ABSTRACT
Introduction
Definitions of terms
Types of addiction
Traumatic
Discussion and conclusions
Author: L. CANCRINI , D. COSTANTINIand, S. MAZZONI
Pages: 125 to 133
Creation Date: 1985/01/01
On the basis of clinical observation, the authors have classified drug addiction into four types: traumatic, actual, transitional and socio-pathic. Such classification helps in epidemiological research to understand better the distribution of people addicted to a given drug. Each type of addiction differs in respect of onset, evolution, prognosis and certain other characteristics relevant to the treatment of drug-addicted persons. Thus, the classification helps in making an appropriate selection of a treatment method and in the evaluation of a treatment programme.
It has been observed that (a)traumatic and actual types of addiction have a much more favourable prognosis; (b)individual psychotherapy and support in a medical setting is effective for the traumatic type of addiction; (c)treatment in a family setting appears to be suitable for actual and transitional types of addiction; and (d)the therapeutic community may prove to be effective in the treatment of persons affected by socio-pathic type of addiction.
The situation regarding drugs in the past was characterized by a weak drug market and strong negative attitudes on drug abuse. Drug abuse was practised primarily within deviant groups of people.
The current abuse of drugs, particularly heroin and cocaine in Italy and elsewhere, involves a wide range of young people from all social strata [ 1] . Heroin and cocaine are readily available and the number of drug abusers is continually increasing [ 2] whereas social condemnation of such abuse is diminishing. This evolution has had important repercussions on the epidemiology of drug addiction.
* This study was carried out as part of the research project on drug addiction, supported by the Consiglio Nazionale delle Ricerche, Italy.
While public, private and volunteer services and agencies are developing and carrying out various treatment programmes, it is not known which types of addiction are being dealt with and, therefore, which treatment in a given programme is most suitable for a particular type of addiction.
The question is whether drug addicts are a homogeneous group for the purpose of treatment or whether they should be classified into different types in respect of their differences in personal needs that are fulfilled by drugs; kinds of relationship with drugs; development and prognosis of drug addiction; and the usefulness of a given therapeutic programme. This study considers these questions.
"Drug addiction" is defined in this study as a state of intoxication provoked by the repeated and voluntary use of natural or synthetic drugs, and it is characterized by (a)the compulsive need (physical or psychological) to Continue using the drug; (b)the irresistible craving for the drug and consequent necessity to procure it all costs [ 3] ; (c)a general loss of interest in other pursuits and other relationships [ 4] ; (d)total personal involvement with drugs [ 5] ; and (e)the acceptance of the social role of a drug addict.
"Drug habit", although characterized by a state of intoxication provoked by the repeated and voluntary use of drugs, similar to that which determines addiction, differs from addiction in that the drug user is capable of resisting the urge to procure the drug and continues to pursue other interests and maintain significant relationships with others, avoiding total dedication to drug use and rejecting the social role of the drug addict.
"Drug use" is a form of drug abuse characterized by more or less repeated use (only in certain circumstances) and by the user's ability to stop or postpone drug use at any time.
It is assumed that certain forms of psycho-social difficulties that are conducive to the development of addictive behaviour usually existed before the occurrence of drug addiction, and that such difficulties can be identified. Mitigated, controlled or modified by the effects of drug use, the manifestation of these difficulties becomes apparent through a careful study of drug addicts and their case histories.
It should be emphasized that this assumption does not suggest that there is a possibility of identifying various types of personalities leading to drug addiction [ 4] .
On the basis of their clinical observation and with regard to classical psychoanalytical classification of neuroses [ 2] , [ 6] , the authors have proposed four major categories of juvenile drug addiction: traumatic, actual, transitional and socio-pathic. This classification is primarily intended to facilitate the appropriate selection of a treatment modality for a young drugaddicted person.
Traumatic addiction follows a trauma, generally with an abrupt and acute onset. Drug use may help to relieve the suffering of a person. For this reason the user may deny the existence of the trauma and, as a result, the drug becomes the centre of the attention of the addict, who is caught by addiction. The abstinence syndrome is a trap that acts as soon as the effects of the drug wear off. The degree of discomfort related to withdrawal also indicates that the drug was used as a substitute for an unbearable source of psychological pain and suffering.
Three clinical elements are identified that characterize the development of this type of addiction. These are:
The person lacks meaningful relationships in his or her social environment, which is conducive to the evolution of the crisis provoked by the trauma [ 7] , [ 8] . This is due to the solitude of the subject or, often, a direct consequence of the role the person is obliged to play, that is, to listen to others instead of making them listen to him or her;
The destructive, dramatic and isolating nature of the drug effect is conducive to resorting to the use of hypnotic substances in an attempt to get drunk, which is more important to the user than the sense of pleasure the drug may procure. The rapidity with which the addict resorts to increasingly larger doses and, consequently, the higher risks of accidental overdose also characterize this type of addiction;
The exclusive, self-destructive and defiant behaviour and attitudes of the addict.
Despite its dramatic nature, the traumatic type of addiction often responds favourably to treatment. The recovery is often successfully accomplished if drug addiction has not caused severe physical damage or seriously harmed the addict's social relationships.
The treatment should commence as soon as possible and focus on preventing complications in the acute phase of addiction and on providing personal and social support to the addict, who usually needs to "let it all out" and get command of himself or herself.
The family pattern in which the traumatic type of addiction occurs does not present typical characteristics. Even a "good" son or daughter, who is busy and accustomed to keeping problems to himself or herself, becomes addicted to drugs in an attempt, though irrational, to alleviate the effects of a trauma.
The trauma seriously threatens the young who are in the phase of transition in which their old relationships no longer provide support and their new relationships are still too precarious to ensure a significant comprehension and sympathy for their need to discuss and share their experience and feelings [ 9] , [ 10] .
Case study No. 1
Mario started using heroin at the age of 20, several months after the death of his father and the discovery that his older brother was seriously ill. Initially he appeared to have adjusted to his new role as head of the family and the responsibilities this role entailed, but subsequently he began to use heroin and rapidly became addicted. A period of exaltation was followed by an extremely dramatic experience connected with an overdose. This episode marked both the peak of addiction and the beginning of a period of critical reconsideration of the problem. Therapy began with out-patient detoxification treatment followed by a series of individual sessions. With the therapist's assistance, Mario slowly began to reorganize his life without resorting to drugs. After six years Mario is working and has had no relapse.
Actual addiction is characterized [ 11] by the existence of an active conflict in a young person s social environment that gives rise to feelings of uneasiness and inadequacy, moodiness, various idiosyncracies, reduction of activities and interests, and demonstrative attitudes. The addicts often indicate that they use a drug (e. g. heroin) because of its hypnotic rather than its euphoric effects.
The young addict shows an expression of challenge and intolerance directed primarily towards those persons who are perceived as responsible for the conflict, usually parents, but often therapists and others who try to help the addict.
The family structure in which this type of addiction develops is usually characterized by a deep involvement of the parent of the opposite sex in the addict's life and illness, and a marginal role of the other parent. The content of the message given by the parents is often contradictory, with polarization on "bad" son or daughter and "good" (model) son or daughter [ 12] . A pattern of communication and organization of the family has important analogies with those found in typical families with young delinquents [ 13] , psychosomatic disorders of children [ 14] , and children with behavioural disturbances [ 15] .
Case study No. 2
Marco's addiction was characterized by demonstrative manifestations, suicide attempts, theft at home and dramatic incidents provoked by heroin injection. This was a very difficult experience for the family. Marco's mother became so intensely involved in his addiction that at times she injected her son with the drug. The onset and evolution of the addiction were clearly related to the conflict that was produced by Marco's first attempts at separation from the parents, which was his manifestation of the need for independence. His mother was a dominant figure in Marco's relationship, while his father had a marginal role to play. Suicide attempts, rebelliousness and the abuse of heroin were obviously part of Marco's demonstrative behaviour as a reaction to conflict in the family. A structural family therapy [ 2] , [ 6] was used as the approach to treatment. It was initiated with the gradual reduction of heroin in a week of home detoxification, which was carried out under his father's direct supervision. Later Marco's girl-friend was involved and finally the therapist dealt separately with Marco, his girl-friend and his parents. In the 10 years after addiction, Marco has had no relapse and has been leading a relatively "normal" life.
Transitional addiction is characterized by various psychological disorders that go with the onset of drug addiction. Among such disorders, repeated maniac states, more often in young heroin addicts, have been observed. Addicts report "honeymoon states" with sudden and wonderful effects of the drug (e. g. heroin), which control personal pain that existed before the use of the drug. Repeated depressive states have also been observed with ritualistic, compulsive, destructive and obtuse forms of addictive behaviour. There is a need to become chronically drunk rather than enjoy specific drug effects. In some cases, maniac and depressive states have succeeded each other.
In this type of addiction it is difficult to link the onset of drug addiction with events of the patient's life. Case histories show that drug abuse can begin in a good period of the patient's life or it can stop when physical damage or actual pain takes place. The. risk of suicide is very high, particularly when drug use is abruptly ceased. This type of addiction has a strong tendency to relapse even a long time after treatment.
The pattern of the organization and communication in the family in which this type of addiction occurs shows a close analogy to that found in the family characterized by psychotic interaction [ 16] . The members of these families show a tendency to react to rejection by acting out explosively and provocatively, involving external people in family matters and calling on them to defend their position. They often react dramatically to various situations and tend to manipulate therapists, friends and relatives thus increasing the group of people touched by the problem.
Addictive behaviour usually develops when the family reaches a turning point causing incomprehensible reactions. Initially these families seem to be of little help in the treatment of their members who are addicted to drugs. It is, however, difficult to help people with this type of addiction without involving their families. A skilful therapist can in such cases beneficially use so-called "specialized system-oriented techniques" of family therapy.
Case study No. 3
Sandro, 23 years old, has already abused drugs for seven years and for the last five years has been addicted to heroin. He had been treated in public health facilities several times with methadone, using gradually smaller doses. He kept changing therapists, which usually resulted in incomplete treatment episodes, and there was an impression that he was incurable. The first therapeutic interview with the authors of this article included Sandro's mother and younger sister. During the interview they blamed each other showing no concern that Sandro should give up his habit and be helped. The therapist concluded the interview by indicating that the family would need two weeks to find out whether it could be helped. This triggered the interest of the family members who during those two weeks made numerous telephone calls to confirm the appointment with the therapist. A therapeutic technique, proposed by P. Caillé [ 17] , directed at the understanding and management of a family "myth" was used. In a programme of 10 sessions the treatment was successfully concluded and Sandro recovered without the use of drugs.
Socio-pathic addiction is characterized by a psycho-social conflict that is expressed in the manner of "acting out" and by a number of personality disorders [ 7] , [ 10] .
There is usually evidence of anti-social behaviour in the past of the person, prior to the onset of addiction. Drug abuse is rapidly assimilated into the life-style of a young person.
The person affected with this type of addiction is usually defiant, acts with coldness and is inconsiderate of other people, unable to give or to accept love [ 10] and to establish meaningful and lasting relationships, often perceiving his or her social environment as cold and hostile. The addicted person is frequently involved in multiple drug abuse.
The most serious cases often report traumatic experiences in the early years of their life, such as being totally abandoned in childhood. They also report recurrent care in such institutions as orphanages, psychiatric hospitals and prisons.
The families in which persons afflicted with this type of addiction have grown up are often profoundly disorganized, similar to the type of family described as "disengaged" [ 13] , [ 16] . These families are found in all social strata. The major characteristic of the members of such families is that they are isolated.
These addicts are characterized by marked psychological and social immaturity and a troubled family life, which is itself a source of disorder in the child. They often have disorders in psychomotor development, difficulties in school and, during adolescence, violent clashes with social rules and the law. Prostitution, theft and homosexual behaviour are common disorders among persons with this type of addiction. A lack of self-confidence and an accumulation of self-destructive and hetero-destructive aggression are also Characteristics of these individuals. This type of addiction is very resistant to treatment though therapeutic efforts appear to be effective in therapeutic communities. The life duration of these drug addicts is often reduced either because of overdoses, accidents or intervening illnesses or involvement in delinquent activities. Drug addiction is often a phase of a delinquent career or other disorders leading to chronic institutionalization such as in prison or a psychiatric hospital.
Case study No. 4
John lived with his family in precarious conditions: his father never managed to find a steady job and his mother was an aggressive person and an alcoholic. John was in a conflictual relationship with his parents and from the age of 14 stole, argued with his parents, organized parties at which drugs were abused, and he ended up in prison several times. He abused alcohol, then heroin and a variety of other drugs. He lived as a drug addict for 11 years until he joined a therapeutic community. At present John is drug free and remembers having lived that period with a deep sense of self-destruction and discomfort.
Case study No. 5
Tonino never knew his father and his mother died when he was very young. He grew up in an orphanage, finished elementary school and then trained as a mechanic. After a suicide attempt he was hospitalized for four months in a psychiatric hospital and on discharge began to abuse drugs, primarily amphetamines but also heroin and alcohol. He has undergone treatment on several occasions but without lasting success. During the 10 years of his deviant career, addiction offered a temporary but always inadequate relief in his life.
In a society where people are encouraged to immediately relieve any kind of suffering and to satisfy feasible desires, the availability of certain drugs, such as heroin, provides an option for artificial relief, and in many situations drug abuse transforms trivial family difficulties, crises of adolescence or problems of social integration into drug-abuse problems. With regard to the spread of heroin abuse, it has been observed that when heroin is difficult to obtain and social attitudes against its use are very strong, most heroin addicts belong to transitional and socio-pathic types of addiction, whereas when heroin is more available and social attitudes against its use are less strong, traumatic and actual types of addiction are more prevalent.
The classification of drug addiction helps to overcome deceptive and over-simplified considerations that regard addiction as a common facade for substantially different problems. Such classification helps in a therapeutic process to make the correct diagnosis and prognosis of an addiction case.
Instead of helping young people who have fallen into the trap of heroin or other drugs to restore meaningful communication within the family and with their peers, current treatments tend to generalize and dramatize the problem, avoiding possible useful intervention by parents and peer friends. An adequate knowledge of the type of addiction can help in the choice of the most useful intervention. The authors observe that many cases of the actual type of addiction are reinforced by the inadequacy of therapeutic interventions.
Typology of addiction helps in making the appropriate selection as well as evaluation of treatment programmes. Traumatic and actual addiction have a much more favourable prognosis than the other two forms of addiction; family therapy appears to be suitable for treatment of the former two types of addiction. In this regard, general statements that a given modality of treatment gives successful results for a certain percentage of persons addicted to a particular drug have no meaning unless they clearly indicate which types of addiction have been involved in such treatment. A given treatment programme may best suit certain types of addiction, thus classifying addiction provides a possibility of making the appropriate choice of treatment.
The therapeutic community seems to be a suitable method for the treatment of actual and transitional addiction if the addict's family is called in to the therapeutic programme. The therapeutic community is a crucial point in strategies for the treatment of cases of socio- pathic addiction, which is the most serious type of drug addiction and usually resistant to other forms of treatment [ 18] .
The records of therapeutic community programmes for young drug addicts are sometimes difficult to understand, showing the transformation of seemingly hopeless drug addicts into generous persons with natural equilibrium, who succeed in life with a sense of altruism and comprehension. Obviously additional reliable data, obtained through research, are needed to explain the phenomenon. Available evidence is not sufficient to explain human personality and the potential that may exist within even the most disturbed and deviant persons.
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