Drug Abuse

VIII Personality and Addiction: A Structural Perspective

As we pointed out in Chapter I, the role of personality disorder in adole'scent opiate addiction was an open question when we began our research. We began without theoretical predispositions about the strength of one or another set of factors; we wished to explore the problem from the perspective of various behavioral sciences, to take a fresh look at it through our own clinical experience and systematic interdisciplinary study, formulating our concepts as our data and experience developed.

The generalizations in this chapter and Chapter IX draw on the psychiatric experience of one of the writers with adolescent addicts in the community or hospitalized at the United States Public Health Service Hospital in Lexington, Kentucky, and at the Riverside Hospital in New York City. They also draw on clinical reports from hospitals and clinics that have dealt extensively with adolescent addicts in recent years. They are considerably influenced by the findings of a systematic study of adolescent addicts and control cases that will be described below and by relevant findings in the studies we have already reported above. Diverse as the sources may be, they do point to a remarkably coherent characterization of the teen-aged addict.' In this and the following chapter, we attempt to develop this characterization systematically, largely within the framework of psychoanalytic theory. We start, however, with two major propositions which, it seems to us, help to put the manifold characteristics of the addict in clear perspective.

I. The addiction of the adolescents we have studied was an extension of, or a development out of, long-lasting, severe, personality disturbance and maladjustment.

II. The addiction of the adolescents we have studied was adaptive, functional, and dynamic.

These two propositions are in themselves answers to the orienting questions of this aspect of our study: what kinds of person are the adolescent addicts, and why do they use drugs? Though these questions may be separated for purposes of exposition, in reality they cannot be dissociated. As we discuss those clinically most relevant facets of the addicts' personality—their pathologic structure, as it were—we observe and perforce must discuss how this pathological structure relates to the how and why of their drug use. Conversely, to answer why they use drugs, we have had to focus in some detail on aspects of what they are like; here, as elsewhere in life, structure and function interpenetrate.

I. Personality Disturbance and Adjustment

There are many levels at which the personality and psychopathology of a clinical population can be described, from the tabulation of individual symptoms or behavior traits to the presentation of case histories in which each patient is described in his rich uniqueness and complexity. The clinical population we are describing in these two chapters are male adolescent opiate addicts. We mean addicts and not users; they have used opiates long enough and consistently enough to have histories of dependence on these drugs, they have become tolerant enough to them so that they have had to raise the dosage in order to continue to obtain the effects, and they have experienced some degree of craving for opiates while not physically dependent. The generalizations which follow, then, are limited to such young addicts; they need not pertain to any adolescent who ever used opiates. The distribution and range of personality psychopathology may differ from those of a population of young addicts seen in a jail. There may, for instance, be crucial forces in the police and legal handling of young addicts which selectively place differing kinds of young addicts in jail and in a hospital. However, from the variety seen in hospitals, we would speculate that, although the frequency distribution of various psychiatric diagnostic groups might vary from jail to hospital, no type would be entirely excluded from one or the other institutional setting.

The psychiatric diagnosis is useful for the general description of a clinical population, so long as it is recognized that the diagnostic classifications are of limited reliability and that they are convenient labels which do not do justice to the individual differences among the cases. Nevertheless, they do have some value in indicating the extent and severity of psychopathology. We have found it convenient to describe the major varieties of adolescent opiate addicts in terms of the following schema, and our experience is that others working with adolescent addicts find this schema appropriate to their own clinical experience. To fill the picture out a bit, a brief description is appended to each classification.

1. Overt schizophrenia. These patients were not hallucinated or psychotically destructive. However, they displayed flattened affect, severe thinking disorders, delusions of reference and grandeur, and withdrawn social behavior.

2. Incipient schizophrenia, or "borderline," status. These patients were struggling against an actively disorganizing and disruptive process in which they experienced extreme anxiety related to feelings of inadequacy and lowered self-esteem. Paranoid trends and early thinking-disturbances were noted. Though moralistic, struggling toward conventional goals in work, marriage, and education, they were unable to carry out the required roles and relationships. Their hold on reality was tenuous. In situations which put them under stress, they became unrealistic and confused. They strove to maintain intellectual control and to avoid situations requiring emotional participation.

3. Delinquency-dominated character disorders. These patients were extremely hostile, defensive, provocative, demanding, and manipulative. They could be divided into two types which, though not mutually exclusive, nevertheless permitted the classification of most of the patients as predominantly of one or the other pattern.

a. PSEUDOPSYCHOPATHIC DELINQUENTS. These patients attempted to deny and repress underlying wishes for passivity and dependency by adopting roles in which they defined themselves (and were usually responded to) as dangerous, criminal, and strong men. They had been involved in serious delinquencies (e.g., gang fights, robbery, assault), and, both prior to and during their drug use, they described these activities as pleasurable.

b. ORAL CHARACTERS. The predominant role systems these patients attempted to establish were those in which they were nurtured and cared for. They reacted with rage and anxiety to situations in which nurturance was refused. They were easily upset by, and reacted excessively to, frustration. The petty delinquencies in which they were involved, both prior to and in the course of their drug use, were intended to punish ,and control significant figures. At times, they almost said in so many words: "If you don't do what I want, then I'll be a bad boy, and then you'll be sorry."

4. Inadequate personalities. These patients showed a paucity of interests and goals and an impoverishment of thinking and emotional expression. They were neither "good" delinquents nor "good" schizophrenics. They were successful in establishing role systems in which people responded to them almost as if they were just "not there."

It is evident from the above that, at least as far as psychiatric classification goes, there is no single type or syndrome of maladjustment specific to the adolescent opiate addict. Similarly, we have not been able to discern any single deep-lying need or conflict common to, or specific for, opiate addiction. This is not to say that there is no basis for discussing the adolescent opiate addicts collectively, but rather that such discussion cannot, in terms of our clinical experience, be meaningfully focused on some unitary characteristic. We have found it useful to generalize the personality characteristics of adolescent addicts in the framework of four concepts from psychoanalytic psychology:

A. ego pathology
B. narcissism
C. problems of sexual identification
D. superego pathology

We use the term "framework" advisably, since none of these concepts are nuclear or elementary; they are themselves highly complex rubrics, beneath which a number of subsidiary ideas are to be considered.

A. Ego Pathology

The term "ego" refers to certain aspects of the psychic structure which regulate or govern, as it were, the relationship between the world outside the person and the drives, impulses, demands, values, and goals within him. Many ego functions can be distinguished; each can be regarded as a resultant of the important life experiences and relationships in interaction with biologically conditioned, autonomous, "conflict-free" mental organizations or capacities for organization. The ego apparatus is probably formed in early childhood or infancy, conditioning the perception of, and reaction to, the experiences of later childhood and later life. We have observed insufficiencies in three major areas of ego function among adolescent opiate addicts. These are: response scope, synthesis, and purposeful action.

1. Response scope. As a group, the adolescent addicts are relatively unresponsive to the world outside them and to their own creative urges. In our clinical experience and from what they tell us about their interests and activities, we note that their interests are meager and the range of their activities limited. When they are exposed to special opportunities for learning or acquiring work or recreational skills, they respond slowly or not at all. Though such attitudes as suspicion play some role in this reaction, our impression has been that this unresponsiveness reflects a general lack of interest, a blunting of curiosity, a narrowing of the inlet of experience.

School teachers at the Riverside Hospital, working with small classes in a highly flexible, individually oriented school program, have told us about the (often friendly) indifference of the adolescent addict students to the school program. It is not that the adolescent addicts are devoid of talent or skills; like any group of adolescents, there are those who can paint or draw or make things with ceramics. Indeed, a distorted view of their potential creativity is obtained from the fact that a teacher may succeed in getting them interested in any of a variety of activities (e.g., both art and ceramic work were favorite activities) so that the discrepancy between the student's current production and his prior level of interest and productivity makes it seem that there is an untapped well of talent and creativity. In general, however, the relation between the teacher and the student addict's level of interest is dependent on the teacher's efforts and enthusiasm; as soon as the teacher stops pushing the addict patient, the latter ceases to perceive or to respond to this aspect of his environment.

These observations are supported by some data from the study reported in Chapter V. As already indicated, adolescent users were aware of fewer opportunities for supportive, enriching experiences or situations than actually existed in their communities. They participated in a smaller range of leisure activities than did their peers; they showed little interest in extracurricular programs, in any aspects of the political situation, or indeed in anything outside their immediate lives. These clinical observations and social-psychological data illustrate our thesis, namely, that the response scope of the adolescent addict is limited. Further evidence bearing on this point may be drawn from a study by Gerard and Kometsky.2

The addicts in this study were thirty-two consecutive admissions of male patients under twenty-one years of age at the United States Pdhlic Health Service Hospital at Lexington, Kentucky. The controls were twenty-three cases meeting specified criteria who were indicated as friends by patients at Riverside Hospita1.2

The subjects were given psychiatric interviews and several psychological tests.4 Of immediate interest are the findings of the Rorschach test.° On the basis of this test, the addicts were characterized by a more meager affective life and a more shallow and stereotyped fantasy life.a After the standard administration of the test, it was administered again with the instruction to produce new responses.° The addicts were far less successful than the controls." As judged by performance on the Rorschach test, therefore, the addicts show up, at least on the average, as much more constricted individuals. They lead much more impoverished lives, inwardly and outwardly, than their immediate situations require of them.

It is possible that living in a chronically multidimensionally impoverished environment leads in some simple and direct manner to a constriction of the life space. It may well be that one needs to learn to take advantage of such stimuli and other opportunities as exist and that an impoverished environment, with its meager offerings, does not facilitate such learning. On the other hand, it is also possible that the constriction of the life space represents a defensive maneuver. Seeking to take advantage of the apparent offerings also invites disappointment. One may learn that the beckonings of opportunity all too often turn out to be empty invitations. One may, consequently, stop responding to such invitations as a technique of protecting oneself from disappointment and frustration. Observation of addicts—like the fact mentioned earlier concerning the capacity of many of them for some degree of creative expression so long as they receive specific encouragement, with subsequent relapse—suggests that we are dealing, to a considerable degree, with defensive constriction.

From the standpoint of ego development, we would speculate that serious, gross disturbances in the early life of the child must have occurred in order for him to have adopted a constricted pattern of responsiveness. Indeed, constriction is highly protective, in the same sense and with the same liabilities as a life spent in a windowless, cork-lined, air-conditioned room.

2. Synthesis. The term "synthesis," used in reference to ego functioning, refers to a complex of activities which have to do with the organizing of that perceived and with the coordination of conflicting needs. Although the ego usually functions silently and to a large measure subconsciously (we use the term "subconscious" to include both the "preconscious" and "unconscious" of ordinary psychoanalytic usage), it is concerned with questions which can be formulated in terms of conscious intellectual activity—e.g., Is such a course worthwhile for my future welfare? What will happen if I do this? How will I feel about it later? Judgment, reality-testing, delaying, accepting frustration, and moderating between alternatives are all involved in the synthesis of experience. In a broad sense, synthesizing entails a social-temporal orientation; we might say that the adolescent opiate addicts are disoriented in this context.

They give up school and jobs readily (in the great majority of cases, prior to drug involvement). They do not recognize that their inner demand for status implies meeting the situational requirements for achievement, e.g., sustained effort. Thus, Zimmering et al.7 described the addicts they had observed as "unable to apply themselves to intellectual tasks"; Forts emphasized the important role which "inability to form realistic goal orientations" played in the addicts' maladjustment. Inability to synthesize is one of the important factors in the early drug use and addiction of our patients. Almost every one of the addicts we studied had observed the socially degrading consequences of opiate use in his community either before his initial use of drugs or early in the course of his nonaddictive use. He learned that regular use of opiates creates dependence and tolerance; that sale, purchase, or possession of narcotic drugs is illegal; and that people are often arrested and jailed for these reasons. Despite "knowing" this very well, he was unable to make use of the knowledge. He believed that "it can't happen to me." In short, he did not utilize restraint.

Situations which are unpleasant, painful, or anxiety-provoking make special demands on the synthetic function of the ego. In a painful situation, the least difficult and most immediately effective behavior is to withdraw or to strike out angrily and directly against the source of displeasure. However, this is often not adaptive in terms of future plans and roles. For instance, adolescent addicts, in the presence of what they regard as insult, criticism, or harshness, leave the field. Thus, they quit jobs because the boss speaks harshly to them, rather than trying to determine the basis of the criticism and modifying their behavior accordingly. Early in the course of addiction, they typically suffer mild withdrawal symptoms. Though they know by then that each day of prolonging their physiological dependence makes the inevitable reckoning the more painful, they nonetheless take another shot to avoid present pain.

Clinic No. 1° has also observed this phenomenon. The staff comments on the addict's low frustration tolerance and his readiness for collapse and retreat into passivity. Zimmering et al." have also described the reaction to frustration of the adolescent opiate addicts; they state that their reaction to frustration typically consists of "withdrawal, inhibition and passive dependent strivings." There are a small number of adolescent opiate addicts who respond to unpleasant or displeasing orders, in the army for instance, with aggressive acting out—striking noncommissioned officers or going AWOL. Whether they respond actively or passively, in either case, from the standpoint of synthesizing, their behavior is malapropos.

We have already referred to the finding by Gerard and Kornetsky that, when asked to produce additional responses to the Rorschach ink blots, addicts are not only typically less able than controls to rally to the demand for additional output, but they also tend to show marked deterioration in performance under the stress of such a demand. Their reality-testing becomes less efficient, and their emotional participation and perception becomes "regressive."

The major difficulties experienced by adolescents (conflicts over autonomy, genitality, and particularly identity),11 are normally dealt with gradually, progressively, and repetitively. Relationships are established, skills acquired and improved, roles clarified in innumerable settings. Through such a developmental flow of experiences, the anxiety associated with the adolescent's insecurities is distributed into, so to say, manageable bundles, and stressful situations (typically those which accentuate or bring more problems of autonomy, genitality, and identity into awareness) are kept within the bounds of an ever-increasing competence to deal with them. The adolescent addict, however, sidesteps such growth by at first simply avoiding the situations in which he can gradually acquire competence or by passively going along with the whims and decisions of others and eventually by substituting the anxiety-reducing "normative" influence of the opiate drugs. This evasion of maturation is probably the most dangerous and seductive aspect of opiate use.12 From the viewpoint of ego function, maturation in adolescence is dependent on ability to stay within the context of the unfamiliar and the difficult. This calls for all those aspects of the synthetic function of the ego which we have discussed, tolerance of frustration, consideration of and recognition of the consequences of behavior in its social-temporal context, and maintenance of reality-testing under stress.

3. Purposeful action. The adolescent addicts display a disturbance of action. When, despite the limitations imposed by their constricted life patterns and the deficiencies of their synthetic capacities, they do embark on a realistic or (hopefully) potentially gratifying course of action, they are inhibited, slowed down, or halted. To use a term of Redl, the "power function" of their ego is defective; they have "weak egos." They have great difficulty in starting, stopping, or changing course midstream. To take a physical analogy, they suffer from inertia. They may, therefore, appear passive, fatalistic, "lazy," dependent, or negativistic. One of the clinically significant areas in which this action disturbance is important is in entering a hospital for detoxification; among even the best "motivated" addicts, this commonly takes place long after he has perceived the hopelessness of his current course and come to the conclusion that he must get help. This delay is often misperceived by the community or family or even by the addict himself as malignant, stubborn, and purposefully dilatory. In our view, it is ego weakness, not immorality. The addict commonly seeks an outside authority to incarcerate him or bring him back to the hospital because he knows he cannot get himself there even though he actually wants it for himself.

Since the influence of the ego is most evident in the organization and daily conduct of one's life, it is germane at this point to review findings reported in earlier chapters that show how differently the nondelinquent and non-drug-using peers of adolescent opiate addicts in high-drug-use areas structure their lives. The social personality of the nondeviant youth—the goals, values, content, and activities which are consciously experienced and openly manifested—is quite different from the adolescent opiate addicts'. From responses to a structured interview, we can construct a picture of the social personality of the nondelinquent, non-addicted youth which statistically differentiates him from his addict peers. The concepts in the following paragraph should be prefaced in the reader's mind by the phrase, "In contrast to the adolescent addict, . ."

The nonaddicted, nondelinquent youth in high-drug-use areas does not feel himself to be playing the role of a grownup—a man—until he has passed some culturally defined transition point, e.g., graduating from high school or getting a job; nor does he feel that responsibilities are forced on him; nor is he nagged by his parents about his future and vocational plans. He has definite plans for his short-range future. In difficult situations, he goes to his father, teacher, or priest for advice and support. Though he knows many youths who have been in jail, reformatory, or on probation, few of these are intimate friends. He has stable, intimate friendships which he entered on the basis of association in school or purposeful selection and not simply because they happened to grow up together in the same neighborhood. He divorces himself, with considerable affect, from antisocial behavior and antisocial groups—if necessary, at the cost of loneliness. He does not spend much of his leisure time at movies, hanging around candy stores, "goofing off," going to parties or dances, or gambling at cards or pool. He spends more time in active sports. His friends are not greatly concerned about wanting to have a car, expensive clothes, and much pocket money. He has more acquaintance with boys who are concerned with current events, books, art and such things than with those concerned with going places and seeing things.

When he was about sixteen years old, lie wanted, but felt he could not get, a different way of life for himself—in contrast to the addicts, and delinquents, who wanted but could not get enough fine clothing. Highest on his list of values are workmanship, job security, and health—in contrast to his addict peers, who rank refinement, freedom, and comfort as their highest values. He selects his ideal in terms of personal qualities (e.g., courage and kindness), rather than in those of possessions (e.g., wealth and skills). He does not feel isolated and without support in a malicious and untrustworthy personal environment. He actively explores the limited opportunities his community offers him for leisure activities, both in and out of school. He uses public libraries or book clubs and devotes relatively little time to the reading of comic books.

B. Narcissism

In psychoanalytic thought, the term "narcissism" is applied in a number of contexts. First, there is what is sometimes described as "primary narcissism," a failure in the inner awareness and acceptance of the separateness or differentiation between self and object world: the "self" is unbounded, and the individual is hence never aware of himself as such.

In the newborn child, some degree of primary narcissism is assumed to be a normal state of affairs; in the first phase of his life, the child only gradually develops an awareness of his separateness from those who care for him. Under good conditions, he learns slowly and not too painfully that he is indeed quite separate; that he cannot make unlimited demands on their care, attention, or interest; that they have only a limited capacity to give to him; but that they are respect-worthy and lovable persons nonetheless. His earliest attachments to others are rooted in this lack of differentiation even as he begins to realize that he is, in fact, not unbounded. The others who serve him are extensions and parts of himself, in much the same sense that an older person perceives that the parts of his body are parts of himself. He seemingly has but to wish or cry out, and these extensions do what is necessary to relieve distress. Again, these extensions function in much the same way that an older person grasps a desired object; he, not merely his hand, grasps the object. Since he is not aware of external objects as such, he cannot attribute pleasure and pain, gratification and frustration to others as causal agents; affective states are conditions of being and can only be perceived reflexively. Being is wonderful, or being is hateful.
As the self becomes more bounded, more-or-less sharply demarcated from' the not-self, a discriminated object in a world of discriminable objects, the infant enters a second phase of his existence, a phase of what may be described as "secondary narcissism."13 His attachments to other persons are appropriately modified. From extensions, they become instrumentalities. The failure to make an effective transition to this type of relationship—i.e., to acceptance of separateness and to the formation of relationships with other persons who are consistently seen as different and separate—leaves him subject to certain maladaptive consequences. He never quite succeeds in perceiving others in terms of their objective properties. When they fail him, the ensuing rage is not focused simply on the frustrating object; it is, at least in part, directed at the primordial undifferentiated self, at the fact of existence. When they satisfy his needs, there is a correspondingly unbalanced and unfocused elevation of mood which embraces the inadequately perceived others in its glow, but which also cannot achieve recognition of the qualities of others that have made the desirable outcome possible or which can give due credit for services rendered. By the same token, such a person can never get to see himself in anything approaching an objective perspective. One consequence of this is that he cannot make any realistic appraisal of his own qualities and, therefore, cannot effectively deploy his resources toward the attainment of his ends.

The successful negotiation of the second stage of person-object relationships is itself normally superseded by a third stage, one in which others are no longer merely instrumentalities of one's own purposes, but beings with needs and rights of their own." In part, this development is simply an emergence of the long view, a realization that, in the long run, others will not play their roles in the satisfaction of one's needs if one does not play his own roles in the satisfaction of theirs. In part, this development is a consequence of the extension of one's own need system so that one cannot be entirely happy when confronted with the unhappiness and frustration of others or feel entirely secure when others are threatened.

In a sense, the third stage represents a return to the first, in that the self, augmented by identifications with others, is again not confined to one's own person. It is a return, however, with a difference. Identification with others does not obliterate the self-other distinction, a distinction that makes possible a wholesome and realistic regard for one's own capabilities and accomplishments, along with a realistic assessment of the qualities of others and regard for their achievements. The fact that one's need system requires the support, gratification, and happiness of others only gives point to the distinction, albeit an interdependent distinction, of self and other. It is only in this stage that mature love is possible, but mature love is accompanied by an enhanced sense of one's personal existence, not by its obliteration. It is also only in this stage that one finds true self-respect, self-respect that can withstand the confrontation of one's deficiencies and accept defects that would be too costly to correct, self-respect in which the sense of personal worth is rooted in a realistic assessment of one's resources rather than in a comparison of himself with impossible ideals or, alternatively, too-low standards.

Although normal in the growing child, the failure to negotiate the third stage as one matures leaves a variety of psychopathic and neurotic types, just as the failure to negotiate the second leaves a variety of psychotic types and severe character disturbances.

It must not be supposed that the normal transition from the first through the third stage is a smooth one. One may progress much more rapidly and further in this development in one's relations to some people than in one's relations to others. Typically, for instance, the maturation of personal relationships is most difficult with respect to one's mother. Moreover, progress in this development does not preclude regressive movements of more-or-less brief or prolonged duration, so that one reverts to forms of object relations characteristic of earlier developmental stages, either in one's relations to particular persons or in general. Finally, the true level of progress may be more or less effectively concealed by a verbal façade; people talk the third stage even when they do not live it.

The adolescent addict has typically progressed well into the second stage, but has not outgrown and easily regresses to, the first. Although his involvement with the outside world, in the sense of establishing sympathetic and empathic relationships with peers and adults, is meager, one figure does occupy a prominent place in his psychic life—Ais mother. He has little love for her, in the sense of warm, sympathetic, responsible concern for the welfare of another human being. In part, this is a relationship with another person which features the gratification of many infantile impulses. In part, and in a more basic sense, it is a relationship with an undifferentiated portion of himself, with the hated, feared, and loved mother from whom he has not yet fully distinguished himself and who is still a part of himself or of whom he himself still remains a part.

1. Deficiency in healthy self-regard. Although it is questionable that the global concept "self-esteem" has exactly the same connotation for all clinical observers, there is no doubt that students of the addiction problem find this term useful in communicating to other clinicians about their patients. Fenichel's statement—"More important than any erogenous pleasure in drug elation . . . is the extraordinary elevation in selfesteem"1-5—emphasizes the significant role which low self-esteem plays in the motivation of drug addiction. Zimmerimg et al. explicitly described the young heroin addicts (or users) they studied as burdened by feelings of weakness, inferiority, and diminished self-esteem even more than the other disturbed youth on the same adolescent ward.'6 Boshes et al. describe their clinic patients as having "strong feelings of inadequacy, insecurity and unworthiness, sometimes manifested in overconfidence and arrogance."7 Reference should, however, again be made to the study by Schiff, described in Chapter VII.'8

Clinically, we have taken the concept "low self-esteem" to be relevant to individuals who have feelings of inferiority or inadequacy accompanied by intense feelings of self-denial or disapproval and who talk about this (and, for that matter, about any aspect of their life which is difficult) with great hesitancy, evasion, denial, or distortion. They are aware that they cannot communicate.

We have based our appraisal of self-esteem on:

a. The quality of the person's prior social adjustment, particularly in the context of how the person describes and evaluates his performance, accomplishments, or failures.
b. The expressed self-concept in clinical interview. It is assumed that self-esteem and defensiveness are inversely related, that acceptance of self and acceptance of others are directly related.
c. The projected self-image in response to the Rorschach, TAT, human figure drawings, and similar projective tests.

a. PRIOR SOCIAL ADJUSTMENT. The adolescent addicts we have studied had little sense of accomplishment and, indeed, had accomplished little. They had adjusted poorly prior to drug use. They had given up schooling and were involved in overt misbehavior or deviant behavior. Their work history was also unsatisfactory. If they had worked at all, their attendance and punctuality were poor. Though there were some adolescent addicts who reported these phenomena as indications of their inferiority or incapacity to deal with life, in general they usually reported these indications of their maladjustment as though they signified superiority to, and meritorious detachment from, conventional values and norms. However, when a psychotherapeutic relationship had begun to develop, even the latter often spoke of themselves in more sober and more tragic fashion. Although they confessed that their façades of arrogance and self-satisfaction covered considerable self-doubt and self-distrust, it was most touching, in dealing with these disturbed adolescents, to learn from them how badly they regarded themselves. Charlie, for example, who seemed the ideal example of a "cheerful psychopath," confessed after many months of treatment that he was trying—through the excitement, stimulation, and provocativeness of his misbehavior in school; his stealing; and his life as an addict—to run away from his desperately concealed feelings of worthlessness and weakness. Even as a small boy, he had believed that he behaved outrageously and sinfully toward his own family, even though in fact he was outwardly a well-behaved child.

b. DEFENSIVENESS. In clinical interviews, the adolescent addicts were extremely defensive. They strongly resisted discussion of themselves and their relationships. Despite overt and obvious evidence to the contrary, they denied emotional problems and were, in general, hostile or indifferent to treatment. Many displayed difficulties in establishing rapport, some to an almost psychotic degree. Evasion, suspicion, and hostility were common responses to the diagnostician or to the therapist who sought to intervene in their maladjustment. Conversely, they were cooperative and friendly as long as the interview "didn't count," i.e., did not imply anything about the possibility or worthwhileness of a change in their personal attitudes, orientations, or identifications. They were pleased to participate in discussions about getting drugs, the development of bebop or junkie slang, their experiences of corruption or dishonesty among politicians or law enforcement personnel.

C. THE PROJECTED SELF-IMAGE. Although indications of lowered self-esteem and a corollary dysphoria (a depressive mood and a pessimistic outlook) may be inferred from any of the projective test materials, the most explicit expression of the self-image and how it is esteemed is to be had from the Thematic Apperception Test.'9 The central characters in the TAT stories told by the adolescent opiate addicts we studied in Lexington were involved in murder, rape, strangulation, fatal cancer, rotting-away, failure, and impotence. The mood of the fantasies they created tended toward depression; their expectations were pessimistic (with occasional exceptions of bizarrely unrealistic optimism, e.g., "for magical reasons, great success awaits me in the future"). This was covered with a façade of strength and cunning intended to impress others into seeing them as neither threatened nor weak; the world must protect itself against their predatory ability.

2. Relatedness to others. The normal adolescent is involved in a complex transition; his relationships are tentative, relatively loose, changeable, and not serious or "adult." He has a limited capacity for love, in the sense of establishing a warm, sympathetic understanding and responsible concern for the welfare of some valued individual.

Indeed, adolescents are not expected to love in this sense, yet they do establish relationships in which they practice the arts of love, both physical and emotional. They form "crushes" and sustain friendships which are perceived as passionate, important, and everlasting (some of which actually continue into adulthood). They choose friends purposefully as an expression and an extension of their developing self-image, identity, and goals. The adolescent opiate addicts do not form such adolescent relationships; their ability to enter close relationships of even a tentative nature is limited. Their friendships are marginal; they hang around with, but they are not actually emotionally involved with, their peers. Data substantiating this formulation come from three sources: our own personality studies, observations of other clinical obseivers, and personality implications of sociological studies.

All the clinical observations of young addicts accord with this formulation. Brill comments that the addicts he worked with "seem incapable of maintaining a sustained relationship."2° Fenichel comments that addicts "never estimated object relationships very highly."21 Zimmering et al. state that their object relationships are tentative and easily given up. They describe the users they studied as having no real buddies and casually accepting peer-group rejection because of their habit.22 Adams comments that, even where the youngster experiments and uses drugs in an attempt to identify with the group, there is no real integration into it.23 Boshes et al. describe them with the phrase, "shallow interpersonal relationships.3924

Earlier chapters have reported data supporting these psychiatric observations. Thus, we have learned that users have fewer intimate friends than nonusers; that the selection of friends by users is more casual than purposeful; and that, if users belong to street clubs, they tend to be marginal members. It is only to the most casual, unsystematic observer that the drug-user appears seriously, personally, "normally" involved with his peers.

One reason that nonclinical observers may perceive the adolescent addicts as capable of normal relatedness is that, like other adolescents, they do participate in group relationships. These group relationships are not, however, typical of the normal adolescent. Since the procuring, distribution, and use of drugs rests on an elaborate social structure, an ability to participate in certain kinds of peer and group activities is requisite to being a drug addict. Furthermore, the group activities of the adolescent addicts are supportive for these youths in several ways.

First, anyone is accepted in the adolescent addict group with little regard to his personal characteristics, so long as he is willing to focus his life on drug use. The activities of this group, unlike those of delinquent or nondeviant adolescent groups, are extremely limited. They do not go as a group to dances, ball games, street fights, or to the homes of their members for birthday parties or religious celebrations. They have no treasurers, presidents, or sergeants-at-arms. Their association is based only on the fact that they have a shared dominant interest—obtaining, using, and enjoying drugs. No matter how limited a particular adolescent addict may be in establishing relationships with nondeviant peers, among addicts he is welcome as long as he identifies himself as a "junkie." This has much to do with easy relapse into drug use. The path to acceptance by the nonaddict is difficult; a return to the addict group is easy.

Second, addicts of all ages participate in an isolated in-group with its special mores, traditions, and argot which encourage suspicion, deceit, and manipulativeness toward both the in-group and the world of "squares." These attitudes in the addict's social milieu lend support to his own disturbed perception of human relationships. He can conceal the discrepancy between his attitudes and expectations and those of his nondeviant peers by immersing himself in a deviant subculture. In his own estimation, he is not ill or disturbed, since he functions attitudinally like everybody else he knows.

Third, there are few barriers to membership in terms of race, religion, or nativity. Adolescent addicts are very democratic. This is a valuable feature of addiction for adolescents from deprived social groups. Interestingly, in a hospital, after they are detoxified and are no longer functioning socially as drug addicts, the "normal" group prejudices of these youths rapidly return.

3. Persistence of a narcissistic relationship with the mother. A prominent feature of the family situation of the adolescent opiate addict which has been noted in our own and other clinical studies is the peculiarly close relationship between the addict and his mother. It is not a closeness of warmth or mutual regard so much as it is a clinging and feeling of being bound together.

Zimmering et al., Fort, and Adams have commented on this in slightly differing terms. Zimmering et al. note that there is a very close identification with the mother.25 In the same report, however, they state that addicts plead to be sent where there are no drugs, whereas other boys in trouble resist giving up even the shred of a parent. In our experience, though they plead to be taken away from home, they are extremely uncomfortable as soon as this wish is granted. It is difficult to capture the force of this binding mutual attraction in words. For example, after months or years of increasing addiction, penury, delinquency, and stress, a patient gets himself to a hospital. As soon as the 'withdrawal experience is over—or at least the overt, painful aspects of it—he is eager to return home; he is needed there; he "belongs" there; his mother cannot manage without him; he wants to make up to her all the harm and pain he has caused her through his drug use. He may add, as an afterthought, "and, besides, I am cured now." The following case material illustrates these formulations.

Jay was aware that there was something peculiar about his relationship with his mother. He knew something troubled him when he was at home with her. He was preoccupied with this phenomenon and knew that it interfered with his life, work, and studies. He knew that his mother and grandmother fought possessively for him, and this (which had led to an earlier suicide attempt, in the setting of which he began his heroin use) was something which he feared would recur if he were to return to live with his mother in New York City. He wanted, therefore, to live with his father in California. He wrote this to his mother three weeks before he left the United States Public Health Service Hospital in Lexington, telling her that he was going to live in California. However, he reneged on this plan, deciding that he would return to New York after all to live with his mother despite his better judgment.

He arrived in New York at his mother's apartment without informing her that he had changed his plans. He found her living with her boyfriend with no room for him and went to live with his grandmother. He requested advice from one of the writers. Jay was referred to the Community Service Society. One of their psychiatric social workers attempted to lead him toward educational opportunities, ego-acceptable employment, and living quarters separate from his family. Despite wishing for these things, Jay sabotaged their plans. He found a night job doing unskilled kitchen work, which, he correctly observed, was below his intelligence and dignity. He continued to reside with his grandmother, who promised him financial support and educational opportunities if he stayed away from his mother. However, he could not do this. Within a month after his return from Lexington, his mother and her boyfriend broke off their relationship. Jay returned to her apartment; became bored, upset, and unhappy; and then returned to using drugs. It is of interest that Jay worked and stayed out of trouble while living with his grandmother despite her vituperation and emasculating criticism; return to drug use was associated with his return to his mother.
Willie, after leaving Riverside Hospital, recognized that he was better off in Washington, D.C., where he had lived with an older cousin, than he would be at home with his mother. He remained in Washington for four months, staying out of trouble, working regularly. On Mother's Day, he impulsively returned to New York City; that evening, he resumed drug use.

Harry was sent by a court in New York City to Miami to live with his aunt and uncle. There he worked steadily for almost a year and established positive, satisfying relationships with peers and with his relatives. However, he felt more and more strongly that there was something missing from his life. For this reason, he returned to New York City to be with his mother. He recalled that, as he stepped off the airplane, he felt that he had made a terrible mistake in returning but that he could not change his plans. Almost immediately, he resumed drug use.

In each of the three cases cited above, these patients were able to describe their mothers—probably correctly—as domineering persons who limited their sons' self-assertion, used them unfairly for their own emotional and physical needs, and gave them little in return. Despite this, they were blocked in the expression of hostility toward their mothers. The mothers, on their parts, consciously suffered from the difficulties of their addicted sons. They felt that they were being martyred by what their sons were doing to themselves. They felt that they were being depleted by the experience of supporting a chronologically almost-adult person who was not only dependent on them but stole from their purses and pawned their movable properties.

Walter Adams has placed considerable emphasis on this state of affairs.26

• . • It is only in the subtle nuances picked up in the relationship [between the mother and her addicted son] that we find the subtle causative factors underlying the personality or character defect which begets narcotic addiction. . . . This feature of ambivalent and helpless clinging to a rewarding, yet at the same time non-rewarding home seems distinctive for the addict.27

The other side of this narcissistic relationship between the adolescent addict and his mother is seen in the often destructive and hostile behavior of the mother toward her addicted son. Though the mothers are unable to encourage or enhance the development of their sons toward independence or maturity, many have great difficulty in refusing things. They tend to be indulgent in material things, unable to discipline the boy, and inconsistent in their expectations and in the setting of limits. Some of the mothers are, however, repressive and nongiving even of material things. These aspects of the family structure, however important they may have been in the course of the adolescent addict's childhood and early personality development, take on a new and crucial significance in relation to efforts to intervene therapeutically in the addiction process. Though their mothers are consciously eager to see their sons improve, they fail to carry through on plans.

For example, when Jack left the hospital after a year of intramural treatment, his mother arranged for him to take a two-month vacation before going to work.

When Harry left the hospital for weekend home visits, plans were made with his mother, who was advised not to give him money. However, she did give him money—invariably, by a remarkable coincidence, the current price of a bag of heroin ($3). Harry assured us, when we commented on this, that his mother knew nothing about the price of heroin.

Harry's mother was not unique in her skill in doing the most wrong things at the most crucial moments. Bob had been home on a visit and was due to return to the hospital at 9 A.M. The night before returning, he stayed out late with his friends; for this "reason" his mother did not want to awake him early in the morning. Instead, she let him sleep until the afternoon and then gave him "a real good meal" before suggesting that he go back to the hospital. Instead of returning to the hospital, he took the remainder of the afternoon off and used drugs. He returned to the hospital at night, when admission causes maximal difficulty for the nursing staff.

Willie returned to New York City from Washington, D.C., and to drug use for three months before his mother called the hospital to say that he had returned, even though she had undertaken to keep the hospital informed of his whereabouts. It was not until Willie had become increasingly involved with and addicted to drugs that his mother called, at this point to inquire what she should do. She said that she had been meaning to call before, but had been too busy to do so.
Such antitherapeutic behavior usually occurs in the context of an extraordinary eagerness to please, to cooperate, to improve the reputation of the hospital, and to keep their sons away from drug use. One of the most striking instances of this occurred in the case of Bert, a twenty-year-old adolescent addict, the son of a woman who played an extremely active role in an association of parents and relatives of addicts. With much therapeutic effort, plans were made for him to live away from the overprotective, emotionally indulgent atmosphere of his parental home. These plans were discussed at length with his mother, who accepted and agreed with them. However, as soon as Bert left the hospital, she gave him money for his rent (rather than sending a check directly to the Y.M.C.A. as had been planned), which Bert promptly converted into heroin, and arranged for him to take his evening meals at her apartment. This was interpreted by Bert as an expression of her wish that he remain at home with her, rather than establish himself independently.

These data suggest that the narcissistic relationship of the adolescent addict with his mother, this failure in psychic differentiation and separateness, is not to be understood as a pathology of the addict per se. It seems to us that there is a strong need on the part of the mothers to maintain their sons in a weak, dependent position for their own security. We regard the ambivalent interference with the therapeutic process by the addicts' mothers as an instance of such a need, rather than of ignorance or of spite.

C. Disturbance of Sexual Identification.

According to Erikson, establishing personal identity is the crucial adolescent problem.28 Personal identity has many facets—vocational, religious, class, sexual, and so on. All these areas of identity are probably related; not knowing what and who one is in any of these areas weakens or complicates the sense of identity in the others.

The adolescent addict has a weakened sense of, and a deep-lying disturbance inhibiting the acquisition of, personal identity. Perhaps this is why the almost exclusive identification—"I am a junkie"—is so supportive. It is often observed that an exclusive, affect-laden, predominant group identity can conceal or substitute for a weak sense of personal identity; e.g., the person who identifies himself as a veteran, Rotarian, physician, and so on. Since the relationship in the primary family group between mother, father, and child plays such a central role in the decisive phases of personal development, it is no wonder that problems of sexual identification—orienting the self in terms of being or becoming a man like father or a woman like mother (or ,their surrogates)—plays such a central role in the total sense of identity. Whether the weakness of the total sense of identity of the adolescent addict is based on it or not, disturbance of sexual identification is a prominent area of pathology among these youths. It is not that they assert explicit concern over their sexual identities, but, rather, the subtleties of feeling about themselves—sometimes dimly conscious, more often repressed—give evidence of the disturbance.

Though this hypothesis—that adolescent addicts have a serious disturbance of sexual identification—is based on clinical experience and impressions which are difficult to objectify, there are substantiating behavioral correlates and attributes which we can cite. The concept, "disturbance of sexual identification," has two major components. For the first component, one inquires, "To which gender do you belong?" For the second component, one inquires, "Can you do that which belonging to this gender entails, socially as well as biologically?"

There are three types of historical or observational material, cited in our own and other reports, indicating that adolescent addicts display disturbance in sexual identification in either or both of these components, that they are confused as to their genders and/or are unusually inept in carrying out their roles.

The first type of data does not have to do with sexuality in a limited biological sense, but rather with what can be inferred about the patient's masculine identification and potency from his performance in vocational, educational, familial, leisure, and other areas of his life. Being masculine is closely tied, in contemporary American culture, to a concept of the self as having power; strength; competence; effective and appropriate assertiveness; and to a role which involves being or becoming a responsible provider, father, and head of the household. In these terms, the addict patients we studied were obviously disturbed in their sexual identification. They were lacking in both the essential ingredients of such a masculine self-image and in the attributes that would justify it. They neither were nor showed any signs of becoming responsible providers. Their being and becoming was oriented, in large measure, in the contrary direction, toward passivity and dependence. They were concerned with getting, taking, or giving, but not with give-and-take.

They were at the opposite end of that continuum in human development which culminates in mutually regulated, mutually satisfactory relationships. Indeed, they were occupied with some of the most primitive and basic problems of human development—with the predictability of gratification and the establishment of basic trust.

Their passivity and dependence is seen in a variety of social interactions with addicted and nonaddicted persons, both in the hospital and in the community. One of the most conspicuous manifestations of this in the hospital had to do with meeting "oral" needs with cigarettes, candy, and soft drinks. They spent a great deal of energy in the giving or taking game. Despite limited funds, they were continually giving the "oral" staples to each other, with hostility and resentment which they consciously experienced but communicated poorly and with feelings of depletion, and taking with extraordinary minimization of their own taking. "They are all taking from me," they complained, "and they never give to me in return." With very little assistance from the therapist, they rather easily expressed their feeling of being manipulated; but they learned to what extent they were themselves manipulating only when they were ready to move toward more mature forms of relatedness. This giving or taking is extremely ambivalent. When they succeed in a swindle, they experience guilt, though rarely shame. When they are taken care of, they sow discontent and doubt in the relationship; after they reap its dissolution, they bitterly accuse themselves of stupidity and misbehavior. They recurrently seek a person to love who will take care of them, no matter how irresponsibly or provocatively they themselves may behave.

Sam, for example, entered into a close relationship with a girl his own age a few weeks after he had been discharged from a city prison in which he had had a thirty-day detoxification. While this relationship was developing, he was casually and irregularly using heroin. When his girl friend discovered this, she told him that he must give up drug use if he wanted to continue the relationship. They arranged in a dramatic fashion (not uncommon for adolescents) that they would separate for a week, during which he would maintain abstinence. After a week of complete abstinence, one hour before their planned meeting, Sam obtained heroin and arrived "stoned" (acutely intoxicated) at their rendezvous. Since she did not want to be involved with him as an addict, this provocation ended their relationship. Sam was bewildered by her behavior; if she really loved him, as she claimed, how could she leave him?

On the other hand, adolescent addicts repeatedly allow themselves to be swindled of money, drugs, or the women they are keeping (or, more accurately, who are keeping them). They "trust" inappropriately, that is, they trust that they will be exempt from a generalization which they offer with acerbity—"You can't trust a junkie." In brief, they repeatedly and, one suspects, compulsively re-enact a drama of getting and losing.

The second type of data indicating a disturbance in sexual identification and role behavior has to do with their explicitly sexual behavior and relationships. These data indicate that adolescent addicts exhibit conspicuous disturbances in their sexual behavior and relationships, which may be categorized as follows:

1. Concern over sexual inadequacy;
2. Deprecation of or expressed disinterest in sexuality;
3. Homosexual relationships and/or concern over homosexual attack;
4. Preference for cunnilinction over genital intercourse.

Apart from these symptomatic disturbances, we noted that they did not experience distress when their sexual drives were curtailed or their capacity for climax blunted or eliminated by heroin. Indeed, the casualness with which they gave up orgastic potency is one evidence of their psychosexual pathology; it is plausible to assume that one gives up or accepts impairment in an area of function only when that area has little or negative value. The following case material illustrates some of the explicitly sexual manifestations of the disturbance of sexual identification we have observed in adolescent addicts.

Joe began using heroin at the age of eighteen, while living in Chicago. He was introduced to heroin by boys four or five years older, whom he idealized as "men . . . who knew life." He originally hesitated to use heroin. Indeed, he had known people who had died from overdoses. With the encouragement of his friends, who assured him that no harm would come to him and that it would be a delightful experience, he began to use heroin irregularly, at most once daily. This pattern of heroin use was continued for seven to eight months. Although he stated that he experienced "relaxation and tiredness . . . which was very pleasant," he was particularly impressed by the regularity with which he experienced nausea; in fact, each time he used heroin, he would get "a miserable feeling, so sick to the stomach." From the beginning of his addiction history, he took heroin intravenously. Without being able to clarify the basis of this decision (further than to state that he did not like it any more), he decided to give up heroin use. He was able to do this without difficulty. This illustrates, incidentally, that use of heroin, even when it is taken intravenously, not infrequently, over a period of many months, does not ipso facto lead to addictive use of the drug.

Joe remained abstinent for eight months. In this period he left Chicago and returned to Jackson, Miss., his birthplace, where he courted his prospective wife. During his courtship, he was jealous and suspicious of Lucy. Although he went out on occasion with other girls, he threatened, with roughness and profanity, to hurt her if she went out with other boys. After a six-month courtship in which they went out together socially at least three or four times a week, they married. At this point, there was a remarkable change in their relationship. Joe no longer wished to go out socially at all, but he almost insisted that Lucy go out without him, with anybody she wished and without his supervision, control, or concern. He became aware all at once of his ambivalent feelings over the marriage. He felt he should not have married her. Although he had experienced sexual intercourse not infrequently since puberty (at age ten) he became distressed by the intimacy of marital life. He was ashamed of his body; he did not wish his wife to see him while he was taking a bath, dressing, or undressing. He thought that it is a blow to a man's pride to be seen naked by a woman. Other data pointing to the severity of his problem of sexual identification and role29 indicated that the marriage was more than he could cope with. His sexual interest in his wife disappeared. He was becoming more isolated and withdrawn.

About one month after his marriage, he experienced an urge to use heroin. At this time, in contrast to the situation when he was first introduced to heroin, he was not solicited by his peers, but rather spent the day almost frantically trying to "make a connection." Finally, in the evening, when he was about ready to give up and go home, he at last found somebody who would sell him heroin. From that time until he came to Lexington (four months later) in 1952 as a voluntary patient, he used heroin daily, increasing his dosage to three or four shots a day, for which he spent about $20 daily.

Joe's marriage was probably a last-ditch stand against his latent homosexuality and complex dependence on his mother. When this attempt to reassure himself of his masculinity by becoming a married man failed, he became an addict and, to support his addiction, a thief.

Carl, a twenty-year-old youth from Harlem, presented himself as a mature, responsible, hard-working young man from a good, cohesive family; as socially active; and as readily accepted by his peers, 'both male and female. He had had several moderately prolonged relationships with nondelinquent girls of his age in which sexual relationships developed out of and were accompaniments to warm mutual regard. He was engaged to marry a good girl who had been graduated from high school and was at that time working in a bank. His marriage date was postponed as a result of his addiction, which he imputed plausibly and nondefensively to deleterious neighborhood influences.

Carl could not, however, sustain this picture of himself Despite strong resistance—for maintaining such a façade was extremely important to him—almost every aspect of this façade crumbled beneath his anxiety. He began to indicate by the fourth or fifth interview that his sexuality was not what he wished it to be. In fact, he dreaded return to the community and the risk of readdiction explicitly for this reason.

Carl had, in fact, been extremely shy with girls since puberty. When he went out with a girl he was afraid even to put his arm around her; he was unable to speak easily or casually with her. When he was twelve, his pathologically jealous and socially withdrawn father separated from his mother. When Carl was fifteen, he was sent to North Carolina to get him away from the bad neighborhood influences which interfered with his schooling. Here, living with a maternal aunt, Carl developed greater ease and confidence in relating to girls. He became a "big flier," "an operator." When he was sixteen, his father died, and Carl returned to New York to help support his mother. His comfort with girls disappeared with his homecoming. However, when he began to use heroin regularly (though not as yet addictively) at eighteen, he found that his shyness melted away. He became verbally and sexually uninhibited with girls; in his own words, he became "a terrible man." Carl liked being "a terrible man." He met his fiancée after he began using heroin regularly.

In retrospect, he became concerned over his ability to sustain the relationship without the use of heroin. He observed that, when he was going with her and was unable to get a "shot," he lost interest in her. This,led to more regular and finally to addictive use of the drug. While in a New York City prison, he fantasied a reunion with his girl friend in which they would hug and kiss, freely and warmly expressing their affection. However, when he left The Tombs, he not only felt unable to kiss her spontaneously, but also, when she asked that he kiss her, refused to do so. After Carl returned to heroin use, he regained the jovial, relaxed, and easy-going "persona" through which he could express affection and participate, albeit rarely, in sexual intercourse.

Carl feared that this sequence—inhibition, taking on the heroin persona, readdiction—would recur after he left Lexington. Despite this, and characteristically for adolescent opiate addicts, he refused therapy because he hoped that his "will power" would keep him away from heroin while he developed new facilities to cope with his emotional problems. Carl married a few weeks after he left Lexington; after a few weeks of marriage, he was readdicted.

Carl's case illustrates a fairly common phenomenon among adolescent addicts—inhibition of sexual activity alleviated through heroin use. This is a consequence of the fact that heroin may diminish anxiety associated with sexuality more than it inhibits the sexual functioning per se. Parenthetically, this illustrates how complex the relationship is between activity, including sexual activity, and opiate use. Opiates depress activity, generally speaking, but also, as we shall elaborate in Chapter IX, inhibit anxiety. Consequently, the net effect of a particular dose of heroin may be to facilitate activity, when this activity had been markedly hampered by anxiety or by obsessive-compulsive symptoms related to controlling anxiety. Indeed, addicts sometimes report getting "drive" from opiates. This paradox stems from the multiple psychic effects of the opiates. The case study of RR" described how work inhibition was alleviated in the course of his heroin addiction, until the problems of being an addict in our society again hampered work even more than the heroin facilitated it by alleviating the obsessive-compulsive symptoms.

Mark, a twenty-year-old pimp from New York City, established parasitic, exploitative relationships with women. In his estimation, however, his women were never to be trusted. Mark had been in institutions since age sixteen in consequence of his addictive use of heroin. In the hospital where he was being treated by one of the writers, he was recurrently involved in fights with other boys because of implications that he was not enough of a man. He said that this happened to him in his earlier intramural treatment, too. Although, to the best of our knowledge, Mark has never engaged in homosexual relationships, he was extremely touchy about homosexuality and was consequently an easy target for other patients who found that they could get a rise out of him with such epithets as "intellectual faggot." Even so, Mark kept his fingernails polished with clear lacquer, was excessively vain about his hair and clothing, and spoke in a rather affected manner. At the same time, a major conscious concern was that he be helped to appear as a "real man." He solicited vitamin prescriptions in the hope that pills would help him to burgeon.

Two things are noteworthy about Mark's fighting. First, he did not look like a fighter, a "tough," or a trouble-maker. In fact, he had a reputation for pleasantness and exceedingly good manners. He presented himself to his therapist as a passive, weak victim of his mother's and sister's influence, to which he was compelled to submit. Apart from his fighting, he was a very good boy, a model patient. Second, Mark won all his fights. Despite concern over his body, he was muscular, tall, wiry, and as skillful as a boxer. After winning a fight, Mark suffered fears of revenge. He perceived his opponent (whom he would fight before an audience large enough to spread the news of his exploit to the total patient population) as a sneaky, treacherous, and unfair person who would get him "on the street" and would probably put a knife in his back. Thus, win or lose, Mark felt attacked and probably provoked attacks by other men. As he saw them, they were all out to stick their hard, penetrating weapons into his unprotected soft spots.

Mark's case illustrates a common phenomenon among adolescent addicts. On one side is the big man who exploits women; on the other is the little boy preoccupied with thoughts of the insufficient masculinity of his body, the insufficient recognition of his masculinity by his peers, and the fear (wish) that he be hurt and attacked (sexually invaded) by other men.

The third type of data indicating disturbance in sexual identification and role has to do with the persona of the addict, his façade, the trappings he displays to the world outside. These somewhat theatrical phrases are especially apt since adolescent addicts are so often like actors. Their roles are fluid, changing, so little an expression of a hard core or perhaps so different from the true core of themselves. To use Erik§on's terms, they suffer from "role diffusion" in an almost explicit sense of that phrase.

A recurrent phenomenon observed by one of the writers, when he conducted diagnostic conferences at Riverside Hospital, was the frequency of flagrant discrepancies between the life history of the patient as reconstructed, respectively, by the psychiatric social worker, the psychiatrist, and the clinical psychologist from one or two interviews with the patient. These discrepancies related not only to the distant aspects of the patient's experiences but also to those immediate events which led to his hospitalization. At times, this led to bitter discussion within the staff. Whose life history was the most accurate?

The most evident source of confusion probably lay in the fact that each of the observers felt that he had established such "good rapport" with the patient that the latter could not possibly have been telling lies to him, that perhaps he had misstated his situation to the other interviewers. Not only were there discrepancies in the life-history data collected by these observers, but there were also hotly argued discrepancies in descriptions of what the patient "was like." A psychiatric social worker described patient Z as soft, passive, and helpless. The psychiatrist perceived him as ingratiating, manipulative, and cool. The clinical psychologist perceived him as aggressive, cunning, and deceitful. In view of the fact that these were not recurrent descriptions utilized by these observers, that the social worker, for instance, might perceive patient Y in the same terms that the clinical psychologist perceived patient X, it seems most likely that these youths present various aspects of themselves to various observers in a bewilderingly luxurious variety of roles. This role-playing is largely unconscious. The roles are evoked by the differing situations and by the differing object of the relationship. This phenomenon is sometimes alluded to as influenceability or as an extraordinarily well functioning "radar system"—a lack of innerdirectedness.

Despite their role diffusion, there are certain aspects of the personae of adolescent addicts which are recurrently described in the literature and noted in our own observations, ways of expressing themselves to the world which are, despite the fluidity and changeability of their role-playing, fairly consistent and which point to the weakness of masculine identification.

They are soft-spoken, well-mannered, and graceful. They present themselves not as toughs, but as gentlemen. As a group, they are good-looking youngsters, often handsome, rarely ugly. They tend to be well-built and roundly muscled, to have symmetrical faces. These impressions were confirmed by our contacts with control subjects, who as a rule were not nearly so handsome, graceful, or "gentlemanly."

An extraordinarily high proportion of adolescent addicts can be seen as "pretty boys." They would not appear out of place in a musical comedy chorus. They are vain of their appearance. They spend much time preening. They are preoccupied with clothing, which they wish to be of the finest materials and the latest styles. They spend much time before their mirrors experimenting with their hair, moustaches, and goatees.

None of these preoccupations are alien to adolescent boys; the difference is of degree and not of kind. The degree to which adolescent addicts exhibit these traits and activities suggests the usual traits and activities of adolescent girls. Adolescent addicts do not look, behave, or deport themselves as adolescent boys usually do; they do not try to appear manly, rugged, vigorous, energetic, rough-and-ready.

These observations suggest that they have strong feminine identifications, a conclusion to which Zimmering et al.,3' Fort,32 and the Chicago clinics33 independently subscribe. A variety of data are offered by those authors illustrating feminine tendencies, interests, occupational goals, and the like.

There are occasional exceptions. Some adolescent addicts are persistently and actively occupied with proving that they really are manly. They behave in an aggressive, hostile, argumentative manner. They are afraid to express or receive warm or sympathetic feelings. They are afraid that they will be found out, that someone will "get the wrong idea" about them. They approach the interviewer with the attitude that he is trying to "bug" them, and they will not give him a chance to do so. They tell with pride how they viciously assaulted a homosexual who accosted them, as though to say: "See how little I would want anything like this for myself, I practically killed him for thinking that. . . ."

They try to impress the observer with their independence and bravery, with their ability to function well in the most difficult circumstances. They know better than any middle-class professional person what life really is. They boast of their exploits with women, crime, and narcotics to prove what strong men they are. In one of Shakespeare's telling observations, they do protest too much; the psychologically trained observer cannot help but see through to the problems of masculine identification beneath the veneer of masculinity.

Though only the minority of adolescent addicts are actively occupied with proving their masculinity, almost all are at least episodically involved with the same issue. As a group, they respond with extreme sensitivity to remarks which might challenge their identification as men. They can be led into a variety of delinquent behaviors through teasing; not appearing "chicken" or "square" is crucial to them. Even though their manner, appearance, and concerns so clearly suggest feminine identification, or perhaps consistent with the fact that this is so, they are often involved in defensive, compensatory behavior intended to assert, guarantee, and define their manhood. Most evident among these are their institutional misbehavior and disciplinary problems. When the hospital staff attempts to impose controls which would be accepted, though not enjoyed, by most adolescents, adolescent addicts perceive this as a threat to their masculinity, so that they are regularly involved in such problems as truancy, keeping late hours, refusing to get up in time for breakfast, and refusing to turn the lights out at some curfew hour. They will let nobody tell them how to conduct themselves, for to do so implies that they are not man enough to know for themselves.

STATISTICAL FOOTNOTES

a Some relevant statistics, medians given in the order addict—control: R:20, 25; F + per cent: 80, 73; F per cent: 80, 71; M: 1, 2; Sum C: 1.5, 2.5. These group differences are all significant, by the Mann-Whitney U test, at .05.

b Percentages producing fewer than ten new responses: 50, 17. Percentages making regressive use of color (CF or C >FC): 89, 31. Median decrease in F + per cent as compared to initial administration: 11.5, 3.

 

1 The reader is reminded that the generalizations which follow are based on study of addicts and need not apply to nonaddicted users of opiate drugs. It should also be emphasized that the relevant experience and data were accumulated before the classification of addicts described in Chapter II was developed. Insofar as there are systematic personality differences among the four types, the failure to make the distinctions would tend to result in a blurring of the image of the addict. In retrospect, we think that the characterization which follows most clearly applies to addicts who have both craving and personal involvement. It would probably also apply fairly well to the other three types, but we would expect much more individual variation from the modal picture; and there may be variation among the four types in the salience of various characteristics, as well as of characteristics of individual types that would have emerged if we had known enough to keep them separate. This is, of course, a matter for future research.

2 D. L. Gerard and C. Kornetsky, "Adolescent Opiate Addiction: A Study of Control and Addict Subjects." Psychiatric Quarterly, 29 (1955) 457-486. This study was conducted while its authors were commissioned officers in the United States Public Health Service, working with the Laboratory for Socio-environmental Studies of the National Institute of Mental Health. Although a close working relationship between these investigators and the N. Y. U. group began late in 1952, when Gerard and Kornetsky began to assemble their control subjects, Dr. Gerard did not join the N.Y.U. group until 1954.

3 The criteria for selection were: residence in a high-drug-rate census tract in New York City, in the sixteen—to—twenty-one age range, not attending college, no history of opiate addiction, no current drug use, and no record of delinquency. A history of nonaddictive use terminating six or more months before they were contacted did not preclude the inclusion of such individuals as controls. In addition, the restriction was introduced that the control sample should as nearly as possible match the addict sample for ethnic composition. Controls were paid $5 an hour for participating, and each gave at least three hours.

4 Although there was a statistically significant difference in the median intelligence quotient for the two groups (101 for the addicts, versus 108 for the controls), there was great overlap between the two groups (the range was 82 to 133 for the addicts and 88 to 127 for the controls). The two groups were not materially different with respect to IQ. Even so, other obtained differences were systematically checked for the possibility that they might be attributable to the difference in IQ; in no instance was this the case.

5 This test consists of ten plates, each a reproduction of an ink blot originally formed by dropping some ink on a page and folding the paper. Three of the blots were formed entirely from colored inks; two used red ink in addition to black. The subject is asked about each blot, presented in a standard sequence: "What might this be?" The subject's responses are coded according to various criteria, and scores are derived by counting the number of responses of each type' and by computing various percentages or ratios. Apart from standard intelligence tests, the Rorschach is probably the most widely used test in clinical psychological practice. One way of understanding this test is to view it as a microcosm, behavior in which is coordinated with styles of behavior in the ordinary macrocosm. The subject may give an unlimited number of responses to each blot. These responses are classified according to the portion of the blot involved (e.g., the entire blot, some part of the blot, and, if the latter, the kind of part or the white space); the determinants or formal properties of the blot that determine the response (e.g., the shape and spatial differentiation of the portion of the blot involved, the color, the shading, and what is commonly taken as a "projection" by the subject—the injection of movement into the perception of human or humanlike figures); and the content or subject matter (e.g., human being, part of a human being, animal, animal detail). Some responses are classified as "popular" (i.e., commonly given) and some as "original" (i.e., rarely given). Responses may be classified in accordance with how well the percepts fit the portion of the blot involved. Other kinds of data are available for analysis, e.g., the time it takes to give the first response to a blot, the failure to give any response to a particular blot, certain aspects of the sequence of responses, and so on. The coding-and-scoring scheme used in the present study was that of Samuel J. Beck, Rorschach's Test, "I. Basic Processes" (New York: Grune and Stratton, 1954).

6 This is a device introduced by Jernigan to study the effects of "stress" on the functioning of the individual. Cf. A. J. Jernigan, "A Rorschach Study of Normal and Psychotic Subjects in a Situation of Stress" (doctoral dissertation, University of Kentucky, 1951).

7 P. Zirnmering, J. TooIan, R. Safrin, and S. B. Wortis, "Heroin Addiction in Adolescent Boys," Journal of Nervous and Mental Disorders, 114 (1951), 19-34.

8J. P. Fort, "Heroin Addiction among Young Men," Psychiatry, 17 (1954), 25.

9 Walter A. Adams, Annual Report on the Activity of Medical and Counseling Clinic of Provident Hospital and Training School (Springfield: Illinois Department of Public Health, 1954).

10 Zimmering et al., op. cit., p. 29.

11 Cf. E. Erikson, Childhood and Society (New York: Norton, 1950).

12 This statement, however, needs to be qualified in the light of the finding by Schiff, referred to in Chapter VII, that the onset of drug use in adolescence helps to preserve the addict from confronting his failure to make an effective transition to maturity. In other words, the addict would probably fail to mature properly in any case. The danger lies in the fact that the "helpfulness" of the drug in maintaining the level of self-esteem in the face of failure deprives the addict of the motivation to benefit from efforts to help him improve his condition. In the absence of such efforts, he is, at least in this respect and for some period of his adult life, "better off."

13 Cf. Otto Fenichel, The Psychoanalytic Theory of Neurosis (New York: Norton, 1950), p. 84: " . . . children frequently are in love with themselves [secondary narcissism] . . . capable of distinguishing objects and of loving objects as long as the objects procure satisfaction."

14 Loc. cit. "This [self-love], however, is certainly not yet love. One can speak of love only when consideration of the object goes so far that one's own satisfaction is impossible without satisfying the object, too."

15 Fenichel, op. cit., p. 377.

16 Zimmering et al., op. cit.

17 Benjamin Boshes, Lee G. Sewall, and Mary Koza, paper read at the May, 1955, meeting of the American Psychiatric Association.

18 It should be recalled that the Schiff study did not include normal controls.

19 Like the Rorschach, the TAT is a test widely used for the assessment of personality. It consists of a series of pictures for each of which the subject makes up a story. Experience supports the view that the central characters and other features of these stories reflect various facets of the personality.

20 Leon Brill, "Some Notes on Dynamics and Treatment in Narcotic Addiction," Journal of Psychiatric Social Work (1954), 67-81, p. 71.

21 Fenichel, op. cit., p. 377.

22 Zimmering et al., op. cit.

23 Adams, op. cit.

24 Boshes et al., op cit., p 8.

25 Zimmering et al., op. cit.

26 Adams, op. cit.,

27 It does not seem "distinctive" to us, since in our experience similar clinging also commonly occurs between schizophrenics and their mothers.

28 E. Erikson, Childhood and Society (New York: Norton, 1950).

29 Data suggesting latent homosexuality included repetitive formation of tense friendships of short duration with older men in which the predominant theme of their interactions was discussion of the older man's sexual prowess, to which Joe listened with rapt attention.
Data suggesting a wish for sexual closeness with his mother included: "She looks too young to be my mother." "I'm crazy about her." "She treats me like a baby instead of like a man." Joe felt neglected when his mother encouraged him to independence, yet resentful when she did things for him.

30 Donald L. Gerard and Conan Kornetsky, "Adolescent Opiate Addiction: A Case Study," Psychiatric Quarterly, 28 (1954), 367-380.

31 Op. Cit.

32 1. P. Fort, "The Psychodynamics of Drug Addiction and Group Psychotherapy," The International Journal of Group Psychotherapy, V (April 1955), 150-156.

33 "Drug Addiction among Young Persons in Chicago," A report of a study conducted by the Illinois Institute for Juvenile Research and the Chicago Area Project (October 1953.)

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