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Behavior therapy with a narcotics user: a case report
Bshav.
Rcs & Therapy.
lii67.
Vol.
5. pp. 251 LO 32.
Pergamon
Press Ltd.
Behavior therapy with a narcotics
Printed
in England
user: a case report
(Received 10 March 1967)
ALTHOUGH behavior therapy seems to be widely used in the treatment of alcoholism, this writer could find no extended reports of its use with narcotics addiction. This report describes the successful application of behavior therapy in the treatment of a narcotics user. The follow-up period is relatively short (IO months) and other variables such as the relationship and suggestion were not controlled, but the success achieved seemed so real that I felt it appropriate to bring this approach to the attention of colleagues. The patient was a 21-yr-old college senior who was seen in thirty-three I-hr therapy sessions over a period of 4+ months. Sessions were initially held twice weekly, but after 3 months (twenty-six sessions) they were given weekly. Discussion of dynamics and background were held to a minimum, though there was much talk of self-assertion and plans for the future, particularly toward the end of treatment. The results suggest the feasibility of a relatively brief but long-lasting method of treating narcotics use and addiction. At the first session. the patient explained, with hesitation, that he had always been anxious and that now he was a “junkie.” As a matter of fact, he was not fully addicted at the time. He had been once before but had successfully “kicked the habit” by leaving college and locking himself in a hotel room until the withdrawal symptoms had passed. He sought treatment from me because he feared that he was once more headed towards addiction. He was taking morphine two or three times a week and he could see that it was becoming increasingly important to him. He was doing poorly in his classwork, when he attended, and he had a number of incomplete grades from previous semesters when he had failed to complete the required work. A few years previously he had received about 6 months of once-a-week psychotherapy with a well-trained psychoanalytically-oriented psychologist. He tried to get help from him again but learned that he was no longer in town. Through him, however, he was referred to the writer. He did not wish to use the college facilities since he feared that his use of narcotics would somehow get on his college record. A case history was taken and it was agreed that he would be seen twice a week. At the second session, a program of behavior modification was outlined which he readily accepted. He seemed relieved by this approach, since he almost dreaded going through all the material he had once discussed with his previous therapist. The program as then outlined included two types of training. First, there was to be training in relaxation to overcome tension and as a substitute for drug-induced relaxation. Second, there was to be training in self-assertion as a way of overcoming his need for the drugs. It seemed fairly clear that he had a rather poor opinion of himself. Finally, he was urged to forsake and avoid his old associates who were drug-users since they might provide temptations which would be too strong to resist in the beginning of training. The patient proved to be exceptionally adept in learning relaxation. A modified Jacobson technique. as described by Wolpe (1958), was used. After the first session, he remarked with amazement how the tingling in his relaxed fingers was similar to the tingling he felt after using narcotics. After only four sessions he was able to relax his entire body. He practiced daily at home and in order to develop a conditioned trigger stimulus he said the word “relax” just prior to beginning his exercises. Eventually he got to the point where merely saying this word was sufficient to bring about deep relaxation. Also, in the second session, he was given a copy of Salter’s (1949) CondLtioned Ref7e.x Therapy. He read this within a few days and the methods of developing self-assertiveness were discussed with him. By the seventh session, he had developed sufficient self-confidence to attend his first college dance. He enjoyed himself and wondered why he had wasted so many years avoiding them. At about that time he turned down two offers of free narcotics. A school vacation came and he went home to see his parents. Unfortunately, since his father was in the medical field, narcotics were readily available in the house. He withstood the temptation for a few days but finally gave in. When he returned to college after the vacation, he visited some addict friends and accepted a “fix.” It was with much embarrassment that he returned for therapy sessions. It seemed obvious that something had to be added. It appeared he not only had to learn self-confidence and relaxation, but he also had to learn to avoid the drugs. He had to learn to associate anxiety with a stimulus that up till then had produced pleasure. Therefore, in addition to the first two steps, aversive
251
252
CASE HISTORIES
AtiD
SHORTER
COMML’XICATl0N.S
conditioning was undertaken. The patient described in detail the procedure of administering the narcotics. He also brought in a hypodermic syringe and rubber nipple which he used to squeeze the dissolved morphine through the needle. Five key steps in the procedure Here listed and he Has asked to think of them one at a time. When he signalled that he had a clear picture of going through a step he was given a painful electric shock to the arm. The shock was continued until he said “Stop.” at which time he also ceased visualizing the key step. Two of the five steps involved actually picking up objects-the syringe and the nipple-and the shock continued until he dropped them on the desk. The aversive conditioning was done tuice a week. At first there was reinforcement on each of the key steps. Since the procedure was done three times at each therapy session, he received 15 sharp electric shocks. After sixteen aversive conditioning sessions, there was a change to partial reinforcemenr, with a gradually decreasing number of shocks being given until at the twenty-fourth and last aversive conditioning session, only five shocks were administered. After 8 weeks, aversive conditioning was done only once a week. Following the eighth aversive session, he had the opportunity to use morphine and he accepted it. He said later that it was a real failure. He did not get the “good feeling” that morphine usually brought, he looked on it as a backward step, and he felt sure that he would not do it again. He became quite sure of Some time was spent in each of the later sessions discussing his future plans. himself and was able to apply for jobs without fear. ,He completed his schoolwork and very proudly graduated. He His parents visited the therapist and commented that he seemed like a different and much better person. was now able to get along with them, whereas before simply being with them was upsetting. Follow-ups conducted 7 and 10 months after the end of treatment showed that he still had not taken hard drugs. He did occasionally smoke marijuana, but he had never stopped this and he never planned to. He had a job in a field related to his college major, enjoyed his work, and felt that he was doing well in it. In letters to the therapist he seemed pleased with the way things have turned out. The letters show him to be a bright sensitive person, very much concerned with the world around him. He no longer feels threatened by the imaginary fears common to so many people, but he does feel a strong sympathy for those. who do have them. The letters give strong support to the therapist’s impression that treatment was highly successful. It is understood that the patient was not strongly addicted to narcotics when he came for help, and also that he was strongly motivated. It is felt, however, that the method described here could have salutary effects even with confirmed addicts following their withdrawal from the drugs. One outstanding advantage for this approach would be a major saving in time, since traditional psychotherapy with narcotics-users involves prolonged treatment.
REFERENCES SALTER A. (1949) New York.
ConditionedReflex
WOLPE J. (1958)
Psychotherapy
6601 S. W. 80th Street, South Miami, Florida 33143, U.S.A.
Therupy.
Farrar,
Straus.
by Reciprocal Inhibition.
New York;
Stanford
(1961) Capricorn
University
Press,
Books:
Stanford,
Putnam,
California.
ERWIN LE.S~ER
Rcs & Therapy.
lii67.
Vol.
5. pp. 251 LO 32.
Pergamon
Press Ltd.
Behavior therapy with a narcotics
Printed
in England
user: a case report
(Received 10 March 1967)
ALTHOUGH behavior therapy seems to be widely used in the treatment of alcoholism, this writer could find no extended reports of its use with narcotics addiction. This report describes the successful application of behavior therapy in the treatment of a narcotics user. The follow-up period is relatively short (IO months) and other variables such as the relationship and suggestion were not controlled, but the success achieved seemed so real that I felt it appropriate to bring this approach to the attention of colleagues. The patient was a 21-yr-old college senior who was seen in thirty-three I-hr therapy sessions over a period of 4+ months. Sessions were initially held twice weekly, but after 3 months (twenty-six sessions) they were given weekly. Discussion of dynamics and background were held to a minimum, though there was much talk of self-assertion and plans for the future, particularly toward the end of treatment. The results suggest the feasibility of a relatively brief but long-lasting method of treating narcotics use and addiction. At the first session. the patient explained, with hesitation, that he had always been anxious and that now he was a “junkie.” As a matter of fact, he was not fully addicted at the time. He had been once before but had successfully “kicked the habit” by leaving college and locking himself in a hotel room until the withdrawal symptoms had passed. He sought treatment from me because he feared that he was once more headed towards addiction. He was taking morphine two or three times a week and he could see that it was becoming increasingly important to him. He was doing poorly in his classwork, when he attended, and he had a number of incomplete grades from previous semesters when he had failed to complete the required work. A few years previously he had received about 6 months of once-a-week psychotherapy with a well-trained psychoanalytically-oriented psychologist. He tried to get help from him again but learned that he was no longer in town. Through him, however, he was referred to the writer. He did not wish to use the college facilities since he feared that his use of narcotics would somehow get on his college record. A case history was taken and it was agreed that he would be seen twice a week. At the second session, a program of behavior modification was outlined which he readily accepted. He seemed relieved by this approach, since he almost dreaded going through all the material he had once discussed with his previous therapist. The program as then outlined included two types of training. First, there was to be training in relaxation to overcome tension and as a substitute for drug-induced relaxation. Second, there was to be training in self-assertion as a way of overcoming his need for the drugs. It seemed fairly clear that he had a rather poor opinion of himself. Finally, he was urged to forsake and avoid his old associates who were drug-users since they might provide temptations which would be too strong to resist in the beginning of training. The patient proved to be exceptionally adept in learning relaxation. A modified Jacobson technique. as described by Wolpe (1958), was used. After the first session, he remarked with amazement how the tingling in his relaxed fingers was similar to the tingling he felt after using narcotics. After only four sessions he was able to relax his entire body. He practiced daily at home and in order to develop a conditioned trigger stimulus he said the word “relax” just prior to beginning his exercises. Eventually he got to the point where merely saying this word was sufficient to bring about deep relaxation. Also, in the second session, he was given a copy of Salter’s (1949) CondLtioned Ref7e.x Therapy. He read this within a few days and the methods of developing self-assertiveness were discussed with him. By the seventh session, he had developed sufficient self-confidence to attend his first college dance. He enjoyed himself and wondered why he had wasted so many years avoiding them. At about that time he turned down two offers of free narcotics. A school vacation came and he went home to see his parents. Unfortunately, since his father was in the medical field, narcotics were readily available in the house. He withstood the temptation for a few days but finally gave in. When he returned to college after the vacation, he visited some addict friends and accepted a “fix.” It was with much embarrassment that he returned for therapy sessions. It seemed obvious that something had to be added. It appeared he not only had to learn self-confidence and relaxation, but he also had to learn to avoid the drugs. He had to learn to associate anxiety with a stimulus that up till then had produced pleasure. Therefore, in addition to the first two steps, aversive
251
252
CASE HISTORIES
AtiD
SHORTER
COMML’XICATl0N.S
conditioning was undertaken. The patient described in detail the procedure of administering the narcotics. He also brought in a hypodermic syringe and rubber nipple which he used to squeeze the dissolved morphine through the needle. Five key steps in the procedure Here listed and he Has asked to think of them one at a time. When he signalled that he had a clear picture of going through a step he was given a painful electric shock to the arm. The shock was continued until he said “Stop.” at which time he also ceased visualizing the key step. Two of the five steps involved actually picking up objects-the syringe and the nipple-and the shock continued until he dropped them on the desk. The aversive conditioning was done tuice a week. At first there was reinforcement on each of the key steps. Since the procedure was done three times at each therapy session, he received 15 sharp electric shocks. After sixteen aversive conditioning sessions, there was a change to partial reinforcemenr, with a gradually decreasing number of shocks being given until at the twenty-fourth and last aversive conditioning session, only five shocks were administered. After 8 weeks, aversive conditioning was done only once a week. Following the eighth aversive session, he had the opportunity to use morphine and he accepted it. He said later that it was a real failure. He did not get the “good feeling” that morphine usually brought, he looked on it as a backward step, and he felt sure that he would not do it again. He became quite sure of Some time was spent in each of the later sessions discussing his future plans. himself and was able to apply for jobs without fear. ,He completed his schoolwork and very proudly graduated. He His parents visited the therapist and commented that he seemed like a different and much better person. was now able to get along with them, whereas before simply being with them was upsetting. Follow-ups conducted 7 and 10 months after the end of treatment showed that he still had not taken hard drugs. He did occasionally smoke marijuana, but he had never stopped this and he never planned to. He had a job in a field related to his college major, enjoyed his work, and felt that he was doing well in it. In letters to the therapist he seemed pleased with the way things have turned out. The letters show him to be a bright sensitive person, very much concerned with the world around him. He no longer feels threatened by the imaginary fears common to so many people, but he does feel a strong sympathy for those. who do have them. The letters give strong support to the therapist’s impression that treatment was highly successful. It is understood that the patient was not strongly addicted to narcotics when he came for help, and also that he was strongly motivated. It is felt, however, that the method described here could have salutary effects even with confirmed addicts following their withdrawal from the drugs. One outstanding advantage for this approach would be a major saving in time, since traditional psychotherapy with narcotics-users involves prolonged treatment.
REFERENCES SALTER A. (1949) New York.
ConditionedReflex
WOLPE J. (1958)
Psychotherapy
6601 S. W. 80th Street, South Miami, Florida 33143, U.S.A.
Therupy.
Farrar,
Straus.
by Reciprocal Inhibition.
New York;
Stanford
(1961) Capricorn
University
Press,
Books:
Stanford,
Putnam,
California.
ERWIN LE.S~ER