Some Observations on Adolescent Drug Use

Some Observations on Adolescent Drug Use Therapeutic Implications

Richard A. Geist, Ed.D.

Observations and understanding of adolescent drug use have emerged from two sources: long-term psychotherapeutic attempts to comprehend the intrapsychic processes of individual patients, and nonclinical descriptions of youth who in times of crisis seek out the services of free health clinics. Because few clinicians choose to work in storefront medical and counseling centers, however, there is a dearth of studies focusing on the inner dynamics of patients in the context of their reality crises. Such omissions are unfortunate, for we can often learn most about the relationship between drug use and personality development during that critical period when adolescent drug users perceive themselves as actively in need of help. As one 16-year-old girl suggested while reflecting on her own situation, it is throughout the course of these episodic crises that You're exposed to parts of yourself that have been so suppressed, and when you're young and don't have someone on your side, someone you can really trust, and you're smoking or dropping an instant pill, you can go through some incredible amounts of changes that are not necessarily good; and to live with those changes, not quite being able to grasp them, is like a torch at the base of your brain, burning far too close-a smoldering puzzle screaming to have its riddle solved. Without wishing to delimit what is obviously a many-faceted expression, I would point to the words "so suppressed," "really trust," and "smoldering puzzle" as circumscribing an area of accessibility during these critical periods. For at such intervals, the clinician is allowed transiently into the adolescent's trust and is offered a glimpse of those Dr. Geist is a Psychologist at The Children's Hospital Medical Center Department of Psychiatry, 300 Longwood Avenue, Boston, Massachusetts 02115, and Instructor in Psychology in the Department of Psychiatry of Harvard Medical School.

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relatively repressed feelings which reflect the puzzle that is screaming to have its riddle solved. Ephemeral in nature, however, the crisis soon subsides and with it the opportunities favorable to clinical observation and therapeutic intervention. For when the transferences of therapy proper commence, one can wait months, and sometimes years, for the reemergence and conscious recognition of those feelings which surfaced during the critical periods. In this context, I have had the opportunity during the past several years to consult with nearly 100 adolescents who were actively misusing drugs. All consultations were requested by the adolescents through a voluntary mental health service which I instituted in a suburban junior and senior high school; thus, the majority of interviews occurred during a crisis period. Several adolescents were seen in long-term, individual psychotherapy; many others in short-term treatment; a few in groups, and a large majority for one or two interviews. Although no formal research was undertaken, I have observed a common behavioral pattern and dynamic psychological structure in those adolescents who utilized drugs excessively; that is, to an extent which interfered significantly with their ability to function within the institutions of school, family, or viable work situation. For these adolescents, daily satisfactions are secured through instant highs, and personal relationships revolve around the exchange of drugs. They are neither experimenting with drugs nor addicting themselves to drugs; rather, they are adolescents for whom a relatively indiscriminate use of marijuana, amphetamines, hallucinogens, barbiturates, and less frequently, heroin becomes for varying periods of time the central aim and object of life. In what follows, I would like to describe the observed patterns and then indicate several therapeutic implications which result from our theoretical understanding. While pursuing these formulations, however, one should remain cognizant of the generalness of the approach and the specific population studied, for any method of investigation will to some extent determine the nature of the findings and the emphasis of the conclusions. BEHAVIORAL SIMILARITIES

The behavioral correlates of dynamic psychological needs are clearly overdetermined; nevertheless, the adolescents with whom I consulted share a number of similar characteristics, the validity of which can be confirmed or rejected only by other workers in the field. These commonalities include the following features.

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A Tendency toward an Unrealistic Sense of Trust in and Demand tor Human Love among People In psychotherapy the drug-using adolescent talks frequently of his or her meaningful relationships with trusting friends in the drug culture. The ubiquitous expectation that human beings should and will sacrifice clothes, possessions, drugs, time, and other people in the service of maintaining mutually responsive and caring human relationships is dramatically isolated from the reality of rip offs, false promises, and the sale of knowingly harmful or purposefully mislabeled drugs for personal gain. Such contradictions were exhibited sharply by an 18year-old homeless girl. Allison told me confidently that she never had difficulties securing bed and food from her many unknown brothers and sisters in the streets. And I watched as the street people welcomed her into their community and supplied her with food, bed, drugs, and clothes. But I also observed her cruel eviction from the community at 2 o'clock in the morning-with no money, no food, and no drugs. Allison was told that if space permitted, she might try returning again in a month. When gently questioned about the discrepancy between her trust in these unknown friends and her rejection, Allison asked me quite indignantly what friend of mine would "kick you out of a house and still let you store your belongings there until you find a new home." As for the lack of money and drugs, her friends would not have ripped her off unless they really needed it. "Besides," she added, "I can find other friends." Such prolific faith in defiance of the concrete, harsh realities of everyday existence is reminiscent of the early relationship between mother and child, when the infant in a demanding and dependent manner continually tries to stimulate an expectable reaction in the mother-a mutual responsiveness which will enhance the possibilities for an enduring sense of well-being inside oneself as well as in the outside world. Within the drug culture, probably because of the unconscious recognition of the finality implicit in the closure of adolescence, this search for trusting people becomes heightened and frantic-almost as if one part of the early personality has been split off and is seeking fulfillment rather than being integrated into the developing individual so as to enhance his growth." The mystical, almost childlike readiness to trust and to love was personified in the flower power movement of the 1960s; but those adolescents' naive openness-which brought a refreshing jolt to a generation of adults who were striving for mechanical perfection of the emotions ! Erikson (1970) seems to suggest the possibility in some youngsters of "totalization" of basic trust and an overrepression of basic mistrust.

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-was soon crushed by criminals and publicity seekers who could not resist the temptation to exploit such seemingly innocent vulnerability. It is this very vulnerability to being hurt which characterizes these youngsters' unrealistic sense of trust.

A Tendency to Deny the Reality of Time For every adolescent the sense of time represents a tangible reality against which his most cherished and eloquent dreams must be molded. Because the protean nature of adolescent functioning resists such scheduling, clocking, and segmenting, there is a natural inclination to deny the reality of future and past while recombining them into the present. Common manifestations of such temporal denial are students' complaints that history is irrelevant to their present plight; the sometimes prolonged reversals of night and day, sleeping during sunlight and working after dark; and the periodic refusal to plan for or anticipate future needs. In those adolescents who misuse drugs, time becomes an unbearable burden to be badgered, controlled, and ultimately stopped. One frequently hears comments such as, "The world is going around too fast, drugs help me slow it down"; or, "Society is so complex, I can't cope with all the parts unless I somehow simplify them"; or, "It's not that I want to drop out, it's that I want to step outside, like stop the world, I want to get off." The temporal rhythms of social progress must be attenuated: watches are not worn, appointments are broken, commitments are postponed, and there is a desperate search for isolated islands of tranquillity where such projects as hand tool making and hand cultivation of food replace rapid technological processing. Even the natural rhythms of the body must be altered, for they too contain-perhaps more rigidly-the concept of time. Just how intense this need to stop time becomes is discernible in the speed freaks, who, while creating the illusion of rapidity, actually see themselves as "making time stand still by going so much faster than time itself." As in all adolescents, the boundaries of these youngsters' fantasies, thoughts, and ideas are limitless, reaching as deeply into the future or past as the imagination will allow. Unlike most adolescents, when these youths deny the concept of time, their imagination reaches across separate realities so as to eclipse the distinction between creator and what is created. This confusion of subjective inner feelings and objective reality lends a psychoticlike appearance to what is actually a frantic attempt to release all the urgency contained in the idea of time. Perhaps T. S. Eliot conveys most eloquently these adolescents' perception of time. In "Burnt Norton" he says:

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Richard A. Geist Time present and time past Are both perhaps present in time future, And time future contained in time past. If all time is eternally present All time is unredeemable.

And, we might add, therefore, all time must be stopped.

A Tendency toward a Flight from Inner Reality The narcissistic turn toward the self at adolescence normally leads to a heightened sensitivity to one's inner reality, to those feelings which are "related historically to the physical experiences, excitements, pleasures, and pains of infancy" (Winnicott, 1935, p. 130). Through the synthesizing and transcending of these feelings in the second decade of life, one attains a flexible sense of mutuality between inner life and external reality, a sense of inner well-being that what is going on within oneself has some fittedness with the world in which one must experience one's existence. In the drug-using adolescent, there is an observable flight from those psychogenetic sensations which normal adolescents attempt to integrate into their developing personalities. In listening to their descriptions of everyday existence, one feels trapped among a series of continual crises in the external world: bad trips, needs for food, medication, housing, near escapes from police, and parental hassles. Rarely do all these unrelated incidents evolve into a discussion of inner feelings; they lead instead further into external reality and thus lend an impression (although often mistaken) of shallowness and superficiality to the personality. The denial of a personalized inner reality is portrayed most vividly when these youngsters discuss their parents. The therapist receives the impression that parents exist, but are peripheral to the life of the adolescent. As one adolescent stated, "Sure, you say I'm angry at my parents; that may be true, but the point is, it doesn't matter, they're not involved, so why bother to get angry at them?" With the same casualness, positive relationships are peripherally acknowledged, but quickly denied and discarded as unimportant. In both instances, there is a flight from the inner world of loved and hated introjects-a process which can only lead to the appearance of a bland, listless life which must be stimulated with a plethora of external adventures. This void in an emphatic response to their internal reality was poignantly illustrated by a group of drug-using adolescents with whom I met regularly. Jill, a perceptive girl who had stopped using drugs, was confronting the group: "No one knows each other in here; there's no relationships. I'm realizing how fucked up I am. It's awful, you bastards, it's painful.

Help me."

...

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The group, with little emotion, rationally and logically criticized Jill for such an outburst, to which Jill responded: "You're not listening to me. I'm telling you about me. I'm letting you know how fucked up I am. At least I recognize it!" Before turning to an external episode, one boy reflected the group's feeling when he said, "I understand what she meant; so what good does saying that do? It only gets her upset." In stressing this flight from inner reality I do not mean to imply a flight from fantasy. Dreams, daydreams, and fantasying are common phenomena in these youngsters, but such processes are treated as if one read them in a book; in other words, they are used in the service of denying the real feelings on which they are based. When adolescents continually flee from inner reality, they unwittingly deny the genetic roots of their current reality and thus vitiate the possibilities for reintegrating these feelings into their developing personalities. A Tendency toward Severe Depression Adolescence is a phase-specific period for alternating depressivelike cycles as youngsters mourn the loss of their dependent relationships with parents. For the drug-using adolescent, however, the cyclical mourning process yields to a constant and severe depressive affect. A sense of worthlessness, futility, and hopelessness pervades the conversation of these youngsters and is reflected in the unattentive care of their own bodies ("My body will wear out some day anyway; now or later, it doesn't matter"); in their inability to acknowledge areas of competence in their lives ("I couldn't get a job; there's nothing I can do that's worth doing"); in their hopeless feeling about effecting any significant change in their environment ("One person can't change the world; we're still in Vietnam, aren't we? Tell me what I can do about it"); and in their proclivity to suicidal gestures and attempts. In each of these areas there is a denial of inner reality and a projection of affect onto the environment: bodies wear out, the world exists as an oppressive fog continually suspended over them, and society offers no work which could be meaningful in the context of their beliefs. In brief, the world becomes a depressing and empty container, impossible to fill, futile to destroy, and tolerated with inane diffidence. A Tendency to Isolate the Process of Physical Sexuality from Psychological Mutuality Sexual freedom has become an acknowledged component of the drug culture. Intercourse and other genital or pregenital variations of coitus

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with varying partners in relatively short time spans appear to parallel the idea of sporadic highs with disparate populations. Availability and willingness are the paramount features of partnerships, and relationships between partners evolve, at first, more out of what happens in bed than any gradual personal investment in each other. Long rap sessions or mutual highs create the illusion that both individuals have really "gotten into each other," and the logical physical expression of such ostensible mutuality is sexual. Discussions about how well one performed in bed mirror comparisons of how well "one got off"-how successful a trip one experienced. These sexual relationships lack warmth, spontaneity, and a mutual regard for another human being because the pleasurable physical sensations tend to be isolated from emotional involvement. As one youngster stated, "Sex is fun. Why not enjoy it? That's different from a relationship." 2 On the other hand, however, a relationship is frequently valued and isolated from recurrent sexual encounters. One girl suggested meaningfully that "Bob was a bastard to seduce me into going to bed with him. He's screwed up sexually and I was stupid to go to bed with him, but I valued that relationship. We talked a lot. He's the only one who understood how I felt about me, and the only one who could have convinced me that I needed therapy." This process of enhancing one's own growth as a person while contributing to another's clarification of herself, however, rarely occurs simultaneously with a meaningful sexual experience. In fact, different partners frequently serve either sexual or emotional needs. When the drug-using adolescent can finally experience a heterosexual relationship which combines psychological and sexual mutuality with the same person, a significant developmental restructuring process has begun.

A Tendency toward Behavioral Passivity Adolescents who misuse drugs tend toward a pervasively passive life style in all areas of living. At home, parents complain of frequent and prolonged sleeping, blank stares in response to questions, a preference for eating meals in their rooms, a penchant for sitting in yogalike positions on the bed while gazing into space, and a general shadowlike presence in the house. At school, one observes small groups of adolescents sitting passively together, smoking dope or tripping in a somewhat desultory fashion through the corridors of the building, disturbing no one, talking infrequently, and expecting no interference in return. On the streets, these youngsters are characterized by their 2

This may also be partially a phase-specific part of adolescence.

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nomadic wanderings, drifting with the prevailing winds, although frequently following the warm weather; neither running to nor running from, but, as a Kris Kristofferson song suggests, "wasted on the sidewalk . . . wearing yesterday's misfortunes like a smile." In all of this passivity, however, which clearly goes beyond a manifestation of depression, there is a certain gentleness of manner which strikes a particularly responsive chord in animals and children. The combination of this passivity and gentleness is reminiscent of what Winnicott (1950) in another context described as "a withdrawal to rest which alone allows of individual existence" (p. 212). One often receives the impression that these youngsters exist in a bubble of clouds, the surrounding haze providing an elusive screen which impedes attempts to gain access to their real selves. Lethargic and acquiescing, they present the world with an uncanny sense of calmness which is ominous to others in much the same way as the calm before a storm. It is just this sense of foreboding which elicits in adults a need to "do something"-to prepare themselves-and just this sense of calm disquietude which promotes self-righteous rage when the anticipated explosion fails to materialize. For these adolescents keep their parents and teachers and therapists continually in the eye of the storm, anxiously making preparations against an unreal opposition. Perhaps what their behavior conveys most clearly is a passive readiness to respond to environmental impingements rather than any active searching to master environmental stimuli. These, then, are the behavioral characteristics most frequently observed in my consultation with drug-using adolescents. When one studies the above description, an obvious question germane to this paper is how the tendency toward passivity, depression, denial of time, isolation of physical and sexual mutuality, accentuation of the need to trust, and the flight from inner reality-how this interconnected pattern of behavioral observations reflects the inner structure of adolescents in the drug culture. It is to this more dynamic orientation that I now turn, with the hope that by conceptualizing drug misuse not as a clinical symptom but as part of the adolescent's attempt at ego synthesis, we can gain a better understanding of its use as an adaptive, although abortive, attempt to promote the developmental restructuring of the personality. DYNAMIC FORMULATIONS

The characteristic state of the ego in these adolescents reflects a philosophy of nonexistence. Just what I mean by this vague concept was conveyed quite dramatically by a student with whom I consulted when

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she was seriously and frighteningly demonstrating its implementation. Gail nonexisted: she immersed herself in drugs, sat passively in her room listening to rock music extolling the virtues of loneliness, crouched huddled in the corridors of the school, legs crossed, hair covering her eyes, and frantically rocking back and forth in her torn blue denim shirt, responding to no one except those few friends who would accept her without demanding a relationship in return. "I don't care, I don't care about anything or anybody" came the persistent cry, and her words were strikingly confirmed in the eyes of her teachers through Gail's behavioral passivity, her seemingly hopeless disregard for her commitments and her life. One morning in my office, as she was slowly descending from a frightening LSD trip, I was asking Gail to explain what all her drugs meant to her when she was high. Gail provocatively said: "I want to be nonexistent. I don't want to be anything anyone wants me to be, so I'll be not me, in other words, I'll nonexist." This philosophy of nonexistence describes more eloquently than any of our theories the atmosphere in which the adolescent drug user lives. It is a state of animated death-a world of being high, stoned, freaked out, tripping, getting off-a partial suspension of worldly participation in order to cope with earthly dilemmas which seem unresolvable when

approached with humanly psychic efforts. From Gail and others like her, I learned that this state of animated death was tantamount to living in an opaque bubble where reality is recognized but contains an "ever not quite" quality. As one youngster said to her therapist, "I know you're real, but you don't exist; you're not really there because I don't exist." This shadowy existence militates against all those factors which Erikson (1959) describes as promoting growth through ideological commitment at adolescence: a clear perspective of the future, a collective work experience, a submission to leaders who escape the ambivalence of the parent-child relationship, an introduction to the prevailing technology of the day, and the promotion of a correspondence between inner and outer worlds. In other words, a philosophy of nonexistence seems to replace the normal adolescent commitment to an overriding ideology which facilitates the process of ego identity formation. Although I cannot be more concrete in describing this sense of nonexistence, it does seem to have several dimensions. It appears to reflect the helpless intrapsychic impasse which occurs in these youngsters around the reemerging struggle between activity and passivity at adolescence. Those therapists who have worked extensively with adolescents will probably agree that at no other developmental period does the individual move with such fluidity between the subjective sense of "being done to" and "doing to" (Bios, 1966); at no

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other maturational phase can one observe such dramatic shifts between communal existence through participation and individual noncommitment through withdrawal and diffidence; and at no other times does man drift so easily between a sense of restrictive control and impulsive expression. This struggle between activity and passivity at adolescence is crucial to ego development for the very reason which Rapaport (1957) delineated so clearly: that the hallmark of structural development in any person is contingent on the ability to turn what was once done passively to the self into active performance and mastery. It is just at this turning point, however, that the drug-using adolescent becomes stuck, somehow fixated between the regressive pull to earlier developmental problems and the progressive pull toward an anticipated future of integrated possibilities. It is just at this point that a philosophy of nonexistence seems to take over as a compromise holding action which expresses both sides of the dilemma. On the one hand, there is a passive withdrawal into an isolated existence; on the other hand, there is a paradoxical, active decision, as Gail suggested, to nonexist-an intense commitment actually to choose a state of animated death as a moratorium that allows a respite from the ego's sense of impotence. It is an active, although abortive, attempt to achieve the feeling of mastery which says, "I did something and my doing it actually effected something." And in the observation of these youngsters actively feeding themselves substances which they will then passively experience, one discerns the complexity of the problem. What seems to interfere most dramatically with the resolution of the activity-passivity antithesis is an overwhelming sense of helplessness and vulnerability resulting from two psychogenetic factors: an early lack of maternal, emotional nurturance, and perhaps more importantly, an early and continued failure of one parent to protect the child from the irrational demands of the other parent. In my experience, these demands have been of a sexual or aggressive nature and have occurred chronically in situations when adolescents, as children, were terrified by the external physical or emotional overstimualtion of their own sexual or aggressive fantasies; the children searched for protection from the opposite parent and continually found him or her physically or psychologicallyabsent. One girl put it most absorbingly when she said, "I feel like a branch: every branch needs a tree [protection] and roots [nurturance] to grow. I didn't have either, so how can I grow?" Contained in this metaphorical statement is the dual sense of vulnerability which these adolescents feel-a sense of holding on for dear life lest they be regressively pulled back to earlier fixation points, and thus to total passivity; and a sense of terrifying anxiety about the future, about their vulnerability to life. As Zetzel (1965) put it:

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Richard A. Geist renunciation and loss are essential to human experience. Mature, passive acceptance of the inevitable thus remains a sustained prerequisite to the remobilization of available adaptive resources at all times. . . . failure in this vital area . . . represents a serious potential vulnerability that becomes increasingly relevant in the later years of life, when experiences of loss, grief, and frustration are not to be avoided [po 273].

It has been my experience that chronic loss of protection as a child has led drug-using adolescents to feel a certain vulnerability in accepting the inevitabilities of life, and thus a hesitancy to take the risk of attempting to turn passivity into activity. Apparently, much of the psychic energy deflected from this task reinvests itself in the sense of primitive rage which develops around feeling unprotected. And it is just this vulnerability which seems to underline the behavioral attempt to stop time. Perhaps the sense of vulnerability is expressed most clearly in the adolescents' frequently verbalized wishes to live in a cocoon, or to hibernate, again implying both the possibility of passivity and the possibility of actively reemerging with renewed strength. One also can observe the corresponding social phenomena in the spontaneous growth of drop-in centers, crash pads, and self-help programs which shield youngsters from parents, police, and society, while offering support and nurturance; they act as a holding environment which provides a certain homeostasis to the philosophy of nonexistence, while implicitly promising a renewal of strength. With the restructuring of the personality at a relative impasse, the philosophy of nonexistence reflects the adolescent's magical attempt to confront another important structural development of adolescence: the incipient differentiation between inner feelings and outer reality. Inhelder and f@ge.!jI958) have demonstrated that at puberty the adolescent acquires' certain mental structures which enable him to generalize and hypothesize about problems, to take many factors into account in making his decisions. These new capacities affect the way the adolescent thinks about himself and his reality relations, for he is now in control (of the concepts) of "hypothetico-deductive reasoning and new experimental proof" (Shapiro, 1963). In other words, the adolescent now bases his decisionmaking process on a host of new variables or considerations which were unavailable to him in the past. He attempts to reason out and provide rationale for his ideas. But the adolescent is usually unsure of the realities of his conclusions. He is just beginning to learn how to combine objective reality with internal feelings and subjective experiencing, and he often becomes unsure of what is real and what is fantasy. As Hartmann (1956) states, "reality testing . . . refers

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to the ability to discern subjective and objective elements in our jUd~g­ ments on reality" (p. 43). This increasing capacity to differentiate be tween inner and outer is one of the major psychological developmen of adolescence. I: Life in a cocoon, however, augurs poorly for such differentiation because the artificial bubble in which these youngsters live relegates reality to a tangential or peripheral sphere. As one youngster said to me, "I can say anything I want to you; it doesn't matter if it makes sense 'cause you're not really here-you don't exist in my mind." Through the continued denial of time and the increasing isolation of the self, reality recedes into the further recesses of the mind; it clearly exists, for few of these youngsters are psychotic, but only as an environment which impinges on the cocoon. The nonexistent world, on the other hand, contains its own reality based on what one feels should exist rather than a perception of what actually exists. In other words, there is a pervasive narcissistic and magical quality to the nonexistent life style, a magical quality which prevents the differentiation of objective from subjective and thus permits one omnipotently to select out of one's nonexistent state those unpleasant qualities in oneself or reality. In my experience, the most painful aspect selected out of the nonexistent state is the realization that one is separate from the mother, and it is just this denial which impedes most severely the separation of inner and outer reality. For to recognize one's separateness implies first, an inability ever to recapture the sense of nurturance and protection which has been perceived as missing; and second, an assumption of responsibility for one's own life rather than attributing the power for personal growth to others. The opaque bubble creates an illusion of separateness by omnipotently excluding what is painful and threatening in reality; simultaneously, within the cocoon separation is denied through omnipotent thinking which provides a magical affective connection with the parent from whom one has ostensibly separated (e.g., "If I get angry, I'll drive people away"). Life in the cocoon avails itself of adaptive possibilities only so long as one believes in the possibility of some kind of rebirth or reemergence. Intense magical thinking precludes such a rebirth and soon leads to an insidious growth of frustration, anger, and depression as one slowly loses the active choice of nonexisting. This stimulates a further use of magic to provide relief, and congruent with the general societal belief in medical magic, spiritual precepts, and superstitious rituals, it is not surprising that drugs are used in the service of a miscarried attempt actively to master the separation problem. Let me explain further. BIos (1967), in comparing adolescence with early childhood development, states:

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Richard A. Geist The disengagement from internalized objects-love and hate objects -opens the way in adolescence to the finding of external and extrafamilial love and hate objects. The reverse was true in early childhood during the separation-individuation phase, when the child gained psychological separateness from a concrete object, the mother. This was achieved through the process of internalization that gradually facilitated the child's growing independence from the mother's presence, her ministrations, and her emotional supplies as the chief and sole regulators of psychophysiological homeostasis [po 163].

The adolescent, while in his cocoon and thus avoiding a direct regression to the preoedipal mother, utilizes the drugs as a substitute for mother's presence; he recreates the ambivalence of the early motherchild relationship-talking of good stuff and bad stuff, a trip with potential to be a bummer or a creative experience, a possibility for intense loneliness or overwhelming ecstasy-in the hope that the quality of the drug, the honesty of the dealer, and the context in which the drug is taken all will help the positive side of the ambivalence and promote what Mahler (1963) called a "hatching from the symbiotic membrane [in our language, "cocoon") to become an individuated toddler" (p.322). Drugs, then, are employed in much the same way as Winnicott's (1953) transitional phenomena, serving as an object provided by the environment while simultaneously invested with the magical qualities from the inner world. The instant high is an illusion-that is, a "reality that corresponds to the capacity to create," and an intermediate area of experiencing which will not be challenged (p. 239); "this intermediate area is necessary for the initiation of a relationship between the child and the world" (p. 241). In normal adolescence, the loving care invested in these transitional objects has been replaced by higher levels of intermediate experiencing; these include youths' artistic and creative endeavors which serve as common grounds for group membership, ideological commitments, and periodic assuaging of the strain of reality acceptance. In drug-using adolescents, however, the intrapsychic structural development (described previously as turning passivity into activity) is so compromised that they literally need to recreate within the cocoon the early mother-child relationship in order to facilitate ego development. This recreation feels impossible both because of the warded-off regressive pull to the pre oedipal mother and because of the sense of vulnerability in human relationships; therefore, a turn to transitional phenomena within a protective cocoon appears as a viable adaptive effort. It provides an emotionally protective shield from environmental impingements, and through a sense of magic promotes the unchallengeable illusion of omnipotent self-sufficiency and gratification.

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This is the reason that drugs are so difficult to relinquish, for they hold out the illusory promise of individuation. THERAPEUTIC IMPLICATIONS

Treatment of drug-using adolescents is an arduous task, for they present innumerable problems: broken appointments, demands for availability, continual crises, frequent traveling, extreme passivity, excessive demands for the therapist to provide a panacea; all impede therapeutic progress and exasperate the therapist engaged in the comparatively more tranquil task of helping neurotically motivated adolescents. Therapy of patients from the drug culture must also struggle against a rigidly entrenched and an unwitting social reinforcement of the drug ideology as a viable means of existence. For the topic of adolescent drug abuse has become a social phenomenon: educators, businessmen, politicians, parents, and mental health workers all have contributed to the rhetoric of what can only be described as a pejorative ideology-a system of negative ideals which encourages adolescents to glorify themselves as "symptoms" of a chaotic historical era. No other societal issues have been portrayed to youth as so frightening, so dangerous, and yet so real and meaningfully antithetical to this culture's accepted mores (however hypocritical they may be). Naturally, then, the excessive use of drugs becomes a ready-made component of what Erikson has described as a negative identity. The combination of social pressures and difficulties inherent in longterm individual psychotherapy suggests the advisability of modifying some of the traditional, psychoanalytically oriented techniques. In commenting on the implications of the foregoing theoretical understanding for individual treatment, however, I do not minimize their relevance for other modes of therapeutic intervention. 1. The relationship between therapist and patient must evolve into a dyad which replaces the use of drugs as a transitional object within the cocoon. In other words , treatment necessitates the emergence from the narcissistic bubble. To facilitate the evolution of this process, the therapist allows the adolescent expedient availability to his services: requests for additional appointments to discuss daily crises, and missed or broken appointments which the adolescent wants to reschedule require an unchallenged and positive response. Just as the mother-infant relationship, in which rising instinctual tension in the baby stimulates the presentation of the mother's breast and thereby generates the illusion that what one created really exists, just as this illusion ultimately leads to the mother's "disillusioning" (Winnicott, 1951) the infantin a similar way the therapeutic parallel of availability is the primitive

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precursor of the adolescent's feeling of being active in his own behalf, of sensing that his actions can significantly affect him or his environment. As one youngster said to me after 21h years of treatment, "I sat down yesterday and figured out why I was depressed. You know, that's the first time I ever did anything like that without your help. I was proud of myself, and, you know, it even worked." The susceptibility of drug-using adolescents to feelings of unprotectedness necessitates initial availability. If this accessibility does not exist contemporaneously with the youth's intense feelings of vulnerability, the probability of a youngster remaining in treatment diminishes, and he is prone to wander off in search of other persons who extend promises of availability. I believe this accounts partially for the frequent utilization of crash pads and storefront drop-in centers and the concurrently high dropout rate from outpatient therapy. In advocating such initial availability, however, I am in no way suggesting the pursuit of these adolescents beyond communicating to them one's willingness to serve as an "average expectable" human being. If youngsters are not capable of responding to this holding environment-and many adolescents are not-a residential setting is probably indicated." 2. During the initial period of psychotherapy, often extending beyond a year, caution is advisable in consciously or unconsciously indi-

cating a desire for the patient to cease using drugs. For the drugs are clearly serving as a transitional object which allows an unchallenged intermediate area of experience, an illusion, which assuages the intense pressure involved in the structural differentiation of inner and outer reality. To encourage relinquishing such an "escape" before the relationship with the therapist is secure leads in some instances to suicidal gestures and psychotic episodes. The same admonition applies when confronting the adolescent with his irregular attendance at therapy sessions; acting out of therapeutic resistance is only partially responsible for such behavior, for the attempt to stop time is also the adolescent's abortively adaptive endeavor to control his reality acceptance. Indications that the relationship is becoming secure enough to confront this behavior as resistance without driving away the vulnerable patient include the adolescent's growing preoccupations with higher level transitional phenomena-artistic productions, yoga, writing journals, philosophical and ideological commitments. When such age-appropriate transitional phenomena begin to emerge, there is usually an important, if only incipient, structural progression which allows the turning of passivity into activity. 3. What promotes the possibilities for structural development is the 3

One of the diagnostic criteria for judging the feasibility of outpatient therapy is the

evaluation of significant holding environments in the patient's life.

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therapist's initially selective response to the active and passive sides of the patient's behavior. Rather than pointing out how the patient's passivity is employed defensively against anger with parents or within the transference, therapeutic progress seems to result more from acknowledging first the healthy, active strivings in the patient's often destructive actions. For example, early treatment hours frequently begin with: I tripped this weekend and stayed at John's house and slept with him. Then Monday I split from school and met John again at my house 'cause my mother was working. She came in unexpectedly, though, and found the two of us in bed; she was furious, not only 'cause of that, but 'cause she found some acid and mesc in my room. Then the principal called to tell her I skipped school. Following the retelling of her weekend, Jennie requested my help in solving each crisis. Attempts at this stage to deal with the anger and guilt, the relationship with her mother, and the self-defeating behavior are typically rejected as irrelevant; but Jennie could listen when I attempted to split the active, healthy side of her behavior. I responded to .Jennie'S series of crises with "Gee, all those things-drugs, sleeping around, skipping school-they're all the opposite of everything you tell me your parents say they believe in." This brought forth an adamant "That's right!" to which I replied, "So you want to have your own life, one that's different from your parents." Jennie responded: "I could never live the way they lived. When I do all that they say I'm just like my brother. They're always comparing me to my brother-into drugs and everything. If they compare me to him, I'll just act like him." Such discussions opened the way for a consideration of (1) jennie's separation problem-at first, how doing just the opposite of what someone wants is acting just as dependently as acquiescing to their demands; and (2) the genetic roots of her self-defeating behavior-how the leftover problems of childhood prevented her from attaining a life style of her choice. It is by beginning with the active parts of behavior that the therapist helps prepare the patient for the important realization that as a child one had no choice in how to cope with anxiety, but as an adolescent one is free to choose, to decide actively for oneself, and ultimately to assume sole responsibility for one's own decisions. 4. If during the initial phase of treatment the relationship begins to replace the use of drugs as a transitional object, one typically sees a decline in the use of drugs, although it is often reverted to when the therapist leaves for vacation or when important heterosexual relationships dissolve. At this juncture, when the patient knowingly vacillates between getting stoned and remaining straight, between accepting the

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relationship as a viable alternative to drugs and plunging back into his cocoon, he frequently precipitates a crisis. Such crises reflect the consciously felt sense of vulnerability resulting from the realization that "if I don't do drugs, I only have you and some unknown ways of behaving to depend on; it may be easier to stay fucked up." When the decision reflects the patient's choice (if possible), inpatient treatment can be beneficial at this point, for hospitalization serves both as a holding environment in which there is an opportunity for continued availability of human relationships, and as a protective island which allows the feelings of unprotectedness to emerge with all their accompanying depression and anger. Although on very unsure grounds, I am beginning to question whether successful treatment can regularly occur without such precipitation of "a turning point for better or for worse" (Erikson, 1959). 5. In my experience, drug-using patients utilize heterosexual relationships in four ways: (a) as an acting out of the transference; (b) as additional transitional relationships which promote an emergence from the cocoon; (c) as an attempt to bridge the gap between sexual and psychological mutuality; and (d) as an attempt, through frequent dissolution of relationships, to cope with the anxiety around the loss of one's parents by mourning the separation. In the initial stages of therapy, the latter three issues seem appropriate foci for discussion of the adolescent's sexual behavior. When there is an incipient convergence of sexual and psychological intimacy, those feelings are frequently directed toward the therapist, and the patient's consequent fear of "getting too close" tends to disrupt the treatment process. At this point the therapist can profitably deal with the adolescent's sexual acting out as a manifestation of the transference, particularly that aspect of the transference which Erikson (1968) has called "identity resistance." 6. With these patients-more so than with other adolescents-there is a need occasionally to share one's own feelings and beliefs during therapy. For such sharing encourages the emergence from the narcissistic shell and provides a context in which the adolescent can test the validity of his newly formed conclusions about reality. Discussions of political beliefs, music, or information about my family or background is often conveyed in the context of a widening relationship with reality. In addition, it seems to encourage these adolescents' curiosity about committing themselves to philosophical inquiries and ideological commitments which eventually must replace their philosophy of nonexistence.

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CONCLUSION

In conclusion, I would merely like to emphasize that behavioral descriptions, theoretical understanding, and therapeutic suggestions can eclipse the nature of the therapeutic process: formulations require only a few pages of explanation, while personality change is often contingent upon years of therapeutic work. That is the most publicly misunderstood paradox of the helping profession. And it has contributed, in the case of excessive drug use, to reactive social responses which attempt-through the public channeling of information and prescriptions-to circumvent the time-consuming relationships involved in therapeutic change. Valuable as these reactive developments may be, I believe it necessary to return repeatedly to the individual adolescent and to ask ourselves what may be the psychological structure of those youths who become excessively involved with drugs. Only in this way can therapeutic programs-be they groups, .individual treatment, crisis intervention, or other promising approaches-be based on the psychological needs of the individual patient. REFERENCES Br.os, P. (1966), The concept of acting out in relation to the adolescent process. In: A Developmental Approach to Problems of Acting Out, ed. E. N. Rexford. New York: International Universities Press, pp. 118-136. - - (1967), The second individuation process of adolescence. The Psychoanalytic Study of the Child, 22: 162-186. New York: International Universities Press. ERIKSON, E. H. (1959), Identity and the Life Cycle [Psychological Issues, Monogr. I]. New York: International Universities Press. - - (1968), Identity: Youth and Crisis. New York: Norton. - - (1970), Reflections on the dissent of contemporary youth. Daedalus, 99:154-176. HARTMANN, H. (1956), Notes on the reality principle. The Psychoanalytic Study of the Child, 11:31-53. New York: International Universities Press. INHELDER, B. & PIAGET, J. (1958), The Growth of Logical Thinking from Childhood to Adolescence. New York: Basic Books. MAHLER, M. S. (1963), Thoughts about development and individuation. The Psychoanalytic Study of the Child, 18:307-324. New York: International Universities Press. RAPAPORT, D. (1957), The theory of ego autonomy. In: The Collected Papers of David Rapaport, ed. M. M. Gill. New York: Basic Books, 1967, pp. 722-744. SHAPIRO, R. L. (1963), Adolescence and the psychology of the ego. Psychiatry, 26:77-87. WINNICOTT, D. W. (1935), The manic defence. Collected Papers. New York: Basic Books, 1958, pp. 129-144. - - (1950), Aggression in relation to emotional development. Collected Papers. New York: Basic Books, 1958, pp. 204-218. - - (1953), Transitional objects and transitional phenomena. Collected Papers. New York: Basic Books, 1958, pp. 229-242. ZETZEL, E. R. (1965), Depression and the incapacity to bear it. In: Drives, Affects, Behavior, Vol. II, ed. M. Schur. New York: International Universities Press, pp. 243-276.