r i e f , i s the contention of t h i s t h e s i s : to show how and why soci a l work can play a major role i n the r e h a b i l i t a t i o n of the narcotic addict. Chapter II THE ADDICT AS A PERSON. It becomes more and more apparent, as one examines the lay literature on drug addicts, that a great deal of confusion, uncertainty, and misunderstanding exists about them; the type of l i f e they lead is quite mysterious to the outsider; the drugs employed by them are not clearly differentiated as to the effects upon them; and the addicts themselves are not understood as being anything but addicts. In real-ity, the delineations are there, and are significant; to know and properly understand these afflicted people, to be able to work with them, i t becomes necessary to know them, not as an undifferentiated mass, but as individuals, to know what they experience, the sort of daily existence they lead, the language they speak, the drugs that they use, and the various effects upon them as a result. There are, to begin with, a number of expressions used in relation to addicts which can bear much clearer definition of meaning. To cite just a few of the more common and significant expressions, there are the terms like abstinence, whichy when used in reference to drug addicts, signifies the purely voluntary aspect of their abstention from drugs. And in speaking of the abstinence syndrome, reference is being made to the symptom complex which appears when the individual with physical dependence undergoes drastic reduction in his dosage; the signs of this symptom, in order of importance, range from yawning, rhinorrhea, - 22 -and perspiration, to loss of weight, collapse, and possible death in the 1 more severe cases. The "cured" addict remains a questionable term in this f i e l d , and most authorities feel that i t would be better to speak in terms of self-control rather than of cure. Habituation refers only to acquired psychological need and dependence upon drugs; this i s quite similar to speaking of the addict's habit formation, in which he seeks to avoid a l l discomfort, or pain by taking refuge in .some form of addiction. Narcotic drugs, as defined by Federal (U. S.) statute, refer to a l l derivatives of opium, such as morphine and heroin; also included are cocaine, marijuana, and peyote. Legally, the user of these drugs — t h e addict — is defined as one who, by his use of the drug, endangers society, or has lost self-control. The former user who has been abstinent for over eighteen months 2 is not legally classed as addicted. Physical dependence upon drugs inplies that the user no longer derives pleasure from the drug, but must 3 take i t to keep from becoming i l l . It seems to increase up to a certain level, with the length of time that narcotics are used regularly, and with the dosage.4 After a drug has been used for some time, the. addict finds that his tolerance for that drug has increased, that he has to increase his dosage in order to obtain the original effect.^ Tolerance refers to the amount he needs to gain this desired effect. 1 L. Kolb, Mental Hygiene (Oct. 1925), p. 699. 2 J. Reichard, Prison World, Vol. 5 (1943), pp. 12-13. 3 C. Himmelsbach, op. cit., p. 352 4 G. Himmelsbach and 0. Mertes, "The Nursing Care of Drug Addicts", N.Y.C., The Trained Nurse and Hospital Review, Nov., 1937, p. 459. 5 C. Himmelsbach, op. cit., p. 352. - 23 -ARGOT OF THE DRUG ADDICT Symptomatic of the clandestine and deviant sort of l i f e led by most addicts i s the extensive and secretive argot used by them. Listed below are a few of the more common expressions found among addicts in a l l parts of Canada and the United States. I t w i l l be noticed among these expressions how revealing of the attitudes and habits of the addicts are the feelings incorporated therein: A l l l i t up. Under the influence of narcotics. Black Stuff. Opium. Blowing. Inhaling narcotics. Brody. A feigned spasm to e l i c i t sympathy and perhaps dope from a doctor. Coasting. The exhilarating sensation produced by cocaine. Cold Turkey._ The sudden, abrupt withdrawal of drugs from addicts in institutions. Courage P i l l s . Heroin in tablet form. Do Right People. Legitimate people, or those with no criminal connections. Hoosier Fiend. A. 'yokel' who has become addicted, perhaps . accidentally, and does not realize he i s 'hooked' un t i l he develops withdrawal symptoms. Joy Popper. A person, not a confirmed addict, who indulges in an occasional shot of dope. Kick Back. The addict's almost inevitable return to narcotics after 'kicking the habit'. Main Line. The vein, usually in the forearm near the elbow, into which the conditioned addict shoots the drug. Mr. Fish. An addict who gives himself up and goes to prison in order to break the habit. - 24 -. Pad. A party for addicts, generally given by a pusher. Tickets are issued only to trusted customers, or to potential users. Panic Man. An addict who is desperate for narcotics. Pusher. A narcotics peddler. Snow. Cocaine. A major reason for this addiction argot stems from the constant fear of betrayal that exists among addicts and 'peddlers'. For self-protection, they have their elaborate, effective underground facilities for transmitting both information and narcotics. The great degree of clannishness among addicts is certainly another cause for such an argotf DRUGS USED BY ADDICTS, AND .THEIR EFFECTS The attractiveness of the opiates, which include morphine, heroin, and codeine, lies primarily in the satisfaction they provide in the urge for peace and calm. A l l opiates quiet the nerves, reduce aware-ness of pain and discomfort, and, in addition, tend to wipe out mental conflict and the uncomfortable pathological strivings that result. The tensions produced by the strivings are relieved, and, under the drug's influence, the neurotic or psychopathic patient feels free, easy and con— tented* ,as contrasted to his usual anxious state. Continued use produces mental and physical lethargy, and loss of ambition. The only pleasure later received from the drug is the pleasure in relief from withdrawal symptoms. Frequently, the first dose of opium produces more pleasure 7 than any subsequent indulgence. Users appear to become hyper-suggestible 6 D. Maurer, op. cit., p. 116 7 L. Kolb, U S P H S # 211 (1925), p. 4. - 25 -•while addicted. Those addicted are often comparatively free from signs of deterioration for years. When the addict's supply'of opiates i s stopped, he becomes i l l - w i t h pain, suffers from cramps, vomiting, diarrhea, sleeplessness, and possible death. 9 According to recent investigations in the United States, heroin is by far the most commonly used drug today in the i l l i c i t market. This drug, a narcotic derived from morphine, tends, like morphine, to soothe abnormal impulses of a l l kinds. unlike alchohol, i t does not release, but rather i t inhibits activity. It is decidedly the most toxic of the drugs used, 1 0 and i t s symptoms resemble those of morphine. The latter drug, morphine, is the most potent in dependence-producing properties, and, with heroin, has pain-relieving action, a tendency to quiet anxiety, and to relieve mental distress. I t relieves the individual of his physio-logical discomfort, and decreases the urge to action. Long use of morphine may result in melancholia,^ihd increased loss of memory. Memory is one of the f i r s t faculties affected by use of the drug. Severe cases sometimes show' visual hallucinations. - Recent studies indicate that the use of morphine has not increased mental deterioration, and the habitual use of 8 V. Vogei, "Suggestibility i n Narcotic Addicts", Public Health Report No. 132, Washington, 1937, p". 4. 9 A. Wikler, " C l i n i c a l Aspects of Diagnosis and Treatment of Addiction", Bulletin of the Menninger C l i n i c , Topeka, Kan., Sept. 1951, p. 158. 10. L. Kolb and A. DuMex, "Experimental Addiction of Animals to Narcotics", Public Health Report #1463,.Washington, p. 30. 11. L. Kolb, Mental Hygiene, Vol. IX (1925), pp. 78-85. 26 the drug does not cause a chronic psychosis or an organic type of intellectual deterioration. The addict may suffer from ethical and social regressions, but this is not due to the direct effect of the drug. 1 2 There are many cases on record of very psychopathic individuals becoming fairly good, well behaved citizens after becoming addicted to 13 ' morphine. It would appear that withdrawal of morphine is not suffic-ient in itself to cause a psychosis, but i t may intensify the symptoms 14 of a psychosis that already exists. Addiction to the drug codeine is, in Canada, apparently far more serious than in either the United States or x he United Kingdom... Codeine has been used as a principal ingredient in cough relieving syrups. Many individuals of unstable emotional character who originally had taken the medicine for its primary purpose, found themselves develop-ing a craving for the drug, then seeking increased dosages of codeine, and eventually switching to morphine or heroin for their greater stimu-15 lation effect. Marijuana, obtained from a species of hemp plant, grows thoughout the world in both temperate and tropical climates. Many people with normal nervous constitutions use i t , 1 6 as do others of less stable char-acter. It is taken primarily for the intoxication i t causes, and also 12 Pfeffer and Ruble, op. cit., p. 670 13 J. Reichard, DNS Vol. IV (1943), p. 278. 14 A. Pfeffer, "Psychosis During Withdrawal of Morphine", Archives  of Neurology and Psychiatry, Aug. 1947, p. 225. 15 L. Davenport, "The Abuse of Codeine: A Review of Codeine Addiction and a Study of Minimum Cough-relieving Does", Public Health Report #145, Washington, 1938. . . . 16 L. Kolb, "Marijuana", D S P HS. reprint #B-2575, pp. 2-4. - 27 -for i t s inhibition-releasing qualities. Users of i t limit themselves to a certain amount, not needing — as with opiate users — to increase the dosage rapidly to get the desired'effect. I t ' i s more intoxicating than alchohol, and more abusive use of i t would lead to insanity sooner than an abusive use of alchohol; - in this respect, i t is more harmful than opium.^ When the smoke is inhaled, the user becomes hyper-active> anxious, has vague fears, may even fear death, and become panicky; this is quickly followed by feelings of ease and elation. The user then becomes talkative and is f i l l e d with a vi v i d sense of happiness; the sex impulse i s aroused in some because the sex object appears more attractive. A loss of interest i n the environment, and an ina b i l i t y to concentrate long on any one subject generally follows the second or third day of using the drug, after v/hich users become more lethargic. After several weeks, users w i l l complain of headache, fatigue, dryness of mouth, and w i l l often be i r r i t a b l e . In general, the feelings of exhilaration and euphoria rendered by marijuana are followed by a general, lassitude and indifference which results in carelessness in personal hygiene and lack of productive activity. The drug seems to increase cerebral activity, 18 but has a lack of effect on body sensation (smell, touch, etc.). When used by unstable, anti-social, or inebriate persons, mar-juana w i l l release anti-social behavior as a symptom of abnormal attitudes already present. The intoxication caused by marijuana i s considered 17 Loc. c i t . 18 I . Williams, B. Lloyd, and A. Wallace, "Studies on Marajuana and PyraheXyl Compound", Public Health Report # 2732, Washington, 1946, pp. 16-21. - 28 -desirable by "some musicians, although actual tests reveal that poorer 19 . . performance results from its usage. It produces temporary psychosis in unstable persons, but no evidence has been found of any irreversible 20 damage to the nervous system. Continued use of the drug can cause insanity, but most patients recover when use of the drug is ended. Mari-juana does not cause any physical dependence; after withdrawal, however, users usually experience feelings of restlessness, sleep poorly, have 21 poor appetite, and often report "hot flashes" in their bodies. Cocaine, a stimulant used as a local anaesthetic in medicine, when taken internally lessens fatigue and makes the user more energetic. It acts as a direct antidote to whiskey and opiates, and is used as such by drunkards and opium addicts. Cocaine and opiates are often taken to-gether by addicts to gain the more intense pleasure afforded by the combination. The drug stimulates the mind and body, and, up to a certain point, increases confidence and courage. The immediate effects of the drug are pleasurable sensations; this pleasurable stimulation is enhanced in the feeling of some psychopaths because in them the drug also produces mental calm— they get a blotting out of excessive worries. Sex power is increased, and appetite is decreased. Cocaine never causes confusion like whiskey, nor stupor like morphine and heroin. Excessive 22 use of cocaine causes delirium, severe weight loss, and premature death. 19 C. Himmelsbach, pp.. cit., p. 353. 20 J. Reichard, Fed. Probation, Vol. X (Oct.-Dec. 1946), p. 16. 21 Williams, Lloyd, and Wallace, op. cit., pp. 16-21. 22 C. Himmelsbach, op. cit., p. 303. - 29 -Beyond the point of maximum stimulation, i t produces uncertainty, fear, and anxiety, which often develops into persecutory delusions. Cocaine addiction produces marked personality changes; when a psychosis devel-ops, hallucinations of bugs crawling tinder the skin become characteris-23 t i c . Most users of cocaine eventually switch to opiates to counter-balance the excessively stimulating effects of the drug. Withdrawal of the drug produces gastric disturbances, and oftentimes fearful hallucina-tions; however, no significant physiological changes have yet been 24 demonstrated during, abstinence following abrupt withdrawal. Among other drugs which, thus far, have not been seriously abused are the barbiturates which may, however, be habit-forming; i f used abusively, they may give rise to psychotic reactions which are usually temporary and recoverable. Addicted users often are confused, irritable, and react and speak slowly. Withdrawal of the drug may cause grand mal seizures, or bizarre, involuntary movements of a l l extrem-25 ities. Methadon, one of the new drugs developed during the war, has proven more effective for relieving most kinds of pain, and also produces less physical dependence. Its danger lies in this very fact, and users of i t , many of whom regard i t as more pleasant than morphine, are likely to develop stronger habituation for i t as a result. Neurotic and psycho-pathic persons are most liable to abuse the drug, taking to i t because of 23 L. Lowrey, Psychiatry for Social Workers, N. Y. C, Columbia Univ. Press, 1947, p. 141. 24 Wikler, op. cit., p. 157 25 Ibid., p. 164-165. -30 -the long, sustained type of euphoria i t offers. Another new drug, Demerol, acts like the opiates, causing physical and emotional depend-27 ence. Abuse of i t can lead to delirious reactions and convulsions. CLASSIFICATION OF ADDICTS The very heterogeneous composition of the group known as drug addicts has already been suggested. The entire group can arbitrarily be subdivided into as many classifications as there are foci of study. Inasmuch as treatment is the consideration here, the classification will be considered from that angle only, and the one that follows is based on treatment arrangements at the Lexington Hospital. Following each class-ification, a brief description is included of the typical inmate of that group —. as determined by studies made at the hospital — the relative proportion of inmates in that classification, and finally, where feasible, 28 the prognosis of each sub-group. 1. Normal individuals accidentally addicted. These are persons of normal nervous constitutions accidentally or necessarily.addic-ted through medication in the course of illness. They comprise 3.8% of all patients. The typical case in this group was past the age of forty 26 H. Isbell and V. Vogel, "The Addiction Liability of Methadon", American Journal of Psychiatry, June, 1949 , p. 9 1 3 . 27 Vogel, Fed. Probation, (June 1 9 4 8 ) , p. 1 0 . 28 M. Pescor, "The Kolb Classification of Drug Addicts", Supplement  #155 to the Public Health Reports, Washington. A l l descriptions given are of Lexington Hospital patients covered in this study. Patients included are male and female, young and old, prisoner and volunteer. - 31 -when fi r s t addicted; he used morphine to alleviate pains, and continues to use i t . He is a voluntary patient, with no anti-social record. He had a normal childhood adjustment, is happily married, and has an accept-able social adjustment despite his addiction. His parents were comfortably off, and provided average discipline at home. The prognosis of this group is above average. 2. Psychoneurotics. These comprise 6.3$ of a l l patients. The typical case tried twice to break his habit, but relapses because he feels that he needs i t for therapeutic reasons. He is a volunteer at the hospital. As a child, he was shut-in, studious,.and obedient. He went to college, has a good income, and is congenially married. No anti-social record is evident, and he has an acceptable social adjustment. His parental home was intact during the developmental years; his father's income was moderate. The patient had some neurotic disorders as a child, and probably had a nervous breakdown as an adult. He is uncooperative at the hospital, always demanding his release, and is unpopular with the other patients. (The uncooperativeness of patients in this group is somewhat surprising in the light of. the fact that, ordinarily., this group in a mental hospital does lend itself rather readily to attention and treatment. It may be possible that methods of handling this group at the hospital are at fault. A common irritation to patients at mental hospitals who are not too seriously disturbed, is the physical arrangement whereby individual movement and liberties are severely restricted in...the buildings. . Such aggravation can conceivably interfere with receptiveness-to treatment, and - 32 -so leave the patient with a strong desire to leave rather than to stay for further care. A less restrictive atmosphere — perhaps one in which only ;the external limits of the institutional grounds (a high wall, e.g., appropriately disguised) to serve as a restraint, with free movement within this area at a practical maximum — would l i k e l y be more conducive to treatment for patients bothered seriously by existing restrictions.) 3. Psychopathic diathesis. 54.5$ of a l l patients f a l l in this group. The group consists of individuals who show psychopathic dispositions or tendencies; i t i s characterized by behavior resulting from mis-interpretation of environmental settings or situations, but i t is-not a well crystallized personality defect. The typical case i s a male-prisoner who is 35 years old. His parents lived marginally and enforced average discipline at home; family relationships at home v/ere congenial. He had normal childhood adjustment. As an adult, he tends to l i v e in poor city areas. He employs i l l e g a l means to support his habit. He is married, but not for long. He indulges in a l l forms of vice at times, and became addicted through the influence of his friends, and through curiosity. He was addicted for ten years when reporting to the hospital, and showed a history of one enforced prison treatment, but relapsed within two years because of association and desire to recapture the pleasant sensation produced by drugs. He had no delinquencies prior to his addiction; after that, his offenses were confined to drug viola-tions. His prognosis: he w i l l probably relapse. 4. Psychopathic personality without psychosis. This group comprises 13.4$ of a l l patients. The typical case rationalizes his - 33 -addiction on the basis of curiosity and association. He has never tried voluntary treatment, but had several enforced attempts, each of which met with later relapse. He has a history of juvenile delinquency, is antirsocial, and is single. His parents were of marginal circum-stances, and his home l i f e was uncongenial; family tie s were loose. He was anti-social as a child, and as an adult, lives by gambling and other extra-legal pursuits. His social adjustment was poor befdre addiction and remains so after i t . His prognosis i s poor. I t would appear that the two classifications above, psychopath and psychopathic diathesis, are more or less continuations of the same process; that i s , both can be included under psychopathy, with the latter group forming the less severe"cases of a continuum, and the former group (4, above) comprising the more severe ones. In gauging prognosis, then, i t might be feasible to use the same continuum as a scale of reference, with position on that scale ~ the relative severity of the case — serv-ing as possible indication of treatability. The relatively low degree of success with this psychopathic group corresponds in general with similar d i f f i c u l t i e s encountered at other mental hospitals treating psychopaths. 5. Inebriates. These individuals, comprising 21.9$ of a l l patients, were persons in whom alchoholic indulgence played a significant role as a precipitating factor in their addiction. The typical case takes to drugs as a means of sobering up after alchoholic sprees. He has a history of at least two voluntary cures, with relapse through the alchoholic route. There i s no history of earlier misdemeanors. His family history shows a prevalence of alchoholic addiction. - 34 -6. Drug addiction associated with psychosis. Less than 1% of a l l cases are included here. I t is comprised of individuals suffer-ing from frank psychosis, organic, toxic, or functional. SUMMARY It can be seen, from a l l of the foregoing, that -the addict as an individual can have a background as varied as any in the general popu-lation. He i s the person accidentally addicted, and he i s the individual who deliberately resorts to drugs because of i t s euphoric effects. As a child, he may have been studious or flighty, well-behaved or obstreperous. Whatever the case, soon or later the fact of his addiction begins to put him in a group that, for i t s own protection and interests, uses i t s own language code, follows a pattern of clannishness, and, in general, comes to regard i t s e l f as a distinctly separate unit in society. Whatever their individual differences among themselves, drug addicts — the great majority of them — do feel that they are somewhat different from others, and that they are, because of their unique way of living and adjusting with drugs, in a social grouping by themselves. Chapter III SOCIAL ASPECTS Informational material thus far presented indicates rather clearly that drug addicts are not of one distinct type: their back-grounds vary considerably, as do their degrees of intelligence, their adjustments at work and in the neighborhood, their marital relation-ships, etc. It would seem, then, that involved in the causation of addiction are many factors; and to determine these factors, i t would be view the drug addict not only from the purely psycho-logical points of view, but from -the medical, emotional, and sociological viewpoints as well. I t would, in other words, be helpful to see him as he develops from childhood on, and to notice in this development, and in his present circumstances, a l l those pressures which, singly or in combi-nation, impel him toward this sort of deviancy. SOCIAL HISTORIES OF NARCOTIC;.: ADDICTS It i s extremely precarious, for reasons already presented, to deal confidently with stat i s t i c s giving background data of addicts. Studies made at hospitals or prisons, e.g., are not necessarily represen-tative of the addicted population at large; to be accurate, one can only say that the facts brought out are indicative only of those associated with the particular institution in question. I t is very l i k e l y , in addition, that the institution in question is dealing only with the more - 36 -glaring cases, so that the more routine strain of addicts i s l e f t un-charted; such limited observation can only serve to dilute, or even negate in some cases, many of the conclusions that can be drawn from the studies. On this continent, by far the most thorough study made has been that done at the Lexington farm, and appraisals included in the following section are drawn primarily from these studies."'" Other sur-veys-are accredited as they appear. In more than half the cases studied, the childhood of the patients can be described as normal. , Among the others, i n c o r r i g i b i l i t y , truancy, delinquency, marked shyness, and feelings of inf e r i o r i t y were characteristic. In school, the average grade completed was the eighth, though many went to college. In both Canada and the United States, the general education level of a l l known addicts i s lower than that of the general population. 2 The average mental age is 13 years 8 months, as contrasted to an M. A. of 15 years for the general population. 41.7$ of the patients at Lexington had no history of familial diseases or psycho-pathic determinants. Addiction occurred in other members of the family in 8.2$ of the cases. Over 50$ of them had blood relatives with nervous d i f f i c u l t i e s (psychosis, asthma, alchoholism, etc.). The majority came from intact homes; a big minority from disrupted ones. In most of the latter, the mother took care of the children after the separation or divorce; a majority of the patients in this group did not remain at home 1 M. J. Pescor, U S P H S # 143. (1943). 2 Josie, op. c i t . , p. 22 1 - 37 -to help support the family, thus revealing a lack of responsibility even prior to their addiction. Most patients came from congenial homes where average discipline was applied; about 40$ had poor discip-line at home. A small percentage show a mother fixation, and a smaller group expressed hatred for their fathers. The majority had religious training in childhood, but gave up their religious devotions in later years. Over half the patients had poor dentition; as children, their medical history was not unlike that of the general population. About half the married patients have no children, but some of the others have large families. Occupationally, the biggest concentration is in the domestic and personal services; many professional individuals, espec-i a l l y physicians, are included. A majority are in marginal economic circumstances, and above one-third are comfortably off. Regarding medical history, i t i s interesting to note how addic-tion so often starts as a result of medical attention. In one study of 1225 addicts among whom the development of addiction was traced, i t was notedathat in 23$ of the cases, addiction stemmed from previous use of drugs in medical treatment, and in 17$ of the cases, to.self-administra-3 tion of drugs for the rel i e f of pain. I t is likely that, as a rule, addiction does not result simply from 'shots' of morphine given to allev-iate pain. If a "normal" person has a chronic, painful condition for which opiates have to be given, and he develops physical dependence, the result is not necessarily a drug addict. If his physical dependence can be relieved, he can live without going back to drugs. But i f he suffers 3 Davenport, op. c i t . , p. 3 - 38 -from marked tension plus pain, and finds that opiates give him relief , 4 from physiological unhappiness, then he may become addicted. SOCIAL PRESSURES Recent studies at Bellevue Hospital in New York City throw light on the strong situational and social forces which are often c?oper-5 ative in the genesis of addiction among adolescents. ; In one study, a l l but one of twenty-two cases observed came from minority groups, and a l l of these youths suffered psychologically from racial discrimination. These youths, who first obtained drugs free from 'peddlers', or — as is more often the case — from other youths in the neighbourhood already addicted, took drugs as a result of either curiosity or group pressure: to remain in the neighborhood gangs to which they belonged, they had to follow the drug-taking pattern already established. Perusal of their social histories reveal this picture of the young addicts: they have many casual friends, but few real ones. At home,'' the mother is the domi-nant person; they reveal l i t t l e rapport with their fathers. None of these mothers took a punitive attitude towards the boys, and many of the yotiths wanted to go into an effeminate occupation; most felt their closest relationship in the family is with the mother. Heroin is the drug of their choice because i t helps them counteract their feelings of weakness and inferiority. Their I. Q.' s tend towards the dull-normal; emotionally they are immature, unstable, have low frustrations and anxiety tolerance. 4 Reichard, DNS, Vol. IV (1943), p. 277. 5 P. Zimmering and J. Toolan, "Heroin Addiction among Adolescent Boys", Journal of Nervous and Mental Diseases, July, 1951, pp. 19-29. - 39 -Confronted with anxiety-arousing situations, they usually do not respond with open and impulsive aggression, but rather, they repress their hostile feelings and draw into their fantasies. They also regress to an oral, dependent stage. Other studies of teen-age addicts bear out the fact of broken homes in the big majority of cases; in these homes, inadequate parental control, a lack of moral and ethical values, and a total disregard for personal responsibility i s noticeably the picture. In areas where such addiction i s rampant, there i s a marked hos t i l i t y evident towards a l l symbols of authority. The social forces which are effective in helping to precipitate addiction can be detected in much of the evidence about teen-age addiction. Caseworkers at the Bellevue Hospital who are in contact with young addicts both in and out of the hospital f e e l strongly that group pressure and group association i s a major cause for the youngster turning to drugs. They go far beyond the claim of studies such as the Toolan one which concluded that young addicts are the dependent, passive type. Experience with cases from a l l areas has led these social workers to the conclusion that group pressure and influence was often sufficiently strong to bring into the ranks of addicts youngsters of almost every personality type. Among adults, too, association with users of drugs is generally the most usual g way in which recruits are added. Broadly viewed, i t can be seen how the i ' 6 Dumpson, op. c i t . , p. 12 7 Zimmering and Toolan, op. c i t . , •8 Orgel, op. c i t . , p. 206. 4© " entire turbulent picture of today contributes to the insta b i l i t y , uncertainty, and insecurity of family and community l i f e , and this in turn adding to forces within the family making for added nervous ten-sions among the members. Another interesting b i t of evidence on the influence of social forces in drug addiction can b® seen in the history of narcotics addic-tion among women. Whereas, in the late 1800's, female addicts exceeded male addicts two to one, today there are at least three or four male addicts to each female addict. The reasons can be attributed largely to the keener sensitivity of females in our society to social taboos than males. During the earlier period, taboos and laws against use of drugs were Comparatively slight, and women experiencing serious frustrations, having few other outlets, often chose narcotics as their solution. Today with our s t i f f e r laws and attitudes, female indulgence as compared with 9 male has dropped sharply. In consequence of these sociological pressures which help fos-ter addiction, the addict is more or less forced into the singular situa-tion in which he i s held in contempt, not only by society at large, but by the 'underworld' as well. He is thus drawn ever closer into the inner ci r c l e of his co-addicts and their unique way of l i f e . EMOTIONAL FACTORS IN ADDICTION The tendency to regard the-addict as a sort of defective psycho-path, responsible for his own condition, has been noted by many authorities 9 Kolb, "Drug Addiction Among Women". U S P H S Bulletin - 41 -in the. field. Lindesmith deplores this as being more in the .nature of placing blame than in helping to explain the condition. In his view, users of drugs do not become addicts until after they have experienced withdrawal distress, known its nature, experienced relief of withdrawal symptoms by re-administration of the drug, and have learned the name of the drug. It is, as he claims, the knowledge of the true significance of the withdrawal symptoms when they appear and the use of the drugs thereafter for the consciously understood motive of avoiding these symp-toms that makes the user an addict. 1 0 "It is not the purpose here to become engaged in the polemics of the controversy regarding cause of addiction. Rather, i t would appear that because social and emotional distresses are so often associated with addiction that the understanding — and then relief — of these conditions would be most pertinent for social work purposes in dealing with the prob-lem. That these factors do appear in most cases is already evident. The escapist basis for so much of addiction is interestingly indicated in this very terse and very typical comment of an addict who speaks of his reason for taking opiates: "It makes my troubles r o l l off my mind." The emotional conflicts and feelings of inadequacy are suggested in such remarks. By taking opium, the user realizes a feeling of mental peace and calm to which he is not accustomed, and cannot normally achieve. It appears that the intensity of pleasure produced by opiates is in direct proportion to the degree of psychopathy of the person who becomes addicted, 10 Lindesmith, A J S (Jan. 1938). - 42 -and that the subsequent depression resulting from long-continued use of the drug carries him as far below his normal emotional plane as the fir s t exaltation carried him above i t . 1 1 Persons suffering from marked feelings of inferiority find that use of drugs does help inflate the personality, but in an un-aggressive way. The morose, irritable, dis-r contented person takes the drug, becomes temporarily agreeable, pleasant, and non-aggressive. While under the influence, /the addict feels conten-ted, and has no ambition; he feels that nothing matters. The near-uni-versal desire to escape the disagreeable features of l i f e help explain why cocaine users so often switch to opiates; where cocaine stimulates the senses, opiates depress them. In the. long run, the use of drugs complicates the situation in which the addict finds himself, and for treatment purposes, frequently makes it more difficult to handle. It is to be noted that use of drugs is essentially a result, and not the 12 cause, of a person's abnormality. DETERIORATION AND RECIDIVISM To speak of the deteriorating effects of drugs is to speak in generalities which, for one thing, are in fact often contrary to the evidence, and for another, may render an inaccurate impression. A group of twenty-five professional men who are addicts, for example, was studied for signs of degeneration, and only eight of them revealed 11 Kolb, H S P H S l 211. 12 Reichard, Fed. Probation, Vol. VI, No. 4, p. 18. - 43 -mental deterioration. Some persons have taken opiates for over twenty-years, and have shown no moral or intellectual deterioration; these addicts have started off with a varying degree of mental and moral equip-14 ment that has not demonstrably been changed by the use of opiates. A large proportion, of course, have deteriorated, and i n isolated cases, particularly among former drunkards, the use of opium has actually been of help in this respect. From a l l evidence, i t would appear that s (a) criminal psychopaths and inebriates are already deteriorated before becoming -addicted; and (b) the near-normal addicts generally are stable enough to withstand deterioration despite their addiction. The greatest deterioration appears in the group of carefree, pleasure-seeking young persons who are mildly neurotic or slightly deviant, and who get addicted. In conclusion, one cannot easily say that the drugs caused moral deterior-ation in any addict; in most cases, the early l i f e of these people has already been a distorted one, and resorting to drugs merely added another handicap to good adjustment. Where "mental deterioration" appears to be the case, i t remains a moot question as to whether this i s the condition per se, or whether a decline i n clear thinking is not simply characteris-t i c of the social consequences of a l i f e of addiction. The fact that seventeen of the twenty five professional men referred to above, who are addicted, did not show signs of mental deterioration would indicate that ordinarily the use of drugs has no such negative affects, but that the psychological effects of associating with other addicts, dodging the 13 Kolb, U S P H S #211, pp. 9-14. 14 Loc. c i t . - 44 -police, resorting to drugs for escape, etc., w i l l , i n i t s e l f , tend to cloud clear thinking. The same habit-patterns of evasion of real i t y , seclusion, improper association, etc., which are a l l concomitants of the addiction process, leads also, as a rule, to the social and ethical regression characteristically found in the addict group. The high rate of relapse among treated narcotic addicts is certainly one of the most distressing features of the entire thera- , peutic attempts A lapse — away from drugs — of months, a year, often , several years, i s characteristic of the individual released from a hospi-t a l , or even the addict who voluntarily enforces his own abstinence; but stat i s t i c s show the strong proclivity of these people to then return to their former habit. The reason for this recidivism i s explainable not only by the physical dependence which urges him to take drugs again, but also by- the very psychic stresses which originally impelled him in 15 that direction. The addicted individual over the years experiences a constant cycle of alternate comfort and discomfort: his need (both psy-chological and physiological) for the drug, the struggle to get i t , the dodging of the police to get i t , etc., a l l contribute to his discomfort; and, in strong contrast to this feeling is the comfort he enjoys when he does obtain his drug. The strongly addicted person i n this predicament becomes restless, discontented, and unhappy. He soon derives less satis-faction out of l i f e than he did before addicted because as his physical addiction grows in intensity and more drug is needed for his comfort, the power of that drug to give him temporary relief from the original 15 L. Kolb and C. Himmelsbach, " C l i n i c a l Studies of Drug Addiction", Supplement # 128 to the Public Health Reports, Wash., 1938. - 45 -i n f e r i o r i t y i s proportionately lessened u n t i l a point i s f i n a l l y reached where pleasure i s completely over-shadowed by pain. I t i s at t h i s point that he generally seeks a cure which, i n most cases, i s rather e a s i l y achieved from the point of view of r e l i e f from withdrawal symptoms and the physical need f o r the drug. This o r i g i n a l treatment i s then followed by an improvement i n h i s health; but coupled with t h i s the fundamental emotional disturbances which i n the f i r s t place i n c l i n e d him to the use of drugs, again assert themselves. The addict thus "cured" r e c a l l s the o r i g i n a l pleasures of the drug, and soon i s again resolving h i s predicament i n h i s o r i g i n a l way. I t i s i n this manner that the phenomena of the repeated cures and relapses of c e r t a i n types of addicts occurs. These cycles of comfort and discomfort may be sev-e r a l years i n length, but i n long-standing cases of addiction without cure, the depressive phase i s continuous. Thus i t can be seen that the cause of relapse i s due to the o r i g i n a l cause of addiction, to which i s added the greater dependence upon drugs f o r the r e l i e f of any unpleas-antness, the force of habit, and the many impelling memory associations of the r e l i e f afforded by n a r c o t i c s . SOCIAL IMPLICATIONS I t becomes evident, i n reviewing the s i t u a t i o n s surrounding and preceding n a r c o t i c s addiction, that the f a c t o r s leading to t h i s condition are many; s.nd quite often, more than one cause i s responsible. 16 Kolb, U S P H S l 211, pp. 1-2. - 46 -There are the emotional and psychological stresses stemming, for example, from inadequate constitutional ability, or from poor childhood adjust-ment, or from inability to socialize properly, or from work that is too demanding. There is the fortuitous addiction resulting from medical attention; there are the strong sociological factors of group pressures, social disorganization, availability of narcotics in %he i l l i c i t market, etc. In short, any or all of a number of psychological, physiological, and sociological forces can and do contribute to narcotics addiction, and a l l of which demonstrates the broad social implications of the entire problem. It is for these reasons that narcotics addiction needs to be recognized as a social problem; and, correspondingly, i t points to the need for treatment on a social scale much broader than now exists on this continent. Chapter IV TREATMENT There has been, to date, a number of schemes formulated in various parts of this continent for treatment of drug addicts, some of which have had varying degrees of success when applied, and a few of which have not existed long enough to allow for study of results. The narcotics farm has been tried at both Fort Worth, Texas, and at L e x i c o n , Kentucky; this latter remains as the biggest treatment center in the United States. Several clinics, the Menninger Clinic among them, have worked with the problem, as have several public hospitals in various parts of the country. On a smaller scale, there is the occasional work done by welfare agencies with individual addicts, and the attempts by some psychiatrists to treat addicted patients. Of a l l the efforts, the narcotics farm has been attracting the bulk of attention by experts, and is certainly deserving of most study. Institutional Committal The sending of an addict to an institution such as a narcotics farm is rapidly being recognized by authorities in the field of narcotics addiction as the major positive method of treatment for addicts. The reasons for this conviction are many, and include the following:-- 48 -1. In cases of long standing addiction, physical readjustment to abstinence is not complete for months after withdrawal, a readjustment which would be extremely d i f f i c u l t ih a surrounding less sheltered than that of a hospital; 2. Treatment of neurotic, psychopathic, and psychotic dis-orders which help pre-dispose individuals towards addiction often c a l l s for intense, sustained attention attainable only in properly staffed and equipped hospitals; 3. The addict's attachment to his drug is -very strong; so strong-, that, for most cases, only the careful observation and control exercised in a hospital prevents the addict from r eturning to his drug while treatment is in progress. In a proper hospital, he would thus have no opportunity for such immediate relapse; 4. An institutional setting puts the patient in an environ-ment which does not have those factors which hitherto abetted his addic-tion. Among young addicts, e. g., the efforts of group psycho-therapists to work with them right within their own neighborhoods has often been negated by the continual group pressure put on the youths by their gangs to continue the habit. In the same sense, the hospital would not have the frustrating or vit i a t i n g influences that the adult (encounters in the community, and which impel him to drug usage. Treatment of addicts within institutions has certain weaknesses which, by their nature, would preclude certain types from obtaining adequate help there. In many ci t i e s in the United States, magistrates often depend upon a good social history and recommendation from a probation - 49 -officer before disposing of an addiction case. Such officers — and the trend today is definitely to require that these men have some psychiatric social work training « thus find i t their function to help decide whether the individual concerned should go to a narcotics farm, be placed on local probation, with withdrawal effected at any local hospital, or should be remanded to a prison.- Weaknesses of a narcotic hospital or farm include the fact that such an arrangement calls for a rigid, routinized, and child-hood level type of existence which, in effect, may place an additional stress upon the person going there. If the stay is long, feelings, of dependency are increased, and ability to cope in the competitive -outside world is lessened. For this reason, the addict who is comparatively mature is probably better off being placed on probation away from such an institution. Existing narcotic farms have not had much success with very dis-turbed individuals (the psychopathic personality, e.g., as explained in Chapter II) or with certain cases of very long-standing addiction. Because of limited 'farm' facilities and the fact that other groups have shown favorable prognosis while there, i t would perhaps be as well to recommend these burdensome poor-prognosis cases to a mental clinic of hospital for treatment. Finally, an institutional program calls for close association among inmates, and the addict giving indication of being a corrupting influence to the others is definitely a bad risk at the farm, and should not be recommended for such placement. In working with youthful addicts, i t has been found', though somewhat tentatively, that assignment to a rural correctionalc amp where behavior cases are handled and where the emphasis is proper group living, is often - 50 -sufficiently effective in producing satisfactory changes in conduct away from drugs. Such camps, preferably under trained caseworkers for the more disturbed individuals, regard al l inmates — addict and non-addict — as behavior problems, and devote the bulk of their ener-gies towards proper socialization. Hence, for the majority of youthful drug offenders, recommendation; to a behavior-correcting camp seems advisable where his remaining at home on probation would continue to expose him to too many doubtful influences. The general manner in which institutional care should be employed has been suggested by the Welfare Council of New'York, which recently completed an intensive study of the problem of addiction in that area.1 The principles recommended by the council are: 1. Effective treatment for withdrawal and rehabilitation requires custodial care, under the control of staff trained in the various phases of treatment. 2. Persons not guilty of a criminal offense or adjudged delinquent should not be committed to penal andcorrectional institutions for treatment of addiction. The question of enforced custodial care, both during and after institutionalization, remains a tenous one. Modification of attitudes, interests, and values is the central purpose of the trained staff working with-addicts, and, as casework and psychiatric principle, i t is fundamen-tal that such modification come from within the individual, and not be imposed from without. Force or pressure in any form directed at the 1 J. Dumpson, op. cit . - 51 -addict may arouse either antagonism or mechanical submission, both of which tend to defeat the very purpose of the program. The securing of a cooperative attitude on the part of the patient is a paramount task within the institution, and a necessary accomplishment i f treatment is to be effective. That the addict w i l l not feel cooperative i f he feels that he is being unduly pressured i s to be expected. It is in this area that the psychiatric social worker can be most valuable in helping the patient to understand the reasons for the treatment program. The intake worker, i n particular, can be of tremendous help.;dn relieving the appre-hensions of new patients who expect to suffer considerably during withdraw-a l treatment. , Many newcomers even fear death; hence, proper interpreta-tion can minimise such fears and help pave the way for subsequent worker-patient relationships. In a l l cases, the worker i s in a position to help the newcomer realize that treatment, not punishment, is-^he'sole intention of the hospital staff. The need for some degree of enforced control over the addict while under treatment nevertheless appears evident from earlier experiences. Too often, a non-sentenced addict w i l l voluntarily seek hospital care when the disagreeable phases of his habit overbalance the agreeable ones. Then, once in a hospital, and relieved of his withdrawal distress, he w i l l ask for his discharge, and once again become his old addicted self when the original factors for addiction again come to the fore. His original prob-lem, in short, has not been dealt with, and to a l l purposes, he i s as much an addict as ever* On this same point, the evidence also points to the - 52 -need for additional probationary care once the patient is discharged from the hospital and on his own again. His re-adjustment within society is certainly a most trying experience; a few brief encounters with former friends s t i l l addicted, or with aggravating experiences, and the wheels are again set in motion for relapse. The need for close -- and compulsory follow-up is apparently requisite to the patient's fuller recovery.. Tactful and sympathetic interpretation of this latter area of treatment is just as necessary as it is for the former area. In Kentucky, one part of this problem is being solved by allow-ing volunteers who come to the Lexington farm for treatment — and when they arrive they realize most painfully the need for complete cure — to register with the legal authorities as users of the drug; once they thus agree to offer themselves as "violators", the judge v/ill automati-cally suspend sentence, provided that the violators go immediately to the narcotic farm and remain there until such time as the Medical Officer in Charge deems them f i t to leave. In this way, the addict has no choice; he must remain at the farm until fully exposed to treatment. If he leaves prematurely, then the police arrest him at the gates as a parole or probation violator. The near-futility of volunteer treatment ( i.e. treatment during which the patient is free to leave at his own discretion) is well illustrated at Lexington where 90$ of voluntary patients leave o prematurely against medical advice. Drug addiction, by its very defi-nition, implies a loss of self-control, and i t is for this reason that treatment of the patient will probably be unsuccessful unless there is 2 Vogel, U S P H S Reprint, p. 5. - 53 -authority to hold him until he gains self-control. Many psychiatrists working with addicts, especially the younger ones, feel that even this extent of control being tried in Kentucky does not go far enough; that after discharge the addict should be placed on legal parole, compelled to return to a clinic for periodic check-ups, and to accept help from a probation officer adequately trained as a psychiatric worker. Because both measures for compulsion just described might tend to cause resentment in the patient — and adult addicts who have been to treatment centers like Lexington almost unani-mously agree about their extreme sensitivity regarding coercion by the authorities and staff — i t remains for the team at the hospital to employ a l l its s k i l l in presenting the reasons'for parole to the addict in as understanding and sympathetic a manner as possible. The need for some type of compulsory treatment, without the stigma or suggestion of criminality, has been similarly suggested by the - recent report of the Mayor's Committee of New York City. Here too, - • ' ' 3 psychiatric parole or probation is called for. As a point of interest, i t can be related how, in certain other parts of the world where the addiction problem became acute, attempts were made by the government authorities to allow addicts to either register as addicts (with no pen-alties involved) or to go to government hospitals for treatment. In one attempt (Formosa, 1929), only 30 out of 25,000 known addicts asked for 4 the cure. i t would be pertinent, at this point, to record certain ; 3 Mayor's Committee Report, Spring 3100. 4 Lindesmith, A J S (Jan. 1938), p. 595. - • ' - 54 -evidence brought out during the June, 1951 investigations into drug addiction in New York. At the hearings, many of the young addicts stated quite strongly that they had often felt desperate during their addiction days, and would gladly have gone for help to the authorities i f i t were not for the fact that the 'authorities' generally means the police, and they resented or feared going on that basis. In their words, had they been able to go directly to a clinic or hospital, they would have accepted a l l measures of treatment offered by these institu-tions. Going on these revelations, i t would seem logical to suggest that here in British Columbia, any program of treatment would best f a l l — in its entirety — under the Department of Health and Welfare, where both hospital service and psychiatric parole are already within that department's jurisdiction. To summarize, the steps in treatment which today seem most efficacious are: 1. Control of the addict, which means physically holding him in custody in a hospital or quasi-hospital setting. Treatments can be more effective where the team has fuller control over the patient, but even with this, it may be difficult, and often may not work satisfactor-ily the first time of admission. Here, again, the interpretive role of a social worker can be vital to help prevent the relapsed patient from becoming hopelessly fatalistic and discouraged. 2. Relief of physical dependence. This transition from a l i f e with drugs to one without is fraught with dangers, the nature of which is not fully understood at present. At Lexington, the number of deaths during this stage is far beyond normal expectation,* and points to the need for this withdrawal to be carried out only under most care-ful hands. Withdrawal itself can be: (a) slow, a method in universal use up to forty-five years ago, in which daily dosages of opiates were gradually reduced over one month; (b) rapid, withdrawal being completed in from several days to two weeks; (c) abrupt. Where the habit is strong, abrupt withdrawal is not only cruel and dangerous, but unnecessary In any withdrawal therapy, the psychological factor is considered most significant: the patient must feel that something is being done for him; that is, he must feel that he is actually being helped, and not that the hospital is just cutting off his drug. Good interpretation is therefore essential. In some centers, i t has been found that stabilizing the strongly addicted patients when they are first admitted by giving them a few grains of morphine per day has been of very positive value; the patient thus has an opportunity to become used to the environment, and realizes that he is not going to be harshly treated. After stabilization withdrawal is effected in from four to ten days. Along with withdrawal, the patient is given up to three warm baths per day to reduce agitation. It has been noted that lobotomy has managed to reduce craving for drugs in strongly addicted patients, but i t is not yet certain that personality weaknesses resulting from such operations are preferable to problems associated with narcotics addiction. 5 Reichard, DNS, Vol IV, No. 9 (Sept. 1943), pp. 279-281. 6 Wikler, op. cit., pp. 160-163 56 -3. Making the addict w i l l i n g and able to l i v e without drugs. Most addicts coming to the h o s p i t a l are w i l l i n g ; i t remains f o r the hos-p i t a l team to help him i n his a b i l i t y to do so. I f p h y s i c a l handicap i s a f a c t o r , then that must be dealt with. His emotional problems, where they e x i s t , need studying. Psychotherapeutic attempts must be 7 made to discover why the patient f i n d s i t necessary to resort to drugs. F i n a l l y , i n planning f o r h i s r e h a b i l i t a t i o n , a well-regulated, orderly l i f e with i n t e r e s t i n g work and s u f f i c i e n t r e c r e a t i o n become important habits that need to be i n s t i l l e d i n him while at the h o s p i t a l . I d l e -ness, by a l l means, has to be avoided, and -this i s more than so f o r the neurotic p a t i e n t . The psychotherapist must help the patient to achieve a s u b s t i t u t i o n of more s o c i a l l y acceptable means of g r a t i f y i n g h i s needs than by h i s r e s o r t i n g to drugs. The usefulness of group therapy within the h o s p i t a l has been repeatedly stressed by treated ex-addicts; i n the words of one sxich i n d i v i d u a l , i t i s at these sessions that the addict has his greatest opportunity to discover why he took to drugs. In . t h i s group, he i s with fellow s u f f e r e r s ; he and the others can discuss mutual problems; the "leader" (as he is c a l l e d by t h i s i n d i v i d u a l ) i s himself one of them --except that he has better i n s i g h t into his problem. In t h i s s e t t i n g , the addict f i n d s himself ready to dig deeper into himself to f i n d the causes of his problem. Such a group functions best,when l i m i t e d to no more than ten or f i f t e e n members; and, i n addition has been useful to the addict only a f t e r he i s f u l l y r e l i e v e d of his withdrawal symptoms. The fu r t h e r b e n e f i t of such therapy i s the pattern i t sets f o r post-7 Orgel, op. c i t . , p. 209. - 57 -institutional work with him. Group therapy in the community with the discharged patient is just as important as treatment within the hospital; with their experiences with such sessions already provided, the future meetings on the outside can then go along that much more smoothly and effectively. Hypnotism has been suggested as a means of implanting health-g ier attitudes into patients' minds after withdrawal has been accomplished, but its value has been questioned inasmuch as hypnotic suggestion is too seldom assimilated into the actual psychological attitudes of the patient. A l l told, lengths of treatment within the hospitals vary from four months where prognosis is very good, to an average of six months, and to a maxi-mum of twelve mpnths for difficult cases. 4. Placement after discharge, and proper followr:up. Here, the social worker enters the picture as a major figure in readjustment. Placement back in society offers the most difficulty, not because the addict re-enters s t i l l uncured, but because, among other things, society is inclined to regard him as incurable, unreliable, and potentially dangerous because of his old habits. A fuller discussion of these post-institutional .problems will be given in the following chapter. Suffice it to say here that post-institutional worker-patient rapport depends r largely upon the patients' experiences with the social service staff while in hospital. The discharged addict is usually very badly in need of a helpful friend once he is on his own; i f , while in, he felt that his social worker was both warmly sympathetic and competently 8 J. Wortis, Soviet Psychiatry, Baltimore, Williams and Wilkins Co., 1950. p. 88 - 58 -helpful, then i t is a matter of course that his next, outside, social worker will be most welcome to him in his attempts at readjustment. THE NARCOTICS FARM The outstanding effort made on this continent to contend with the addiction problem on a treatment basis is the "Narcotics Farm", as it is familiarly known, at Lexington, Kentucky. Founded in 1935, addicts who were, at that time, at the Fort Leavenworth Penitentiary were trans-ferred to the farm for attempts at rehabilitation. This move, with Dr. Kolb as the first Medical Officer in Charge, represented the pioneer effort in the United States to separate the addict from the regular prison population. From its beginning in May, 1935, until January, 1948, 9 11,041 addicts were received. Of this number, 2,199 were females. The staff at this hospital includes physicians, psychiatrists, supervisory guardians, social workers, occupational therapists, nurses, etc. The big majority of patients at Lexington are sent there as pris-oners or probationers; the median sentence of the prisoner-patient is from 18 to 24 months. United States judges have the prerogative of sending addicts to the hospital on probation; when thus sentenced, the addict must agree to remain until cleared for dismissal by the hospital. If the offender is primarily an addict, then he is treated as such by the hospital; i f he is a criminal —that is, would be a thief despite drugs — then i t is urged that he be sent elsewhere, as his anti-social habits may have a 9 Vogel, Fed. Probation,(June, 1948) p. 1 - 59 -disrupting effect on the others. Voluntary cases are accepted at the hospital, but, on an average, such patients remain only eighteen days. Only 0.2$ of voluntary patients who leave against medical advice after a stay of less than thirty days remain off drugs. In contrast, of . 10 volunteers who remain the f u l l time, 24$ become abstainers. When patients are admitted to the farm, no drugs are given until definite signs of the abstinence syndrome occur. Usually, i t takes ten days to relieve him of physical distress. To occupy his time 1 and interests, there is a farm, clothing factory, furniture factory, plus a l l types of activity, from the very simple to the very complex. Length of treatment at the hospital extends from four to twelve months, the time depending on when i t is thought the period of treatment is nec-essary to give the patient the best possible chance to abstain from drugs. Where the court remands an addict to the farm for a period longer than is deemed necessary for treatment, hospital authorities have no recourse but to retain the prisoner for the f u l l time. This is not an ideal situation inasmuch as the additional time on the farm often undoes much of the good effected by the desired course of treatment. An indeterminate sentence, with the time limit set by the hospital itself, is obviously a more desir-able arrangement. In the hospital, signs of abstinence syndrome serve as a signif-icant measure of the patients* progress, and nurses on duty have the responsible task of observing carefully a l l symptoms. Many patients will attempt to get drugs by begging, bribery, and some even by threatening or 10 Vogel, "Treatment at Lexington" U S F H S Reprint, pp. 6-8 - 60 -attempting suicide — an attempt which i s usually insincere because 11 the patient i s really seeking sympathy, and narcotics. Regarding adjustment of patients at the hospital, the voluntary ones are the least co-operative, always seeking ways to get out. About 10$ of a l l patients violated rules sufficient to c a l l for disciplinary action; 2.5$ were recommended for transfer to other institutions because they were regarded as detrimental to the other patients. Less than 10$ of a l l patients were regarded as shirkers, about 50$ were willing workers, and 25$ did more than was asked of ^hem. The majority liked to work with their fellow patients, and were regarded by custodial 12 officers as pleasant and agreeable. The social service unit at Lexington has essentially the same function as the social service in any mental hospital; namely, estab-lishing a relationship with the patient and his family as soon as possi ble after admission,, using that relationship during his hospitalization to enable the patient to obtain the maximum possible benefit from hospi talization, and also using i t to help i n discharge planning. Social workers at Lexington f e e l that i n working with addicts, as contrasted to working with usual psychiatric cases, they are more struck with the similarities than with the differences of such work. Results of treatment at Lexington are d i f f i c u l t to tabulate because: (a) records of patients after discharge are d i f f i c u l t to keep usually, only the relapsed addict voluntarily returning for treatment, the one caught by the police, i s recorded; and (b) complete cure means lifetime abstinence, and i t is far too early to speak in such terms at 11 Himmelsbach and Mertes, op. c i t . , pp. 495-496 12-Pescor, 13 S P H.S 143, (1943) PP« 17-18. - 61 -this stage. To date, in a study of 4766 patients who have been out likely that a fair portion of the unknown group are abstinent: those who relapse usually get into trouble and the report then gets back to the hospital. The recidivism rate is 61.4$ admitted only once; 25.6$ twice; and 12.7$ admitted three times or more."""4 CONCLUSIONS AND SUGGESTIONS From the above record, some doubt may arise as to the wisdom of employing so expensive an arrangement as a narcotics farm, since results thus far are far from convincing. In answer, i t can f i r s t of a l l be stated that at least 13$ — and perhaps closer to 20 or 25$ — of a l l addicts admitted do remain abstinent after release. In terms of human l i f e , this is important, and can hardly be overlooked. As for the others, i t can be suggested that even under the most favorable cir-cumstances (within the framework of our present knowledge and skills), a certain large proportion of addiction admittals could not benefit by treatment there — that is, not any more than a comparable group of psychopaths, for example, could be benefitted by treatment at any modern mental hospital. Since the farm is established primarily to effect abstinence in addicts, i t might seem pertinent to suggest that poor-prognosis cases should not be admitted in the f i r s t place: their own 13 J. Reichard, DNS Vol. IV (Sept. 1943), p. 281. 14 Vogel, "Treatment at Lexington", U S P H S Reprint, p. 8 It is - 62 -chances of rehabilitation are very slim, and by their presence at the farm, they prevent the staff from devoting more of its time and energies to patients more capable of achieving benefits. Unless and until farm facilities are expanded considerably, and better techniques for working with the more severe psychopaths are developed, i t would appear to be pointless to have any such cases admitted for treatment. For these reasons, a classification arrangement for potential narcotics farm patients might well be in order. Such a classification set-up — which could be similar in structure to the classification teams found in modern , correctional schemes, the team consisting pf psychiatrist, psychologist, and social worker, as a rule — would be in a position to decide just which addicts can best benefit by going to the narcotics farm, and which ones had best be sent elsewhere for treatment or custody, as the case may be. The°present method in the United States, whereby virtually any indi-vidual addicted to drugs can enter the farm, fails to deal with the treat-ment factor in these people; consequently, a continuingly low percentage of "cures" can, for the present, be expected in any such arrangement. On the basis of treatment results under the Kolb classification scheme, such a classification team could, with some confidence in results, elect for admittance to a narcotics farm individuals in the following groups: 1. Normal individuals who are accidentally addicted. 2. Psychoneurotics. 3. Cases of psychopathic diathesis and psychopathy in which the deviant tendencies are not too pronounced, or where the individual's existing pattern of adjustment, aside from the addiction syndrome, is not too erratic. - 63 -Any grouping such as the above would, necessarily, have to be regarded wuth due f l e x i b i l i t y ; in the f i n a l analysis, each case needs to be considered on i t s own merits. Estimation of the treatability of individuals in the third group above would, of necessity, be rather d i f f i c u l t to determine accurately, and use of Rorschach tests, encepha-lographs, etc., would li k e l y be needed to render a more careful evaluation. Intrinsic to the good prognosis of individuals in any of the groups would be the cooperative attitude of such persons to therapy; the addict showing consistent resist, therapy and to continue the habit would, ordinarily, not be one who could easily benefit by help at a narcotics farm. A psychiatrist or social worker discussing treatment with him before an evaluation is made may help considerably in making him more amenable to the acceptance of help. Of inestimable help in determining his attitude on the matter — indeed, in determining much that would indicate treatability of any of the addicts — would be the social history and evaluation submitted to the classification team by, the caseworker involved in the case. Groups to be discouraged from going to a narcotics farm would probably include the following: 1. The more serious psychopathic cases. 2. Criminal addicts whose presence would be disruptive at the farm. 3. Psychotics. 4. Relatively mature addicts capable of benaficial treatment in their own community, especially i f the restrictive routine of institutional l i f e would be disturbing to them. - 64 -5. Youthful addicts who can benefit by going to a borstal-type institution, or who can receive adequate guidance, where this would be sufficient, from a trained probation officer. There are, or can be, treatment f a c i l i t i e s other than the nar-cotics farm, and such resources should, of course, be considered by the classification team in disposing of each case. The following chapter w i l l , in part, deal with these other methods, most of which would be found on the community lev e l . Chapter V COMMUNITY IMPLICATIONS Organized local attempts to treat"narcotics addiction have been relatively rare on this continent. In 1920, two interesting but short-lived efforts were made in California, one in San Diego, the other in Los Angeles. . In both areas, clinics were set up Under the respective local Departments of Health, and both were operated on the basis of supplying addicts with their needed drugs, and at reasonable prices. Theoretically, the clinics hoped by such legal control of supply to accomplish several objectives, namely: 1. It was felt that addicts, when sure of their continuing supply, would not be reduced to carrying on in the frantic manner char-' acteristic of those who must surreptitiously seek and obtain the drugs. The anxiety of this search in itself acts as an added stimulus to the more extensive usage by the individual concerned. Hence, by removing this doubt, the anxiety factor would be reduced, and with i t the tensions contributing to heavier usage of drugs. 2. The i l l i c i t market would be eliminated. Not only would the big time pusher be thus deprived of his lucrative market, but, in the process, the by-product crimes and anomalies associated with the obtaining of the i l l i c i t high-priced drugs — prostitution, peddling, robbing to pay for supply, social and personal deterioration resulting from such a l i f e , etc., — would be greatly diminished. - 66 -3. The addict coming to the clinic would he encouraged to accept psychiatric help to end his craving for drugs; the plan was to sell gradually diminishing doses of the drugs, while at the same time, increased psychological help would be offered. 4. The addict, in utilizing the clinic, would ' s t i l l be able to remainhome, support his family, and attempt to adjust in a normal way. Unfortunately, neither one of the clinics lasted more than a year, so that results of both are far from conclusive. From a l l evid-ence, it appears that the closing of these clinics was' in no way due to any obvious failures of the scheme.1 Professor Lindesmith, who has done long and extensive research among addicts, is emphatic in his suggestions that legalization (which conceivably might be somewhat along this line) is the most feasible plan possible for coping with addiction. But . equally emphatic in rejecting any scheme whereby sale of narcotics would be legalized are many psychiatrists who have been working with addicts in the past^ears. Legalization would, in the opinion of those in this latter group, only serve to perpetuate the problem since i t does l i t t l e to solve the individual problems of those affected. One of the very few city hospitals currently handling addicts is Bellevue Hospital in New York City. At this hospital, only young offenders who are not too seriously addicted or disturbed are treated; 1 Terry and Pellens, op. cit., pp. 872-876 2 A. Lindesmith, "To Control Narcotics", N. Y, Times, July 15, 1951. - 67 -adult addicts and the serious young cases are urged on to the hospital at Lexington. The city hospital cares for both court cases (offenders remanded by the Children's Court) and volunteers, which would include any youngster brought in by a teacher, parent, policeman, etc., without a court order. Most of the youths in coming here ask to be sent to a correctional camp outside the city; this is in interesting contrast to the other (non-addict) delinquents at Bellevue in that the latter group generally resists any effort to send them away from their city area. In court cases, the youth, upon entering the hospital, is interviewed by a psychiatric social worker, a psychologist, and finally, a psychia-tri s t ; as a rule, these interviews will be completed within the fi r s t few days of admittance. On the basis of mutual agreement among these three team members, the psychiatrist issues an evaluation-of the case to the court, and also includes his recommendation as to what is needed for the youth. The team members do not necessarily hold a conference among themselves to decide about each case, but the psychiatrist here does depend in part upon the social worker* s report in each case before drawing his own conclusions, using this report as a guide in his own evaluation. In a l l cases admitted to*the hospital, there is the preliminary investigation and study of the youth; if i t is decided that he is to remain there, he is given occupational and recreational therapy, and he continues on with his schooling right on the hospital grounds. During the summer months, the youths generally engage in light work around the hospital. Regular movies and dances are held throughout the year. - 68 -Vi s i t s from the family to the youth occupy up to three afternoons a week, and v i s i t s by the team members take up s t i l l more of his time, so that, on the whole, each youngster is well occupied during his stay. Retention at the hospital ranges from three to six weeks at the most. Complete medical and psychiatric check-ups are provided. In the course of each committal, i t becomes the function of the assigned social worker to establish family contact, and to work with the family when i t is needed. It is also the worker's task to prepare each youth for his eventual dismissal from the hospital. I f, e. g., i t is f e l t that the youngster would need further guidance after release, then the worker w i l l attempt to motivate him to contact a family agency i n his neighborhood for the purpose of receiving this later help. Where the youth does accept this idea of continued guidance after release, the hospital worker may then arrange to have the appropriate agency send a worker to v i s i t the youth while he is s t i l l in hospital so that worker-patient contact remains constant. In some cases, periodic v i s i t s back to the hospital are advisable after release. Here again, the hospital social worker discusses with the youth the need for these v i s i t s . Compulsion to make the young addict accept post-hospital help is avoided at a l l times; instead, team members employ understanding and interpretation to bring home to the youth the need for future v i s i t s . Some staff members at this hospital express the opinion that the brief period in which they have control over the young addict i s insufficient for really effective results, and suggest that, after the youth's release, probation for at least nine months is desirable. - 69 -1 PSYCHIATRIC PAROLE The institutional efforts made thus far to treat addicts on this continent have been few enough, and of these few, the outstanding one — the narcotics farm at Lexington — has had only fair success: up to 87$ of a l l cases handled there return to their drug habit. The question arises as to whether or not such methods as are used in these institutions are adequate and feasible; and if so, why such a high per-centage of relapse exists. Without getting too involved in this entire basic argument, i t can be suggested here that the type of program offered at such institutions -- whatever the other weaknesses — can likely be greatly augmented if the existing arrangement did not stop short as soon as the addict is discharged. That is, treatment at the institution, as far as i t goes, may actually be far more helpful than the cold statistics on results indicate, but this treatment does not go far enough; i t is actually incomplete. The addicts return to society is the real test to him, and for this challenging situation, he is almost always left on his own. The condition is almost analogous to the medical case given excel-lent surgery — and then immediately discharged from the hospital upon leaving the operating room. The true addict's need for hospitalization has been made more urgent by the emotional distresses he has had to endure in his social area. To return him there relatively unprotected and unguided after hospitalization exposes him altogether too abruptly to the very conditions which originally weakened him. The hospital therapy and recuperation, i t would appear, is not sufficient in itself for him; the - 70 -the setting while there is an art i f i c i a l , protected one which, for its part, helps to comfort him while undergoing treatment. But i t is to the competitive outside world that he is being returned, and for this final period of readjustment, the existing programs pay too l i t t l e attention. Dr. Vogel has stated that the patient treated under probation 3 has the best chance for rehabilitation. The director of Narcotics Anonymous, D. Carlsen, agrees that after hospitalization the addict should have the help of qualified workers. But as it is, the addict released from the h(B pital is, by and large,,on his own, and the renewed pressures put on him in civilian l i f e too often incline;: him again to seek escape from these pressures with the help of narcotics. Some addicts are released from the hospital on parole, as per court order, and so must make periodic reports to a parole officer in their home areas. Discussions with addicts who have been to institutions for treatment lead one to the conclusion that use of such officers for future guidance, or correction is not a good idea. The exceptionally well-trained officer — one having a background in psychiatric social work — may be able to break down the resentment or distrust of his charge and establish warm enough rapport for constructive help. But by and large, the addict's extreme sensitiveness and shyness will make him rebel inwardly at his being treated like any malefactor on parole. Parole officers can hardly help their own conduct in being watchful and somewhat suspicious of their cases. That, after a l l , is part of parole. But the recovered addict 3 Vogel, "Treatment of the Narcotic Addict", U S P H S Reprint, pp. 3-4 - 71 -will do everything possible to avoid contact with his officer i f he feels for a moment that he is being watched or is suspected of misconduct. Because of this sensitivity, and since most such officers lack the needed skills and attitudes, i t would appear best to avoid putting any released addict into the hands of any individual so intimately associated with the police departments. The Probation Officer can, of course, effectively play the role in the handling,of addicts, and that is in his pre-sentence report where addiction is involved; he can recommend those cases deemed able to benefit by treatment at a narcotics hospital; he can help weed out the addict who is primarily a criminal, and he can see the reason for not urging an addict to the hospital where the sentence will be a long one. In short, he is in a position to help the classification team, described earlier, decide which addict should go to the narcotics farm; which should remain on probation right within the community; which should be turned over to other custodial officers, etc. 4 But beyond helping in this selection, a l l evidence indicates the need for a non-judicial (in the f u l l sense of the word) psychiatric social worker to handle a l l post-institut-ional cases, as well as most non institutional ones. The role of the social worker within the institution has already been dealt with. His role outside the hospital is a much bigger one, and i t is essentially his job alone, for here the team is not i n the pic-ture to help him. The case worker must know his addict as well as his casework thoroughly, and, more than that, he must know the meaning and manifestations of the whole problem of drug addiction. The significance 4 J. D. Reichard, "The Role of the Probation Officer in the Treatment of Drug Addiction", Federal Probation, Washington, D. C, Vol. VI, No. 4 pp. 18-20. of this latter point will be discussed shortly. On the former, i t should be brought out that a great number of recovered addicts who have had professional contact with social workers complain of the many pretensions surrounding so many workers in their workj the addict, in accepting the help of a social worker, wants simplicity, wants real understanding; he wants to be considered a human being; he emphatically does not want to be a "case". The addicts find the cold, analytical -approach common in these inept social workers very repugnant. He resents being studied; instead, he seeks the warm, human touch; he seeks, in plain, a helpful f jtrerid. These observations by recovered addicts sug-gest but one thing: only thoroughly skilled social workers— and only workers with appropriately sympathetic personalities — can and should be trusted to work with addicts. Lacking these essentials, the assigned worker in any case can only cause additional stress to a discharged patient, and so become a hindrance to his re-adjustment. Aside from his general casework skills, the worker must also have a good understanding,of whatbdrugs mean to the individual who is addicted. It has already been shown how addicts turn to drugs for any of a multitude of reasons. To know and properly understand his addict, the worker has to know what the particular reasons were for each separate case: if case A followed group pressure, for example, then re-direction of interests into other groups is indicated; i f cases B deals with a weakened ego by taking heroin, then ego-support is to be stressed, etc. For these reasons, the worker has to be in close touch with the institution from which his case was discharged, learning from them a l l that should be - 73 -known regarding social history, type of personality, ways of adjustment previously adopted by the addict, etc. Among drug addicts, deception becomes in time almost a way of l i f e for them. The addict may impress his worker as being the most cooperative person possible, yet at the very same time, he may be again secretly taking drugs. He will use every ingenious means at his command to conceal the fact, and his ability to do so is borne out by the fact that even doctors experienced in treat-ing addicts are often fooled by this deception. An incompetent worker could hardly expect to learn of such'early relapse in time, yet these first shots, indeed the very f i r s t shot, are the danger signals showing that relapse is taking place, and return to a hospital has to be consid-ered immediately. Probation officers working with treated addicts are often told not to get alarmed if they discover that their case has, on the sly, taken a few shots. But recovered addicts agree that the f i r s t shot is the dangerous one, and if help is to be effective, i t must be dealt with properly at that time. The help of local physicians and psychiatrists is therefore often necessary, and the efficient discernment in time by a good worker is mandatory to check- this relapse when i t fi r s t appears. For reasons s t i l l not clear, treated addicts remain overly-sensitive to drugs for some time after hospitalization. Quite often a treated addict will go to his home doctor for a sedative when he wants to "settle his nerves". In a l l innocence, and even with his doctor's "'awareness that the patient once took narcotics, he may receive an other-wise innocuous prescription of barbiturates. Again, experience has shown how even these mild sedatives can prove disastrous. Many a treated - 74 -addict has found himself slowly re-introduced to drug usage by this apparently harmless route. The worker knowing enough of the medical aspects of addiction i s in a position to realize the possible danger of this move, and so by pointing out to the ones concerned the meaning of sedatives to recently treated addicts, he can play a v i t a l part i n checking relapse from this source. S t i l l another addict in his — the worker's — care may be fighting consciously, with a l l his might, any reversion to drugs after he has returned home. Subconsciously though, this same individual may well be looking for a reason to return to drugs, and so — subconsciously — may be engaging in behavior that w i l l result in his i l l n e s s . Practically every addict who has been free of drugs for a year has also been i l l enough during that year to provide him with an "excuse" for resorting to drugs again. The worker must be quick to learn of these illnesses, and must realize the significance of such sickness in order to cope with i t , for i t may well be the overt sign of the addict's covert desire to take drugs again. , The above are some of the special problems encountered i n doing casework with treated addicts. Aside from a l l this, there s t i l l remains for the parole worker the usual methods of casework applicable to the whole f i e l d of social work. Work with the families i s as important here as elsewhere in behavior problems. Oftentimes i t is unsatisfactory home conditions — inter-family relationships, family attitudes, etc., — which are despairing to the addict. Effective results with the addict may remain blocked unless and until.these sore spots are significantly eliminated. The addict, returning from a hospital may want a whole new - 75 -environment in which he can start anew; here, the worker may well be his only contact and friend u n t i l he gets established in the new area. Starting work again may prove another t r i a l for the addict: a prospec-tive employer may want to know what he has done i n the recent years. The worker w i l l have to discuss f u l l y with him this problem of how to explain his past. Neighbours may hear that he was a "dope fiend", and treat him accordingly; under such circumstances, he w i l l need a maximum of interpretation and ego-support from his worker. If he himself feels that he i s slipping, and is thinking of taking drugs again, he should fe e l free enough to discuss this with his worker, and fee l adequately comfortable within himself — after such discussion — i f he decides to return to the hospital for treatment. It i s up to the worker to leave him feeling that return i s a positive step, and i s not cause for despond-i. ency. This ever-present danger of relapse i s perhaps another reason why probation for a long ,period — i t may be for l i f e in some cases — seems advisable whenever an individual is f i r s t entered into an institution for treatment. Under probation, he i s free to return to the hospital whenever he feels the need; he does not have to endure any further court orders, studies, investigations, etc., with a l l their disturbing effects, i f he has taken to drugs again. Rather, he simply checks in at the hos-p i t a l , and i s discharged when this part of treatment i s over. In large c i t i e s , where many treated addicts may be congregated, the social worker may urge his ex-patient client to attend group therapy sessions where others in predicaments similar to his own get together to 76 -discuss their mutual problems and solutions. The value of such group therapy can hardly be stressed enough. In such groups, the addict feels that he belongs, that these'others can really understand him. He trusts them enough to admit that he is having trouble when he is tempted with relapse; faced with this challenge, his group w i l l usually do a l l in i t s power to help him. In effect, the others, in thus helping him, are actually strengthening their own position in their fight to stay free of drugs. It is this mutual assistance which can make group therapy effect-ive on the community level, and which i s , actually, one of the psycholog-i c a l p i l l a r s of- such groups formed into the organization known as Narcotics Anonymous. NARCOTICS ANONYMOUS Patients at the Lexington farm have long been encouraged to join Alchohol Anonymous chapters in order to be with others who, like themselves, want to stay free of addiction in any form. Many have heeded such advice, but by and large, this step has,proven ineffectual. Drug addicts complain that the alchoholics do not understand ;them, that they have their own special problems, and so,feel l e f t out in A. A. meetings. Misunderstandings and i l l - f e e l i n g s have resulted where the two groups mixed, with the result that the drug addicts usually drop out,from the organization. In an attempt to solve this problem, Narcotics Anonymous chapters are now beginning to appear in some large ci t i e s in the ..United States. Structurally and philosophically, the two organizations are similar: there are, in Narcotics Anonymous, no dues, no assessments, no constitution, no officers, and no by-laws. They have no religious committments, and steer clear of a l l , controversial issues. N. A. offers i t s services only to those who want i t , and i n their words, they make no pretense at being reformers. The strength of this organization l i e s , for one thing, i n i t s function as group therapy units. There i s a definite sense of belonging among the members, and there exists the strong desire among them to help one another in the common fight against addiction. Each member can thus draw strength and courage, from the others. Briefly, the organization describes i t s steps of recovery as proceeding in this fashion: f i r s t , the that he i s addict must be honest with himself, honest enough to realize /•-xSSufSfc powerless to c o n t r o l h i s habit;second,he must r e a l i z e , o r a t least ijH keep an open mind on this point — that there is a power stronger than himself: This power can be of whatever description he chooses: God, an inner self, etc; whatever that power, he must rely on i t , and pray to that power for strength; thirdly, he must decide to relate personally to i -that power. In doing this, he undergoes the profound mental and emotional change needed in his recovery; and f i n a l l y , he must engage in a more ef-5 factive way of l i v i n g . Narcotics Anonymous claims to be effective with many of i t s members, some of whom had previously been to many psychiatrists and i n s t i -tutions without success. That this group has some merit seems clear from the record, and i t should be accepted by social-workers as an auxiliary service in follow-up treatment of addicts. Among i t s other a c t i v i t i e s , N. A. tries to convince addicts that they can find a new way of l i f e ; i t tries to show beginners the dangers of addiction; i t secures psychiatric help for members needing this; and for those requiring hospitalization, 5 "pur Way of L i f e " , Published by N. Y. C. chapter, Narcotics Anonymous. - 78 -i t points out the possible benefits of going. For those just returning 6 from an institution, i t helps obtain satisfactory employment. SOCIAL WORK AGENCIES AND DRUG ADDICTION In areas where psychiatric parole for treated addicts is not provided, the task of continued guidance may rest on social work agen-cies, both public and private, within the community. In the New York area, for example, where addicted youths are treated at a city hospital and then released in f u l l , i t becomes the function of neighborhood family agencies to assume responsibility for further casework and help when i t is needed. A youngster may receive very valuable vocational therapy within the institution, but i t could easily be an acquired s k i l l gone to waste i f the youth, upon his release, does not have someone ready to help him capitalize "upon i t . The agency worker acts as a sort of big brother to the young addict, aiding him in translating his learning into a r e a l i s t i c new way of l i f e . For many youngsters, a complete chmge of environment after release i s necessary. It is then the worker's respon-s i b i l i t y to explore use of possible relatives, foster homes in the country, etc., for this change. It has been mentioned that many addicts do desire to make a break from old acquaintances in order to free themselves of addiction and all. that i t involves. But attempts $0 steer them into groups such as Boys' Clubs, Y. M. C. A's, etc., usually meet with resist-ance because the youngster fears the derision from his old gang i f he tries 6 D. Carlsen, op. c i t . - 79 -to go to such organizations. This fear thus becomes another factor in considering those cases where re-location may then be deemed ad-visable. Work with addiction-prone youths is by no means confined to those who have been to a hospital for treatment. It has been shown already how the average age of inchoate addiction i s probably in the middle and late teens. Actually, most such youths have not been found to be truly habituated; but lack of attention to the problems of these youths at this early stage can result in the complete addict later. In this sense, any youngster presenting behavior problems can be regarded as a possible addict later, and attempts by workers i n working with them should be to help them face reality according to their own situation, and not to resolve their problems by use of such releases as drugs. Any youngster, of whatever personality type, f a l l i n g into groups that use drugs needs to be helped to be free of such influences. Narcotics addiction is s t i l l too generally regarded as an adult problem, whereas case studies point out irrefutably the fact that the problem begins to crystallize in adolescence. Hence, any worker in the community — group worker or caseworker — is dealing with a phase of the matter when he works with disturbed or deviant youths. It needs to be recognized by such workers that the youths involved in addiction are of a l l personality types, and so any youth in trouble can be rightly regarded as possible addict material because he — the youth — is that much closer to staying or going on drugs i f he has serious emotional problems which he finds temporarily alleviated by resorting to narcotics. Disturbed youngsters who have beenifdund to have had just one - 80 -or two shots do not ipso facto present a threatening addiction, problem. Presented with any such case, i t remains for the caseworker involved to estimate how serious i t may be, and to take steps commensurate with such seriousness. A mildly neurotic youth taking a few shots can, perhaps, bei.handled right in the community, with the caseworker himself taking f u l l charge. This would hold equally true for the adult user who gives signs of being sufficiently mature to remain in his neighbor-hood while a local hospital administers his withdrawal. Ordinary case-work, done by any adequately trained social worker in a family or public agency, would be sufficient for such individuals. In brief then, where institutional treatment and psychiatric parole would not apply to an addiction case, then the family and public welfare agencies can most often .become operative in such work. Generally, casework with any such individual would follow the usual pattern of established techniques in the f i e l d ; and since the case in question was not, in the f i r s t place, considered serious enough to c a l l for institutional committal, i t i s like-l y that the agency case worker involved would not need to have any special awareness of the addiction problem to do a satisfactory job with the addict. CONCLUSION The f i n a l picture evolving from the mass of data and opinions recorded in the foregoing pages i s , unfortunately, neither too clear nor too encouraging, as far as the entire addict population is concerned. It can be seen that drug addicts are of a l l types: they have varied back-grounds, constitutions, ways' of adjustment, attitudes, and a b i l i t i e s . - 81 -They include some who were predisposed to a l i f e such as they now lead by home conditions traceable to the pre-oedipal period; and they include others who would be free of any d r i f t to addiction were i t not for purely fortuitous circumstances occurring in their later l i f e . There are some who can work well though addicted, some who adjust better in the community after they become addicted, and some — the big majority — who experience severe disorganization, either before or during their addiction, which more or less hinders them in any proper adjustment. Some present a simple problem in their rehabilitation; others appear to be hopelessly involved. Some are addicts whose addiction is only i n c i -dental to their other anomalies; others are anomalous only in their addiction. The narcotically addicted population, i n short, i s an extreme-ly heterogeneous one, and to understand the addict, i t is necessary to know him as an individual. Certain features are held in common by a great majority of them; the~secretive l i f e they lead to gain drugs, the use of drugs as an escape mechanism, the feeling of being separate from others, etc., these help set them apart. But this separation notwith-standing, the addict himself stands forth as unique in his own particular background and present circumstances. To know him well, i t becomes necessary to know both the sociological factors which make him part of a distinct group, and the psychological and physiological factors which lead him into that group. It is because this addicted group runs the whole gamut of personality types that the treatment picture for a l l addicts can, for the moment, be neither too clear not too hopeful. Treatment for addicts, - 82 -i f i t is to be based on a psychiatric approach, necessarily calls for differentiation according to types within the larger group. This means that mildly disturbed cases, neurotics, etc., stand to gain much from treatment; for them total abstinence is a real possibility i f they agree to accept enlightened help. But i t also means that a very large percentage of the addicted population cannot be aided by this same, approach. Psychotics and pronounced psychopaths, who do form a large segment of the addicted population, do not gain much from treat-ment i n mental hospitals or on narcotic farms; to send, them to a nar-cotic farm would l i k e l y be of no help to them, and would be a hindrance to others present who are more treatable. Remanding them to already overcrowded mental hospitals does not help much either. And to put them in prison i f addiction i s their only offense would only aggravate an already bad situation. This part of the picture; may seem to lend i t -self to the argument advanced by some for legalized control of the drug t r a f f i c : for those individuals i n this very disturbed group who can somehow manage to liv e tolerably well i n the community without menace to others, the legal s ale and control of drugs may help to placate them; at the same time, i t would help to reduce or eliminate the entire i l l i c i t narcotics trade with a l l i t s accompanying evil3. For the present, at least, i t would appear that neither psych-i a t r i s t s nor social workers can be of much real help to this poor-prognosis group. One can only hope and work — for mitigation of the general social scene with a l l of i t s disturbing pressures, to the end that social — i . e. non-constitutional — factors contributing to serious personality - 83 -disorders w i l l be eliminated. L i t t l e can be done at the moment for the individual who has become a pronounced psychopath and who i s an addict; but much can be done to r i d society of those forces which have helped contribute to his regrettable condition. The argument for legalized control of drug sale to users has this serious drawback: easy procurement of drugs would be too tempting for individuals who might otherwise receive therapeutic help that could be useful to them. A great many addicts can be helped, not only to be freed of the habit per se, but also of the emotional disturbances which impel them to use drugs. If drugs are legally obtainable for these treatable people, i t may prove much more convenient for them to persist in their habit rather than to accept proper assistance. An answer to this dilemma — how to simultaneously satisfy the needs of both treatable and 'untreatable* addicts — w i l l not be attempted here; f i n a l decision in this matter may well rest with a classification team such as the one discussed earlier. Rather, i t can only be repeated here that for indiv-iduals who are not too seriously disturbed, and who are ready to accept help in overcoming their addiction, there are a number of methods that can be applied. Narcotic farms, borstals, probation, local c l i n i c s , welfare agencies, etc., can a l l be profitably utilized, each according to the type of case in question. In each, there i s a place for social workers. Indeed, not only can social workers offer their share of services i n the usual institutional settings, but potentially they have a great deal.more to offer i n the very area where existing programs are weakest: the commun-ity follow-up treatment for those returning from institutions such as the - 34 -narcotics farm. The social work profession, in short, has much that i t can contribute to the alleviation of the problem of drug addiction, and elimination of the problem w i l l be that much closer to reality when i t s s k i l l s are appropriately exploited. Bibliography Canada,Dominion Bureau of S t a t i s t i c s , S t a t i s t i c s of Crimin- a l and Other Offenses, Ottawa,Kings Printer,1949. D.Carlsen, "Facts about Narcotics",N.Y.C., Narcotics Anonymous. R.N.Chapra," The Present P o s i t i o n of the Opium Habit in India",Indian Journal of Medical Research, 1928,Vol.XVI. L.Davenport,"The Abuse of Codeine",Washington,Public  Health Report #145,1938. J.Dumpson,The Menace of Narcotics to the Children of New York", N.Y.C.,Welfare Council of N.Y.C . ,I95I. C.Himmelsbach,"Comments on Drug Addiction", Hygeia,I947(May). C.Himmelsbach, "The Nursing Care of Drug Addicts",N.Y.C., The Trained Nurse and Hospital Review, Nov.1937. H.Isbell and V.Vogel, "The Addiction L i a b i l i t y of Methadon", American Hournal of Psychiatry,June,1949. ' G. Josie, A/Report on Drug Addiction i n Canada, Ottawa, Dept. Of Health and Welfare, 1948. L. Kolb, "Drug Addiction Among Women", Washington, U.S.Public Health Service B u l l e t i n . L.Kolb,"Drug Addiction i n i t s Relation to Crime", Mental Hygiene,Jan.1925, Vol.IX. L.Kolb, wThe Narcotic Addict: His Treatment",Washington, Federal Probation, Vol.Ill,No. 3 . L. Kolb,"Pleasure and Deterioration from Narcotic Addiction", Washington,Public Health Report #211. L.Kolb and A.DuMez, "Experimental Addiction of Animals to Narcotics",Washington,Public Health Report $1463, 1931. L.Kolb and C.Himmelsbach, " C l i n i c a l Studies, of Drug Addiction", Washington.Public Health Report #128(Supplement),1938. A.Lindesmith, Opiate Addiction,Bloomington,Indiana, P r i n c i p i a P ress, 1947. A.Lindesmith, "A S o c i o l o g i c a l Theory of Drug A d d i c t i o n " , American J o u r n a l of S o c i o l o g y , J a n . 1938. A. Lindesmith, "To C o n t r o l Narcotics",K.Y.Times. J u l y 15,1951, p.8. L.Lowrey,Psychiatry f o r S o c i a l Workers,New York, Columbia U n i v e r s i t y P r e s s , 1947. D.W. Maurer, "The Argot of the Underworld N a r c o t i c A d d i c t " , P a r t I,rAmerican S p e e c h , A p r i l , 1936. "Mayor's Committee Report on Drug A d d i c t i o n Among Teen-Agers", N.Y.C..Spring 3100.Police Dept.,Sept.I951. . M.Moore," The Management of the A l c h o h o l i c P r o b a t i o n e r " , H.Y.0.,Probation and P a r o l e Progress,I941, ed.M.Bell. N a r c o t i c s Anonymous, "OUr Way of Life",N.Y.C.Chapter. S.Z.Orgel, P sychiatry.Today and Tomorrow.New York, I n t e r n a t i o n a l Univ. Press, 1946. M.Pescor, "The Kolb c i a s s i f I c a t i o n of Drug Addicts",Wash., P u b l i c H e a l t h Report.Supplement #155, L939. M.Pescor, "A S t a t i s t i c a l A n a l y s i s o f the C l i n i c a l Records of H o s p i t a l i z e d Drug A d d i c t s " , Washington,Public  H e a l t h Report Supplement #143. 1943. A. P f e f f e r , "Psychosis During Withdrawal of Morphine", A r c h i v e s of Neurology and Psychiatry.(Aug.1947),Vol.58. A . P f e f f e r and D.Ruble, "Chronic P s y c h o s i s and A d d i c t i o n to Morphine", A r c h i v e s of Neurology and P s y c h i a t r y . (Dec.1946),Vol.56. H.Price,"The C r i m i n a l A d d i c t " . R o y a l Canadian Mounted  P o l i c e Quarterly.Oct.1946. J.D. Reichard, "The N a r c o t i c A d d i c t as a C u s t o d i a l Problem".Prison World.(Mar.-Apr.J943),Vol.5. J . R e i c h a r d , " N a r q o t i c Drug A d d i c t i o n " , D i s e a s e s of the  Nervous System,(Sept.1943).Vol.IV. J.Reichard, "The Role of the Probation O f f i c e r i n the Treatment of Drug Addiction" Federal Probation,Vol.Vi, No.4. J.Reichard, "Some Myths About Marijuana",Federal Probation, (Oct-Dec. 1946),Vol.X. S.D.Spragg, "Morphine Addiction i n Chimpanzeec",Baltimore, Comparative Psychology Monographs.(April 1940),Vol.XV. E.H. Sutherland, P r i n c i p l e s of Criminology,4th.ed.,N.Y., J.B Lippincott 8o., 1947. A Systematic Sourcebook i n Rural Sociology.Minneapolis. Univ. of Minn. Press,1932,Ed. by P.Sorokln and Carle Zimmerman, Vol. I I I . Terry and Pellens, The Opium Problem Today.N.Y.C..Bureau of S o c i a l Hygiene, 1928. V.Vogel, "Sug g e s t i b i l i t y i n Narcotic Addicts",Washington, Public Health Report.Supplement #132. 1932. V. Vogel, "Treatment of the Narcotic Addict by the U.S. Public Health Service", Federal Probation.June.1948. A.Wikler, " C l i n i c a l Aspects of Diagnosis and Treatment of Addiction", Topeka,Kan., B u l l e t i n of the Menninger  Clinic.Sept. 1951. E.Williams,Si Lloyd,and A.Wikler,"Studies on Marijuana and Pyrahexyl Compound", Washington,Public Health Reports. Reprint #2732, July, 1946. J.Wortis,Soviet Psychiatry.Baltimore. Williams and Wil-/-kins, Co:'/', 1950. P.Zimmering and J.Toolan,"Heroin Addiction i n Adolescent Boys",Journal of Nervous and Mental Diseases,July,1951. 


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