Issues in Controlled Substance Use Papers and Commentary, Conference on Issues in Controlled Substance Use (1980) / Chapter Skim
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Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices
Redemption of the Overuser: An Appraisal of Plausible Goals and Methods for Changing Substance Use Practices
Pages 96-141
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From page 96... ...
. In this paper we will discuss the multicausal roots of overuse and the manner in which ecological perspectives are applied in three alternative models that shape treatment goals and methods to control overuse and excess: the medical model, the holistic model, and the redemption model.
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From page 97... ...
Likewise, health effects may not influence a decision to stop what others consider heroin overuse as much as may social pressure, either through the threat of jail or through the economic consequences of law enforcement that make heroin too difficult and expensive for use to be maintained. Definitions of overuse are often based on the consequences of use.
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From page 98... ...
Long-term consequences of even limited amounts of alcohol use over time may include damage to physical health by destruction of brain cells or by increased susceptibility to various other parts of the body as well as damage to emotional health through stressful social situations. Relatively light or moderate cigarette smoking similarly affects short-term and long-term health outcomes.
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From page 99... ...
Patterns of substance use are also influenced by the kinds of help made available to curtail overuse. Should society provide free psychiatric care, the user may perceive overuse in the context of the medical model and may consequently resist help.
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From page 100... ...
A knowledge of those factors that promote behavior falling within the social definition of substance abuse or, for that matter, any other excess behavior is a precondition for their manipulation. And it is the manipulation of the determining variables that allows the alleviation of the excesses.
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From page 101... ...
set (host) substance (agent)
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Excessive behaviors engaged by "commonly abused substances" on one hand and persistent activities on the other have in common a
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It has been difficult for ethical reasons to conduct experiments to analyze the acquisition, maintenance, and cessation of excessive behaviors engaging drugs and the like in human subjects, and an experimental analysis of other excessive behaviors in humans has scarcely begun. Therefore, the experimental data base on which to draw direct evidence is small.
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From page 104... ...
For present descriptive purposes, a host may be regarded as being in hazard of developing substance abuse and raaladaptive habitual behaviors if there is a paucity of repertoires, or if they are poorly articulated or inflexible with regard to situational requirements. In their original contacts with invading Caucasians, for example, Native Americans had no individual knowledge of or social rituals concerning the safe use or consequences of "firewater." The Multidimensional Environment The environment has physical, cultural, social, and emotional dimensions.
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From page 105... ...
appear to be absent, seems to us to be highly plausible. Animal research has helped to describe the conditions that generate adjunctive behaviors (Falk, l969; l97l)
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(2) Substance abuse has been produced by generating adjunctive behavior.
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From page 107... ...
We have selected three models from the array of available alternatives to illustrate how emphasis on host, agent, environment, or some combination of interaction among these factors influences goals and methods for working with individuals who are self-motivated or motivated by others to change behavioral repertoires involving substance overuse or other excess behavior. We will discuss the medical model, which is widely employed in public and private programs, the holistic model, which has growing numbers of supporters, and the redemption model, which is less frequently considered.
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From page 108... ...
. Thus, while the medical model focuses primarily on altering agent-host variables, with consideration of such key environmental forces as the family, the holistic model more heavily stresses multiple interactions among host-agent-environment and proposes that environmental intervention be a prime target in treatment (Hayes-Bautista and Harveston, l977, pp.
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From page 109... ...
It resembles the medical model in viewing the host as a deviant and is unlike the holistic model in placing society above reproach. In redemption, the overuser has behavioral repetoires that include amoral agents that separate "us" from "them." The redemption process aims to re-educate the amoral host in order to avoid social isolation and stigma.
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From page 110... ...
Assessing the validity and generality of this concept is important for both theoretical and practical considerations. THE REDEMPTION PROCESS Ambivalence as a Motivating Force in Overuse When a user weighs benefits and risks of use performances, it is not unlikely that personal ambivalence accompanies some proportion of motivation to reduce or stop overuse as well as motivation to engage in
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From page 111... ...
Total Abstinence Fig. 2: Coals for liters Achieving the goal of controlled use for such addictive agents as heroin is projected for fewer users in contrast vith an addicting agent such as alcohol where lost users are projected as capable of achieving controlled use.
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From page 112... ...
For example, once society at large and a significant segment of the individual's own social contacts define overuse as reprehensible, punishing effects are brought into play to offset the intrinsic effects of the overused agent and the social bonds between users serving to strengthen and maintain excessive behavior. One might expect that the censure of society at large would be sufficient to reduce severely the future probability of overuse.
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From page 113... ...
The Alcoholics Anonymous model applies this principle to aid abstinence. If the ecological configuration of factors that produce undesirable excessive behavior remains in effect, substitution may be one of the best strategies for reducing overuse and excess behavior.
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From page 114... ...
For example, the health value to the patient of a heroin prescription must be weighed against the likelihood of the prescribed heroin being sold on the street. These are not uncommon issues for redeemers and they raise significant questions about the appropriateness of an uncritical acceptance of the medical model.
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From page 115... ...
In addition, while redemption goals are actually set by the overuser, they may be influenced by the redeemer and others significant to the overuser's world. It has been most expedient to apply the medical model in arriving at goals for the organization and delivery of redemption programs, although attempts to modify environmental factors through job training and placement, housing relocation, and family counseling indicate a trend toward a more holistic model.
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From page 116... ...
If we consider a redemption goal to fall within the continuum from total abstinence to some form of controlled use of the overused substance, what should the attitude of the redeemer be toward the various options? For the majority of overusers, significant reduction of use, at least during the redemption process, is a realistic goal.
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From page 117... ...
In redemption, the development of such a profile has often been hampered by the traditional medical model and its preconceptions of the addict and addiction. The major diagnostic determinant of overuse, for example, has typically been the primary chemical of abuse rather than the personality and the overall clinical and social characteristics of the overuser.
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From page 118... ...
The ASI is used throughout redemption to measure the extent to which redemption goals and methods are succeeding to control overuse. OUTCOMES OF REDEMPTION Several problems prevent clear understanding of the efficacy of redemption methods, not the least of which is the lack of systematic data on overuse (see Levison and Stunkard in this volume)
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From page 119... ...
There are many advocates of holistic diagnosis to develop and apply valid redemption goals and methods. Such advocates claim that this diagnosis is necessary to select the most appropriate treatment plan.
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' I ft > • m " cost-effective t» 8 C u e o M 1 O «I u 0 3 in |
From page 121... ...
Both the medical and redemption models afford limited approaches for formulating goals and methods to minimize the causes and effects of overuse and excess behavior. The former model's focus on the agent of overuse and the latter's focus on host conformity to external environmental standards of use ignore the complex, multifaceted environmental system that appears to influence etiology, maintenance, and change in addictive processes.
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From page 122... ...
The significance of what we are treating impacts not only on the redemption process but also on the outcomes. If there is some basic mechanism underlying overuse, the possibility exists that those whom we attempt to redeem from one substance may simply adopt another.
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Under what conditions might coercion work? If controlled use is the redemption goal, prospective studies of success in attaining controlled use are required.
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(l976) A medical model vs.
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Evaluation of substance abuse treatment. Health Services Research and Development, Project 284, Veterans Administration Hospital, Coatsville.
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In Proceedings, Conference on Commonalities in Substance Abuse and Habitual Behavior. Committee on Substance Abuse and Habitual Behavior, National Research Council.
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From page 127... ...
Medically, any nonmedical use is abuse by definition, so that the social circumstances of use become important. The concept of substantiality, as explained in the paper, is used to define overuse as use to a point at which physical or emotional health is at a critical threshold of damage, but using substantiality as a criterion for defining overuse is extremely complicated; what is reasonable, harmless use for one group or individual is not for another.
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From page 128... ...
Obviously, nobody would take the word of junkies about how effectively they had been treated, nor would anybody take the word of the people who ran the treatment programs because they might be biased in favor of their own programs. In their attempt to develop objective measures, Dole and Nyswander, the originators of the methadone maintenace method, focused on things like the number of crimes and arrests following treatment.
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From page 129... ...
The entire subject was distasteful to them, and one way of expressing that distaste was to restrict their knowledge. Restricted knowledge about drugs can affect drug users in many ways.
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From page 130... ...
The setting can be more readily manipulated than the drug or the individual, particularly if we look at the relationship between formal and informal controls. For example, formal controls on drinking, such as reducing the proof of liquor, represent attempts to influence drinking that are part of a socially evolving process.
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From page 131... ...
Education of the public at large holds great promise for developing changes in informal controls. This must be part of the changing concept of redemption that encompasses the relationship between drug, set, and setting and is part of a social historical process.
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From page 132... ...
. Concept papers and deliberations of groups such as this can be extremely helpful to program planners, not only in terms of advancement of knowledge and skills in dealing with substance abusers, but also in terms of supportive and interpretative communications to legislators and funding agencies.
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From page 133... ...
For example, the medical model is too narrowly perceived and anachronistic. To my knowledge, there are very few substance abuse treatment programs that focus on the origin of illness within the host.
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From page 134... ...
Economic factors that exacerbate the substance abuse problem, such as rising unemployment rates, inflation, inadequate housing, and inadequate education, are deplored and attacked piecemeal instead of in a coordinated system that gives the primary value to the need of each citizen to feel competent and capable of achieving a decent quality of life. In passing, there are several groups involved in drug abuse treatment who employ a redemption model philosophy: Ten Challenge, Hasidic Judaism, Seventh Day Adventists, Mormons, etc.
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From page 135... ...
The assumption was that the courts diverted addicts to drug abuse treatment programs primarily when they were supportive of the principle of rehabilitation. We found that it was impossible to identify two matched cohorts.
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From page 136... ...
Some people in the drug abuse treatment community resented the use of any drug abuse funding for this activity, pointing out that alcohol and mental health programs did not have to expend the same amount of effort to justify their existence. We agree that the drug abuse treatment system is in the vanguard of evaluative research, probably because drug abuse is a frequent source of political controversy (i.e., the deployment of resources for supply reduction versus that for demand reduction)
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From page 137... ...
And then work up toward the substances that invite sympathy rather than condemnation -- and probably not to even take on yet the inherently controversial subject of illicit drugs. Several reasons may be given for this approach.
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From page 138... ...
And I particuarly have in mind the ways that people try to protect themselves from their own habits. I incline to the view that in most discussions of addictive and habitual behavior not much credit is given to the possible conscious exercise of control over their own behavior that people may be capable of.
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From page 139... ...
One is simply that most people know very little, and don't know where to go to learn more, and have never had any training, with respect to the control of habits, whether innocuous or serious habits. Some people have discovered only by accident that changing their hair style is enormously helpful in avoiding a hair pulling habit, or that professional manicures can be enormously helpful in nail control, or that certain tools and implements can double their reading speed, or that changing the time of day for exercise will help them stay on a regime.
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From page 140... ...
Johnson commented that some have contended that treating alcoholism (or other forms of substance abuse) is disadvantageous from a cost-benefit standpoint.
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From page 141... ...
l4l Conversely, formal antidrug ads in the late l960s were rarely effective, since there was great sentiment in favor of drugs among many young people. De Rios stated that regardless of the social situation, media messages can impact usage.
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