Science
in Christian PerspectiveScience
in Christian Perspective
Heroin Addiction: Teen Challenge vs. Transactional Analysis: A
Statistical Study
ARCHIE JOHNSTON
California State College
Dominguez Hills, California 90747
From: JASA 25 (September 1973): 106-110.
Heroin addiction was viewed from the standpoint of treatment outcome. Seventeen subjects were randomly assigned to each of three treatment regimes: No Treatment (NT), Teen Challenge (TC), or Transactional Analysis (TA), with the subjects in the last two groups being under treatment 6 to 12 months. The purpose of the experiment was to determine whether these approaches had a differential effect on heroin addiction. A score on a standardized questionnaire and recidivism (returning to heroin) rates, measured over a 29 month period, were used a an index of the effectiveness of each treatment. Both TC and TA treatments were statistically significant over NT. While the TC subjects displayed a lower score on the questionnaire, and therefore less drug addiction identification during this period and as measured by the index, TA had a one-hundred percent lower recidivism rate suggesting that TA may get at the etiology and root causes which allowed the addict to become addicted with slower, but longer-lasting effectiveness.
Introduction
Seevers (1962) has suggested that addiction is characterized by an
(a) overpowering
desire to continue to take the drug, (b) a tendency to increase the dosage, (c)
psychological and physiological dependence on the drug, and (d)
detrimental effects
both to society and the individual. Addiction differs from drug
habituation, for
in habituation there is (a) a desire but not a compulsion to continue
taking drugs,
(h) little tendency to increase the dosage, (c) some psychological
but no physiological
dependency, and (d) any detrimental consequences primarily affect the
individual.
Lieberman (1967) in his discussion on current trends in rehabilitation of drug
addicts, adheres to the belief that an outmoded typology of treatment
has employed
punitive and medicalpsychiatric methods, which to some have been
viewed as a gross
failure (O'Donnell, 1964). Lieberman (1967) suggests that five themes
of rehabilitation
have emerged over the last decades: (1) communal, resembling the homogeneity of
the
folk culture with strong roots in face-to-face interaction; (2)
community interaction,
involving the interaction of the addict with his given community; (3)
religious,
providing an intense religious experience for those willing to be
saved, who are
then expected to return to the community and become involved in the salvation
of other addicts (Wilkerson, 1963; Teen Challenge, Inc.); (4)
rational authority,
placing the addict on probation, if convicted of a crime, rather than send him
to prison; and (5) chemotherapy, such as cyclazocine or methadone maintenance
(Jaffe, 1966; Dole and Nyswander, 1965). Lieherman (1967) in
conclusion adrnonishes
us of the need for combined approaches and selectivity in treatment.
The present author is concerned with out-come research in heroin addiction. He
has elected to study two approaches: Teen Challenge (TC) and
Transactional Analysis
(TA). The purpose of the experiment is to determine whether one of
these approaches
has a differential effect on the treatment of heroin addicts.
Therapeutic Techniques
Redlich and Freeman (1966) suggest that conventional therapeutic
techniques, strictly
speaking, refer to biological and psychosocial methods of treatment
based on scientific
evidence, which by definition excludes unscientific beliefs, magic,
supernatural
forces, and commonsense. These two authors suggest a classification
of therapies
based on phenomenological description of treatment or on a differentiation of
underlying principles and theories. The most fundamental differences
can he seen
between: (1) somatic therapies, involving organic and biological
therapies employing
various chemicals and hormones; and (2) psychosocial therapies which
use verbal,
symbolic and behavioral methods that influence the total behavior of
the patient
and his social performance. The technique must be based on some
scientific rationale.
The psychotherapies can be divided into analytic-insight,
directive-suppressive,
and behavior-modification. The two authors believe "all therapies involve
support and direction as well as learning." The behavior
therapies are usually
individualized involving a relationship in which conditioning theory
and techniques
are employed. The psychotherapies may he fuller subdivided into individual and
group, with the latter including milieu and communal. The authors
warn: "habits
that are learned can be unlearned, or at least not employed. Psychotherapists
should not lose sight of the fact that there are many human problems that are
determined by economic, social, cultural, and legal processes, which
essentially
are not accessible to psychotherapy."
James (1959) distinguishes between two types of conversions. The first he calls
"volitional" conversion, where the change is on a
predominantly conscious
and rational or intellectual level. Calverton (1934) labels this type
of conversion
"the logical" or "intellectual" approach to religion. The
second type of conversion James (1958) mentions is the
"self-surrender"
where the personal will must be abandoned. The conscious aspects of conversion
according to James (1958) are predominantly two things: first, there
is a feeling
of incompleteness and wrongness ("sin"), and second, an
imagined ideal
that is desired for the self. Basically, these are not so different
from the self-concept
(a desire to be whole and good) and the concept of the ego-ideal. Interestingly
enough, the sense of incompleteness according to Calverton (1934) did not exist
in the group-centered society but is a dominant characteristic of the
individualistic
centered society.
Knight (1969) believes that:
The religious area appeals to youth as a medium for orienting themselves, and their involvement in this area often reflects their attempt to establish themselves as individuals with their own identity and personal set of values. The adolescent, as a part of his movement toward independence, feels constrained to examine, challenge and reconstruct the religious beliefs given him by his family.
Teen Challenge
Teen Challenge uses the Christian conversion as a pivot point for their milieu
therapy. A leading evangelical authority on conversion has said
(Graham, 1965):
The word "conversion" means simple "turning." God pleads with man to return to Him. However, it is impossible for man to return to God, to repent, or even believe, without God's help. All one can do is call upon God to "turn one" to Him. There are at least two elements in conversion repentance and faith. Repentance carries a recognition of sin involving personal guilt and defilement before God. Repentance means also a change of feeling. This means genuine sorrow for sins committed against God. Faith is not just hanging on. It is laying hold of Christ, for Christ is the object of faith. It is not a subjective feeling, but an objective act.
The purpose of the experiment is to determine whether one of these approaches (Teen Challenge and Transactional Analysis) has a differential effect on the treatment of heroin addicts.
James (1958) believes "we tend to speak of the conversion phenomenon, and wonder at it as a transformation," However, for the many members of TC, most of whom have been in jail or prison, the traditional psychotherapies of the social and insight orientation have seldom provided any real freedom from drug usage. What does seem to work for TC members is their confrontation with Christ in their individual conversion. This conversion together with their daily group process of Bible study, prayer, song and working on the streets, in schools and half way houses with other addicts is said to aid the addict on this program to become drug free and a useful member of society. One youth put it this way:
A 19 year old parolee, dope fiend, factory worker does not make ripples. I did not have any worth. Today, I am free and clean. This freedom is in Christ. It is a freedom with a purpose to help someone else be set free.
Lieherman (1967) believes TC members, like missionaries, devote their lives to
carrying out their religious theme. He asserts that TC has many of
the same elements
as Alcoholics Anonymous with their missionary zeal in helping the
suffering addicts.
Lieberman (1967) was "impressed by the apparent power of the conversion
in effecting a profound involvement with a new and more socially
acceptable style
of life,"
Transactional Analysis
Transactional Analysis according to Harris (1969) is both a teaching
and learning
device. He suggests that TA works at its best in groups where the
more transaction
to analysis the better the interaction. It distinguishes three active elements
in each person's make-up: the parent, the adult, and the child. The
parent personifies
the "don'ts" and a few "do's." The child
represents spontaneous
emotion. Both parent and child must keep in proper relationship to
the adult whose
function is that of a "reality computer that grinds out decisions based on
the data derived from experience." The goal of TA is
strengthening and emancipation
of the adult from the "archive recordings in the parent and child to make
possible freedom of choice and the creation of new options." Harris (1969)
explains there are four life positions underlying people's behavior:
(1) I'M NOT OK-YOU'RE OK, which is the anxious dependency of the immature.
(2) I'M NOT OKYOU'RE NOT OK, showing the "giver-up" or despair position.
(3) I'M OK YOU'RE NOT OK, indicating the criminal position.
(4) I'M OK-YOU'RE OK, which is the response of the mature adult, at peace with himself and others,
Harris (1969) concludes that most people still operate unconsciously from the
position I'M NOT OKYOU'RE OK.
Berne (1969), the founder of TA, adheres to the position that TA is
not a restatement
of Freudian, Jungian, or other psychology. Superego, ego, and id are concepts,
whereas ego states used in TA are experiential and behavioral realities. Berne
(1969) suggests that TA uses only five words in its vocabulary. It
will be advantageous
to look at several more words to fully comprehend the meaning of TA
and the procedure
involved. The following are those words which need a working
definition supplied
by the founder of TA (Berne, 1969):
Transaction: A transaction stimulus plus a transaction response In a complementary transaction, the vectors are parallel. In a crossed transaction they are crossed, An ulterior transaction is effective at two levels, the social and the psychological. An ulterior transaction may he angular involving three ego states, or duplex involving four.
Structural Analysis: Analysis of the personality into its constituent parent, adult, and child ego states.
Game: A series of ulterior transactions with a gimmick, leading to a well-defined pay off.
Script: An unconscious life plan. In some eases it may be preconscious or conscious.
Ego State: A consistent pattern of feeling and experience directly related to a corresponding consistent pattern of behavior.
Parent: An ego state borrowed from a parental figure. It may exert itself as an indirect influence; or be directly exhibited in parental behavior.
Adult: An ego state oriented toward objective, autonomous data.
Child: An ego state which is an archaic relic from an early significant period of life. The adopted child is influenced by parental parameters. The expressive child is more autonomous.
In view of the above the meaning of Transactional Analysis should now
become clearer:
Transactional Analysis: 1. A system of psychotherapy based on the analysis of transactions and chains of transactions as they actually occur during treatment sessions. Its principal phases are structural analysis, transactional analysis proper, game analysis, and script analysis. 2. A theory of personality based on the study of specific ego states, 3. A theory of social action based on rigorous analysis of transactions into an exhaustive but finite number of classes based on the specific ego state involved. 4. The analysis of single transactions by means of transactional diagrams. This is transactional analysis proper.
Harris (1969) suggests how TA group treatment is conducted. The
transaction consists
of a stimulus by one person and a response by another, which response in turn
becomes a new stimulus for the other person to respond to. The purpose of the
analysis is to discover which part of each person-parent, adult, or
childis originating
each stimulus and response. There are many clues to help identify stimulus and
responses as parent, adult or child, and with these clues to assist
one to begin
to identify parent, adult, and child in transactions involving the individual
and others.
Although the concepts of the therapeutic community operate to a lesser degree
in the TC program because of the lack of funds, than with the TA program, these
concepts are important to the author's thesis. The environment at both the TC
center and the federal institution provides a 24hours-a-day
therapeutic community.
Jones (1968) has described the therapeutic community treatment as sociotherapy
and a livingl-earning situation where confrontation with other group members is
concerned with everyday behavior. Each individual is helped to become
more aware
of the thinking and feeling of others often for the first time-and
this can contribute
to personal growth.
While those subjects on the TC program do not have any conventional
therapy sessions,
and are even somewhat opposed and outspoken against it, they do have group rap
sessions, prayer, Bible study, and they do work with other addicts,
all of which
is not on video tape, but apparently somewhat successful. Those heroin addicts
on the TA program receive group treatment and interaction, video tape replay of
the TA sessions, some vocational training, and are aided by "linkers"
who are themselves former-addicts going between the authoritarian
structure (warden,
program directors, employers) and other resident addicts.
Based on the lower questionnaire score when compared to no treatment and the lower recidivism rates, Transactional Analysis is the best regime of treatment for heroin addiction of the three treatments investigated.
Method
Subjects:
The present author employed the term "selectively-admitted" into any
one of the following treatment groups to mean: (1) that the individual addict
wanted and asked for treatment from either the court or from the program, and
(2) that the court or the director or the program was convinced that the addict
did desire and could benefit from the form of treatment being given.
Once selectively-admitted
into one of the two treatment groups or placed on the waiting list forming the
no treatment group, the individual was then part of one of three
treatment populations
from which the author drew his three randomly assigned samples. This
was accomplished,
for each group, by taking every fifth questionnaire and recording
that individual
score and entering it into the sample. No one subject was used in more than one
treatment condition.
No treatment: Seventeen; heroin-addicted males made up this group. All of these
had an arrest record, and all but six had been convicted and sentenced to jail
or prison for crimes ranging from assault/robbery (11 years in
prison) to narcotics
sales smuggling. One subject with a history of 12 narcotics offences had spent
four years in prison. None were in prison at this time. Their ages ranged from
18-44. These subjects who were still taking heroin were randomly
assigned to this
group from a waiting list prior to any therapy and prior admission to
the selectively-admitted
TC program.
Teen challenge: The all-heroin-addicted subjects for this group were randomly
assigned and consisted of 17 males selectively admitted into this program. All
had arrest records and twothirds had been convicted of a crime, with
the remainder
having been placed on
probation. Their ages ranged from 18-43. They had been under the
"treatment"
from 6-12 months living in a therapeutic community.
Transactional Analysis: This heroin-addicted group consisted of 17 male inmates
of a specially funded congressional program at the Federal
Correctional Institution
at Terminal Island where they lived in a therapeutic community. Each inmate had
been selectively admitted and sentenced, after his court case had
been given careful
consideration and after the inmate had asked to be placed on this
program falling
under the Narcotics Addiction Rehabilitation Act (NARA) of 1966. Each
inmate had
met the qualification of admission to the NARA program in being a heroin user,
and having an arrest record directly or indirectly linked to such
usage. The subjects
had been under treatment 6-12 months and their ages ranged from 21 to
36 years.
Measurements
In a former study (Johnston, Midtlying, and Ell, 1970) the author and
his colleagues
created a drug addiction questionnaire which was an instrument to
predict whether
or not the drug-user would become a drug addict. The score based on that test
and recidivism rates became the dependent variables for the present
author's study.
Each subject was asked to respond to each of the 20 questions in the test with
a "yes" or "no" response. One (1) point was
assigned to each
"yes" response and a score of zero (0) for each
"no" response,
the test being designed so that a "yes" response indicated
drug usage.
Those receiving 11 or above were considered drug addicts. From this process it
is obvious that the higher the score, out of a total of 20 points possible, the
more apparent the addiction involvement.
There were two groups used in normalizing the questionnaire: 96 drug users from
among the drug subculture cities of Southern California and 100 heroin addicts
under TA group treatment at the Federal Correctional Institute at
Terminal Island.
(The results for the drug users were: A split-half correlation of .72, a mean
of 3.84, the standard deviation of 4.00, standard error of the mean of .40, and
a Kuder-Richardson of .81. The last correlation indicates a fairly high degree
of homogeneity (Cronbach, 1951). The heroin addict group had a
split-hall correlation
of .51, with a standard deviation of 4.30 and a standard error of the mean of
.44.)
Because of the transitory nature of the drug users group, the authors
were unable
to secure a test-retest reliability. In view of this and of the fact that drugs
were believed generally unavailable, it was decided to employ the
heroin addicts
group for the test-retest reliability (r=. 35) even though they were under TA
group treatment. The 8-10 week test-retest reliability was
surprising, for three-fifths
of the heroin addicts answered the questionnaire lower and this was believed to
be due to the effects of the TA treatment method being used. These
findings also
provided the hypothesis for the author's present study.
Procedure
In each treatment condition except no treatment, the author relied on
raters who
were members of the program being studied to obtain his questionnaire results.
Since he entered two on-going groups, he was unable to follow and report on the
subjects from day one to the end of the experiment. The methods of
treatment have been explained above. In addition to the therapeutic community
process of living-learning, each addict, except those in the no treatment group,
were under TC group "rap" sessions or transactional analysis for two
one-and-a-half hour sessions twice a week. Sometime between the
individual's 6th
and 12th month of therapy the author obtained his questionnaire
results and these
were combined with the recidivism rates (returning to heroin) as shown by the
records from each treatment condition to make up the two dependent variables.
The no treatment group was also given the same questionnaire and the
comparative
results for all three groups follow.
Results
Duncan-Range Test:
Groups
TC
TA NT
Ranked Means
n
2.18
8.82 14.53
n
17
17 17
Recidivism Rates
32%
16% none
(29 months)
Difference between
6.64 (R2 =2.83*
groups 1
and 3
Difference between
5.71 (R3 =2.98*
groups 1 and 2
Difference between
12.35 (R3 = 2.58*
groups 2 and 3
*Significance at 0.05 level
The Durscan-Range test for two and three groups with 48 degrees of freedom was
statistically significant for all three groups. The data as measured by the
It is hoped that some consideration could be given to the incorporation of some psychotherapy, such as Transactional Analysis, into the Teen Challenge program.
criterion, that is the questionnaire results and recidivism rates,
give unequivocal
support for three findings. First, that TC is an effective program of
treatment.
Second, TA is a very effective method of treatment. And third, based
on the lower
questionnaire score when compared to no treatment and the lower
recidivism rates,
TA is the best regime of treatment for heroin addiction of the three treatments
investigated. However, TA is one-hundred per cent lower in recidivism
rate, over
a 29 month period, than that of TC. Recidivism rates, computed from the TO and
TA records and being defined as again returning to drugs, are for TO
and TA programs
32% (American Magazine, 1968) and 16% respectively.
Discussion
The results of the TO and TA programs both seem to be effective and offer hope
to the addict and the mental health worker. While it is true that the
TO program
seems to help the addict increase his self-awareness, it is also true that the
approach deals with heroin and other addictions in a repressive manner, i.e.,
the motivation of the addict had been changed because of his
conversion to Christ
whom he accepts as his Lord and Master and accordingly views drug-taking as sin.
It appears that dealing with heroin addiction in this manner masks the symptoms
and etiology, and in doing so does not get at the real causes which led up to
the addict becoming addicted to heroin or other drugs. Thus, the
addict's belief
in Christ, even though sincere and real, becomes a drug substitution
which often
never grows beyond that little spark of embryonic faith.
From the recidivism rates over the 29 months and the fact that these men on the
TA program are successful even after parole, it would suggest that TA operates
at a deeper level of the basic personality structure, permitting
greater adjustment
without drugs as it changes the addiction concept of the self-image
more thoroughly
and at a slower pace, perhaps accounting for the lower recidivism rates.
Looking at the TO group scores, it seems likely that the approach changes the
addiction concept in the addict's self-image rapidly at the point of
his conversion,
this change being based upon his faith in Christ. It is this
continuous and literal
working-faith and the "love of Christ which controls" him. However,
this suggests too that if the addict does not fervently keep active in the TO
program or a church, he may encounter a personal loss of faith-even momentarily
which
could result in his returning to drug-usage. It
seems possible, at least for part of the 32% counted in
the TO recidivism rate, that the cure is encased in the legal
contractual language-a
promise for a promise, "if you will-then I will," i.e., if the addict
will be good in responding to the wishes of his heavenly Father, then his cure
from addiction is continued. Addicts often have had a rather poor relationship
with their earthly fathers. These negative feelings which come about
as the result
of the poor interpersonal relationship between father and addict
could very well
be carried over into the matter of their faith in Christ. This loss
of faith would
occur because the addict had only had a change of environment,
conversion, undergone
detoxification, and was now beginning to feel better because of regular hours
and eating habits, but the root causes which allowed that individual addict to
become addicted in the first place had not been acted upon in
psychotherapy. This
could account for the higher recidivism rates.
Based upon this study, the author suggests there
is a real danger in TO's belief in the individual loss of salvation
and the great
emphasis on works in hieu of psychotherapy, and he would hope some consideration
could be given to the incorporation of some psychotherapy, such as
TA, into their
program. This step hopefully would decrease the recidivism rate and allow some
individuals who are at present returning to drugs become in the
future drug-free
and a useful member of society.
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