AM, J. DRUG ALCOHOL ABUSE, 19(1), pp. 51-64 (1993)

A Psychotherapeutic Approach to Substance Abuse: Preliminary 0 bservat ions

Evelyn Patrick Silvers, Ph.D. 2901 Ocean Park Boulevard Santa Monica, California 90405 Telephone: (3 10) 859-9308

ABSTRACT

Twenty-four long-term substance abusers were told that addiction is an attempt to adapt to an insufficiency in natural neurochemicals that contribute to a sense of well-being; this insuf- ficiency is experienced as a craving for abuse substances which mimic the missing anxiolytic and euphorigenic neurochemicals. They were also told that they could satisfy their cravings immediately and completely without taking abuse substances by intentionally restoring ade- quate levels of the depleted neurochemicals. To perform this self-regulation, they were taught a specific psychological technique that united reason and emotion in an unambivalent order to the brain. Nineteen abusers (79%) were able to use the procedure to relieve all substance cravings and withdrawal symptoms. Their remissions have lasted 41 to 66 months to date (July 1991). A replication of the findings reinforces the desirability of further studies of the treatment’s effectiveness and mechanisms.

INTRODUCTION

The troubling incidence and consequences of substance abuse make it necessary to explore a variety of approaches to prevention and treatment [l]. Kalant [2] argued persuasively that ‘‘the arbitrary separation of psychological and phar- macological approaches . . . is no longer tenable. ” In keeping with Kalant’s con- clusion, the present paper describes a psychotherapeutic approach designed to alter substance abusers’ emotional, cognitive, and volitional state in such a way as to enable them to evoke natural neurochemicals for relief of substance cravings.

The approach derived from a procedure developed by the author in 1975 in an effort to evoke analgesia in patients diagnosed by physicians as having

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rheumatoid arthritis, osteoarthritis, migraine headaches, genital herpes, and lower back pain. The procedure not only relieved pain but, if the patients were addicts, also relieved substance cravings - in one case after a drug habit of 20 years. These observations suggested that whatever changes in neurochemical function were evoked by the pain-relieving procedure might also relieve substance cravings in substance abusers who did not have pain.

To examine this possibility, a preliminary study was made of 24 long-term abusers of stimulant, anxiolytic, and narcotic substances, nine of whom also suf- fered recurrent physiological pain. All were taught a modification of the analgesia- evoking procedure designed to fit their needs as substance abusers.

METHODS

Subjects

Observations were begun on a total of 24 substance abusers. At the onset of treatment, all 24 were feeling substance cravings. Because of inabilities to con- centrate or remember, two subjects proved incapable of carrying out the pro- tocol and were not followed.

Of the 22 subjects able to perform the self-regulatory technique, 9 were men and 13 women. Individual ages ranged from 23 to 60 years. Twenty subjects were Caucasian, one was Hispanic-American, and one was African-American. They ranged in socioeconomic status from manual laborers to graduates of professional schools, most being well-educated, professionally successful, or both. One-half of the subjects were divorced or separated, but all were experiencing difficulties in their primary relationships.

At the time of treatment, 9 subjects were abusing 1, and 13 were abusing more than 1 stimulant (cocaine, low-dose alcohol), anxiolytic (benzodiazepine, high-dose alcohol), or narcotic (heroin) substance. Asked to name their favorite substance, 10 subjects named cocaine, 9 named benzodiazepines, and 3 named alcohol. As a favorite or secondary substance, alcohol was abused by 11 sub- jects, often to temper the simulant effect of cocaine ( n = 5 ) or to reinforce the tranquilizing effect of a benzodiazepine (n = 3) . The amounts of alcohol used daily by the 4 subjects who drank the most usually ranged from 1 bottle of wine plus 1.5 quarts of vodka to 2 bottles of wine plus 1 quart of tequila or vodka. The maximum amounts of cocaine used on each occasion ranged from 2 to 3 g for the 5 subjects who abused cocaine occasionally on weekends and from 2 to 7 g for the 8 subjects who abused cocaine daily. Subjects would

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sometimes use more cocaine than usual until they “crashed,” but 7 g was the most ever used.

All the subjects had been continuously abusing substances for periods of time that ranged from approximately 5 to 40 years. Three subjects began using alcohol, marijuana, or tobacco when 5 to 7 years old. Five subjects began extensive use of cocaine when 14 to 16 years old, of whom 3 freebased or injected cocaine by the age of 16. As reported about other long-term substance abusers [3, 41, the subjects had come to feel so wretched that they kept taking drugs or alcohol not for pleasure but to make themselves feel temporarily well enough to func- tion. Therefore, all 22 subjects were in conflict between their desire to stop substance abuse and their need to continue it as the only practice that enabled them to feel normal.

Nineteen subjects reported alternating between depression and agitated anxie- ty, of whom 9 also reported suffering one or more forms of recurrent pain-lower back pain (n = 5), migraine headaches ( n = 4) , genital herpes (n = 3), osteo- arthritis ( n = 3), knee pain ( n = 2 ) , and rheumatoid arthritis (n = 1 ) . Sub- jects’ reports of depression, agitated anxiety, and painful physical disorders were confirmed by their family members and physicians.

Every subject voluntarily approached the therapist for the treatment after hear- ing about it from a trusted friend or employer whom the therapist had previously treated for substance abuse. Seven subjects expressed a belief that the treatment was their last chance to gain control over their substance cravings. However, all subjects expressed doubt about the possibility of their gaining control because preceding attempts at self-initiated remission and various forms of therapy had failed to end their substance abuse.

After learning the self-regulatory technique, the 22 subjects received suppor- tive psychotherapy aimed at helping them to reorganize addiction-free lives. During these sessions they were reminded and encouraged to use the technique for deal- ing with recurrences of substance cravings, pain, depression, and anxiety. The psychotherapy was carried out at individual sessions supplemented, in some cases, by group sessions. The frequency of posttreatment psychotherapy ranged from 4 sessions per week to 4 sessions per month, and generally decreased with relief of substance cravings.

After treatment, all 22 subjects were followed to date, even if posttreatment psychotherapy had concluded. Data were collected over the entire follow-up in- terval, as later recommended by Sobell et al. [5]. The study began in January 1986. The longest period of follow-up has been the 5 years, 6 months until the submission of this paper (July 1991). The shortest period of follow-up has been the 3 years, 5 months since treatment of a subject in February 1988.

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PROCEDURES

Therapeutic Intervention

The treatment intervention consisted of four steps, during which the attitude of the therapist was sympathetic, nonjudgmental, encouraging, and confident.

The purpose of the first step was to reinforce the subject’s desire to help himself or herself. Addiction was defined as an attempt to adapt to a hereditary or spon- taneous insufficiency in brain substances that contribute to a sense of well-being. After histories were taken, subjects were asked to describe their emotional state. One man called the process “facing the tornado” because his emotions were almost entirely negative. Besides the prevalent depression and agitated anxiety, other commonly reported emotions included desperation at the prospect of continual cravings that would lead to further substance abuse, guilt, shame, and remorse for the damage each had caused himself or herself and others. Self-contempt, self-pity, and anger were reported for the perceived lack of morality or willpower revealed by previous failures to end their addiction, which was condemned by relatives, friends, associates, and authorities. To help the subjects reclaim their personal dignity, drug abuse was described as a medical rather than a moral problem.

The second step consisted of providing subjects with relevant information about neurochemical networks. This satisfied the substance abuser’s need to understand addiction as a medical problem, and to explain his or her desperate drive to ac- quire and abuse drugs.

The subject was told that the repeated craving for cocaine and other abuse substances was a symptom of an insufficiency of activity in brain networks in- volved in a sense of well-being and other normal feelings [6, 71. These networks were hypoactive because they were inadequately stimulated by opioid and other neurotransmitters that normally stimulated them [8,9]. This hypoactivity created a real need for substances that would stimulate euphorigenic and anxiolytic net- works. Abuse substances stimulated these networks [lo, 111. Therefore, substance abuse was an attempt to adapt to a medical problem [ 121.

Because many subjects lacked scientific sophistication, this explanation was often given in layman’s language: “You have been using drugs for good reasons. The drugs that are abused mimic natural substances with which the brain nor- mally activates its circuits for making people feel normal. In the case of a drug user, these natural brain drugs are in short supply, because of a hereditary or spontaneous shortage and because abusing street or prescription drugs makes the brain lower its own production of natural substances. Your emotional and

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physiological cravings were your body’s way of giving you important informa- tion that a problem had arisen in your brain; your drug use was an attempt to solve the problem. Although drug use has dangerous consequences, in itself it is nothing to be ashamed of. It is something like taking insulin for diabetes.”

Each subject was told it was possible to replace the drug he or she had been using by evoking the brain’s own natural drugs that it mimicked or triggered. Doing this would give the subject control over the drug habit, because one could always choose to satisfy recurrent substance cravings with naturally occurring brain drugs rather than with neuroactive street drugs. Moreover, it appears that the continual stimulation of natural neurochemical activity gradually raises such activity toward normal levels and correspondingly reduces cravings for exogenous substances.

In some cases these words were rephrased and personalized. “Your brain is the best-stocked pharmacy in the world, a free pharmacy that never closes. You can direct your brain to dispense all you need of your natural cocaine (tranquilizers, alcohol, heroin). Never again will you have to drive into strange neighborhoods at 2 A.M. in a desperate search for a pusher. You have in your brain an internal medicine chest that can provide itself with natural drugs even better than those you’ve been buying, because they are free, instantly accessible, absolutely pure with no side effects, and not addictive in the way that street drugs are; they can’t control you; instead, you can control them. Whenever you want to, you can have your brain give itself just the right amount of the natural chemicals needed to give you whatever feelings the coke, vodka, Valium . . . has been giving you. The peptide, beta endorphin, one of the opiate-like neurochemicals, has the same molecular structure as morphine. In fact, beta endorphin is 300 times more power- ful than morphine. The neuropeptide dynorphin is something like 300 times stronger than beta endorphin. If you focus on giving yourself a hit of one of these drugs, you can be assured of an experience that other patients have reported as being extraordinary. The long-term effect is that the more you depend on your natural drugs, the more you are stimulating their ability to function for you. Your craving for drugs will decline over the next few weeks, and will eventually disappear. ”

Step three, the treatment technique, was introduced by telling subjects that it was easily within the capacity of the rational mind and intuitive feelings to change the functioning of the brain. “We have learned of vast numbers of braidbody chemicals and, although only 50 or more have been specifically identified, we do know these substances play significant roles as messengers carrying informa- tion from one place in the braidbody to another, bringing about change in vir- tually all of the body’s activities. We seldom recognize our ability to directly

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influence the manner in which these chemicals function, yet our thoughts and emotions are continually involved in exciting and inhibiting neurochemical secre- tions. For example, if we ‘think’ of a loved one, certain chemicals are released into the braidbody that relate to that thought. If we ‘feel’ sexually aroused, associated substances have been released; and, if we ‘decide’ to act upon those feelings, still other substances will be released and translated into physiological sensations. When excited or frightened, we can all identify the rush of the natural chemicals adrenalin and noradrenalin distributed through our bodies by the blood and the sympathetic nerves. But what happens when we frighten ourselves with only a thought? The answer is the same. There may not be any immediate danger, but the mere thought of something or someone we fear can produce the same secretions that make us tremble when there is a real and present threat. Thoughts and feelings command chemical activity evoking profound changes in braidbody behavior.

“Doesn’t it seem reasonable, if we are continually changing the function of our brains without awareness, we can easily change it with awareness? When we become familiar with the distinctive properties of substances produced and stored in the braidbody that are unconsciously summoned to perform certain tasks, the implications for conscious specific use are endless.”

Each subject was then told that the way to access internal stimulants or tran- quilizers as substitutes for abused drugs was to intentionally unify thoughts and feelings in one clear, unambivalent order to the brain. If the subject had any emo- tional doubts or contradictory thoughts, it would be impossible to influence specific neurochemical changes because “sending the brain two diametrically opposed messages (‘I must do drugs, I don’t think I should do drugs’) cancels the brain’s ability to carry out either instruction, creating a kind of chemical confusion.’’ Although all the men and women knew that substance abuse had made them lose jobs and loved ones, burned them out, and made them unable to cope, they also knew they would “do” street drugs again because, if they didn’t, they felt they would die. Therefore, the brain had been receiving two diametrically opposed messages. The rational mind knew it must stop abusing drugs and the emotional mind knew it had to have some kind of drug. Subjects were told, “By doing brain drugs, you satisfy both needs. By committing yourself to using brain chemicals, you integrate both rational mind and intuitive feelings. Then, instead of sending your braidbody conflicting messages, you are united in purpose and can con- sciously direct the brain to stimulate the production and release of whatever chemical is needed to experience satisfaction.”

With permission of the subject, each person was guided through step four: focused concentration and unambivalent determination. “Close your eyes. Take

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three deep breaths to enhance your concentration. Focus on the sites in your brain that are laden with stimulant (tranquilizing) chemicals. Now, unite your intuitive emotions and rational thoughts in one unambivalent, determined message and con- sciously order your brain to release the natural equivalent of the cocaine (alcohol, Valium, etc.) that you need. Feel the cocaine (speed, etc.) flowing into your face, down your shoulders and back, into your lungs and through your body.” Step four was then repeated.

For subjects who were attracted to this treatment because it raised expecta- tions of achieving self-control over their addiction and those subjects who organized their lives more extensively around their emotions, this information and direction was all they needed to experience immediate relief.

Six subjects who were initially uncomfortable with the concept of influencing change in their own brains (primarily those who were abusing prescription medica- tions) were led by the author in the first session through a 20-minute relaxation exercise that included deep breathing and the specific directions mentioned above.

Before leaving the office, subjects were reminded to perform the exercise several times during the day. They were also reassured that they now had the ability to control all future craving for drugs and alcohol.

RESULTS

Immediate Effects

Within seconds of the final step of the treatment, 22 of the original 24 subjects reported feeling “high” or “stoned,” as if they had just taken the usual amount of their favorite abuse substances. The claim was consistent with their appearance and behavior, but differed among subjects according to the abuse substance. Co- caine abusers who reported experiencing a rush were, at first, incapable of com- pleting sentences. For some minutes they could only repeat 1-word or 2-word terms (such as “Oh, wow!”), expressive of wonder that the effect of the natural “cocaine” had been as good as that of the first cocaine they had used, while laughing at the success of their first neurochemical “fix.” Repetitive hand, leg, and foot tremors typical of high-dose cocaine users ceased. When they did utter sentences, many recalled childhood memories associated with early distress. Ben- zodiazepine abusers experienced a restful effect which they reported in complete but stuttered sentences (i.e., repeating the beginnings of words). Two subjects addicted to high-dose Valium over 10-year and 12-year periods who had facial tics and repetitive hand movement were relieved of these symptoms and

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experienced complete rest. Alcoholics sprawled in relaxation, often being able to discuss calmly issues for which they had previously been defensive. They said they did not feel agitated and spoke with hope for their futures. In order to let the effects wear off enough to make driving their automobiles safer, subjects were kept at rest for 10-20 minutes after the treatment.

The 19 subjects with depression and anxiety (with or without recurrent pain) reported its relief. The 9 subjects who had recurrent pain also reported complete or substantial relief. As subjects reflected on their self-evocation of what seemed to be endogenous drug effects, many expressed amazement at having personal control over the substance cravings they had been experiencing at the beginning of the session.

Subsequent Effects

The same 22 subjects reported that substance cravings returned soon and repeatedly, but that the cravings were immediately satisfied by performing the self-regulatory technique. Doing this also reduced recurrent physical pain and/or anxiety, which tended to return during periods of high stress, and reduced recur- rent depression, which tended to reappear during periods of feeling overwhelmed by unresolved problems of daily life.

As a result of apparently being able to evoke endogenous satisfaction of their substance cravings, the subjects stopped gratifying their cravings with abuse substances. They reported that they did not experience such withdrawal symptoms as lacrimation, rhinorrhea, nausea, headaches, trembling, or sweating. As recom- mended by Sobell and Sobell [13], the subjects’ claims of substance-abuse remis- sion and of no withdrawal symptoms were checked with friends, family members, physicians, employers, and professional associates, all of whom corroborated the claims. The claims were also consistent with the subjects’ appearance, behavior, and interests during posttreatment psychotherapy and follow-up interviews. For ex- ample, 3 months after the specific treatment, the 22 subjects were asked (at the sug- gestion of John Melanson, M.D.) whether they would feel better if they were to take the substances they had abused before treatment. AU answered “no” and said that they were feeling better than they had ever felt.

Remission and Relapse Rates

Of the 22 subjects who were able to follow the protocol, 19 used the self- regulatory technique to relieve all subsequent substance cravings to date. Of these

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remissions of drug and alcohol abuse, 11 have lasted 5 years, 6 months to date and 8 (including 7 instances of alcohol abuse) have lasted more than 4 years, 6 months. Two years was recently recommended as the minimum period for follow-up data on alcohol abuse remissions [14].

Of the 3 subjects who used an abuse substance again, one was a woman who had been abusing cocaine, alcohol, and marijuana for 25 years. This subject, after 11 months of abstinence, smoked half of a marijuana cigarette. Three weeks later she did the same thing, but abused no substances for the following 10 months. She then began work-related travel and could not be reliably followed. Another was a male who drank heavily for 20 years and used cocaine and marijuana for 19 years. During the 5-year period after treatment, he did not use cocaine or marijuana again; however, beginning at 6 months after treatment, he drank alcohol excessively 16 times, 1 night each time, during the following 4% years. The third was a male with a 20-year-long habit who, before treatment, had been injecting cocaine and freebasing a mixture of cocaine and heroin (up to 7 g per night), using alcohol to temper the cocaine effects, and taking other stimulants and depressants. Four and 6 months after treatment, he used 0.5 g of cocaine once each time, and 12 months after treatment, he abused cocaine again (up to 4 g per night for 5 days). This man then reported that he could not identify with the other members of the study and needed daily emotional support. He joined Alcoholics Anonymous and has remained abstinent for 34 months.

Most subjects developed a similar pattern of performing the self-regulatory technique for relief of substance cravings: 8 to 10 times per day for the first 3 days, 4 to 5 times per day for the following 3 to 3% weeks, 5 to 7 times per week for the next 4 to 5 months, and 6 to 8 times per month thereafter, if needed. As implied by this general pattern of repetition of the self-regulatory technique, a decline was reported by all subjects in the frequency and urgency of their post- treatment cravings as time passed. However, there were individual differences in the time required for cravings to stop. The periods of time seemed to be roughly proportional to the previous duration and extent of the subjects’ habits. The ma- jority, who had abused substances less heavily and/or for shorter periods of time, required about 1 to 3 months for cravings to stop; the minority, who had abused substances more heavily and/or for longer periods of time, required about 3 to 9 months.

Thus, after 1 to 9 months of using the self-regulatory technique, 19 of 22 sub- jects reported no further drug cravings and no further obsessive substance abuse which, before treatment, had been a major focus of their lives. However, troublesome consequences of their previous habits-for example, the lack of friends who were not substance abusers, the loss of educational opportunities,

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and the need to reorganize their lives-remained as topics for supportive psychotherapy.

DISCUSSION

The goal of the approach described in this study was not to “cure” or “end” substance abuse per se, but rather to give individuals control over their substance cravings by enabling them to act to evoke endogenous neurochemical satisfac- tion of these cravings, which it appeared to do. Because control over cravings is manifested behaviorally in remission of addictive behavior, remission and relapse are the outcome measures discussed in this evaluation.

Attempts to change addictive behavior by self-initiation or professional treat- ment have achieved various rates of remission [ 15-1 81 and have typically been marked by high relapse rates [ 191. These rates are in contrast to the high remis- sion and low relapse rates found in this study, which are, however, preliminary findings from a relatively small and possibly biased sample.

The findings of this study have been replicated in a clinical study of 6 women and 15 men, conducted by a physician-psychotherapist in Barrie, Canada [J. Melanson, M.D., Certified by the American Society of Addiction Medicine (ASAM), unpublished data]. Melanson’s subjects had been predominantly abus- ing alcohol, whereas the subjects of this study had been predominantly abusing cocaine and benzodiazepines. After treatment, Melanson’s 2 1 subjects were followed for periods that ranged from 22 to 46 months. Sixteen subjects reported that they were able to relieve substance cravings without experiencing withdrawal symptoms, on condition that they performed the self-regulatory technique as directed. Three subjects reported reducing their substance abuse to only occa- sional use, and two reported reducing their obsessive-compulsive alcohol drink- ing from 3-day-long binges every weekend to 1 scotch-and-soda and 6 to 8 beers per weekend, respectively. All subjects who continued to use the self-regulatory technique reported a general decline in substance cravings as the procedure was repeated over time.

Studies with long-term follow-ups of alcoholism treatments have found less than 15% of complete abstinence [20,21]. If remission of alcohol abuse is defined as including nonproblem drinking as well as abstinence, an overall remission rate of 34% was reported in 68 studies of alcoholism treatment outcomes reviewed by Riley et al. [22]. In a recent study [23] of a multimodal treatment program for problem drinkers, 43 of 107 subjects (40%) remained totally abstinent for 1 year, 8 had only 1 slip during the year, 4 drank but not to intoxication, and

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3 maintained several months of abstinence following a few initial slips. In the present study, 2 of 3 subjects whose favorite abuse substance had been alcohol achieved complete abstinence for 5 years, 6 months, as did all of the 9 other sub- jects whose multidrug abuse had included alcohol. In Melanson’s clinical replica- tion, in which 15 of 21 subjects had abused alcohol and 3 others had abused both alcohol and either benzodiazepines or narcotics, similar high rates of remission were achieved.

Rates of posttreatment relapse into drug abuse resemble those for alcohol [24], even though alcohol abusers and drug abusers seem to differ in some ways -for example, in taking longer to become dependent on alcohol than on cocaine [25]. With regard to the efficacy of psychotherapy for drug abuse, supportive and cognitive forms have been found useful primarily as a supplement to phar- macological therapy in opiate addiction [26]. Similarly, in cocaine addiction, psychotherapy and behavioral therapy have been thought most likely to be effec- tive in combination with pharmacological therapy [27]. In the present study of a psychotherapeutic technique that appears to evoke natural chemicals, 19 of 24 (79 %) subjects who abused illegal or prescription substances achieved remissions that have lasted up to 5 years, 6 months to date.

In this preliminary investigation it was not possible to study the contribution of extratreatment factors to the treatment outcomes [28]. However, 19 subjects have remained in remission despite having posttreatment life problems that re- quired psychotherapy. With regard to the study population, these subjects represented a biased sample of substance abusers, for all of them sought the treat- ment voluntarily after failing at attempts to self-initiate remission or failing to benefit from one or more other therapies for substance abuse. Also, all subjects entered treatment after hearing about the effectiveness of the described therapy from trusted familiars. In this regard, Miller and Hester [28] concluded tentatively that alcoholics who receive the treatment of their choice accept, comply, and benefit more from it than do those with no choice.

Frank [29] proposed that “. . . all psychotherapeutic procedures share certain healing components which account for a considerable proportion of their effec- tiveness.” Frank’s list of shared therapeutic components includes: 1) an emo- tionally charged, confiding relationship with a helping person; 2) a healing set- ting; 3) a scientific rationale, conceptual scheme, or myth; and 4) a ritual logically derived from the rationale that is believed by both patient and therapist to be the means of restoring the patient’s health. Furthermore, “all therapeutic myths and rituals, irrespective of differences in specific content, have in common functions that combat demoralization by strengthening the therapeutic relationship, inspir- ing expectations of help, providing new learning experiences, arousing the

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patient emotionally, enhancing sense of mastery and self-efficacy , and affording opportunities for rehearsal and practice. ”

The treatment described in this study included Frank’s four common therapeutic components. It certainly combatted demoralization. For example, many subjects had never before heard that they were not bad or weak for abusing substances. The treatment also included other common elements of effective therapy (e.g., Refs. 30 and 31), including relaxation [32,33]. The extent to which these shared elements of psychotherapeutic treatments for substance abuse contributed to the particular effectiveness of the treatment procedure described here cannot be determined.

The most salient treatment-specific factor was its concluding “ritual,” the self- regulation technique. Frank advocated “caution in attributing remission of a symp- tom to a particular maneuver” because sometimes therapeutic rituals ‘ ‘provide a face-saving excuse for the patient to abandon a symptom or complaint when ready to do so . . . . (Also) The more spectacular the ritual, the greater its usefulness from the individual’s standpoint” [29]. Clearly, the psychopharmacological “ritual” was not spectacular, because this self-regulatory procedure was inter- nal, brief, and accomplished by the subject. In fact, the ritual was so unspec- tacular that subjects were able to conceal its posttreatment performance when afflicted with substance cravings during business meetings and other public oc- casions. “What the subjects did find spectacular was the novelty of the ritual’s scientific rationale” [34].

In conclusion, although population biases and nonspecific factors may have contributed to the positive results obtained in this study, the relative effectiveness of the described treatment seems attributable primarily to its self-regulatory tech- nique, in which unified thought and emotion appear able to induce physiological responses that satisfy substance cravings. In view of recent studies of the behavioral effects of neurochemical substances [35, 361, it is possible the treatment works in the way that subjects are told that it works - by the endogenous release of neuropeptides. This possibility merits further investigation.

ACKNOWLEDGMENTS

The author thanks Samuel X. Kaplan, Chairman of the Board of U.S. CARE for supporting and Theodore Melnechuk for providing substantial editorial and library-research assistance in the preparation of this paper, John Melanson for unpublished data, and Robert Ader, Jerome D. Frank, George F. Koob, John C. Liebeskind, Neal E. Miller, Candace 9 . Pert, Michael Ruff, George Solomon, and Herbert Weiner for helpful discussions and suggestions.

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