Detailed information on ADHD children in the classroom: How ADHD affects a child's learning ability, ADHD medication during school, and helpful school accommodations for children with ADHD.

What is ADHD?

Attention Deficit Hyperactivity Disorder is a neuro-developmental disorder, the symptoms of which evolve over time. It is considered to have three core factors, involving inattention, hyperactivity and impulsivity. In order to have a diagnosis of ADHD the child would need to show significant problems relating to these three factors which would then constitute an impairment in at least two different settings, usually home and school.

The child with ADHD is easily distracted, forgets instruction and tends to flit from task to task. At other times they may by fully focused on an activity, usually of their choice. Such a child may also be over-active, always on the go physically. They are often out of their seat and even when seated are restless, fidgety or shuffling. The phrase "rump hyperactivity" has been coined to describe this wriggling restlessness often seen in children with ADHD when they are required to sit in one place for a length of time. Often children with ADHD will speak or act without thinking about possible consequences. They act without forethought or planning, but also with an absence of malice. A child with ADHD will shout out in order to be attended to, or will butt into conversation and show an inability to wait their turn.

In addition, to the three core factors there are a number of additional features which may be present. Most children with ADHD need to have what they want when they want it. They are unable to show gratification, being unable to put off the receipt, of something that they want, for even a short period. Linked to this they also show "temporary myopia", where they have a lack of awareness or disregard for time - they live for the present, where what has gone before or what might be to come is of little consequence.

They may show insatiability, going on and on about a particular topic or activity, not letting the matter drop, with constant interrogation until they receive what is an acceptable response to them. Frequently they have a social clumsiness where they are over-demanding, bossy, over-the-top and loud. They misread facial expression and other social cues. Consequently even when they are trying to be friendly their peers can isolate them.

Sometimes there is also a physical clumsiness, occasionally because of their impulsivity, but also perhaps because of poor co-ordination. Some of these problems may be related to developmental dyspraxia, which is a specific learning difficulty sometime seen alongside ADHD. These children will also be dis-organised and experience problems with planning, tidiness and have the right equipment for a task.

As well as the developmental dyspraxia, many other difficulties can be present in children with ADHD. These include other specific learning difficulties e.g. dyslexia, Autistic Spectrum Disorders, Oppositional Defiant Disorder, Conduct Disorder, etc.

At Primary School age up to 50% of children with ADHD will have additional problems of oppositional defiant behaviour. About 50% of children with ADHD will experience specific learning difficulties. Many will have developed low self-esteem in relation to school and their social skills. By late childhood children with ADHD who have not developed some co-morbid psychiatric, academic or social disorder will be in the minority. Those who remain as having purely ADHD are likely to have the best outcome in relation to future adjustment.

Additionally some professionals suggest that any primary age child who has developed Oppositional Defiant Disorder or Conduct Disorder will have ADHD as the primary problem, even if this is not immediately evident from their behaviour. At present, a diagnosis of ADHD is usually determined through referral to DSM IV criteria. (Appendix 1) There are three types of ADHD recognised: - ADHD predominantly hyperactive/impulsive; ADHD predominantly inattentive; ADHD combined. The ADHD predominantly inattentive is what used to be referred to as ADD (Attention Deficit Disorder without the hyperactivity).

Generally, it is considered that there are five times as many boys than girls who show ADHD (HI), compared with twice as many boys to girls who show ADHD (I). It is recognised that around 5% of children are affected by ADHD, with perhaps about 2% experiencing severe problems. It should also be noted that some children will show aspects of an attentional deficit, which, although significant from their point of view, would not trigger a diagnosis of ADHD. There is a continuum of severity of problems in such a way that some children will have an attentional deficit but will not be ADHD. Yet others will show attention problems but for other reasons, for example, daydreaming/inattention because of something on their mind e.g. family bereavement.

ADHD - Probable Causes

It is generally agreed that there is a biological predisposition to the development of ADHD, with hereditary factors playing the most significant part. It is likely to be the genetic transmission which results in dopamine depletion or under-activity in the prefrontal - striatal - limbic regions of the brain which are known to be involved in behavioural disinhibition, which is considered to be most significant in ADHD, sensitivity to behavioural consequences and differential reward. Dopamine is a neurotransmitter, which facilitates the action of neurones by allowing passage of messages across the synaptic gaps between neurones. The condition is made worse by perinatal complications, toxins, neurological disease or injury, and dysfunctional child rearing. Poor parenting doesn't itself cause ADHD.

In looking at potential predictors of ADHD there are several factors, which are found to be predicative of ADHD. These include: -

• a family history of ADHD
• maternal smoking and alcohol consumption during pregnancy
• single parenthood and low educational attainment
• poor infant health and developmental delay
• early emergence of high activity and demanding behaviour in infancy
• critical/directive maternal behaviour in early infancy

As baby's children with ADHD tend to be colicky, difficult to settle, failing to sleep through the night and show delayed development. Parents will make comments, which reflect aspects of the ADHD - "He never walks, he runs", "I can't turn my back for a minute", "The terrible two's just seemed to go on forever". Parents often feel embarrassed about taking their child anywhere. The young child with ADHD is more accident-prone, probably because of the high speed of movement, lack of caution, over-activity and inquisitiveness. Often they have relatively more files at the Accident and Emergency Unit. Toilet training is often difficult which many children not bowel-trained until after three years and they continue to have accidents long after their peers do not. There is also found a strong association between ADHD and enuresis. There is the suggestion that ADHD should not be diagnosed in a child under the age of three years, perhaps the term 'at risk of ADHD' is more appropriate.

Diagnosis is usually made once the child is at school, where sitting appropriately, attending to directed activities and turn taking are expected of all children.

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Impact of Children with ADHD on School Staff

Within the UK, there has been a gradual increase in the number of children diagnosed as having ADHD. Many of these children will be prescribed medication, to such an extent that it has been suggested that the 3R's are now made up of reading, writing and Ritalin.

There is the recognition that there is therefore the need to increase staff awareness about ADHD and it's implications. To this end Lennon Swart, Consultant Clinical Psychologist, and myself (Peter Withnall) were commissioned by a Multi-Agency Working Group in Durham to produce an information leaflet for teachers, proving awareness raising details covering diagnosis, associated disorders, causes, possible classroom strategies, medication and possible side effects of medication.

Once teachers are aware of ADHD and it management they are in an ideal position to help in the assessment, diagnosis and monitoring of pupils with ADHD in their schools. All too often, however, the first that they hear of any child with ADHD being diagnosed and treated is from the parent, sometimes even from the child, with an envelope with medication. This is not a satisfactory approach and does not encourage school staff "on board" in a child's treatment.

There are also other effects on staff, which can make things more difficult if they are not aware of them. For example, off task and inappropriate behaviour has an effect on shaping a teacher's behaviour, over time students who perform badly are praised less and criticised more. Teachers tend to take appropriate behaviour for granted and therefore provide low rates of positive reinforcement even when the child with ADHD is behaving appropriately. In terms of rating the performance and behaviour of children with ADHD it is likely that the ADHD provides a negative halo effect in terms of a teacher's perceptions, where the children are seen as worse than they actually are.

However, adults who had been hyperactive as children report that a teacher's caring attitude, extra attention and guidance were the turning point in helping them overcome their childhood problems. Also, if teachers perceive that their opinions are sought, respected and valued and that their input is important in the process they will be advocated in the child's treatment and management.

Teaching staff are often the first people to express concern about children who have or may have ADHD. Many professionals feel that school is the optimal place in which to diagnose ADHD, with some clinician suggesting that school impairment must be an essential component if the diagnosis is to be made.

To this end it is helpful if school staff monitor and record a child's behaviour once a concern has been expressed. Frequently they will be asked to complete a questionnaire or rating scale to provide the clinician with quantitative information. The most frequently used rating scale is the Connors Teacher Rating Scale, the short version of which consists of 28 items to be rated on a four-point scale. Quantitative information is then calculated in relation to four factors - oppositional, cognitive problems/inattention, hyperactivity, ADHD in - the raw scores from the ratings having had the age of the child taken into account. The ADHD index provides an indication of the 'risk of ADHD'.

Re-administration of this scale may also be carried out in order to assess the effects of any treatment / management strategy. A shortened version, of ten items, call the Iowa-Connors Rating Scale may also be used to monitor treatment effects.

ADHD in the Classroom

Children with ADHD have problems with their cognitive processes in terms of working memory, temporal myopia and the associated difficulties of disorganisation and poor planning, as well as the behavioural aspects involving impulsivity, inattention and over activity. Many children with ADHD also have problems with social interaction and social rejection because of their behaviour and poor social skills. This, along with the likelihood of aspects of specific learning difficulties, results in failure within the classroom and a low self-esteem. This all results in a downward spiral for the child.

'Self-esteem is like a rain forest - once you chop it down it takes forever to grow back' Barbara Stein (1994)

Intervention Strategies

It is recognised that multi-modal responses to the management of ADHD are the most appropriate and beneficial. However, by far the most effective single approach is that involving medication.

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Use of ADHD Stimulant Medication During School Hours

Drug therapy can be an integral part of treatment but show not be considered the only treatment for ADHD. However, it has been found that it is effective in up to 90& of the children diagnosed as having ADHD. It is important that there is a diagnostic evaluation before starting treatment and for continued monitoring during treatment. The drugs commonly used are Methylphenidate (Ritalin) and Dexamphetamine (Dexedrine). These are psycho stimulants. They have what might be considered a "paradoxical effect" in that they "calm the child down", but do so by stimulating the inhibitory mechanisms, thus providing the child with the ability to stop and think before acting.

Stimulant medication was first prescribed for children in 1937, with this increasing signification in the 1950's when Ritalin was released for used in 1954. It is reportedly one of the safest paediatric drugs in current use.

Dosage and frequency requirements are highly individual and depend only in part on the size and age of the child. Indeed, it is often found that higher doses are required for younger, smaller children that are needed for older adolescents. Each dose provides improved attention for about four hours. Both drugs act within thirty minutes and the effects peak after about one and a half hours for Dexamphetamine and after about two hours for Methylphenidate. The Methylphenidate appears less likely to produce any unwanted side effects so this is generally the first choice. The effectiveness of the medication can be monitored with the use of behaviour rating scales and side-effect rating scales completed by teachers and parents, in addition to home-based and classroom observation. The usual mode of application consists of three doses, four houses apart, e.g. 8am, 12 noon and 4pm. Variations do occur, in order to meet the individual student's needs. Some psychiatrists recommend a mid-morning dose, for example, so that the pupil's attention and concentration are not impaired for the last hour of morning school but also to help their impulse control during the less structured lunch break.

The beneficial effects are often noted from the first day of use of medication. The behavioural effects are well documented and are:

• reduction in classroom disruption
• increase in on-task behaviour
• increased compliance with teacher requests
• decrease in aggression
• increase in appropriate social interaction
• reduction in conduct problems

Children are generally calmer, less restless, less impulsive, less insatiable and more reflective. They can complete work without supervision, are more settled, more organised, with neater writing and presentation.

Children with hyperactivity tend to respond more consistently to stimulant medication than those without. What must be noted is that if a child in unresponsive to one of the psycho stimulants it is still reasonable to try another, as they tend to work in slightly different ways. It has been reported that up to 90% of children with ADHD respond well to one of these forms of medication.

Possible Side Effect of ADHD Medication

The vast majority of people have no significant side effects from Ritalin; however, the unwanted effects of psycho stimulants may include initial insomnia (especially with a late afternoon dose), suppression of appetite and depression of mood. These can usually be avoided by careful attention to the dosage and its timing. Other common side effects are weight-loss, irritability, abdominal pain, headaches, drowsiness and a proneness to crying. Motor tics are a rare side-effect but do occur in a very small proportion of children being treated with medication.

Some children experience what has been termed a "rebound effect" in the evenings, when their behaviour appears to deteriorate markedly. This may be a perceived deterioration in that it may simply be a return to the previous behaviour pattern evident prior to use of medication, once the effects of the afternoon dose have worn off. Also occasionally children who are in effect receiving too high a dose can show what is termed a "Zombie state", where they show cognitive over focussing, blunting of emotional response or social withdrawal.

Consequently, although many of the most serious possible side effects are rare, their potential impact means that children on medication should be monitored very carefully. This monitoring is necessary in relation to the beneficial effects as well as the unwanted effects. If the medication is not having the desired effect then there is no point in continuing with this course of action, bearing in mind the previous comment in relation to the possible use of other psycho stimulant medication. Information from school concerning the monitoring must be made available to the person prescribing the medication. It needs to be realised that school staff can provide essential, critical, objective information on the child's response to the medication and any other interventions. A monitoring form is included later.

It must be remembers that individual children differ in their response to medication, with increased variation and lack of predictability more evident with children who have recognised neurological damage.

Medication is seen as one component of intensive long-term treatment of ADHD. It must be remembered that this is a chronic disorder for which no short-term treatment is sufficient or effective, although at times the effects of medication can be almost magical.

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Classroom Organisation and the ADHD Child

There are many aspects of classroom organisation, which can make a difference to the way in which children with ADHD behave. In this section some simple suggestions will be made which have been found to provide, in effect, increased structure, which has then had a positive effect on behaviour.

• Placement of the child so that distractions can be minimised
• Classrooms relatively free from extraneous auditory and visual stimuli are desirable - complete removed of distractions is not warranted.
• Seating between positive role models
• Preferable those who the child sees as significant others, this encourages peer tutoring and co-operative learning.
• Seating in rows or U-shape rather than clusters
• Among children with behavioural problems on-task behaviour doubles as conditions are changed from desk clusters to rows - rates of disruption are three times higher in clusters.

Provision of structure to lessons and routine to the day

Within a consistent routine the child will function significantly better when provided with multiple shortened work periods, opportunities for choice among work activities and enjoyable reinforcers.

• Regular breaks/changes in activity - within understood routine - Interspersing academic seated activities with those that require movement diminishes fatigue and wandering.
• General calmness - Sometimes easier said than done, this reduces the likelihood of any over reaction to a situation.
• Avoiding unnecessary change - Keep informal changes to a minimum, provide additional structure during transition periods.
• Preparation for change - Mention the time remaining, time countdown and advance warning and indicate what is expected and appropriate
• Allow the child to change work sites frequently - Provide some variation for the child and reduces the likelihood of inattention.
• Traditional closed classroom - Noisy environments are association with less task attention and a higher rate of negative comments among hyperactive children. Opportunities for these are less within a closed classroom that with an open plan arrangement.
• Academic activities in the morning - It is recognised that there is generally a progressive worsening of a child's activity levels and inattention over the course of the day.
• Orderly routines for storing and accessing materials - Easy access reduces the effects of the child's disorganisation - perhaps colour coding could facilitate access e.g. all materials, books, worksheets etc. in relation to maths could be indicated by the colour 'blue' - blue signs, blue containers etc.
• Appropriate Curriculum Presentation - Varied presentation of tasks to maintain interest. Use of different modalities increases novelty/interest which enhance attention and reduced activity level
• Child to repeat directions given - Compliance in the classroom is increased when the child is required to repeat directions / instructions
• Removal of extraneous information - For example, from published work sheets or other documents, so that all the detail is relevant to the task, perhaps also reducing the amount of information per page
• High novelty of learning tasks
• Short spells on one topic, operating within the child's limit of concentration. Assignments should be brief, feedback immediate; short time limits for task completion; perhaps use of a timer for self monitoring
• Provision of tasks of appropriate duration where the start and end point are clearly defined

There are three key goals for any child in a classroom setting:

• to start when everyone else does
• to stop when every one else does and
• to focus on the same things as the other children

Consistency of management and expectation

• Clear, concise instruction which appear specific to the child
• Maintain eye contact with the child; compliance and task completion increase when simple, single directions are given
• Short sequences of instructions
• Minimal repetitive drill exercises
• Again to reduce the likelihood of inattention and boredom
• Active participation throughout the lesson
• Low level of controlling language
• Tasks appropriate to the child's level of ability
• Assignments in small chunks
• Alternate sitting and standing
• Provide documents with large print

This, as well as giving less information per page, allows for easier access to the information.

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Behaviour Management

General points:

• Develop a workable set of rules in the classroom
• Respond consistently and quickly to inappropriate behaviour
• Structure the classroom activities to minimise disruption
• Respond to, but do no become angry with, inappropriate behaviour

Despite the substantial success of teacher administered behaviour management programmes there is little evidence that treatment gains persist once the programmes are terminated. Also the improvement produced by contingency management in one setting do not generalise to settings where the programmes are not in effect. The fact that most behaviour management strategies are based on consequences means that they are not as effective with children with ADHD as they would be with children who are aware of, and concerned about, consequence.

There are several strategies which are considered to be effective with children with ADHD.

Continuous reinforcement

It has been found that children with ADHD perform as well as non-ADHD children when provided with continuous reinforcement - that is when they are rewarded every time they do what is expected of them - they perform significantly worse with partial reinforcement.

Token Economy

In this strategy there is set up a menu of rewards, which the child can purchase with tokens that he or she earns for agreed appropriate behaviour. With young children (y - 7 years) that tokens need to be tangible - counters, beads, buttons etc - the menu of rewarding items needs to be changed regularly to provide novelty and avoid habituation. For older children the tokens can be points, starts, ticks on a chart etc. Under this system there is not cost to the child if they behave inappropriately, other then not being rewarded.

Response Cost

This is the loss of a reinforcer / token contingent on inappropriate behaviour. If a child misbehaves he of she not only does not get rewarded but they also have something taken from them - it costs them if they respond in an inappropriate way. Empirical findings suggest that response cost may be the most powerful means of managing the consequence for children with ADHD or other disruption behavioural problems.

However, in the traditional model of response cost many children would be bankrupt very rapidly. It is recommended that one or two bits of behaviour that the child does reliably are also included in order to make it more likely that the child will succeed.

In another variation, which appears to be particularly, useful for children with ADHD the child is initially provided with the maximum number of points or tokens to be earned during the whole day. The child must then work through the whole day to retain those reinforcers. It has been found that impulsive children who better to keep their plates full rather than to refill an empty place.

Using a similar approach for the management of attention-demanding behaviour it is sometimes useful to provide a child with a specific number of 'cards' that can then be spent by the child to purchased immediate adult attention. The aim is to give the child the cards at the beginning of the day so that he or she learns to spend them wisely, the idea would be to work towards reducing the number of cards available to the child over time.

Highway Patrol Method

• Identify the offence - the inappropriate behaviour
• Inform the offender of the punishment - the response cost
• Remain polite and businesslike - stay calm and objective

Self-monitoring

It is possible to improve a child's concentration and application to task by means of self-monitoring. Here the child takes some responsibility for the actual management of his or her behaviour.

Timers

Use of a kitchen time, egg timer, stop watch or clock can provide a structured way of letter the child know what the task expectations are in terms of the length of time that he or she is required to work. The actual length of time used initially needs to be within the child's capabilities and the time would be extended imperceptibly.

Visual Cues

Having visual cues around the room, depicting a message to the child in terms of behavioural expectations can facilitate improvements in self-control. Specific reminders, non-verbal cues from adults can aid the child's awareness of and response to the visual cues.

Auditory Cues

Occasionally taped auditory cues have been used to remind students of expected behaviour. The cues can consist of bleeps produced at varying times during the lesson. These can be simply reminders to the child or they can be a cue to the child to record whether he or she was on-task at the time of the bleep. Such approaches are useful for children with ADHD who are not showing Oppositional Defiant or Conduct Disorder. Tape-recorded cues of reminders to 'get on with your work', 'do your best' etc. have been found helpful, particularly it the cues are recorded using the child's father's voice.

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Student Involvement

It is evident that gaining parental and student co-operation is crucial.

It is not sufficient to assess, diagnose, prescribe and monitor. Sam is an eight-year-old boy who has been diagnosed as have ADHD. He has been prescribed medication and his mother gives it to him as required. Little change in his behaviour was noted either at home or at school. It turned out that Sam was taking his medication, keeping it under his tongue until his mother had gone and then spitting it out. The child needs to be involved and 'on board' in terms of the treatment approach taken.

Old children (7+) should be included during meetings to help set goals and determine appropriate rewards. Involving children in this way often enhances their motivation to participate and be successful in their programme.

Home-school notes are also seen to be beneficial - they need to be clear and accurate but not necessarily very specific. Use of such notes has been found to improve classroom conduct and academic performance of students of all ages - with older students the manner of presenting the note and their active involvement in its use are critical.

Staged Assessment Procedures and Co-morbidity.

There is no need for the initiation of a statutory assessment of special educational needs simply because a child has a diagnosis of ADHD. It depends on the nature and severity of the individual child's difficulties and how they impact on his learning and ability to access the curriculum.

Generally, it is the child with a multiplicity of problems who presents with sufficient difficulties to require resources, which are additional to or different from those normally available. For some children there is the need for the protection of a Statement, for others medication alone is the answer. For others a combinations is required.

It has been found that:

• 45% of those diagnosed ADHD will also have O.D.D.
• 25% - Conduct Disorder
• 25% - anxiety disorders
• 50% - specific learning difficulties
• 70% - depression
• 20% - bipolar disorder
• 50% - sleep problems
• 31% - social phobias

Adult Outcome

Some children mature in ways that cause the ADHD symptoms to reduce. For others, hyperactivity might diminish, particularly in adolescence, but problems with impulsivity, in attention and organisation continue.

There is some dispute about the proportion of children for whom maturation is the "cure" - most believe that one third to one half of the ADHD population will continue to have ADHD symptoms as adults. Some researchers have suggested that only one third of the ADHD population will outgrow the disorder.

Untreated adults who experience multiple symptoms are most likely to engage in serious antisocial behaviour and/or drug and alcohol abuse. A long-term study found that those who were diagnosed with ADHD as children are, compared to the general population, "disproportionably uneducated, under-employed and plagued by mental problems" and by their early twenties are "twice as likely to have an arrest record, five times as likely to have a felony conviction and nine times as likely to have served time in prison".

Some research carried out in 1984 shoed that children with ADHD who are treated with psycho stimulant medication generally have a better adult outcome. Two groups of adults were compared, one group had been treated with Ritalin for a least three years at primary school age and the other group, similarly diagnosed as ADHD, had received no medication. The adults who were given Methylphenidate as children, had less psychiatric treatment, fewer car accidents, more independence and were less aggressive.

However, it has also been found that "most prosperous entrepreneurs have ADHD" - high energy levels, intensity about ideas and relationships, affinity to stimulating environments.

Conclusion

ADHD is turning out to be a significant factor in the lives of a very large proportion of the general population. Not only do we have a relatively high number of children diagnoses with ADHD, perhaps between 5% and 7% of the population, but we also have the ripple effect where these children and their behaviour touch the lives of a much greater proportion of the population.

It is recognised that children with ADHD who are undiagnosed or untreated are likely not only to struggle through their school years but also to underachieve as adults. They are more likely to show deviant, antisocial behaviour and to end up on prison.

It is therefore vitally important that we do all we can to aid accurate diagnosis of children with ADHD, the help to monitor treatment effects and to provide consistent management strategies to facilitate their impulse control and application to task. In this way perhaps we can help to minimise the detrimental effects of the condition and improve the likely outcome for children with ADHD.

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Appendix 2

The IOWA Connors Teacher's Rating Scale

Check the column which best describes this child today.

Please circle relevant number - 1 being highest score and 6 being lowest score.

Appendix 3

A Rating Scale for Common Stimulant Side-effects

About the author: Peter Withnall is Area Senior Educational Psychologist, County Durham.

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• Watch the video on Narcissist Language

In the the narcissist's surrealistic world, even language is pathologized. It mutates into a weapon of self defence, a verbal fortification, a medium without a message, replacing words with duplicitous and ambiguous vocables.

Narcissists (and, often, by contagion, their unfortunate victims) don't talk, or communicate. They fend off. They hide and evade and avoid and disguise. In their planet of capricious and arbitrary unpredictability, of shifting semiotic and semantic dunes - they perfect the ability to say nothing in lengthy, Castro-like speeches.

The ensuing convoluted sentences are arabesques of meaninglessness, acrobatics of evasion, lack of commitment elevated to an ideology. The narcissist prefers to wait and see and see what waiting brings. It is the postponement of the inevitable that leads to the inevitability of postponement as a strategy of survival.

It is often impossible to really understand a narcissist. The evasive syntax fast deteriorates into ever more labyrinthine structures. The grammar tortured to produce the verbal Doppler shifts essential to disguise the source of the information, its distance from reality, the speed of its degeneration into rigid "official" versions.

Buried under the lush flora and fauna of idioms without an end, the language erupts, like some exotic rash, an autoimmune reaction to its infection and contamination. Like vile weeds it spread throughout, strangling with absent minded persistence the ability to understand, to feel, to agree, to disagree and to debate, to present arguments, to compare notes, to learn and to teach.

Narcissists, therefore, never talk to others - rather, they talk at others, or lecture them. They exchange subtexts, camouflage-wrapped by elaborate, florid, texts. They read between the lines, spawning a multitude of private languages, prejudices, superstitions, conspiracy theories, rumours, phobias and hysterias. Theirs is a solipsistic world - where communication is permitted only with oneself and the aim of language is to throw others off the scent or to obtain narcissistic supply.

This has profound implications. Communication through unequivocal, unambiguous, information-rich symbol systems is such an integral and crucial part of our world - that its absence is not postulated even in the remotest galaxies which grace the skies of science fiction. In this sense, narcissists are nothing short of aliens. It is not that they employ a different language, a code to be deciphered by a new Freud. It is also not the outcome of upbringing or socio-cultural background.

It is the fact that language is put by Narcissists to a different use - not to communicate but to obscure, not to share but to abstain, not to learn but to defend and resist, not to teach but to preserve ever less tenable monopolies, to disagree without incurring wrath, to criticize without commitment, to agree without appearing to do so. Thus, an "agreement" with a narcissist is a vague expression of intent at a given moment - rather than the clear listing of long term, iron-cast and mutual commitments.

The rules that govern the narcissist's universe are loopholed incomprehensibles, open to an exegesis so wide and so self-contradictory that it renders them meaningless. The narcissist often hangs himself by his own verbose Gordic knots, having stumbled through a minefield of logical fallacies and endured self inflicted inconsistencies. Unfinished sentences hover in the air, like vapour above a semantic swamp.

In the case of the inverted narcissist, who was suppressed and abused by overbearing caregivers, there is the strong urge not to offend. Intimacy and inter-dependence are great. Parental or peer pressures are irresistible and result in conformity and self-deprecation. Aggressive tendencies, strongly repressed in the social pressure cooker, teem under the veneer of forced civility and violent politeness. Constructive ambiguity, a non-committal "everyone is good and right", an atavistic variant of moral relativism and tolerance bred of fear and of contempt - are all at the service of this eternal vigilance against aggressive drives, at the disposal of a never ending peacekeeping mission.

 

With the classic narcissist, language is used cruelly and ruthlessly to ensnare one's enemies, to saw confusion and panic, to move others to emulate the narcissist ("projective identification"), to leave the listeners in doubt, in hesitation, in paralysis, to gain control, or to punish. Language is enslaved and forced to lie. The language is appropriated and expropriated. It is considered to be a weapon, an asset, a piece of lethal property, a traitorous mistress to be gang raped into submission.

With cerebral narcissists, language is a lover. The infatuation with its very sound leads to a pyrotechnic type of speech which sacrifices its meaning to its music. Its speakers pay more attention to the composition than to the content. They are swept by it, intoxicated by its perfection, inebriated by the spiralling complexity of its forms. Here, language is an inflammatory process. It attacks the very tissues of the narcissist's relationships with artistic fierceness. It invades the healthy cells of reason and logic, of cool headed argumentation and level headed debate.

Language is a leading indicator of the psychological and institutional health of social units, such as the family, or the workplace. Social capital can often be measured in cognitive (hence, verbal-lingual) terms. To monitor the level of comprehensibility and lucidity of texts is to study the degree of sanity of family members, co-workers, friends, spouses, mates, and colleagues. There can exist no hale society without unambiguous speech, without clear communications, without the traffic of idioms and content that is an inseparable part of every social contract. Our language determines how we perceive our world. It IS our mind and our consciousness. The narcissist, in this respect, is a great social menace.

 

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next: Studying My Death

In: W.K. Bickel & R.J. DeGrandpre, Drug Policy and Human Nature, New York: Plenum, 1995, pp. 199-220.

Morristown, NJ

Introduction: Say Whatever You Want About Drugs As Long As It's Negative

In 1972, Edward Brecher -- under the aegis of Consumer Reports -- published a remarkably forward-looking book entitled Licit & Illicit Drugs. Among the many myths of addiction he punctured was that of heroin overdose. To accomplish this, Brecher reviewed evidence that (1) deaths labelled heroin overdose "cannot be due to overdose; (2) there has never been any evidence that they are due to overdose; (3) there has long been a plethora of evidence demonstrating that they are not due to overdose" (p. 102).

In category (1) are historical and pharmacological data. In New York City prior to 1943, very few deaths of heroin addicts had been attributed to heroin overdose; in 1969-1970, 800 overdose deaths were recorded in New York. But over this time span, heroin purity declined steadily. In research conducted at Jefferson Medical Center in Philadelphia in the 1920s, addicts reported daily doses 40 times as concentrated as the usual New York City daily dose in the 1970s (Light & Torrance, 1929). Addicts in this research were injected with 1800 mg in a 2 1/2-hour period. Some subjects received up to 10 times their ordinary daily dosage and showed insignificant physiological changes.

In category (2) are the standard regimens of big-city coroners of simply recording as overdose deaths cases in which an addict died and had no other obvious cause of death. According to Brecher (1972),

A conscientious search of the United States medical literature throughout recent decades has failed to turn up a single scientific paper reporting that heroin overdose, as established by...any...reasonable methods of determining overdose, is in fact the cause of death among American heroin addicts (p. 105).

In category (3) are results of research conducted by two prominent New York City Medical Examiners, Drs. Milton Helpern and Michael Baden, based on the examination of New York City addict deaths, which found that (1) heroin found near dead addicts is not unusually pure; (b) the body tissue of the addicts shows no undue concentration of heroin; (c) although the addicts usually shoot up in groups, only one addict at a time dies; and (4) dead addicts are experienced--rather than novice--users who have built up tolerance to potentially large doses of heroin.

Yet, when we move from the 1920s and 1970s to the 1990s, we find in the New York Times on August 31, 1994, a front-page headline about the deaths of 13 New York City heroin users, part of which read: "They call it China Cat, an exotic name for a blend of heroin so pure it promised a perfect high, but instead killed 13 people in five days" (Holloway, 1994, p. 1). Brecher (1972) would seem to have laid to rest claims about epidemics of "multiple overdoses" of heroin like this one reported in the New York Times. Not surprisingly, two days later, the New York Times announced: "Officials Lower Number of Deaths Related to Concentrated Heroin" (Treaster, 1994, p. B3).

By this time, published reports had attributed 14 deaths to China Cat. The second New York Times article stated, "authorities yesterday lowered from 14 to 8 the number of deaths in the last week that the police believe are related to highly concentrated heroin" (Treaster, 1994, p. B3). The Medical Examiner discovered that

two of the 14 men originally suspected of having died from taking the powerful heroin had actually died of natural causes. Four others died of overdoses of cocaine.... Of the eight whose deaths apparently did involve heroin, seven also had traces of cocaine in their system" (Treaster, 1994, p. B3, emphasis added).

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The follow-up article is notable in that: (1) deaths definitely attributed to overdose on the front page of America's leading newspaper were now only "suspected" overdose deaths, (b) the New York Times, after featuring and embellishing on overdose deaths on its front-page now attributed the overestimate to "authorities," (3) 6 of 14 people (42%) reported to have died of heroin overdose deaths had in fact not taken any heroin (two hadn't had any drugs), (4) 92% of the men who died after taking drugs had taken cocaine, compared with 67% who had taken heroin.

Was this in fact a cocaine rather than a heroin overdose epidemic? Or, alternately, was it an epidemic of deaths due to combining heroin and cocaine (and alcohol along with other drugs)? The follow-up article raised the more basic question of how the "authorities" decided that so many men had died of China Cat in the first place. According to the article, "The police said they found packets of China Cat, the street name of a powerful heroin blend, and a syringe" besides the body of one dead man. However, "they had no similar evidence connecting the China Cat brand to the other victims, but ... they considered it probable that a purer blend of heroin was involved" (even with the six men who it turned out had taken no heroin) (Treaster, 1994, p. B3).

The cavalier attitude with which a leading newspaper reported misinformation as fact is a phenomenon worth examining. To put it simply, saying bad things about drugs is never questioned, and disconfirming information never requires revision of original claims. The paper acts as though its drug reporting is part of its moral mission, one not related to facts. But this absence of a factual basis for its earlier report did not even slow the newspaper after the discovery of the many mistakes in the original article.

In a follow-up front-page report on September 4, the New York Times drew further conclusions about this case of "multiple drug overdose," now involving eight people (Treaster & Holloway, 1994). Only now, more of the original report had been found to be incorrect.

At first, the police suspected that the men ... had all died after using an extremely potent blend of heroin called China Cat.... Now the police and the New York City Medical Examiner, Dr. Charles Hirsch, say the men may have been victims of that brand or some similar, equally powerful blends of heroin.... But as one police officer put it: "They're all still dead." In the end, drug experts said, the brand name probably has little significance (p. 1, emphasis added).

While this may be so, the New York Times did identify China Cat as the cause of 13 men's deaths on its front page. Moreover, by the time this third article appeared 4 days later, it was still not clear on what basis the deaths of these men had been attributed to heroin overdose from any source (which Medical Examiner Hirsch says "may" have been the cause of the deaths). For example, the men all died singly, even though addicts typically use drugs in groups. The third article described the supposed heroin overdose death of Gregory Ancona, the only one of the cases for which eyewitness accounts were available:

[Ancona] and a young woman went to a club ... and went back to Mr. Ancona's apartment.... The woman injected her heroin.... Mr. Ancona, who ... was already staggering from the effects of cocaine and alcohol, snorted his. Soon after, he nodded off and never woke up. The woman ... suffered no more than the usual effects of heroin (Treaster & Holloway, 1994, p. 37).

The lethal effects of a brand of heroin are not supported by a case in which a man--who generally weighs more than a woman and shows less acute reactions to a given drug--died after snorting the drug while a woman who simultaneously injected the same batch of the drug showed no unusual effects. A more likely cause of Mr. Ancona's death under these circumstances would be the interaction of drug effects, and particularly those of alcohol and narcotics. Not only has research suggested the alcohol-narcotic link may be lethal, but addicts themselves generally suspect it and typically avoid drinking when taking narcotics (Brecher, 1972, p. 111).

This retailing of such dubious drug information can occur in a major newspaper with no risk of embarrassment. This is because the New York Times, its readers, and public officials share certain unquestioned assumptions--the assumptions that underlie our past and current drug policies, to wit:

1. Drugs are so bad that any negative information about them is justified. The New York Times will not be called to task for inaccuracy in reporting about drugs, as it might, for example, in reporting with similar credulity, even deception, about crime or politics.
2. Heroin is the worst drug. The New York Times could seemingly have made a better case for the toxicity of cocaine based on the original 14 deaths reported, yet it choose to focus on heroin. This may express a permanent bias against heroin, or a return to demonizing heroin after a period of concern about cocaine.
3. Blaming drug deaths on overdose is highly desirable for propaganda purposes. If drugs are becoming purer, and deaths due to overdose are epidemic, then people should be more reluctant to take heroin.
4. Middle-class heroin users in particular should beware. A focus of this and many other news features has been the perennial concern that street drug use is spreading to the middle class. The middle class status of a number of the dead men was a special feature of the New York Times articles.

One of the nation's most prestigious newspapers confidently misreports this story while it probably feels it is performing a valuable public service. But does the New York Times article actually present a safety hazard? If an addict believed that taking a specific dose of heroin is safe, he might not recognize that combining drugs can be dangerous. In Mr. Ancona's case, for example, he might have felt safe from a heroin overdose by snorting the drug rather than injecting it.

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But there could be even more perverse consequences from labeling drug deaths as overdoses. Drs. Helpern and Baden interpreted their data as making it more likely that the impurities in the injectable mixture (particularly quinine), rather than the narcotic itself, which had been found to be relatively safe over a wide range of concentrations for regular users, were the source of heroin-related deaths (Brecher, 1972, p. 110). In that case, the most adulterated (impure) doses rather than the most concentrated (pure) doses of heroin would be most dangerous, exactly the opposite of the New York Times'warning.

Drug Policy and Models of Drug Abuse and Addiction

The assumptions relayed by the New York Times article are actually quite common. They and similar popular assumptions about drugs underlie much of current drug policy. Policies for dealing with drugs, while presented as rational models built on empirical bases and offering sensible plans to improve American society, are actually largely determined by policy makers' wrongheaded assumptions about drugs use, abuse, and addiction. As a result, policies with long histories of failure and no chance for improving conditions in the United States are taken for granted because their assumptions correspond so well with popular drug myths (Trebach, 1987).

Indeed, the programmatic failure of these policies is directly related to their empirical failures in accounting for human drug use. This chapter outlines the assumptions underlying both our dominant drug policies and more useful, alternative models built on sounder assumptions about drug effects, human motivation, and the nature of addiction (Peele, 1992). It also suggests marketing alternative drug policies based on the appeal of their assumptions.

The Disease and Law Enforcement Models of Addiction

How we think about drugs, about their effects on behavior, and about their pathological use (as in addiction) is critical for our drug policy. Much of American drug policy has been driven by a specific image of how drugs--illicit drugs--work. This image has been that drugs cause addictive, uncontrollable behavior leading to social and criminal excess. Under these circumstances, drugs should be illegal and drug users imprisoned, which is how we principally dealt with drugs for the first half of this century. This is the punitive model, which has evolved into the modern law enforcement model of drug policy, which also incorporates massive efforts at interdiction to eliminate the supply of drugs to the U.S.

But the belief that drugs lead inexorably to uncontrollable consumption and antisocial behavior creates the potential for a wholly different model. In this model, since drug use is biologically uncontrollable, people must be excused for their drug taking patterns and their behavior when intoxicated. Their urges for continued drug use must be addressed through treatment. American society is characterized, simultaneously, by strong urges for self-improvement, by religiomoralistically oriented social groups, and by a belief in the efficacy of medical treatments. The disease model of addiction, which grew in dominance throughout the second half of this century, pulled all of these strands in American thought together successfully for marketing, institutional, and economic purposes (Peele, 1989b).

When public figures in the United States discuss drug policy, they generally veer between these two models, as in the debate over whether we should imprison or treat drug addicts. In fact, the contemporary U.S. system has already taken this synthesis of the law enforcement approach to drug abuse and the disease approach almost as far as it can go. In America today, large components of the prison population are drugsusers or dealers, and treatment for substance abuse--including 12-Step groups like Alcoholics Anonymous (AA)--is mandated for those in prison and many who avoid prison by entering diversionary programs (Belenko, 1995; Schlesinger & Dorwart, 1992; Zimmer, 1995).

While legal, penal, and social service institutions are able easily to incorporate drug treatment in their policies since drug use is illegal, the same synthesis of disease and law enforcement models also prevails for alcohol. Treating alcohol and drug use in the same way, despite their different legal statuses, is possible because the disease theory was made popular with alcohol and was then successfully applied to drug use (Peele, 1989a; 1990a). Meanwhile, the punitive law enforcement model developed with drugs was similarly applied to alcohol. Drunk drivers and even felons who drink excessively are given treatment in place of prison sentences (Brodsky & Peele, 1991; Weisner, 1990), while the many alcohol abusers already in prison are channeled through AA as the modern form of prison rehabilitation.

The differences in the origins and goals of the law enforcement and disease models guarantee that combining them will yield contradictions. But there are also broad similarities in their views of drugs, addictive behavior, and drug policy. Table 1 explores these differences and similarities according to the categories of causality, the responsibility of the individual drug user, the primary modality and policy recommended by the model, and the nature and extent of treatment inherent in the model. (Table 1 also examines two alternative models -- the libertarian and social welfare models -- which are discussed below).

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Table I. Models of Addiction: Their Underpinnings and Policy Implications.

Model	Causality	Responsibility	Primary Modality	Treatment	Attitudes Toward New Policies
Disease/Law enforcement
Disease
- Individual susceptibility: genetic	Internal biology	Individual Ambiguous External	Treatment 12-Step Programs Abstinence	Necessary (no self-cure) Coercive (because of "denial")	Anti-harm reduction
- Exposure: pharmacologic	External biology
Law enforcement
- Punitive	User	Individual	Legal system	Coercive/Punitive (in place of or along with punishment)	Anti-legalization
- Interdiction	Drug	External	Blockading
Current policy -- combined disease/law enforcement	External (uncontrollable)	External Ambiguous	Legal system Treatment	Paternalistic Coercive	No change
Libertarian/Social welfare
Libertarian	Internal/self	Individual	Laissez faire	Voluntary Market demand	Pro-legalization
Social Welfare	External/society	Society	Social services	Paternalistic Universal	Pro-harm reduction
Proposed policy -- combined libertarian/social welfare	Internal (lack of self-control) External (lack of opportunity)	Individual (moral/legal) Society (support/action)	Individual with social supports	Available Voluntary Diversified	Pro-change

1. Causality. The disease model claims that people are driven to consume drugs by uncontrollable biological urges. Since its founding in 1935, AA has implied that the source of alcoholism lies in the individual's biological make-up. And with the behavioral genetic revolution of the last quarter of the century, a largely genetic basis has been proposed for much addictive behavior. While the extreme form of this model--as represented by Blum and Payne (1991) in what they term the "addictive brain"--cannot be sustained, the spirit of Blum's analysis is broadly popular and in key elements is not that far from mainstream behavioral genetic models.
   The disease model has several different guises. Table 1 lists the individual susceptibility version, which includes genetic models, as opposed to exposure models, which emphasize the pharmacologic properties of drugs. The exposure model maintains that pharmacologic properties of drugs directly cause continuous, escalating, and destructive drug consumption for everyone. The law enforcement model also assumes an exposure model of drugs and addiction.
2. Responsibility. The law enforcement model faces a contradiction. On the one hand, the society is obligated to prevent citizens from being tempted by drug availability. But it is also the individual's responsibility not to take drugs, and therefore people are responsible and punishable when they do. However, both the law enforcement model's view that all drug use is uncontrollable and the burgeoning influence of the disease model have seriously undercut the personal responsibility and blame that underlie the punitive component of the law enforcement model. The assumptions that both excessive use of drugs and behavior when intoxicated are uncontrollable have allowed many drug users/addicts to claim such loss of control is responsible for their behavior.
3. Primary modalities. The disease model strongly opposes the possibility of controlled use, as does the law enforcement model. Like the exposure versions of the disease model, the law enforcement model thus strives to prevent everyone from taking drugs and recommends abstinence as the key--indeed the sole--preventive and treatment measure. (Although the disease model ostensibly requires only inbred addicts to abstain, the disease view nonetheless tends to support abstinence from all illicit drugs.) For the law enforcement model, drugs must be prevented from entering the country through interdiction, and criminal sanctions must discourage all drug use. In the disease model, the addict must be treated--or join an AA-type group to spiritually reform users and socially support abstinence--in order to achieve wholeness.
4. Treatment. The disease and the law enforcement models share a paternalism that focuses on peoples' inability to control themselves. In the disease model, the addict who rejects treatment is posited to be in denial, and the life-threatening nature of the disease makes treatment necessary. Adding this element to the law enforcement model, since abstinence is legally required, the addict is forced into treatment oriented towards achieving abstinence. Thus, while the disease and the law enforcement models are often thought to be opposed in their views of treatment, and the 12-Step movement originally emphasized voluntarism, all three currently coalesce in supporting coercive treatment.

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The Modern Drug Policy Synthesis and Its Problems

The modern synthesis of the disease and law enforcement models dominates drug policy in the United States and is firmly entrenched among the public and policy makers. However, several social/economic factors have challenged the consensual support of drug policies this synthesis has garnered. These factors include:

1. Cost. Interdiction, legal sanctions such as prison, and treatment (particularly of the medical kind) are all very expensive policy options. In an era of economic decline, like the one the United States faces, expensive policies-- even when broadly consensual--have come under scrutiny.
2. Effectiveness. Ineffective drug policies have long been tolerated (Trebach, 1987). However, economic pressures to reduce government spending have caused some critical assessment of current drug policies. And the interdiction, prison, and treatment mix seems to do nothing so well as to produce greater need for the very same policies. Despite growing prison rolls of drug offenders and the constant recruitment (or return) of drug users for treatment, there is a steady call for acceleration and intensification of current police, interdiction, and treatment efforts. The contradiction between claims of effectiveness and worsening drug problems has led to a questioning of current policies.
3. Paternalism. Both the disease and the law enforcement models deny the ability of individuals to resist or control drug use. Only the state, in the form of its policing or its treatment apparatus, is capable of making decisions about drugs for people. But such paternalism violates fundamental American precepts of self-determination. Moreover, it implies an endless battle between the state and its citizens that has become wearying.

An Example of the Pervasiveness of the Modern Drug Policy Synthesis: The ABA Report

In the United States, private and public treatment for drug, alcohol, and other compulsive behaviors (such as gambling, shopping, eating, and sexual behavior) modeled on the drug addiction model, as well as treatment for other mental health problems, is more abundant by far than that provided in any other country in the world (Peele, 1989b). Moreover, a growing majority of substance treatment recipients today--including those in AA and related groups--are forced into treatment. In addition to large numbers diverted by the court system for crimes from drunk driving up to and including serious felonies, social welfare agencies, employee assistance programs, schools, professional organizations, and other social institutions insist that members seek treatment at the cost of denial of the benefits of membership or expulsion (Belenko, 1995; Brodsky & Peele, 1991; Weisner, 1990). Healthcare cost controls on private drug and alcohol treatment and several scandals among psychiatric hospital chains shook the industry after the late 1980s (Peele, 1991a; Peele & Brodsky, 1994). Nonetheless, more Americans continue to be treated for substance abuse than have citizens in any other society in history, and this gargantuan treatment apparatus, both public and private, is maintained by coercing patients into the treatment system (Room & Greenfield, 1993; Schmidt & Weisner, 1993).

Even though restricting treatment to those who want it would greatly reduce demand for substance abuse treatment in the United States, the major American policy thrust is to vastly expand treatment rolls. To most Americans, the existence of a drug problem by itself so clearly implies treatment that other options cannot even be contemplated. One striking example of this unquestioned viewpoint was provided the American Bar Association (ABA) Special Committee on the Drug Crisis, which authored a 1994 report entitled: New Directions for National Substance Abuse Policy (ABA, 1994). The president of the ABA, R. William Ide III, introduced the New directions report by listing eight primary drug problems: (1) health costs, (2) drug use incidence, (3) drug-related crime resulting in (4) homicide, (5) juvenile violence, (6) prison overcrowding, (7) drug-related arrests, (8) and economic costs of drug-related crime.

It seems logical that the ABA would be primarily concerned with criminal aspects and costs of the drug problem. But what is remarkable is the extent to which the ABA conceives these as treatment issues. Following are four of six recommendations in section VII of the report, entitled "New Directions in the Criminal Justice System":

(1) The criminal justice system should provide a continuum of mandatory prevention and treatment services to drug-involved offenders.... (2) Alternatives to incarceration that include alcohol and other drug treatment ... should be expanded.... (5) Voluntary pretrial drug testing programs should be supported as a means of identifying and treating offenders immediately upon arrest.... (6) Court officers should be trained to identify and refer offenders with alcohol and other drug problems at the earliest possible point (pp. 34-35).

As John Driscoll, Chair of the ABA special drug committee, noted: "there was remarkable consensus on many of the most critical questions of drug policy" among committee members and consultants (p. 8). The clearest consensus is that drug use must be stamped out. Section III, "New Directions in Reducing Demand," presented a brief "Rationale" and three recommendations:

(1) The federal government should establish a "no use" standard of illicit drugs. We agree with the Office of National Drug Control Policy that [this] is vitally important.... (2) The federal government should continue to focus on casual users through prevention and treatment efforts.... (3) The federal government should increase its focus on hard core drug users through treatment and coercion efforts (p. 24, emphasis in original).

This section of the ABA report is explicit to the point of redundancy: All drug use should be eliminated, casual drug use should be eliminated, addicted users should be forced to quit, all through government efforts at expanding what is already noted to be official U.S. policy. Typically the report had no assessment of how much these policies would cost, what their chances for success are, and what social costs are entailed. Particularly disturbing is the complete absence of any consideration of the civil liberties of individual citizens: the Constitution is never raised in a report from the leading private legal organization in the United States. Yet Constitutional safeguards include those against invasion of privacy, like illegal searches and seizures, and safeguards of personal freedom of beliefs and religion. In several adjudicated cases, the courts have upheld the right of individual Americans to refuse to be forced into treatments--like AA--that violate their religious beliefs and even their self-concepts (Brodsky & Peele, 1991).

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The assumptions motivating the ABA report are those underlying the disease/law enforcement synthesis model of addiction, to wit:

1. Illicit drug use is bad. Moreover, it is inherently bad. Nothing about styles of use or the individual's motivation for using drugs is relevant to this determination. In general, this view of drugs is different from the American view of alcohol, which finds moderate, social consumption acceptable. However, as in the ABA report, drinking--particularly among the young--may be assimilated to use of all drugs in being totally proscribed and disapproved and through policies for an overall reduction in drinking levels. Yet, despite the fact that alcohol use has declined steadily for more than a decade, people report having more serious alcohol problems than ever before (Room, 1989), problems that are growing most rapidly in the youngest cohorts (Helzer, Burnham, & McEvoy, 1991).
2. Illicit drug use is unhealthy, uncontrollable, and addictive. While the badness of drug use can be defined socially and legally--it is wrong to take drugs--the ABA assumes drug use is unhealthy. Moreover, it is unhealthy in the sense that even if some drug use would not harm the individual, no one can guarantee that drug use will be limited to this level, because drug use holds out the inevitable or irresistible danger of becoming all consuming (i.e., drugs are addictive).
3. Prevention and treatment work and can reduce harmful drug use. The fundamental precept of the ABA report is, "Unless we make a commitment to treat, we will never solve the drug problem, regardless of the number of persons we arrest, convict, or confine" (p. 24). However, the report ignores the actual treatment landscape in the United States and assessments of current treatment efficacy. In fact, particularly with widespread alcohol treatment, there is almost no variety in treatment options, and the least effective treatments, such as compulsory AA, dominate almost entirely (Miller, Brown, Simpson, et al., 1995).
   Similarly, while touting greater prevention efforts, the report notes that "statistics indicate that junior high and high school students, in particular, are not paying attention to messages about the consequences of substance abuse" (p. 25). This is not accidental, since the standard programs--which emphasize negative results of drug use-- have been found to be totally ineffective and often counterproductive (Bangert-Drowns, 1988; Ennett, Rosenbaum, Flewelling, et al., 1994). But even if effective treatment/prevention programs exist and are utilized, it is an additional questionable assumption to believe that enough people who would otherwise abuse drugs can be processed by such programs--and that the impact of the programs is robust enough to withstand post-treatment factors--to affect drug problems at a national level (Peele, 1991b).
4. Individuals are not able to choose whether or not to take drugs or to regulate their drug use. This is the external view of drug abuse--that it "happens" to people without their choosing it. Drug use is presented first as being both incredibly alluring and pleasurable, so that children and others cannot resist it without constant support and instruction (if drugs cannot be entirely eliminated through interdiction), and second as being maintained by the involuntary motivations of addiction. By accepting this assumption, the ABA must devise policy after policy to prevent people from taking the drugs they want. The alternative assumption is that people will take drugs if they want to and that the best approach is to limit the potential dangers of this use--i.e., harm reduction.
5. Coercing people into treatment is justified and effective. The ABA endorses combining "treatment and coercion efforts," so that "hard core drug users who are in the criminal justice system should be required to quit their drug use" (p. 24). This entails even greater efforts than are already in place to force people into treatment within the legal system and to offer treatment in place of usual criminal sanctions. Whether or not coercive treatment administered by the legal system is effective is a lively question (Zimmer, 1995). It also shows a fundamental disregard for traditional notions of voluntarism psychotherapy, as well as the Constitution. Finally, it holds out endless possibilities for gaming by criminals seeking to avoid jail time (Belenko, 1995).
6. There is an end to the drug war. Presumably, the ABA expects its recommendations will eventually reduce drug abuse at its sources, and hence the need for constantly expanding drug services and policing efforts. In other words, the goal of the plan is to enable us to cut back on treatment and school programs, on interdiction and the policing of American cities, on the creation of more institutions to house the growing proportion of the prison population convicted of drug offenses, on drug and alcohol research that dominates social and biological scientific agendas, on political negotiations for greater funds for programs like those the ABA endorses. Is there an end in sight, or are these programs a continuation of the never-ending escalation of the drug war?

Because the ABA and its expert panel are engaged more in a symbolic than a policy declaration, the panel feels no need to explore basic policy considerations in its report. After identifying the problem in the "Rationale" part of each section, the report provides no evidence that its recommendations would have any impact on the problems identified. Furthermore, none of the ABA's recommendations is costed out. Even if we had reason to expect the recommended policies would be effective, how can anyone seriously propose that they could be implemented with no regard for cost? The ABA simply states the costs of current drug and alcohol abuse, and these are the rationale for following their recommendations. Interesting figures the ABA could have presented are the spending on remedying drug abuse over the past decades, a projection of the costs of implementing the ABA's programs, and a projection of how much the United States will be spending on drug abuse in the year 2000 and beyond. Any realistic projection of the ABA's proposed policies will inevitably inflate this last figure exponentially.

The ABA's remarkably shopworn bromides simply express long-standing and hard-to-prove assumptions about drug abuse and its solutions. In what way is it beneficial or useful to public opinion, politicians, or public health officials to broadcast alarmist statistics and rote demands for expanded treatment, which is already so widely accepted as a panacea? Presumably, the ABA feels it can gain public relations points by telling people what they already believe, and by boldly labelling this "New Directions." Yet policy alternatives that might directly impact all the problems identified by the ABA--those that normalize users of illicit drugs so that they can work, receive nonemergency treatments, and potentially outgrow drug abuse and addiction, along with reducing or eradicating illicit drug trade and resulting street crime--were not even discussed in the ABA report (Nadelmann et al., 1994). Policy options such as decriminalization and harm reduction (including needle exchange and provision of health services for street drug users) would represent actual new directions in U.S. drug policy.

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Alternative Views: The Libertarian and Social Welfare Models

Much evidence suggests that U.S. drug policies are wrong-headed and ineffective, or at least nonoptimal, not the least of which is the constant need to escalate these same failed policies. Clearly, some evaluation of alternative policies to accomplish desired goals is in order. Two alternatives to the dominant models of drug policy are fairly well recognized in the United States. One--the libertarian model--is put forward by a well-heeled ideological minority. This model, while politically extreme, can nonetheless call on strong strands in American thought--such as self-reliance and free-market capitalism--for support. The other--the social welfare model--has wide acceptance and has been dominant politically in the recent past. Today, although it has lost its cache and is often presented by political opponents as antediluvian, the social welfare model nonetheless gathers enough support to be present in every policy discussion of drugs and related issues.

Table 1 reviews the major dimensions of the libertarian and the social welfare models. The models contrast not only with the disease and law enforcement models, but also with each other:

1. Causality. While the disease model of addiction claims that personal choice has little or nothing to do with continued drug use, the libertarian model regards personal choice as the only explanation for drug use. In this view--as expressed, for example, by Thomas Szasz (1974)--addiction is an unnecessary construct that does not improve our understanding, explanation, or prediction of drug use. The social welfare model, on the other hand, identifies social deprivations as the source of addiction. It counteracts a genetic model of addiction, which must rely on inbred sources as the explanation for epidemiologic differences in susceptibility such as the greater prevalence of intensive drug use in inner cities.
2. Responsibility. The libertarian model holds the individual strictly accountable for drug use and antisocial behavior while using drugs. The social welfare model emphasizes the social forces that foster drug abuse and addiction.
3. Primary modalities. The libertarian model allows people to choose to use drugs or not on an open-market basis, the logical extension of which is the policy of legalizing all drugs (Szasz, 1992). The social welfare model believes that the key to curing addiction is to create a fulfilling society through social welfare policies, like those designed to enhance the addict's educational, employment, and family resources.
4. Treatment. The libertarian model views treatment in free-market terms as a service to be provided as required by market demand. The social welfare model, on the other hand, views treatment as an essential service. It is the most programmatic provider of treatment services, maintaining that the state should provide as much treatment as addicts want whenever they demand it. On the other hand, the social welfare goes beyond the disease model in its view of the panoply of treatment services--including healthcare, job opportunities, skills training, and economic supports. This model of reducing addiction through enhancing potential addicts' environments is more of a social prevention than a treatment model.

Issues Limiting the Potential of Alternative Models.

While the libertarian model may be gaining ground, it is still a distinctly minority--even radical--point of view. And while the social welfare model is still very apparent in American thought, it is clearly losing ground in a conservative political environment and a declining economy. The factors that limit the acceptance of each include:

1. Extremist social positions. Most Americans are too steeped in current drug assumptions to even consider libertarian views of a free market for prescription and illicit drugs. They are furthermore uncomfortable with the libertarian Darwinian social model that would allow the addicted simply to fall by the wayside if they won't stop using drugs. On the other hand, Americans do not seem in a mood to tolerate expanding social welfare services at a time when economic boundaries for Americans in general are contracting.
2. Effectiveness. In the view of a clear majority of Americans, the social welfare model has been tried and found wanting. After a period beginning in the 1960s of greatly expanded services to underprivileged sectors of society, large segments of these sectors--perhaps expanding in number and deepening in their despondency--remain unable to engage in mainstream society.

An Innovative Synthesis of Drug Models and Its Implications for Drug Policy

In place of the synthesis of the disease and law enforcement models that dominates current American policy, let us contemplate a synthesis of the best points of the libertarian and social welfare policies (see Tables 1 & 2). The libertarian and the social welfare models appear to be opposite politically (indeed, the social welfare model has similarities to the disease model). But the two models have in common more empirically sound assumptions than the law enforcement and disease models, as well as relying on sound values. The social welfare model makes clear the factors--in the form of personal history, current environment, availability of constructive alternatives--that are the major determinants of the individual's likelihood of abusing drugs (Peele, 1985).

The libertarian model correctly identifies the critical role of personal responsibility in drug use, even in extreme cases of addiction (Peele, 1987). In this way, it maintains the valuable assumption of personal causality for addiction (and along with it personal efficacy) by noting that continued drug use is a personal choice and by demanding personal responsibility for misbehavior. It is significantly different from the law enforcement model in these areas, however, in that it does not contradict itself by simultaneously endorsing the strict exposure model of addiction. Moreover, it is nonmoralistic in that it does not assume drug use per se is harmful (Peele, 1990b).

While personal responsibility and motivation are crucial in this synthesized model, social forces are obviously critical to the maintenance or discontinuation of addiction. Together, these characteristics determine the nature of treatment in a combined libertarian/social welfare model. In this synthesis, treatment is part of a panoply of supportive resources, the first goal of which is to maintain all citizens' lives and health, the second to capitalize on addicts' desires to reform if and when they desire and feel capable of change. This outlook influences social, prevention, and treatment policy so that skills training, economic assistance, and healthcare for addicts are included as part of the general social welfare and health systems.

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At the same time, the social welfare--and particularly the libertarian--models prefer voluntary choice of treatment. Few people would select the most expensive and repetitive forms of intensive addiction treatment, which would be downplayed as only an extreme resort that is too expensive and limited in its benefits to be justified as the main response to substance abuse. This attacks the mainspring of the disease model. Addiction treatment would also be eliminated for those users of illicit drugs who do not display signs of distress other than that they are engaged in an illegal activity. This is the primary impetus for the law enforcement model. Eliminating the right of the state and other institutions to demand the individual undergo treatment for simply using a disapproved substance implies some form of decriminalization of use of currently illicit drugs.

Table 2. Assumptions of the Proposed Libertarian/Social Welfare Model Synthesis

Drug abuse is primarily a function of social, environmental, and personal factors, and not of drugs. This is in contrast to the externality of the disease/law enforcement model, which holds that the drug, and not the individual, is the source of drug abuse. Personal values are critical in the continuation of drug use, and addicts -- like everyone else -- are responsible for their criminal behavior. Personal responsibility and self-efficacy would thus replace the confusion over the determinism of the disease model and the punitiveness of the law enforcement model. Drug abuse treatment falls within a panoply of health, social, and economic services that include skills/job training, general healthcare, and family supports. This approach, called harm reduction, replaces the separate, highly specialized, disease-based, primarily private substance abuse/addiction treatment system. Drug abuse treatment is voluntary, and the form of treatment should respond to the values, needs, and preferences of the individual. This replaces the coercive, one-size-fits-all current disease treatment system of hospitals, AA, and the 12 steps, which are increasingly administered within the framework of the law enforcement system. Addiction treatment and jail are inappropriate for drug users who are not in distress and who do not violate laws other than those making drugs illegal. This implies reevaluation of the criminal codes with regard to drugs, an evaluation that the disease model considers impossibly dangerous, and that would largely eliminate the activities associated with the law enforcement model.

Harm Reduction, Drug Legalization, and Models of Addiction

To practice harm reduction relative to drugs implies (1) acceptance of non-harmful drug use, and (2) continued use of drugs, even by the addicted, with the goal of providing healthcare, clean needles, and other services to intravenous and dependent drug users (Nadelmann et al., 1994). In other words, harm reduction suggests--and begins the path towards--legalization or at least decriminalization of drug use. How do harm reduction and drug legalization play within the four basic models?

1. Disease/law enforcement model. The law enforcement and the exposure version of the disease model are obviously opposed to legalization, since they assume any legitimizing of drugs and potential greater use will translate into addiction. The individual susceptibility disease model, on the other hand, would suggest that--since only a preselected minority will become addicted--that no increase in addiction would result from legalization, greater availability, and even greater use. However, harm reduction approaches in the case of alcoholism--which is generally assumed to be genetic in American treatment circles--are completely verboten (Peele, 1995). In this, the U.S. is almost alone among Western nations.
   Moreover, while often claiming there is a genetic basis for alcohol dependence, U.S. alcohol education works on a seemingly very different model. For example, all children are warned against drinking on the grounds that it leads to the disease of alcoholism (Peele, 1993). Typically, the only speakers on alcoholism allowed into U.S. schools are members of AA. In fact, the disease model as popularly practiced--while claiming a medical basis--is in fact the old moral model dressed in sheep's clothing (or a doctor's white jacket--see Marlatt, 1983). Likewise, a disease model that purports concern for the individual drug user is so preoccupied with abstinence that it cannot bend to accept harm reduction, as exemplified by needle exchange programs (Lurie et al., 1993; Peele, 1995).
2. Libertarian/social welfare model. The libertarian model provides a fundamental philosophical underpinning for legalizing drugs (Szasz, 1992). Libertarians maintain that the government cannot deprive individuals of personal and private activity which does not interfere with the lives of others. The social welfare model is less clear about legalizing drugs. However, harm reduction as an expression of humane and nonjudgmental concern for individual drug users is central to the social welfare philosophy. Indeed, it is this acceptance of legalization and/or harm reduction and the need to change drug policy that most distinguishes these models from the disease/law enforcement synthesis.

Marketing Alternative Drug Policies

The message from the previous sections is that it is impossible to discredit drug myths, since even information that refutes them is interpreted in their support. Two of New York's most prominent medical examiners regularly testified against the diagnosis of drug overdose (see Brecher, 1972, pp. 107-109), and yet New York City is just as likely as ever to resort to this diagnosis--and the New York Times to trumpet the diagnosis and its readers to accept it. Clearly heroin overdose will not disappear from usage. There is a cultural need for the concept, just as there is a need for the "man with the golden arm" stereotype of the heroin addict.

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Given the popularity of stereotypes about drugs and treatment, we need to market alternative assumptions in order to create sounder drug policies. Many of the assumptions that underlie the libertarian and social welfare models and conflict with the disease and law enforcement models are not only saner and more accurate, but appeal to fundamental American values. Focussing the discussion of drug policy around these superior assumptions and values offers the best possibility for reversing misguided drug policy in the United States today. A marketing plan for better drug policies should hit the following notes:

1. Traditional civil liberties. The readiness of proponents of the disease/law enforcement model to intervene in citizens' lives--whether claiming the benign need to overcome denial or protect Americans from their appetites or the punitive goal of punishing people--is directly opposed to fundamental American civil liberties. Some of the images that can be marketed to show the incompatibility of current drug policy with traditional civil liberties include: (a) raids on purchasers of gardening paraphernalia; (b) drug testing, which seemingly violates in the most basic way the Constitutional prohibition of unreasonable searches; (c) forfeiture of property not only by drug users but by those who own property on which drugs are found; (d) police raids gone wrong, like the one in Boston during which an African-American minister suffered a heart attack and died (Greenhouse, 1994); (e) the 1984ish "Big Brother/government image, which seemingly arouses so much suspicion and resentment in America today.
2. Humaneness. Americans pride themselves on their humanity and their willingness to help the needy. The inhumanity of American drug policy thus has strong marketing possibilities. These include: (a) the denial of marijuana as a popular anti-nausea chemotherapy adjunct (see Treaster, 1991), (b) the medical benefits of marijuana (or THC) in glaucoma treatment, (c) the willingness of antidrug advocates and public officials to in effect sentence many drug users to death through the increased likelihood of AIDS in the absence of needle-exchange programs, to which America is singularly opposed among Western nations (Lurie et al., 1993).
3. Effectiveness/cost. Beginning in the late 1980s, insurers largely decided that substance abuse treatment was not cost-effective (Peele, 1991a; Peele & Brodsky, 1994). Although in most cases this resulted simply in providing less intensive versions of the same therapies previously practiced in hospitals, many people continue to doubt the efficacy of standard disease- and hospital-based drug and alcohol treatment. Images of this ineffectiveness include: (a) prominent failures of treatment in cases such as that of Kitty Dukakis, (b) the revolving door for most of those in public treatment programs and many in private treatment, (c) the costly implications of filling American jails with drug law offenders, (d) the gargantuan overall costs of the disease/law enforcement system at a time when governmental and health costs are overwhelming U.S. public policy.
4. Justice. Americans are offended by unfairness in our legal and social system. Examples of these drug injustices include: (a) murderers in some prominent cases have received less time than some drug users, (b) the imprisoning of drug users who lead otherwise lawful and unexceptional existences, (c) the violation of the right to self-determination, which has become a popular conservative theme--even though in most cases the most virulent anti-drug voices are from the Conservative Right.

Useless and wildly expensive drug policies could continue unabated for years. But the possibility for epochal change in other areas of American life offers real opportunity for change in drug policy. Nonetheless, even as our healthcare, political, and economic systems evolve around us, such change can only occur if it is presented in terms of traditional American precepts.

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References

American Bar Association (1994, February). New directions for national substance abuse policy (second discussion draft). Washington, DC: ABA.

Bangert-Drowns, R.L. (1989). The effects of school-based substance abuse education: A meta-analysis. Journal of Drug Education, 18, 243-264.

Belenko, S. (1995, March). Comparative models of treatment delivery in drug courts. Paper presented at Annual Meeting of Academy of Criminal Justice Sciences, Boston.

Blum, K., & Payne, J.E. (1991) Alcohol and the addictive brain. New York: Free Press.

Brecher, E.M. (1972). Licit & illicit drugs. Mt. Vernon, NY: Consumer Reports.

Brodsky, A. & Peele, S. (1991, November). AA Abuse. Reason, pp. 34-39.

Ennett, S., Rosenbaum, D.P., Flewelling, R.L., et al. (1994). Long-term evaluation of Drug Abuse Resistance Education. Addictive Behaviors, 19, 113-125.

Greenhouse, L. (1994, November 29). Supreme Court roundup: Court to weigh 2 search cases. New York Times, p. A1.

Helzer, J.E., Burnham, A., & McEvoy, L.T. (1991). Alcohol abuse and dependence. In L.N. Robins & D.A. Regier (Eds.), Psychiatric disorders in America (pp. 81-115). New York: Free Press.

Holloway, L. (1994, August 31). 13 heroin deaths spark wide police investigation. New York Times, pp. 1, B2.

Light, A.B., & Torrance, E.G. (1929). Opium addiction VI: The effects of abrupt withdrawal followed by readministration of morphine in human addicts, with special reference to the composition of their blood, the circulation, and metabolism. Archives of Internal Medicine, 44, 1-16.

Lurie P, et al. (1993). The public health impact of needle exchange programs in the United States and abroad. Rockville, MD: CDC National AIDS Clearinghouse.

Marlatt, G.A. (1983). The controlled-drinking controversy: A commentary. American Psychologist, 38, 1097-1110.

Miller, W.R., Brown, J.M., Simpson T.L., et al. (1995). What works?: A methodological analysis of the alcohol treatment outcome literature. In R.K. Hester & W.R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed., pp. 12-44). Boston, MA: Allyn & Bacon.

Nadelmann, E., Cohen, P., Locher, U., et al. (1994, September). The harm reduction approach to drug control. Working paper, The Lindesmith Center, 888 Seventh Avenue, Suite 1901, NYC 10106.

Peele, S. (1985) The meaning of addiction. San Francisco: Jossey Bass/Lexington.

Peele, S. (1987). A moral vision of addiction: How people's values determine whether they become and remain addicts. Journal of Drug Issues, 17, 187-215.

Peele, S. (1989a, July/August). Ain't misbehavin': Addiction has become an all-purpose excuse. The Sciences, pp. 14-21.

Peele, S. (1989b). Diseasing of America: Addiction treatment out of control. San Francisco: Jossey-Bass/Lexington.

Peele, S. (1990a). Addiction as a cultural concept. Annals of the New York Academy of Sciences, 602, 205-220.

Peele, S. (1990b). A values approach to addiction: Drug policy that is moral rather than moralistic. Journal of Drug Issues, 20, 639-646.

Peele, S. (1991a, December). What we now know about treating alcoholism and other addictions. Harvard Mental Health Letter, pp. 5-7.

Peele, S. (1991b). What works in addiction treatment and what doesn't: Is the best therapy no therapy? International Journal of the Addictions, 25, 1409-1419.

Peele, S. (1992). Challenging the traditional addiction concepts. In P.A. Vamos & P.J. Corriveau (Eds.), Drugs and society to the year 2000 (Vol. 1, pp. 251-262). Montreal, Que.: XIV World Conference of Therapeutic Communities.

Peele, S. (1993). The conflict between public health goals and the temperance mentality. American Journal of Public Health, 83, 805-810.

Peele, S. (1995, April). Applying harm reduction to alcohol abuse in America: Fighting cultural and public health biases. Morristown, NJ.

Peele, S., & Brodsky, A. (1994, February). Cost-effective treatments for substance abuse. Medical Interface, pp. 78-84.

Room, R. (1989). Cultural changes in drinking and trends in alcohol problem indicators: Recent U.S. experience. Alcologia, 1, 83-89.

Room, R., & Greenfield, T. (1993) Alcoholics Anonymous, other 12-step movements and psychotherapy in the U.S. population, 1990. Addiction, 88, 555-562.

Schmidt L., & Weisner, C. (1993) Developments in alcohol treatment systems. In: Galanter M. (Ed.), Recent developments in alcoholism: Ten years of progress (Vol. II, pp. 369-396). New York, NY: Plenum.

Schlesinger, M. & Dorwart, M.A. Falling between the cracks: Failing national strategies for the treatment of substance abuse. Daedalus, Summer 1992, 195-238.

Szasz, T. (1974). Ceremonial chemistry. Garden City, NY: Anchor/Doubleday.

Szasz, T. (1992). Our right to drugs. New York: Praeger.

Treaster, J.B. (1991, May 1). Doctors in survey support marijuana use by cancer patients. New York Times, p. D22.

Treaster, J.B. (1994, September 2). Officials lower number of deaths related to concentrated heroin. New York Times, p.B3.

Treaster, J.B., & Holloway, L. (1994, September 4). Potent new blend of heroin ends 8 very different lives. New York Times, pp. 1, 37.

Trebach, A. (1987). The great drug war. New York: MacMillan.

Weisner, C.M. (1990). Coercion in alcohol treatment. In Institute of Medicine (Ed.), Broadening the base of treatment for alcohol problems (pp. 579-609). Washington, DC: National Academy Press.

Zimmer, L. (1995, January). Anglin' for approval: Effectiveness of compulsory drug treatment. Working paper, The Lindesmith Center, 888 7th Ave., Suite 1902, New York, NY 10106.

next: Behavior Therapy—The Hardest Way: Controlled Drinking and Natural Remission from Alcoholism
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I study death as one would an especially curious insect, part metal, part decomposing flesh. I am detached and cold as I contemplate my own demise. The death of others is but a statistic. I would have made a great American governor, or general, or statesman - sentencing people to a bureaucratic, emotionless, end. Death is a constant presence in my life, as I disintegrate from within and from without. It is no stranger, but a comforting horizon. I would not seek it actively - but I am often terrified by the abhorrent thought of immortality. I would have gladly lived forever as an abstract entity. But, as I am, ensconced in my decaying corpse, I would rather die on schedule.

Hence my aversion to suicide. I love life - its surprises, intellectual challenges, technological innovations, scientific discoveries, unsolved mysteries, diverse cultures and societies. In short, I like the cerebral dimensions of my existence. I reject only the corporeal ones. I am enslaved to my mind and enthralled by it. It is my body that I hold in increasing contempt.

While I fear not death - I do fear dying. The very thought of pain makes me dizzy. I am a confirmed hypochondriac. I go into a frenzy at the sight of my own blood. I react with asthma to stress. I don't mind BEING dead - I mind the torture of getting there. I loathe and dread prolonged, body dissolving, maladies such as cancer or diabetes.

Yet none of this motivates me to maintain my health. I am obese. I do not exercise. I am internally inundated by cholesterol. My teeth crumble. My eyesight fails. I can barely hear when spoken to. I do nothing to ameliorate these circumstances beyond superstitiously popping assorted vitamin pills and drinking wine. I know I am rushing towards a crippling stroke, a devastating heart attack, or a diabetic meltdown.

But I keep still, hypnotized by the on-coming headlights of physical doom. I rationalize this irrational behaviour. My time, I argue with myself, is too precious to be wasted on jogging and muscle stretching. Anyhow it would do no good. The odds are overwhelmingly adverse. It is all determined by heredity.

I used to find my body sexually arousing - its pearly whiteness, its effeminate contours, the pleasure it yielded once stimulated. I no longer do. All self-eroticism was buried under the gellous, translucent, fat that is my constitution now. I hate my sweat - this salty adhesive that clings to me relentlessly. At least my scents are virile. Thus, I am not very attached to the vessel that contains me. I wouldn't mind to see it go. But I resent the farewell price - those protracted, bilious, and bloody agonies we call "passing away". Afflicted by death - I wish it only to be inflicted as painlessly and swiftly as possible. I wish to die as I have lived - detached, oblivious, absent minded, apathetic, and on my terms.

 

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next: Beware the Children

• Peele, S. (2000), Consumption and dependence: Inextricable link or cultural/subjective connection? Presentation held at "Measuring drinking patterns, alcohol problems, and their connection: An international research conference," SkarpÃ, Stockholm, April 3-7. (Microsoft PowerPoint file)
• Peele, S. (2000), How are we doing with drinking in America? Testimony at Bureau of Alcohol, Tobacco, and Firearms: "Health claims and other health-related statements in the labeling and advertising of alcohol beverages," Washington, DC, April 26. (Microsoft PowerPoint file)
• Peele, S. (2000), The Life Process Program. Derived from "The Truth about Addiction and Recovery." (Microsoft PowerPoint file).
• Peele, S. (2000), The nature of addiction and its implications. Presentation held at 25th Annual Epidemiology Symposium of the Kettil Bruun Society, Montreal, May 31-June 4. (Microsoft PowerPoint file)

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FAQs regarding Methylphenidate (Ritalin), an ADHD stimulant medication, plus answers to questions on diagnosing ADHD in children. (Note - this is a UK-based site.)

Q. What is the clasification for the medication Methylphenidate?

A. We have been sent the following by the company that makes Equasym, which is a brand name for Methylphenidate. From this, we can therefore see that the clasification for other brands (Ritalin, Concerta and also Equasym) of Methylphenidate are:

Equasym is the brand of methylphenidate hydrochloride supplied by Medeva Pharma Limited, and is available in tablet strengths of 5 mg, 10 mg and 20 mg. It is a class B drug, and this relates to the levels of penalties for offences under the Misuse of Drugs Act 1971.

Q. What are the differences between cocaine and methylphenidate?

A. Methylphenidate is chemically similar to cocaine and other stimulants but presents a pragmatic paradox in that it decreases activity and increases the ability to concentrate in people with ADHD. It has its effect in ADHD, by blocking the activity of dopamine transporters (which usually remove dopamine once it has been released), thus increasing levels of dopamine.^a Some people with ADHD may have too many dopamine transporters^b, which results in low levels of dopamine in the brain.

Many addictive drugs, including cocaine, alcohol and amphetamines also increase dopamine levels. The key difference between methylphenidate and addictive drugs is the length of time which it takes for the drug to reach the brain. Methylphenidate takes about an hour to raise dopamine levels whereas inhaled or injected cocaine hits the brain in seconds.

^a N J of Neuroscience 2001; 21 121 ^b Lancet 1999; 354 2132 2133

Q. What are the most common Generic (Brand Names) for Methylphenidate?

A. Some of the most common Generic (Brand Names) used in the UK are: Ritalin, Ritalin SR, Equasym, Equasym CD, and Concerta XL. There are various other Generic (brand names) in the USA and other countries, if in doubt please contact a local Support Group via our Support Group Pages.

Q. Can I crush the fast acting Ritalin tablet if my child won't swallow it?

A. Crushing is not a good idea as the Ritalin/Equasym is bitter and swollowing is quicker as a tablet, than a powder or pieces. Try giving a quarter which is easier to swallow, placed far back on his tongue, where the bitterness is less obvious with his favourite drink. It should just wash down. When used to a quarter, try a two quarters (half) and eventually a full half and if required a whole eventually. Also compliment him when he manages to succeed. A sip of the drink before you start also helps. However crushed and mixed with something they like may be alright providing the bitter taste does not come through!

The Slow Release tablets such as Concerta XL and Equasym XL should not be crushed or opened in any way as this will make them ineffective.

^a From a question posted on adders.org forum and answered by Dr Billy Levin from South Africa

The following FAQs are reproduced with the kind permission of the stated publications:

Taken from Booklet: Expert Opinions in ADHD Issue 1 Dosing

Authors: Professor Peter Hill, Professor of Child Psychiatry, Great Ormond Street Hospital Dr Daphne Keen, consultant Paediatrician, Great George's Hospital Published by AC publications Ltd Dec 2001

Q. How much methylphenidate or dexamphetamine will a child with ADHD normally need to take?

A. There is no set dose that will suit all children of one age or size or even type of problem, one child may need a higher or lower dose than another similar child. The important thing is to start with a low dose and gradually increase it until the pre-agreed aims of treatment (e.g.: better concentration at school, improved behaviour at home) are achieved. The optimum dose will need to balance effectiveness and any unwanted effects that appear.

Q. How often does a child with ADHD need to take methylphenidate or dexamphetamine?

A. The spacing of doses will also depend on the child. Most children take two or three doses a day at mealtimes. If a child wakes up with severe behavioural problems and need to take a dose straight away and a second dose a couple of hours later for the start of the school day. Further doses may then be more widely spaced during the day. As a general rule, three doses a day is often more effective than two.

Q. Does a child need to take more methylphenidate as he/she gets bigger?

A. This varies. Some children need higher doses when they reach secondary school but this is more to do with the fact that their schooling is more structured and requires greater concentration rather than that they are bigger.

Q. Do children with ADHD need to take methylphenidate during the school holidays?

A. This will depend on the aims of treatment. If the aim is to improve concentration in school, then a child may be less in need of treatment during the holidays. But if the aim is to help impulsive behaviour and social relationships then the treatment will need to be continuous so the child feels consistently successful during week ends and holidays as well. It is important for the child to discuss these issues with parents and doctors. Whereas some children can discuss this maturely, others do not have a good insight into the impact of their difficulties.

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Q. Is methylphenidate addictive?

A.No. You only have to see how easily children stop and start treatment to realise that they are not addicted in any way. Indeed, the usual problem is getting children to take their medication.

Q. What about suggestions that children taking drugs for ADHD become zombies?

A. If a child loses their spark or personality on ADHD stimulant medication treatment they are receiving the wrong treatment. The medication is either unsuitable for them or they are receiving too high a dose for their needs.

Taken from Booklet: Expert Opinions in ADHD Issue 2 Assessment

Authors: Professor Peter Hill, Professor of Child Psychiatry, Great Ormond Street Hospital Jane Gilmour PhD DclinPsy, Lecturer in Clinical Psychology, Great Ormond Street Hospital, London Published by AC publications Ltd Dec 2002

Q. How long does an ADHD assessment take?

A. A complete assessment for ADHD by a child psychiatrist or paediatrician is likely to take about 1.5 hours or more and is quite likely to require more than one appointment if the school is to be contacted.

Q. Are GPs; the only people who can make referrals by assessment?

A. Most referrals for assessment are made by GPs in response to requests by parents, though teachers, educational psychologists or community paediatricians may set the ball rolling. A referral cannot normally take place without the knowledge and cooperation of the parents and the child.

Q. Will the child psychiatrist, paediatrician or child psychologist visit the child's school?

A. This is most likely if there is conflicting information from the parental and school reports. Such visits are an opportunity to see the child in class and in social situations. The child will be told about the visit but can choose whether or not to tell other pupils.

Q. Which questionnaires are recommended for ADHD assessment?

A. The revised Conners Rating Scales (CRS-R) are widely used for parent and teachers assessments as they are reliable and sensitive to changes in behaviour in response to treatment.

Q. Will the child be asked to complete a questionnaire as part of the assessment?

A. Children with attention problems find it hard to complete questionnaires, so assessment is carried out through verbal questioning and practical tests.

Q. Should children be tested for food intolerance?

A. Some children with ADHD may be sensitive to certain foods and many parents will report this accurately. Patch testing for food intolerance or hair analysis for mineral deficiencies are not advisable as results are inconclusive and may suggest such wide ranging dietary changes that they are impractical for the child and his family.

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When lay people and professionals alike talk about dysfunctional families, often the question arises: Did the mother love the children? Or, did the father love the children?

Parental love is a very complicated emotion. If a parent compulsively looks after their children's health, insisting they eat only organic food, and natural vitamins, is this a form of love? How about if a parent makes a child come home after school and forbids any socializing until the studies are completed to her satisfaction--because this way the child will get into Harvard. Is this love? If the parent is looking after the child's best interests, then arguably their actions reflect love. But where is the line drawn? Some parents say to their children: "Everything I did, I did for you--fed you, clothed you, put a roof over your head--all of it for you." While probably an exaggeration, there is still a bit of truth here. Was there love? Probably. One can usually find a kernel of love towards their children in even the most narcissistic of parents. "I love you because you reflect well on me" is still love, however sullied. (One might argue that love in the service of selfish needs is not really love--but the line between selfish and unselfish love is a fuzzy one indeed.) Furthermore, the tears a narcissistic parent sheds when their child dies are absolutely real.

Simply put, love is too complicated an emotion to be of much use in distinguishing narcissistic and healthy parents. In my experience, if you ask adult children of narcissistic parents whether they were loved, many if not most will say "yes, in a controlling, self-centered way" even after they've completed therapy. Another variable, however, is far more telling. The critical questions are: "Did my parent respect and value what I said, see myself as independent from them in a positive way, and feel that my thoughts and feelings were as important as theirs." In other words, did my parent allow me "voice?" No adult child of a narcissistic parent can answer these questions in the affirmative.

These questions define the critical injury to adult children with narcissistic parents. Interestingly, many such people have no problem finding "love." But deep affection does not satisfy them unless accompanied by the granting of "voice" by a powerful person. As a result, adult children of narcissistic parents often go from bad relationship to bad relationship in search of "voice."

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For parents, the implications are clear. Love is not enough. Client after client has taught me this unequivocal lesson:

If you want to raise emotionally healthy children, you must give them the gift of "voice."

About the author: Dr. Grossman is a clinical psychologist and author of the Voicelessness and Emotional Survival web site.

next: Little Voices

What is Sex Therapy About?

Sex therapy is treatment of sexual problems: for example, impotence (inability of an adult male to achieve or maintain erection); frigidity (in an adult female, the inability to achieve orgasm); premature ejaculation; or low sex drive.

The World Book Rush-Presbyterian
St. Luke's Medical Center Medical Encyclopedia

The techniques involved include counseling, psychotherapy, behavior modification, and marital therapy. When possible, both partners usually attend therapy. There are generally good success rates in treating sexual problems by these techniques.

Legitimate sex therapy has nothing to do with sexual surrogates or other paid sexual partners.

Sex Therapy Takes Time and Work

Sexual dysfunction conjures up feelings of guilt, anger, insecurity, frustration, and rejection. Sex therapy is slow and requires open communication and understanding between sexual partners. Therapy may inadvertently address interpersonal communication problems.

What Happens in Sex Therapy?

Sex therapy is conducted by a trained therapist, doctor, or psychologist. The initial sessions should cover a complete history not only of the sexual problem but of the entire relationship and each individual's background and personality. The sexual relationship should be discussed in the context of the entire relationship. In fact, sexual counseling may de-emphasize sex until other aspects of the relationship are better understood and communicated.

There are several techniques that combat sexual dysfunction and are used in sex therapy. They include:

• Semans' technique: helps to combat premature ejaculation with a "start-stop" approach to penis stimulation. By stimulating the man up to the point of ejaculation and then stopping, the man will become more aware of his response. More awareness leads to greater control, and open stimulation of both partners leads to greater communication and less anxiety. The start-stop technique is conducted four times until the man is allowed to ejaculate.
• Sensate focus therapy is the practice of nongenital and genital touching between partners in order to decrease sexual anxiety and build communication. First, partners explore each other's bodies without touching the genitals or breasts. Once the couple is comfortable with nongenital touching, they can expand to genital stimulation. Intercourse is prohibited in order to allow the partners to expand their intimacy and communication.
• Squeeze technique is used to treat premature ejaculation. When the man feels the urge to ejaculate, his partner squeezes his penis just below the head. This stops ejaculation and gives the man more control over his response.

Good Sexual Relationships Take Time

Habits change slowly.

All the techniques must be practiced faithfully for long periods of time to learn new behaviors.

Communication is imperative.

Can I find a sex therapist online

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sex therapy

Name: Dave
Age: 48
Occupation:Bank Manager

Carol and Dave needed sex therapy. Married for 20 years, their most recent sexual encounter had been more than six months ago.Carol, 45, works as an administrative assistant. Dave, 48, is in management at a local bank. They believed their marriage was strong, but that the passion had disappeared. They were living as if they were brother and sister instead of husband and wife.

Name: Carol
Age: 45
Occupation: Administrative Assistant

There was no dramatic event that changed things for Carol and Dave. Rather, they found themselves increasingly making excuses to avoid intimacy, believing that nothing really was wrong. After awhile, it just seemed easier to sidestep the subject altogether. Amazingly, they never even discussed their problem until one evening when Dave got a notion. Perhaps it was the movie they had seen the night before-the one with the sex scene by the pool. Maybe it was the cocktail that Dave had when they got home. Whatever it was, when Dave tried to initiate sex with Carol, she was unreceptive. In fact, she was taken by surprise and was as angry at herself for being unable to get "turned on" as she was at Dave for catching her off guard.

Having the Courage to Seek Help

Carol and Dave are fortunate. They cared enough to recognize that they had a problem they were unable to solve by themselves. They sought counseling and were referred to a Certified Sex Therapist. It came as a surprise to them that sexual dysfunction is a legitimate specialty among psychologists and other health professionals.

Sex therapists can be found in most large cities. Therapists have been trained in techniques pioneered by Masters and Johnson, and are certified by the American Association of Sex Educators, Counselors and Therapists (AASECT). Certification requires sexuality courses, plus two years of supervised practice, and is usually sought by psychologists or clinical social workers.

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The philosophy behind sex therapy is that sex is an important aspect of life, and that sexual problems can be addressed and overcome. Sex therapists believe that sexual dysfunctions can be caused by a multitude of physical or emotional factors, and that those conditions require careful diagnosis. Often, when problems begin, the couple may not recognize or understand what is happening, and inadvertently behave in ways that exacerbate tensions.

Middle Age Can Mark Beginning of Intimacy-Related Challenges

The problems of Carol and Dave were caused by the normal changes that occur in sexually-functioning people as they reach middle age. As Dave had begun to find his own responses less spontaneous, his self-esteem had suffered, and he unconsciously began to avoid Carol for fear that he would no longer be the sexual partner he once was.

Unable to discuss his concerns with Carol, Dave simply made himself increasingly busy. Carol was busy enough herself, and she was not fully aware of her own increasing resentment and feelings of rejection. As their physical distance grew, it began to affect other aspects of their relationship. By the time Carol and Dave met with a therapist, they had begun to wonder if their marriage would survive.

The problems of Carol and Dave were caused by the normal changes that occur in sexually-functioning people as they reach middle age.

The therapist patiently listened to Carol and Dave's story and began the process of educating them. She helped the couple learn a new definition of sex, namely that is love expressed through sensual physical touch. She also taught them that good sex is about more than intercourse alone, and that sex does not have to be a "performance."

In a series of graded exercises, the therapist instructed Carol and Dave on a variety of ways to reach out to each other in a positive manner. Hesitant at first, they overcame their inhibitions and learned to communicate their sexual desires.

Dave realized that carol was not expecting him to be a stud, and that he could focus on pleasure rather than performance. Carol learned that, at age 45, she was no less attractive to Dave than she was 20 years ago, and that Dave did not expect her to look like a sex goddess.

Over several months of therapy, Carol and Dave found new passion, deepened their love for one another, and enhanced all aspects of their lives. They gradually made more time for one another and found more reason to be together than apart.

While sex therapy cannot guarantee such results in all cases, the things that Carol and Dave learned -and the fulfillment they have gained from that knowledge- are typical of what other couples in their 40s, 50s, or 60s experience when they make the critical decision to face the challenge of discussing the most private of behaviors with a trained professional.

next: The Marriage of Thought Field Therapy and Sex Therapy

A woman, living with bipolar disorder, describes what it feels like to be hypomanic and manic.

Personal Stories on Living with Bipolar Disorder

"In order for the light to shine so brightly, the darkness must be present."
~Danny Devito~

This is a cumulative commentary of episodes I have experienced while manic and hypomanic or in a mixed state. I tried to paint a decent picture of what these states feel like. I have rapid cycling so there are many episodes. I have presented a cumulative overview.

~Hypomania~

I feel joy juice surging through my veins. I'm drunk on life! A colossal "high" has found me. I'm witty, charming, quick, talkative and effervescent. Everything becomes deeply fascinating and brilliant. Euphoria is an understatement. I want to share this feeling with everyone so I compulsively call people randomly on the phone while chatting on the computer. I call psychics or get an online consult because I know they can guide me ending up spending countless dollars. I have several windows on my computer open at once as I multi-task. I'm chatting with strangers, shopping for things I don't need, researching for my web site, writing letters and more. Even though I am easily distracted, I can still do all of this because I'm ingenious. I spend hours on-line looking at meaningful quotations that I can connect with and perusing through my CD collection browsing for profound lyrics. Music becomes especially meaningful and touches my soul. Songs repeat over and over again in my head with fleeting swiftness, as I continue to change the CDs quickly in succession. Laughter is infectious, I crack up at everything and find humor in moronic things and I expect others to laugh with me as well. I feel seductive and sensual thinking I can take lovemaking to a new height. I'm running around my house with almost nothing on right in front of the windows. I can clean with lightening speed and get dazzling results. I have little time for sleep because I'm too absorbed with activity. At times irritability creeps in and I'm easily annoyed. I quip at small and senseless things. Eventually the mood changes and it becomes something else.

~Mania~

It starts out with that hypomanic elevated feeling and progresses into a monster of it's own.

Before I was diagnosed:

1985: Agitation and Irritability
I haven't been to sleep in three days. I'm buzzing down the road erratically and much too fast behind the wheel of a car I have no business driving. I'm having a seriously heated argument (about what I don't know) with my fiancé (now my husband). My irritability is off the Richter scale. My mind is racing, things are jumbled, and I am not making clear conversation. The pressure is on for me to keep yelling regardless if it makes sense or not. Thoughts that come out of my mouth are disconnected and don't have any rationale to them. The faster I speak, the more agitated I become. I am distracted by everything around me. Greg is alarmed by my behavior, but doesn't say so. I am screaming and yelling...he says very little. I pull over to the curb and summon him out of the car. He stares at me with bewildered tearful eyes and eventually gets out. I squeal the tires and zoom down the road, leaving him 100 blocks from home with no money to catch the bus. He walks all the way back to my house.

1987: A Grandiose Trip
I'm think I am thinking clearly today even though I'm a bit racy and my thoughts are accelerating quickly. Flights of ideas are fabulous. The cogs are turning. I am overwhelmed by everything that surrounds me. I think I'm well off. No, I know it. I can afford anything I want. Payment plans were created for me! I'm planning a vacation to Mexico. After all, I deserve it. Feeling extremely animated, I picture myself drinking exotic libations under a cool palm tree and feeling the romance of a far off and wondrous place. Xtapa/Zihuatanejo sounds perfect! The travel brochures speak to me! I impulsively book a an expensive vacation and put it on a credit card and tell my husband afterwards. He wants to please me so he agrees because he has no idea at this point what is wrong with me. The trip turns out to be a $6000.00 mess.

Mania:
Manic episodes for me start out like a powerful rush of ecstasy. One experiences certain bravado and elevated esteem. I feel creative, intuitive, and giddy. I've functioned on a level of working 12-hour plus days with little or no sleep for long periods of time because I have "projects" in my mind. Sleep eventually ceases for the most part. I become much more chatty then usual and will converse with just about anyone. The need to be heard is exhausting. I've become so intoxicated on occasions that I have "blacked out" and had no memory of my actions. I do remember one episode when I was manic that I drank to excess and played a piano at my place of business (hotel) until 5AM in the morning. The funny thing is, I don't play the piano. I ran the risk of disturbing sleeping guests and being fired. I have spent thousands of dollars on trips, cars, clothes, etc., etc. My energy is monumental. I'm a seductress with an alluring grin. My discretion is reckless at best. I can't even keep up with all the ideas floating around in my head. This level can continue for a good period of time...then things change.

Thoughts begin to race faster and faster; speech becomes jagged and disconnected. People look at me funny because I can't connect my thoughts to my utterances. Then it really gets bad because the irritability and anger come into play and sometimes violence. Merriment ceases altogether I start to lose touch with reality because nothing I process is accurate. I think my medication is poison so I refuse to take it. Paranoia creeps in and things turn into frightening thoughts. My brain deludes my consciousness and things become very alarming. Arguments become extremely intense, possessions get destroyed, and I become completely out of control. I have seen spider like things crawling in my foot and a large creature from a sci-fi movie moving around in the light in my bedroom. The horror of this is immense. I am entangled in my mind. The next thing I know I crash and wind up in the hospital or end up taking more pills of many colors...pretty yellow, pink, and white. My cycles are rapid most of the time.

~Mixed State~

I'm coming out of my skin. I am so depressed and hopeless that I can't stand it yet I can't turn my brain off. I have racing thoughts and am ruminating about suicide. I'm sitting in bed with my laptop multi-tasking with many windows open, tearfully looking at the screen. I have a cornucopia of emotions swirling around in my mind. I can't concentrate and am very frenzied. I have it in my thoughts to clean, but I walk aimlessly around my house from room to room and am not able to function. I just can't clean anything. I can't sleep, don't want to eat and am busy busy busy. I am so incredibly agitated and irritable. I snap at my husband for no reason at all. Everything is completely out of whack! I'm in an emotional overload and I can't control it. I hold my hands to my ears and shake my head back and forth to try and silence my brain. The disorganization in my mind is too much to bear! I just want to escape but I am not able to. More pills or a nice trip to the fruit loop factory.

next: Diagnostic Criteria for Hypomanic Episode Bipolar Disorder
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