FACTORS CONTRIBUTING TO ADOLESCENT DRUG ABUSE A GENERAL OVERVEIW FOR BASIC TRAINING - THE HOUSE (by Stephen Louw, 1994) CONTENTS 1. OBJECTIVES 2. INTRODUCTION 3. DEFINITIONS 4. THEORIES OF SUBSTANCE ABUSE 5. PSYCHOLOGICAL FACTORS CONTRIBUTING TO DRUG DEPENDENCE 5.1. Emotional Instability 5.2. The Need to Escape 5.3. The role of Immaturity 5.4. Correlations with Delinquency 6. INTRA-FAMILIAL CONSIDERATIONS 7. ENVIRONMENTAL FACTORS 8. CONCLUSION 1 1. OBJECTIVES This paper offers a broad overview of the established literature regarding the development of adolescent drug abuse. Controversial topics are avoided so that the information here is unlikely to be open to argument or question and is generally understood to be true. From this it is aimed to give the reader an uncomplicated introduction to the psychological status of drug addicts and the implication of drug abuse on a person's character. For those interested in the counselling of addicted youth, the paper may add insight into the possible complexities and idiosyncrasies of the clients with whom The House work. Since the paper is based largely on available drug literature, its relevance to the Hillbrow milieu is tenuous in places, but is the information is important in dealing with addicts from any walk of life. 2. INTRODUCTION Before any beneficial rehabilitative help can be offered to the victims of drug abuse, it is essential to establish a clear understanding of the psychological profiles and underlying personality characteristics of the addicted individuals. There are clearly some individuals who are prone to initiate and sustain severe drug habits. This paper will consider the psychological, familial and environmental factors which commonly lead juviniles and adolescents to become dependant on drugs. It will be shown that the events and life style leading to the addiction have a direct consequence on the personality traits of the addict, and that, as a result, rigid and dogmatic approaches to the care and treatment of drug dependant youth are both ineffectual and counterproductive. Before going on to consider the specific issues, however, it is necessary to eliminate any possible ambiguities which may arise in the definition of crucial terms. 3. DEFINITIONS I. DRUG The World Health Organisation (WHO) (1964) defines a drug as "any substance that when taken into the living organism may modify one or more of that organism's functions". This definition is extraordinarily broad, encompassing illegal street drugs; legitimate medications such as tranquillisers, cough mixtures and laxatives; socially acceptable drugs such as caffeine, nicotine and alcohol; and also substances not normally associated with drug abuse such as glues, commercial solvents and aerosols. For the purposes of this paper, however, the term will be confined to refer only to psychoactive substances, which are generally misused for their pleasurable effects on the user's mind, perception and emotions. The classification of drugs of abuse is often confusing. The distinction between hard and soft drugs is 1 deceptive and should be avoided since it implies that some substances are not particularly dangerous. In actual fact, careless combinations of most psychoactive drugs in high dosages are potentially fatal, irrespective of the drug's nature when used on its own. Psychoactive drugs are usually divided into five major categories: a) Narcotics are highly addictive pain-killers which create a sense of euphoria in the user and also tend to cause drowsiness. The best known narcotics are heroin, opium, morphine, pethidene and methadone. Dipipanone Hydrochloride (Wellconal) is categorised as a narcotic. b) Depressants slow down the functioning of the central nervous system. This often results in a decline in anxiety and has a calming effect on the individual. Depressants also retard the action of a number of the body's organs. In high doses, depressants produce intoxification. Among the drugs classified as depressants are barbiturates, alcohol and a variety of other sedatives. c) Stimulants excite the central nervous system, causing an increase in alertness, endurance and energy, generally exciting the user. It results in wakefulness, decreased appetite and euphoria if used in high dosages. Stimulants include drugs such as caffeine, nicotine, cocaine and amphetamines. d) Hallucinogens are those drugs that distort the vital functions of the central nervous system, creating changes in perception that range from small sensory illusions to outright hallucinations. Emotions and cognitive processing are invariably affected. Among the major hallucinogens are LSD, mescaline and PCP. e) Cannabis usually gives the user a sense of euphoria, serves to relax inhibitions, has the effect of enhancing all sensations and activities and can be disorienting. The best known variety of cannabis is marijuana (dagga). Large dosages can produce confusion, hallucinations and anxiety. For this reason, cannabis was at one time considered a hallucinogen. Long term effects include apathy, reduced sex drive, impaired short term memory and learning skills, bronchitis, lung cancer and poor immunity to infections. II. DRUG ABUSE "Drug abuse can be understood as the consumption, without medical supervision, of medically useful drugs which alter mood and behaviour ... for a purpose other than that for which it is prescribed" or "the consumption of any mind changing substances which have no legitimate medical or socially acceptable use." (SANCA, 1985). Such abuse leads to dependence through repeated administrations. III. DRUG DEPENDENCE WHO (1964) defines drug dependence as "a state, psychic, sometimes also physical, resulting from interaction between a living organism and a drug, characterised by behavioural and other responses that always includes a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects and sometimes to avoid the discomfort of its absence." The essential feature of drug dependance, therefore, is an intense craving for repeated administrations of the drug and a single minded pursuit of the substance, to the detriment of all other interests. The intensity of the drug dependance is related to the age at which the individual began taking drugs, the average dosage size and the frequency of the behaviour. 2 Drug dependence manifests itself on both a physical and a psychological level; - Physical dependence involves a physiological change to accommodate the new substance. Once the body has adapted to the introduction of the new drug, the physiological balance will be disturbed if the drug is withdrawn. - Psychological dependence results from the indivdual's reliance on the drug to fulfill emotional needs. Following the withdrawal of the drug, the individual will suffer from symptoms such as depression, anxiety and irritability. IV. TOLERANCE Tolerance is defined as a "state of reduced responsiveness to the effectiveness of a drug, caused by repeated administrations" (WHO, 1964). As the body begins to tolerate the chemical and adapts to its presence, increased dosage size and frequency are needed to recreate the desired euphoria. Addicts with long histories of dependence are thus able to consume larger dosages of the drug than would be tolerated by those with little or no drug exposure. As tolerance developes, physical dependence on the drug increases. A period of abstinence or detoxification leads to loss of tolerance so that, should an addict, after a period of abstenance, administer a dosage which was previously tolerated, there is an increased risk of overdose. V. WITHDRAWAL "A state of severe discomfort following the withdrawal of the substance to which physical dependence has developed" (Ditzler and Ditzler, 1986). The severity of the withdrawel discomfort is directly influenced by the length of the addictive behaviour, the size of the dosages and the presence of stress and anxiety. The symptoms of withdrawal, which differ from drug to drug, are acute, severe and protracted. The acute symptoms usually subside within seven days, but certain observable signs such as weakness and insomnia may continue for as long as 26 weeks. 4. THEORIES OF SUBSTANCE ABUSE Understanding the process behind the initiation and continuation of substance abuse is no simple task. Theorists attempting to explain drug abuse have approached the problem from a variety of directions, emphasizing either the influence of the drug over the user or the psychological and genetic characteristics of the addict. The disease concept, for example, approaches substance abuse as a symptom of an underlying biochemical disorder, disease or deficiency in the addict's metabolism (Pretorius, 1988). The the consequent physiological need for the drug is thus likened to a diabetic's need for insulin. Learning theory, on the other hand, states that dug taking is a learnt response through a Pavlovian conditioning process (Siegel, 1977), where the drug user begins to associate the drug with certain situations, behaviours or needs. In this sense, the drug itself acts as a positive primary reinforcer and the feeling of euphoria being a positive secondary reinforcer. 3 Interactionist models, the theoretical approach followed in this paper, successfully combine various aspects of other theories by emphasising the interaction between personality constructs, the environment, circumstances, psychological dysfunction and possible chemical effects of the drug on the individual. The models stress the unique and diverse reactions that may be elicited through these interactions, and focus on those factors which increase the risk of addictive behaviour. The premorbid personality and environmental factors identified as influencing the vulnerability to drug abuse are thus seen to effect the age at which substance abuse commences, the frequency, and the progression from drug to drug. No validation is offered for the concept of an "addictive personality" which unfailingly leads to drug abusive behaviour. In the following considerations of the aetiology of drug addiction, the emphasis is placed on those personality and environmental factors which increase the risk of addictive behaviour. Analysis of general psychological and physiological traits in substance abusers has revealed certain common features which may, in turn, be used as indicators of vulnerability to drug addiction in teenagers and young adults: On the PSYCHOLOGICAL LEVEL, environmental and personality stressors such as low self-esteem, emotional instability, poor mental set, negative peer pressure, early traumatic experiences, inconsistent familial relations and social alienation lead to an increased risk of drug abuse. On the PHYSIOLOGICAL LEVEL, factors such as a weak physical constitution and metabolism, frequent hospitalisation, tolerance and previous experiences of withdrawal symptoms are likely to aggravate an individual's need for chemical substances. These physiological aspects, as well as other genetic and biochemical influences on the development of drug abuse will be covered in more detail in a later paper. Vulnerability to drug abusive behaviour does not necessarily mean that the individual is destined to abuse drugs, since complex situational factors must also be taken into accounted. Many vulnerable individuals may never become involved with drugs, or may lose interest after a period of experimentation. The interaction between the individual's emotional and psychological disposition, learned values and the demands of the social environment determines whether or not the addiction process will indeed be initiated, and whether a period of experimentation will be sufficient to satisfy the individual's needs. With this in mind, we shall now go on to look at specific traits that are prevalent in drug addicted personalities. By isolating those common traits that are present before the onset of the addictive behaviour, and ignoring those which are a result of the addiction, it is possible to identify those factors which make particular people prone to initiate and sustain addictive behaviour. 5. PSYCHOLOGICAL FACTORS CONTRIBUTING TO DRUG DEPENDENCE "Addicts seem to be, without exception, suffering from one or another of a variety of mental disturbances apart from their addiction .... Normal people do not find the psychic effects of narcotics attractive" (Cockett, 1971). 4 While the abuse of drugs is not regarded as a psychiatric condition in itself, there is a significant positive correlation between substance abuse and psychiatric disturbances, indicating that the development of drug dependence may be a symptom of underlying personality maladjustments or mental health disorders such as retarded emotional development, poor coping skills, severe emotional instability or unexpressed anger. Each of these will now be discussed in more detail. 5.1. Emotional Instability and Personality Disorders The relationship between drug abuse and psychological characteristics such as neuroticism, anxiety, guilt and depression is well documented (Chien et al, 1964; Cockett, 1971). It has also been shown that the intensity of drug dependence is highly correlated to the severity of the psychiatric disorder or emotional dysfunction, so that the proportion of abnormal reactions such as late occurring nocturnal enuresis (bed wetting), epilepsy, suicidal tendencies, severe nervous symptoms, night terrors and sleep walking is directly proportional to the degree of subsequent drug involvement. Administration of the 16 P.F. personality scale to a group of addicts (Cockett, 1971) highlighted correlations between these individuals and factors such as paranoia, suspiciousness, jealousy, low impulse control, unstable temperament, excitability and extreme tension. Barnes (1979) has shown that addicts tend to score highly on measures of psychopathic deviance, while O'Donnell and Ball (1966) uncovered a proportion of both overt and incipient schizophrenia in their subjects. The alarmingly high rate of suicides, deliberate overdoses and self-mutilation among drug addicts offers further evidence of this high level of mental disturbance within the group. These self destructive tendencies provide an effective means with which the addict may express inwardly directed or unreleased anger. Those individuals who are least able to express their anger effectively carry their drug addiction to much higher levels of involvement. It is, thus, without doubt that severe emotional stress, emotional instability and the presence of psychiatric symptoms may increase the potential for substance addictive behaviour. The proportionally high level of psychological deviance evident among substance abusers underlines this as a major contributing factor in the development of addiction. As the addiction process developes, however, the addict's inhibitions and defences are eroded and these psychological dysfunctions which have led to the addiction become more pronounced and obvious. Consequently, the addicts lack of deep emotional response, their inability to profit from experience and their disregard for social norms are often mistaken as symtoms of the drug abuse and not as key aetiological factors. While individuals suffering from depression, anxiety, introversion, and suicidal tendencies are not necessarily drug addicted, they have clearly been shown to be a higher risk of finding the euphoric effect of drugs attractive. Non drug related symptoms of sexual intemperance, stealing, lying and other forms of addictive behaviour are also seen to be a result of these same emotional disorders and psychological abnormalities. 5 5.2. The Need to Escape Chemical substances provide an ideal opportunity to escape from reality, responsibility and ultimately from oneself. Emotional instability in itself leads to a need for change and desire to remove oneself from present environments with little planning or notification. If the individual is not able to make the physical escape, more covert escape mechanisms are needed. So when a debilitating instability is accompanied by a feeling of impotence to make any meaningful change, the intense need to escape from anxiety provoking situations is more easily facilitated through drug induced euphoria. Through this an escape the individual avoids interpersonal conflict, sexuality, commitment and any consequent responsibility related to these issues. The need for chemically induced escape mechanisms are particularly prevelent among those who are haunted by painful memories and negative associations from traumatic experiences, as with adult victims of sexual and violent physical abuse. Since the drug effectively reduces primary drives such as hunger, pain, erotic urges and aggression, it is associated with the easing of anxiety related to these needs. In a state of drug induced euphoria all anxiety, pain, tension and fear of dysphoria are temporarily relieved, providing temporary, but complete escape. Escapist tendencies frequently find expression in a pursuit of hedonistic pleasures or a search for instant need gratification. Drug addicts are often condemned as pleasure seeking hedonists; constantly seeking adventure, excitement and thrill, without any consideration of possible negative consequences (Young 1972). The presenting hedonistic qualities are, however, due to the adoption of a "flight before fight" philosophy, a defence strategy designed to help maintain integrity and composure in the face of adversity and pain. Hedonism of this nature is, therefore, a result of the individual's inability to face life crises or cope with emotional trauma and instability, and not a simple disdain for hard work. The escapism evident in drug addicts is closely related to the arrested developmental process (discussed below). The individual effectively finds chemical escape much easier and more attractive than a mature attempt to deal effectively with reality. (Since the true nature and severity of these aspects differ widely from individual to individual, it is necessary to carefully assess the nature of the presenting escapist tendencies of the addict before any therapetic attention can be directed at remedying its effects on the addiction process.) 5.3. The Effect of Immaturity The impact of immaturity on the development of drug addiction is closely associated with the individual's emotional instability and escapist tendencies. Immaturity in drug addicts is most noticeable in their poor emotional development, negative coping strategies, underdeveloped social skills and general aversion toward adult responsibility. Immature personalities, by nature, find difficulty in suppressing the need for immediate gratification. The more retarded the developmental process, the greater seems to be the individual's need to escape from adult responsibilities. All of these are noticeable in the individual before the onset of substance addictive behaviour and are distinct from the signs of arrested development that may be due to the excessive use of drugs. (To be sure, once the individual is involved in the abuse of drugs as a coping strategy, their 6 developmental processes are largely halted.). Young (1972) outlines four areas of development in the transition from childhood to adulthood which are found to be deficient in drug dependent individuals: 1. delaying of need gratification 2. inhibition of play and the development of responsibility 3. productivity 4. move towards self control. The symptoms of arrested emotional development in individuals who are prone to drug addiction will, therefore, include a tendency to lack appropriate skills for coping with mature adult roles, self centredness, difficulty in inhibiting the expression of play, a disregard for the rewards of adult life and a perception that the means of obtaining their own specific goals are illusive. The addicts focus on the here-and-now, which holds more interest for them than the uncertainties of the future or the pain of the past. Birdwood (1969) clearly demonstrates that addicts have immature and unstable personalities which are a result of a poor developmental process. He proposes that severe nervous symptoms, which manifest in childhood, serve as an early warning system of debilitating emotional deprivation which is likely to hinder subsequent development if left untreated. When emotional maturity cannot keep pace with physical growth (a condition common in adolescence), the individual is particularly vulnerable to delinquency and drug experimentation. Victims of childhood trauma and abuse are subjected to stresses which inhibit proper emotional development, accounting for the high rate of drug abuse among these individuals. O'Donnell and Ball's (1969) in-depth psycho-analytic approach to retarded maturity argues that paternal ineffectuality and maternal overindulgence results in psycho-sexual regression. The child, therefore, is fixated at an infantile level of functioning. This familial pattern leads to instant need gratification during childhood, which becomes frustrated by the demands of adulthood. The individual is left with serious sexual identity problems, disturbed interpersonal relationship formation, weak ego structure and weak super-ego functioning. The resulting social isolation and emotional dependence is a combination which leaves the individual particularly susceptible to drug dependence. Childhood factors which delay emotional development have a direct consequence on subsequent drug dependant behaviour. Severe emotional immaturity evident in a large proportion of addicts is aggravated by the fact that once substance use becomes used as a means of coping, there is very little emotional growth thereafter, so developement is dramatically arrested. It should always be kept in mind, therefore, that responses from addicted individuals in therapeutic settings are sometimes not age appropriate, and that the client needs to be nurtured to a more acceptable level of functioning. 5.4. The Correlation with Delinquency That drug misuse is largely a phenomenon of youth is a well documented fact. The significance of delinquency in the context of drug taking is equally unchallengeable. Drugs provide a valuable outlet for 7 rebellion and a means of expressing defiance, aggression, hostility and non-conformity. Delinquents, in particular, are at higher risk, not only to begin experimenting with drugs, but to continue drug dependant behaviour to higher levels. While the powerful expression of hostility towards society is an initial motivation for young adults and teenagers to take drugs, it is the consequent societal condemnation of the dependent behaviour which becomes the strongest reason to remain within the drug culture. Birdwood (1969) argues that our own hostility towards this age group in general effectively prevents us from seeing delinquent behaviour as a symptom of the teenager's emotional dissatisfaction with the social environment, rather than a result of their own shortcomings. Poor intra-familial relationships and unsatisfactory parental attitudes have been shown to have a causal connection with delinquency. At the adolescent level, the less identification the child has with its family, the more likely it is that the child will adopt the norms of his or her peers. Birdwood (1969) outlines how specific predisposing familial relations and parental neglect can lead to a lack of security, independance, confidence, delinquency and, ultimately, to drug abuse. Since drug taking behaviour is in some cases a consequence of a delinquent or rebellious attitude, it can be concluded that delinquency is evident before the drug dependence begins. In time it becomes difficult to distinguish between aspects of the drug dependant behaviour and that of delinquency. Like delinquents, drug dependants show a high degree of self criticism and guilt, and are less able to give free expression of their emotions. The distiction between the addictive behaviour and other delinquent aspects is crucial, however, for the purposes of identifying the underlying causes of the addiction, as well as for correct treatment coordination. Early and effective intervention in delinquent behaviour is a valuable tool in the prevention of drug addiction among youth if it prevents the development of need for chemical substances. 6. INTRA-FAMILIAL CONSIDERATIONS The importance of the family structure, its learned values and behaviour patterns cannot be underestimated in a consideration of the factors involved in the development of drug addiction in youth. On a superficial level, it is often pointed out that modern society's removal of the maternal role from the mother has laid a much heavier emphasis on the ingestion of medication for the treatment of ailments and encourages a reliance on drugs for general relief. As we have eluded to, current theories on the initiation and escalation of drug dependence focus on the interaction between the individual's psychological profile, familial experiences and the nature of the parent child relationship. Modern society has witnessed a unprecedented breakdown in the structure of family life. Forced schooling has effectively removed education, and to some extent, discipline, from the responsibility of the parent. The improvement in living standards and the rise of women's liberation has freed the women form the traditional roles of child carer and housekeeper and facilited her entry into commercial and professional positions. This, however, has left many children with relatively little parental contact or supervision and increased the level of stress within the family. Furthermore, there has been an alarming increase in the 8 incidence of single parent families, giving rise to the incipient effects of paternal deprivation on the developing child. Despite the universal breakdown of the family, the presence of drug abuse nevertheless reflects serious underlying family conflict and a consequent isolation of family members from each other. This tension between family members intensifies the youth's need for familial support, which conflicts with the desire to establish independence. The use of drugs offers an escape from the internal conflict, compensates for ego deficiencies and provides an opportunity to escape individuation. Furthermore, the drug dependant behaviour attracts attention to the addict and inadvertently draws the family closer together as they attempt to help and rehabilitate the addicted family member. Patterns of maternal overindulgence accompanied by paternal distance, weakness, ineptitude and submissiveness have repeatedly been found to correlate highly with drug dependant personalities. This parental structure results in oscilating extremes of over and under involvement with little or no affection or acceptance, and no consistency. Since the father is distant, there is little or no paternal discipline, as is common in single parent families. This particular familial pattern effectively prevents the youth from developing a sense of independance and autonomy, which inevitably leads to a lack of self confidence and low self esteem. The parental contribution to the initiation and continuation of their offspring's drug dependence can thus be summarised into three broad areas (from Glynn and Haenlein, 1988): a) COMMUNICATION: The proverbial generation gap is characteristic of the interaction between drug users and their parents. The poor communication skills lead to intense conflict and fragile relations, which are debilitating to a family structure which is often already dysfunctional. b) DISCIPLINE: Parents of dysfunctional families are seldomn consistent in their discipline styles. Each parent invokes their own means of interacting with the child, so no joint decision on discipline issues is possible. Communication may be so bad that parents begin to undermine one another, giving the child an opportunity to play one off against the other and short circuit discipline altogether. Paternal influence tends to be distant; either neglectful laissez-faire or tyrannical authoritarian. The emotional distance of the father provokes various overcompenstaion mechanisms in the mother which creates sever intrafamilial inbalances. The inconsistency in discipline ultimately prevents the children from learning effective problem solving techniques, positive coping strategies or socialy acceptable value systems from their parents. c) MODELLING: This, under normal circumstances, is the adolescent's most effective tutor of acceptable behaviour and appropriate coping mechanisms. Dysfunctional family structures perpetuate themselves throught this modelling process as the child associates the parent's behaviour with acceptable adult conduct. For example, let us consider a parents who uses mild drugs as an emotional crutch - the child may begin to associate such behaviour with adulthood, and use similar means to assert independence during adolescence. Poor intra-familial relationships and unsatisfactory parental attitudes thus have a important role to play in the development of delinquency and drug abusive behaviour. 9 Parental neglect and its concomitant lack of security encourage the child to rebel against parental influence and adopt the norms of his or her peers. Coombs and Coombs (1988) point out that the initiation process never occurs in isolation, but rather in some form of social gathering in an attempt to gain recognition, fulfil a need for adventure and excitement, escape from the painful realities of daily existence and rebel against parental authority. In the light of other important influences on the development of drug addiction, strong family bonds and consistent discipline may be an important means to prevent the need for substance addiction (Issues on peer influence can be brought in here.) which offers a secure involvement in a social group, acceptance and a sense of glamour, and the drive for euphoria which eliminates so much pain and suffering 7. ENVIRONMENTAL CONSIDERATIONS The environment to which the individual is exposed plays a key role in the formation and development of personality and emotional disposition. The level of dependence on drugs is effected, and indeed created, by the pre-morbid environment in various ways. This, therefore, necessitates a consideration of those environmental features which young addicts experience, and the specific aetiological impact of the environment on the development of drug dependence. Firstly, a traumatically unstable or inconsistent environment leave the developing individual with a loss of security. Unexpected social upheavals or crises challenge the individual's traditional belief systems, leaving a sense of loss of purpose or feeling of belonging. Among others, this may evoke an attempt to escape from reality and from the demands and obligations of society. In this sense, then, drug abuse is simply a form of social re-adjustment. Secondly, drug epidemics are clearly more prominent in areas with a dense habitation of underprivileged groups, low educational attainment, disrupted family life and overcrowding. The availability of drugs in these environments is an important consideration when assessing the individual's gravitation towards drug experimentation and abuse, since pressure by peers to take drugs is often substantially stronger when the drugs are freely available. One has to be careful though, not to project the effects of this kind of lifestyle onto these of the effects of the drug, or to make sweeping overgeneralisations regarding the debilitating effects of poverty, since high incidence of drug abuse are also evident in highly stressed professionals and businessmen. Chien et al (1966) and Cockett (1971), however, have clearly shown strong positive correlations between drug abuse and poverty/family disruption. The result in all cases is a lack of "middle class" orientation and a distrust of major institutions. Thirdly, there is a strong positive correlation between drug risk and premature home leaving. The deficient limitations placed on the young individual once he\she leaves home leads to a lack of discipline and structure, creating a need for alternative dependence mechanisms. Finally, the poor environment in which drug addiction operates serves to encourage further abuse, crime, extra-legal activity, unemployment, rituals and a sense of security which makes it increasingly difficult for the 10 individual to find a place in an environment outside that of drug dependence. 8. CONCLUSION The above consideration has dealt specifically with those factors that contribute to the development and sustainence of substance abuse among adolescents and young adults. Factors such as the effect of psychological and emotional instability, the individual's need to escape, the role of immaturity the correlation with delinquency, intrafamilial dysfunction and negative environmental influences have been covered to show how they impact on the individual's potential for substance abusive behaviour. While these factors have been dealt with separately, the interaction between them has been alluded to where possible. It is crucial to gain an intimate understanding of the delicate interaction between the various factors, since individual factors will not lead to the escalation and elaboration of the addiction process. Prepared for the Internet by Adéle du Plessis adele@thehousegroup.org The House Group Saving the girl child from the street http://thehousegroup.org 11