I.-

,/

PERSPECTIVES

IN
DRUG ABUSE

TREATMENT

Community
Cor-respondents
Group

PROCEEDINGS, >
VOLUME III

1979

FORECASTING BRANCH

DIVISION OF RESOURCE DEVELOPMENT}
NATIONAL INSTITUTE ON DRUG ABUSE
ROCKVILLE, MARYLAND

 

PERSPECTIVES

IN
JDRUG ABUSE L

TREATMENT

Community
Correspondents
Group

PROCEEDINGS
VOLUME III 1

1979

FORECASTING BRANCH

DIVISION OF RESOURCE DEVELOPMENT
,)._' NATIONAL INSTITUTE ON DRUG ABUSE
‘ ROCKVILLE, MARYLAND

 

 

Portions of these proceedings were edited in
an effort to provide clarity.

Parts of the voiume were prepared for the
Nationai Institute on Drug Abuse by Pianning &
Human Systems, Inc., under Contract Number
271-78-4603; SB3-4-0-8(a) 78-C432.

 

 

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MORNING SESSION
Therapeutic Communities, an Introduction 1
to Daytop ViIIage
AFTERNOON SESSION
The Role of Drug Abuse Treatment over 28

Time -- Response to Changing Trends
and Changing Characteristics

Us
“a

H.

MORNING SESSION

Therapeutic Communities,
an Introduction to Daytop Village

iv

CHARLES DEVLIN

I want to thank you all for being here. I thought it would be impor-
tant that you see this building, which in itself is a very large,
impressive place. I thought you should see our computers and our
murals so that we could impress you, because that's not how we
started. We started sixteen years ago in a very small place in Staten
Island called Daytop Lodge. Daytop Lodge was funded to treat 25 male
addicts from the Second Judicial District, Supreme Court, which covers
both Staten Island and Brooklyn.

The program itself was modeled after a California program called
Synanon. A grant from the National Institute on Mental Health for
$398,000 for five years funded Daytop Lodge. Since Daytop Lodge was
for all males from the same geographical area, it wasn't very success-
ful. It was really a pilot program. One of the things we noticed was
that the clients knew each other and many people who came in to Daytop
or wanted to come in could not come in.

Females were not allowed to come in to Daytop.

It was a one-year program. After one year people were supposed to
graduate from that program. The directorship of Daytop Lodge really
weren't very good at motivating or working with the drug addicts.

One year later Daytop Village opened approximately two miles from the
original site. It was a much larger facility with housing for
approximately 60 more people. He opened up Daytop Village in early
1965 and filled the facility within six months because there were so
many addicts in New York who wanted treatment.

At that time there really wasn't any residential treatment available
in New York City other than hos‘itals.

I
V

(

I 1

The building was full so we found another facility upstate in Sullivan
County, New York, which is approximately 90 miles from New York City.
From that point on Daytop Village grew to its current size of ten
facilities, including outreach and residential, and has a total popu-
lation of 850 people. Five hundred are residential, the remaining are
outreach.

In 1967 we were taking a number of pe0ple in to Daytop for residential
treatment who didn't necessarily belong in a residential program.
These people were younger and they were not addicted to hard drugs.
These were younger users of marijuana, pills, and amphetamines.

What we do here differs from traditional drug treatment programs.

We have two cardinal rules: no physical violence and no drugs or
alcohol abuse. -

The addict is accustomed to striking out any anyone who bothers him.
We encourage people to learn how to get their feelings out by talking,
not by striking out in fright. One can't relate to feelings or with-
draw from drug use unless in a nondrug using environment.

I want to trace what happens to a person who comes to Daytop. The
induction facility is approximately three blocks from here, open 24
hours a day. Anybody at any time who wants help can walk in and say,
"I need help." Any addict.

Years ago we believed that if an addict wanted to have help they had
to call us a number of times and had to prove their motivation. They
had to say, "I want it.“ We would say, "Okay, fine, call tomorrow at
nine o'clock," and they would call tomorrow at nine o'clock and say,
"I want help." We did this for years. The truth of the matter is,
the addict will call you one time. Now as soon as that person wants
help, it is giVen. Once they come to our induction house, or call us
we say come in immediately. They come in at any time of the day
because that's when they are seeking help. Maybe at that time we can
talk to them and see what we can do for them. In our induction facil-
ity we evaluate them. We form a contract between Daytop and the
addict. We explain the conditions of the program and they decide if
they want to stay. If they decide not to stay, that's fine, too. We
don't want that individual to leave our induction facility to go back
to the streets. If that happens we didn't do our job. We did only
part of our job. The idea is to get them there and find out what
their treatment needs are. If our program is not suitable, we try to
get them to another program. New York City is loaded with many dif-
ferent types of programs. ,

I

If they decide to stay with us, they spend approximately a week, maybe
two weeks in the induction house. There they are oriented to the pro-
gram. They are given complete medical and psychiatric testing. If
they are accepted, they are then transferred to one of our residential
facilities.

We have treatment facilities in Swan Lake, Parksville, and Millbrook.

When the addicts first go to the therapeutic community, certain things
start to happen. It's a new environment for them. The facilities are
very large. There are no bars on the windows. They see people walk-
ing around functioning, eager beavers, performing. They don't know
who these people are. The addicts don't know if these people are the
doctors or students. They can't figure this place out. They may even
see people they knew from the streets, from New York, from jail, from
shooting dope or neighbors.

Upon entering the facility the clients are told that they will be
given a job. Everyone in Daytop Village works. They will be given a
job and will start at the bottom of the totem pole. They may be col-
lege graduates; they may be people who are engineers or whatever, but
they are going to start at the bottom of the organization. They will
start cleaning toilet bowls or they will start working on housekeeping
or working in the kitchen cleaning pots--everybody in the organization
works. We don't hire people to do our cooking. We don't hire people
to do our cleaning. We don't hire people to do our fixing. We do it
ourselves.

The clients are then assigned to a job and to a room. The rooms are
bunk beds--three or four people in a room. The new arrivals are put
on the top bunk and told everything they get from that point on they
will earn. We are starting to get the message across that Daytop is
different from the way their lifestyle was before. Before, whatever
they wanted they basically got or they took. We say they have to
start at the bottom and earn what they want in a number of ways:
functionally, behaviorally, showing some positive behavior in both
work and social settings. At Daytop, peers are referred to as
brothers and sisters.

Probably the most important components of Daytop are role models.
When residents come into the program they see other people who have
been in the program up to a year, and are doing very positive kinds of
things and they say, I'Hey, I would like to copy you because you were
once a drug addict."

So the role models are very important. It's the three-month member
who constantly gives support and who takes the newcomer and says, "I'm
going to help you along."

That same newcomer does the very same thing about a month later
because everyone wants to give and help each other because they find
that it works and that it creates something positive. One of the
things that is created is some love and respect for another human
being. They are feeling a part of something and gaining some pride in
their own functioning and their ability to perform without the use of
drugs. Remember, they have never functioned before without the use of
drugs, without being high.

We also find that peer pressure is important. The peers create the
change while they are interacting. One peer tells another what is
being done wrong or what is being done right. It's not the tradi-
tional doctor-patient setting, because when a new resident comes into
the program they can't identify with the staff. As a matter of fact,
they don't even understand the staff at all. They think the staff
members are all different than the new resident is, even though most
of our staff members were in the same place five or six years ago.

We do demand some behavioral change. We say "you have to start func-
tioning and behaving in a positive manner." This is different from
the psychiatric way of saying "you have to first identify your root
causes and if you identify your root causes, then we can help you.“

We encourage residents not to worry about the causes. We want them to
worry about now. "Right now you have to stop putting needles in your
arm and start to function in a positive manner. When you do that, we
will start talking about your program here." That's secondary, not
primary. The nonnal day of a Daytop resident begins at 8:30 with
breakfast. Breakfast is optional. Residents may decide not to have
breakfast and sleep later. But at 9:30 we have a morning meeting. In
the morning meeting the whole family gets together and talks about
what is going on that day in a structured setting.

By the way, just as an aside, I was the very first resident ever sent
to Daytop Lodge in 1963. I was not only the first resident sent to
Daytop, I was the first graduate from Daytop Lodge and I was the first
failure from Daytop Lodge. So I have a lot of firsts. Then I came
back after continuing my research in 1965.

The morning meeting is a very interesting situation because of all
kinds of feelings which get created there. Please remember that we
are dealing with people who never dealt with their feelings. As a
matter of fact, when one uses drugs one has no feelings.

In the morning meeting a staff member or coordinator will say, "Good
morning, family. How is everybody today“? It's a nice situation.
Then the staff member will say, “I have a few announcements to make.“
He gives very nice kinds of positive announcements, "Dry cleaning will
be picked up today,“ or "sheets will be changed."

4

All of a sudden after the announcements something will be said like,
"Who left the lights on last night in the living room"? Everybody
gets quiet. "Oh, God, did I leave the lights on? What happened"? So
the residents go from the feeling of really great to a feeling of "Oh,
wow," and they want to hide, crawl into a little crack in the wall or
crack in the floor. Then the staff member starts doing what we call
pullups. "Who left the ashtray full and who didn't flush the toilet"?
This starts the residents evaluating and saying, "Did I," and if they
did, they either raise their hand and say, “I did it," or they keep
their hand down and say, "I hope nobody saw me." Well, what we are
trying to get is for that individual to raise their hand and to start
admitting or “copping to what they did."

The feelings go from very happy to very low and then after that's over
the staff member will say, “Who has a song to sing? Who wants to tell
a joke"?

At that time the morning meeting will end on a happy note. Then
everybody is given a job assignment and they all go out to work.
Everybody works within the therapeutic community, not outside. They
stop at 12:00, have lunch, and at 1:00 attend “seminar."

A seminar is an opportunity to sit in a formal setting and discuss
particular topics. We do some mental gymnastics. We may put a quota—
tion from maybe Nietzsche, Freud or Emerson on the board to discuss
and dissect. The purpose of this exercise is not to come up with some
conclusion, but to provide an impression of what that quotation or
comment or sentence means. Addicts are notorious for being very
narrow-minded and very rigid in their thinking until they start hear-
ing other people express other ideas. 0r during a seminar a person
may talk to the group about something they know about or have
experience with. It's a give—and-take situation where everybody con-
tributes.

After a seminar they will go back to work. On Monday, Wednesday, and
Friday evenings we have the encounter group. You have probably all
read about the encounter group. We find the encounter group itself is
somewhat changing. As time goes on and as we all learn from different
group techniques, there are a lot of modifications made. The
encounter is a chance for residents to have a catharsis or release of
that hostility and anger. They can't punch somebody, but now they
have the opportunity to get it Out verbally.

But a lot of other things take place, too. During encounter residents
talk to each other and say what their feelings are about certain
people. During the day they do get a lot of feelings. Perhaps a
.department head or boss told a resident to do a particular job without
saying "please." That caused a lot of anger and hostility.

In peer group the peers meet on a regular basis every week. There is
not a lot of hostility in peer group. Peer group is talking identifi-
cation and support in sharing with each other. Sometimes we will use
psychodrama or primal therapy in the group, depending on what indi-
vidual needs are.

As the resident matures and grows in the organization, privileges are
awarded. As they start performing and showing some positive behavior,
they are allowed to call home more, or write home, or have visits or
go out to shows. All of these are rewards for their growing up.

I should also talk about the punishments. To give you an example,
while I was in Millbrook yesterday speaking to the director, he told
me they have a youngster who is like a packrat. He steals from his
fellow residents and hides his booty in the woods. Normally when
somebody does that we tell them in a nice, firm fashion, "No, you
can't do that, we don't steal. You don't steal from your brothers and
sisters. You don't steal, period. It's wrong to steal." The person
says, “Yes, I learned my lesson. I'm not going to.steal any more."
We take that at face value and trust the resident. Two weeks later we
find out they are stealing again. Now we talk to them a little bit
more firmly. Now it isn't a talk. Now we sort of yell at them and
say, "Okay, listen, you didn't learn from the past experience when we
told you. So now you are going to have to let the whole family know
what you do." And the whole family knows because the guilty resident
wears a sign that says, "I am a thief. Please help me and talk to me.
Tell me why I have to steal." That sign is humiliating. But you
would be surprised at the changes that take place from a little bit of
humiliation.

I received a little bit of humiliation when I was in Daytop. I used
to have a habit of leaving my dirty underwear on the hook when I took
a shower. But my peers and friends would bring me my clothes. Final-
ly they got tired of doing that. So the following morning meeting the
coordinator said, "Okay, whose underwear are these"? while dangling
the underwear up in the air. I was sitting there looking and somebody
said, "Somebody is going to be embarrassed about that.“ "Well, whose
underwear“? I wasn't thinking it was my underwear. That can't be me.
We had to put our names in our shorts. He said, "Well, let's see,
let's Spell the name in here." They really tortured me "D-E-V." At
that moment I wanted to crawl and find a little crack in the floor to
hide because it was totally embarrassing. They said, "Charlie, get a
grip and don't leave your underwear hanging on the hook any more." I
haven't done that since. So that little experience changed a little
little piece of my behavior.

Well, that's basically again what the sign does.

Then if somebody does break one of the cardinal rules of no physical
violence, or if they are trying to smuggle in contraband and get high
on d0pe or alcohol, we say "No good." They have an option: either we
can expel them or they clean it up. How do you clean up something
like that within the family? It may be a shaved head for the men or
stocking cap for the women. or wearing a sign, or telling the house
in morning meeting what was done and seeing if the house, the family,
still wants the resident to stay in that program.

But there are a number of things that we will do. The person always
has a choice. The resident decides whether to accept or reject treat-
ment. There are no bars on the windows. Nobody is sentenced here
from the Court. Everybody here basically is a volunteer. They may
have pressure from the Court, but they are voluntarily admitted to
this program.

After they spend approximately one year in a residential therapeutic
community, they then come here to New York City, to this house. This
is our reentry facility. We have approximately 120 people living here
now. We think again reentry is probably one of the most crucial
facets of their treatment program because now it's where the person
starts thinking about self. They start saying, "What am I going to do
for my future"? That usually was not the case previously in the
therapeutic environment. They were usually in a structured family
environment. Now they are all grown up. It's time for them to start
thinking about what they are going to do, where they are going to
work, where they are going to live, who their friends are going to
be.

At first everybody wants to work for Daytop during the reentry period
because they love Daytop; they want to stay home and be with us.
Although we like that very much, we encourage them to go out and work
and go into reentry. Then they can make a decision and return after
that. Once they go to work and start their own lives, they don't want
to come back to us. But they feel protected here and they feel very
comfortable here. Once they go out and they get a job--they don't
want to come back to live or work here.

Less than five percent of the program graduates come back to work for
Daytop after they have worked outside. I find they become better
staff because they have exposure, they have experience, and they have
made a decision after having done other work to come back and work
here.

MR. HAJAZI: I would like to give you some idea about the operational
dimension of Daytop. Charlie referred to the fact that we have two
modalities of treatment. One is residential and the other is what we
call outreach. The outreach consists of two modalities. One is day
care and the other is outpatient.

We have three residential facilities upstate in addition to this
facility, and one induction center. We have five outreach centers:
one each in Brooklyn, Manhattan, Bronx, Staten Island, and West-
chester. We are in the process now of expanding into the Borough of
Queens and hopefully in Dutchess County, an outreach center.

Our funding comes from two sources: The Division of Substance Abuse
Services of the State of New York funds four outreach centers in
addition to all of our residential facilities. The Center in West-
chester is funded through the county. The total operational budget of
Daytop is in excess of $5.5 million a year. We are contracted in the
residential component to service 500. However, for the last six
months we have been averaging 520. In our outreach centers the
utilization rate has been around the 90 percent level.

In addition, part of Daytop is what we call the Parents' Association.
We believe that family therapy is an essential component of treatment.
When a resident first comes to treatment the Parents'Association mem-
bers contact his family and urge them to attend or participate in the
activities of our Parents' Association. We currently have 625 active
parents who meet weekly and monthly for groups. They support the
treatment of the residents. In the reentry stage of treatment we try
to hold groups of both residents and parents together.

You have seen our administrative apparatus here. We have centralized
administration of all personnel services, purchasing, and supporting
services. We have a mechanized system, a computer System 32, which
incorporates all the research data in addition to our fiscal operation
and our third party reimbursement. Approximately 60 percent of our
residents when they come to treatment are eligible for some kind of
public assistance, food stamps, Medicaid, etc.

In addition, the program has a full complement of what you might call
supporting services. These include medical services. Medical doctors
and nurses in each of the facilities attend to the medical needs of
the residents. In addition, we have contracts with various hospitals
for hospitalization referral. We are currently in the process of com-
pleting an application for Article XXVIII, which will license us to be
medical providers, and as such will qualify us for Medicaid rates for
the medical services that we provide.

In addition, we have a mental health division which is under the
direction of Brian Madden and it consists of a complement of social
workers.

We have a training program for social work interns in conjunction with
Fordham University.

We have a sophisticated educational component. The educational pro—
gram consists of two parts. One is a high school program for all the
residents who don't have a high school diploma. Part of their treat-
ment is attending school. We have teachers who are paid for by the
Board of Education. In addition, we have a contract with the State
for Title I for remedial reading and math.

We have a special grant with NIDA. It took us three years to get it.
We call it Daytop Miniversity. The concept of Daytop Miniversity is
to bring the college to residents as part of treatment. We have full
professors under contract with Brooklyn College of the City University
of New York who come into our facilities and give a fully accredited
program. By the time residents complete treatment they could earn up
to 38 credits, which they can either use to continue their education
or to help find better jobs after treatment. In addition, we have a
vocational program with professional counselors who assist residents,
particularly in the reentry phase of treatment, in job placement and
job training.

We have a program of cultural activity through which we try to expose
the residents to various plays, movies, and workshops for photography,
psychodrama, and ceramics. I made reference to our department in
charge of third party reimbursements. Funding that we receive from
NIDA and the State is hardly enough to pay for what it takes to feed
and house a resident. NIDA is still giving a $5,600 figure per annum
to service a resident for a full year, and that's hardly enough to pay
for the basic needs.

50 we supplement our funding with a third party. Currently we average
in excess of $8,000 a year from our third party sources.

In addition, the program has what we call specialized services. We
have women's programs. A director of women with assistants and
approximately 30 professional consultants conduct specialized
groups, especially for the needs of women in treatment.

About eight to ten months ago we started what we call a senior citi-
zens' program. We are really not in the business of senior citizens.
He structured the program so that it will complement the treatment of
the clients we have in the outreach center. Basically the program has
two levels of service. One is the telephone reassurance program.
Each day we have a care client assigned two or three names of older
people and that client is supposed to call them on a daily basis, find
out how they are doing, and what do they need. A social worker is the
coordinator of the program in case there is a problem the resident
uncovers. The senior citizen may need medication, or referral to
legal or medical services. The client can contact the social worker
and the social worker will follow up on it.

Finally, we are in the process of completing a proposal for prescrip-
tion drug abusers. We feel that this is one area that is in dire
need, and we have one person who is a graduate of Daytop who is
addicted to prescription drugs a and is working on that proposal with
us.

DR. VINCENT BIASE: You have heard generally about the philosophy of
Daytop, its history and its administration organization aspects, the
centralized feature. Within both the history and spirit of Daytop and
within the administrative umbrella, there is an active Department of
Research and Development which basically has two forward thrusts
within the research component.

One is a very active client data management system which provides for
the accounting as well as the preprogram and during program client
characteristics that are germane to the individuals who are coming to
the treatment. So that really is the statistical census management
information realm. The other aspect within the research framework is
basically an investigative approach about a wide range of topics that
relate to Daytop per se, to the New York City drug scenario, to
special problems within drug treatment, to trying to generate investi-
gations that are genmane, helpful, and supportive to the treatment
program. So some of what I may present to you this morning is not so
much conclusive, final statements about data as much as it is informa-
tion about investigations that are in progress and will help give you
some of the spirit of that thrust.

The basic disciplines that we rely upon are social science research,
operations research, our adaptation of ethnographic investigations and
utilizing sources and documentation outside of Daytop proper to sup-
plement and complement the kinds of information that we see as direct
observers and even residents see among each other. I firmly believe,
as Charlie mentioned before, that in fact he did research, that each
of us conducts a research endeavor in our own fashion. It's only
those of us who have elected to pursue that discipline who organize
the large amounts of data. But I sincerely think that the kind of
information you all had opportunities to gather the last few days here
in New York, the quasi soft data, as well as the rigorous studies, has
to be blended in order to get a composite picture of what is happening
vis-a-vis drug treatment, the future planning for drug treatment, and
those needs that are not addressed.

We have 12 persons within the research rubric and development divi-
sion. The development part of the research and development division,
for which I have directorship responsibility, begins to marry that
empirical information with sensible projects.

10

The one that is particularly striking is the Daytop Miniversity. It
literally grew out of the observed need for advanced educational
training. There were many residents who had a great deal of inherent
talent, aspirations for higher educational achievements, innate abili-
ties but who had very negative experiences in the past. Most of you
from the drug treatment community obviously have had your share of
residents and clients who, in fact, were students in jeopardy, either
in high school level or at the college level. Their daily opiate con-
sumption was equivalent to the amount of credits they were taking.
Taking a look at this subpopulation within the Daytop overall
population, as well as studying the potential strengths and unique-
nesses of a residential therapeutic communty, caused the project to
emerge.

The program started in February and is very robust. The program is
under the auspices of the School of Science of Brooklyn College, and
we have very difficult courses. Some residents are taking 12, 13, and
13.5 credits while they're actively engaged in their own difficult
clinical advancement and maturation in the program. The Miniversity
student is also an appropriate job definition and title for a resident
to achieve and aspire to and, in fact, what we seek to do is blend the
best of the therapeutic community with the academic program. I should
tell you the kinds of courses that are taken.

In contrast to what we have had in the past, which is somewhat of an
informal random presentation of college level course work for
residents who wanted it, this program is structured in a very particu-
lar way. All the academic activities actually take place within the
Daytop community. The courses, for instance, in the first semester
are Introduction to Finite Mathematics, Introduction to Computers,
English, and Speech.

The second semester advances to Introduction to Statistics, an
advanced course in programming with hands-on experience, and a contin-
uation of the English course.

The third semester takes a group of reentry students to the Brooklyn
College campus for a day-long lab and lecture in college level
geology. They are taking a course in comparative literature, modern
fiction, and human sexuality.

We have tried to set up this aspect of commitment that Charlie spoke
about so that individuals could embark on those courses and complete
them while they're in Daytop. All the benefits of peer interaction
and family support--the provisions that can be made within a 24-hour
residential environment for a person to express apprehensions and
anxieties--are dealt with. The common alienation and isolation that
students feel in any college campus and the sometimes debilitating

11

presence of heavy competitiveness is approached in a very different
fashion. A team of 15 or 20 students starts that semester work and
works through their interpersonal problems as well as their academic
ones, so that, in fact, there is a coalescence and a type of unity.

We are involved in an objective evaluation of that project. This
phase is a feasibility phase. We are attempting to answer questions
about when is the best time to offer the program to residents. We
have tried it both in the early phases of treatment and in the latter
phases, or reentry. Based on experiences of two semesters, including
a heavy summer semester, we find that individuals who are in treatment
after the third month, who have a good education (or have completed
Intermediate Algebra sometime before they were actively involved on
the streets) and who have an expressed motivation to participate and
to work under duress, are the best candidates. We provide as much
support as possible so that the individual can complete that
semester.

Our aspirations are to enhance the individual's self-concept. We want
them to learn that they are not academic failures and that they
develop a sense of achievement. We are objectively monitoring this
with a series of standard psychological self-concept evaluations, such
as Sells Depression Scale, the Tennessee Self-Concept Scale, and
Rotter's Internality-Externality Scales. We will start in September

on a followup of the first group of 80 residents and a complement of
their counterparts who were nonparticipants.

A few facts and figures might put some of what was said in a somewhat
more empirical context. In the fiscal year 1978-1979 we had 1,170 new
admissions to the residential and outreach Daytop treatment facili-
ties. 0ur current population stands at 500 in the treatment centers
and 320 in the outreaches. Just for general information, the utiliza—
tion rates here at Daytop are about the 99 percent level with the
residential treatment center and about the 92 percent level with all
outreach.

The night care, which is the most ambulatory aspect (because it only‘
requires individuals to attend one or two nights), has utilization
hovering between 75 and 80 percent. This is what one would expect in
any somewhat less intense, less well supervised treatment endeavor.

In the last year, based on these figures, we provided a total of
171,550 residential days of treatment in the treatment center, almost
49,000 days of day care treatment, and approximately 13,000 sessions
in the outpatient night care treatment.

We have been concerned, as well as elated, about the kinds of informa-
tion that has been generated about treatment centers. I would

12

imagine most of you are familiar with the nationwide study conducted
by Texas Christian for NIDA which involved more than 2,000 residents
of various treatment modalities a year after their treatment. One
concluding statement that both Dr. Sells (the author) and his staff
and associates reported is that using the most rigid criteria,
including drug abstinence and no return to drug treatment, the treat-
ment center group would probably be selected as having the most suc-
cessful outcomes.

I am not here to proselytize about the treatment center as much as to
highlight certain things. I think by having traveled through Harlem
yesterday and gathered information from other sites around the
country, it's very clear that the problem with opiates and categori-
cally classified addictive substances is somewhat diminishing. What
do you do with a new polydrug abuser? The treatment center stands as
one of the more attainable, realizable modalities. It demands refin-
ement in its process. Certainly there seems to be a very strong need
between the reduction in the characteristic hard—core addict that we
knew from eight to ten years ago and the more typical polydrug abusers
with a composite picture of methadone, illegal heroin, illegal metha-
done or street methadone, supplemented by alcohol, complemented by
barbiturates, enhanced by PCP and supported by some good Colombian
weed. There is no methadone program that really deals with that as
far as I know. If you speak to residents--and I hope you will get
some opportunity even in your short stay here—-they will tell you that
the changes that have occurred within them have been very much focused
on their new knowledge about themselves, about their new levels of
self—awareness, about their admitting to those kinds of secrets and
pressures which very often ran hand in hand with their drug behavior.

It's not uncommon for somebody who downed 30 barbiturates a day and
was truly a human gorilla in their actions to say that all they knew
before they came to Daytop was anger. In fact, you find out that
after they chewed the 30 Tuinals they went back to their apartment and
put a couple of shotgun blasts in the house and did some hijacking
alone or with other individuals. They hardly remember that, but defi-
nitely know that it was some expression of their anger against their
personal situation, their confusion about where they stood in their
life. The majority of our population is in the 22 to 24 year old
range.

Some data that we had in the April to July period showed us that
persons admitting to heroin as a primary drug problem comprised only
30 percent of our total population, which was one of the lowest levels
we have ever seen.

We have done a number of studies and are actively engaged in those.
We have studied the phenomena of PCP in tenns of general usage, the

13

characteristics of the PCP users vis-a-vis the treatment center and,
in fact, have found that even those individuals who used PCP more than
150 times prior to coming to treatment did not present us with any
unique kind of pattern in their response to the treatment center pro-
gram. For general information, females reported using PCP somewhat
more frequently than males. We try to look at a phenomenon that's
currently going on and see how it impacts on treatment modification
based on an individual's previous drug history.

We have done our own ethnographic studies. We have allocated 200 man-
days to study 33 sites throughout the five boroughs. We used New York
City Police Department sites, Drug Enforcement Administration sites,
and outside, every Methadone Maintenance Clinic here in the program of
New York City. The purpose was to (a) identify usage patterns, (b)
identify what was the concept of the treatment centers among persons
who, in fact, needed treatment, (c) try to tag and identify how many
of those individuals inhabited high drug-copping areas, high fencing
areas, also adjacent to methadone clinics.

These were not always the same sites, of course. After interviews
with approximately 675 individuals, we found less than six percent of
former Daytop people were back into their haunts, back into that kind
of style of street addiction.

We found some interesting things. The treatment center seems to have
a better image among the older addict. Those whom it touched said it
was valuable, it helped to get some clarity around self-values. They
learned something. Few of the large group of high risk people 14 to
19 years old knew that such a treatment modality as the treatment
center existed. I think that is unfortunate because among that group
are the very active adolescent users of PCP, alcohol and both licit
and illicit prescription drugs.

We are currently engaged in a pre/post study in conjunction with the
Department of Health, Education and Welfare on the employment rates of
residents who are in treatment for varying periods of time. Basical-
ly, the highlight of that study which involves more than 250 indi-
viduals demonstrates that the transition for many people after
treatment is having the opportunity to find a satisfying fulltime site
of employment that is akin to their own aspirations and directions in
life.

So we are seeing rates hovering between 55 and 60 percent in terms of
employment. But I'm particularly concerned about the differentiation
between parttime and fulltime employment. Certainly the employment
issue relates very strongly to how one begins to adjust with their
life and their drug problem after the program.

14

Another phenomenon that we are monitoring is the rate of readmissions
which concerns us Somewhat. In the national study, over a period of
three years about 51 percent of those individuals who have been in
treatment report having the need to go back to treatment.

So we are seeing return rates approaching the mid—20 percent level,
and what that suggests to us is not necessarily a regression and a
falling back as much as it is a period wherein the individual comes
and experiences the treatment center. Many individuals do not even
know what is involved. So I don't see the issue of dropout rates as
being so critical. An individual comes in and is not oriented to this
modality. Some individuals have to come and stay anywhere from an
hour to a month just to get a sense of it. They get back out on the
street, get bruised up a bit, feel the same dysphoric, negative kind
of effect in mood, find themselves under a particular kind of pressure
and then remember that there is something to be gained and some
changes to be had by participating in the Daytop modality. I will
close my comments here.

QUESTION: Does your Women's Facility house women and their children,
or just women?

MR. DEVLIN: Just the women. We are concerned about their children.
We have some women with children, but that's really not the norm.

At least in our upstate facilities, most of the staff live on the
property with their wives and a lot of them have children. Under
special conditions, if a woman has no place to place the child, there
is no foster care, there is no family, more than likely we will make
arrangements for the woman to have her child or children with her.

QUESTION: But you don't encourage the women to bring their children
and involve the children in the therapeutic process?

MR. DEVLIN: We really don't encourage them to bring their children.
We would rather that they be placed someplace else because we don't
have the facilities just yet. But if they have no place for the
child, we take them in with the children.

DR. BIASE: As a result of the ethnographic street survey, there were
a number of women who are currently involved in methadone maintenance
programs who would give careful consideration and expressed a desire
to enter a treatment center if the treatment center could provide such
a commitment. We have done some planning but have not determined the
best way to meet child care needs, the parenting needs, and the indi-
vidual's treatment progress.

15

MR. HAJAZI: It should be mentioned that we are actively exploring or
investigating the possibility of creating a child care program in
Daytop.

QUESTION: In relation to the PCP research, you mentioned that there
didn't seem to be any distinctive characteristics that ran through
that population. Did you find that in any way there was a difference
in treatment needs in regard to the burnout withdrawal?

DR. BIASE: As a matter of fact, the patterns that were shown were
these: Those who elect in fact to come to the treatment center may
not generally be reflective of what's out there. We saw a higher
reported use significantly by females. We saw a higher use by whites
in contrast to the level of PCP use on the street, which was just the
reverse.

We did not see any particular clinical effects arising out of the syn-
drome that you suggested, and we didn't see any differences in the
degree of participation by individuals in the program. In fact, some
were even Miniversity students and completed their efforts with no
peculiar clinical symptomatology. We did not find a significant rela—
tionship between assaultive acting out behavior and general use.
There was a relationship between the higher users and assaultive
disruptive antisocial behavior.

QUESTION: Were many of those PCP users chronic users who had remitted
right before entering into treatment? In my research I have found
that individuals reported periods of up to a month after total remis-
sion before they began to feel normal again, which is quite a long
period of time, given the length of withdrawal for other drugs.

DR. BIASE: It's a good question. We didn't study it. We did not
look at the relationship between cessation but, rather, overall
experience and use rates in conjunction with other drug use patterns.
That's how it was done, and to what degree did nonusers, if in any
way, differ from users, and what degree did high level users differ
from really significantly and chronically high users? That was the
nature of the study.

QUESTION: Do you find any differences in handling PCP users compared
to other drug users, like flashbacks or in their behavior when they
come for treatment?

DR. BIASE: We have found nothing that has emerged. I mean, there are
isolated instances of someone referred for mental health services and
it is found that there was some PCP use. But there has been no clear
indication that special attention needs to be given clinically to
those individuals who have used PCP at quite high levels. They can

16

become an active, integral part of the group that's in residence. So
the answer to your question is no, we have not found anything unique.

QUESTION: We have found some problems with that since PCP is fat
soluble. The PCP comes back in the system and sometimes the PCP
addicts, when they're in a treatment system, start behaving different-
ly. We had difficulty in training staff for handling PCP addicts in
our facility in Los Angles.

DR. BIASE; How did they behave differently?

QUESTION: They became very aggressive at times. They just sit and
keep on watching the wall for hours. They don't move.

DR. BIASE: Catatonic in some respects. Well, let me say this. We
have 500 residents in treatment and we have a variety of people and a
variety of clinical conditions that are subsumed under that. That
kind of catatonia or that kind of assaultive behavior is not so
peculiar within our domain as one might think.

'In other words, it doesn't stand out, and if you begin to look you
will find other individuals who, in fact, display that behavior, so it
would be absorbed within the clinical domain rather than being iso-
lated and highlighted as needing a peculiar kind of intervention. Of
course, if the person remains disoriented and cannot participate in
the 24-hour regimen, then they are given the supportive mental health
services that they need and they will continue as a resident.

QUESTION: I have a two part question. You mentioned earlier that the
three-month period is sort of the hump. If they are going to volun-
tarily leave the program, they leave within the first three months.
What proportion of the residents leave within the first three month
period and, secondly, can you give us some general breakdown of
referral sources, particularly with emphasis on what percentage of the
clients come from the criminal justice system?

DR. BIASE: I will refer to my records. By the third or fourth month
I would say that we would lose, if you count new admits and follow
them through, somewhere between 40 to 50 percent. That says nothing
about those individuals returning a little later on for treatment, but
if you just clock them in on the turnstyle fashion, that is the
figure.

Now with respect to referral sources, I would like to put that ques—
tion to Felix Arroyo because he has his finger on that better than I
do. I should tell you that in a study of over 1,500 new admits to
Daytop, Daytop itself found it necessary to refer out 11 or 12 per-
cent. The majority went to other programs within the city, because we

17

understood that it was not appropriate for this individual to be in
Daytop. I think Felix would be in a better position to tell you the
source of referrals.

MR. ARROYO: We work with the Probation Department, Parole Department,
and the courts. We do field work which involves going right into the
communities where drug addiction is heavy and we do induction right
there. We have a specialized team that goes out specifically for
induction. We also work with welfare agencies and any other agencies
dealing with those who have drug problems.

MR. DEVLIN: We are also finding a lot of referrals made by friends
who know about DaytOp. The Parents' Association is doing a lot of
that work. Now they are talking to their neighbors about their
children and the neighbors are referring in. In addition to that,
graduates are also out there doing the same kind of thing, giving
referrals. So in many respects, we don't have to be as active in
bringing people in because we are getting many people doing our induc-
tion work for us; namely, the parents and the graduates.

QUESTION: Just shifting a little bit, you talked about induction and
you were talking about PCP. Why are you trying to start a new program
or get a grant to serve prescription drug users?

MR. HAJAZI: One of our graduates was married to a doctor and was
abusing prescription drugs for a number of years. She has a daughter
who was abusing the same thing. She came to Daytop. She graduated
from Daytop. She has her own private practice now, and based on her
work with the Parents' Association, it became evident that the need is
there where Daytop's model can be effective in treating that kind of
population. However, we realized that it has to be structured
uniquely. The program cannot be just created overnight, and we have
been working on it for the last six months to see what kind of program
can we structure and whether the treatment modality is applicable to
it.

QUESTION: You are going after a select population. Maybe the AMA
would be more than happy as a foundation to fund that, as opposed to a
Federal grant.

MR. HAJAZI: We haven't identified the funding source yet.

MR. HALPERN: We had congressional hearings here Friday and it's
interesting, when people are interested in drugs they will tour Harlem
and they will tour whatever. Most of us don't realize that there are
millions of people in this country who are addicts and their source is
a doctor. They get ping-ponged around and, in fact, one of the con—
gressman was a pharmacist himself who attested to it. They go to

18

one place, they are given a drug. They say, "Hey, maybe I want to
stop,“ and they call up the doctor and the doctor will tell them,
“Hey, like, stop." Then they go into convulsive states. If you read
the data about emergency room admissions for prescription drugs given
by doctors, you come away with the feeling that it's a serious health
problem in this country that the medical profession by and large has '
been blind to.

Not to get into any discussion of what AMA's role is or isn't, but
there is no doubt if you look at the emergency room admissions there
is a serious danger to the health and safety of probably literally
millions of pe0ple in this country who don't perceive themselves as
addicts. They went there with the problem and they have been given
pills and we feel that, judging from the pe0ple who have gone through
this problem, there is an area of human service needs that hasn't been
touched. It's a need that really should be almost filled morally.

MR. DEVLIN: I don't think we know really what direction we are going
to go. There is another woman who we have as a consultant, Barbara
Gordon, and she is the author of a book that's entitled, "I'm Dancing
as Fast as I Can," very good, worthwhile reading. Both our graduate
and Barbara Gordon were on the Phil Donahue show talking about this
problem and the calls they received from people who have this problem
were enormous. So we will pursue it from there.

QUESTION: There is a problem similar to what you are planning which
has been initiated in Albuquerque with very good results. What we
found, however, was that they had to move it to an upper middle class
part of the city because many of the pe0ple who had the problem were
not going to go to the parts of the city where the methadone programs
were located. They saw themselves as being different and, in fact,
they were, and by moving to this part of the city they were able to
attract a large number of middle class and upper middle class clien-
tele and it's Operating with very good results.

MR. DEVLIN: No question. We agree with that one thousand percent.
That type of person does not consider himself an addict in the first
place, and they are not going to come into a place like this that's
identified for addicts. We know that. This particular program would
not be housed in any of our existing facilities. There are concerns
about confidentiality that these women or men have so it would be very
different and not necessarily residential. We don't see that as a
residential program. For a few, they may try residential care, but
the majority don't. So that is quite true.

You don't know the name of the program, do you, in Albuquerque?

19

QUESTION: No. It's run under the auspices of the CMHC which handles
all of the drug treatment programs. It's not separate. It's just
separate in terms of physical location and there is not a residential
program. It's a consultation type program.

DR. BIASE: To show you the need for information, Barbara Gordon had
been consuming about 30 mg. of Valium daily. She called for medical
advice on the telephone because she had an inner desire to change what
she was and to reduce some of the cloudiness in her mind. She was a
creative worker and film producer with a major television studio.
Unfortunately the doctor's recommendation by phone was to initiate
cessation of all of the drugs right then and there! She had a history
of between six and eight years taking 30 mg. of Valium daily.

0n the basis of what Cy Halpern mentioned and what you are talking
about in terms of mental health consultation, you can see what a need
there is in terms of just what specific infonnation needs to be
imparted in a clear and accurate way.

QUESTION: There is a greater need along this line. We received a
call from a doctor a few weeks ago who wanted to know if Valium is
addictive. He had a person who had been on the drug for about ten
years and had attempted to stop, and the patient was encountering
problems.

QUESTION: I had a question about your PCP population in the house.
It's in reference to a study that was done some years ago about the
management of PCP patients in clinical settings. One of the largest
difficulties is the unpredictability of those patients as indicated by
their either staring at walls or being violently aggressive. The
specifics of the question have to do with the liability of suicide
gestures or suicide attempts or successful suicide attempts with that
population. I was wondering if you have that particular problem with
PCP users that you are treating--if you have a general problem with
suicide gestures with the population as a whole. If so, does it seem
to be restircted to just PCP users?

DR. BIASE: There are a couple parts to that question. We don't have
any particular or higher incidence of suicidal gestures on the part of
persons who have had extensive use with PCP, number one. There are
incidents of suicidal gestures, but the frequency is less than five
percent within the overall population. That is not to say that sui-
cidal ideation is not present. But gestures in that context are at
five percent or less. I think the PCP question has to be looked at in
two ways. Number one, those individuals whom we studied here used PCP
even at high levels, say more than 200 times, for instance, along with
a host of other substances.

20

MR. DEVLIN: I want to elaborate a little bit on this. It has to be
understood that in the therapeutic community itself, it is really very
caring. A person really is not left alone that often. Part of the
problem is boredom, how to deal with boredom, and where do they go
alone. Very seldom are they alone, and if somebody is having some
problems there is one of their brothers and sisters who are going to
help them and talk to them, certainly spend time with them. If they
are in a slump or they are very low or very depressed, there is some-
body there for them to relate to. It's not a relating where they are
going to a doctor to tell them their problems. They are talking as
friends talk.

So that happens and that may help and that may be why we don't have as
many suicide gestures. Because the person is feeling that there are
people who care, who understand. They feel like they belong to some-
thing. That might play a part.

DR. BIASE: The clinical intervention for certain hallucinogenic
aberrant reactions (aside from diazepam suggested as a possible
prophylactic intervention) is frequently a talkdown in a fairly quiet
environment. It is the treatment of choice. That talkdown is almost
a natural with all the residents who are in treatment here.

QUESTION: Could you comment just informally on some of the ways that
the community does respond other than caring? I'm sure that's
probably the pervasive theme, but with a PCP client who is somewhat
unpredictable, what other ways of responding have you seen?

DR. BIASE: We have not seen such a chronic, aberrant characteristic.
If there were anything, it was transitory in nature and when we
studied these folks who supposedly were heavy duty users, they didn't
leave the program any earlier. They participated in the program to
the same degree. There was no highlighting of the clinical pictures
that are being reported.

We are not saying that that does not occur. What we are saying is,
those kinds of expressions of "catatonia" or "extreme dysphoria" are
common to a lot more people than just the PCP users. That goes on day
in and day out and really is the grist of what goes on in treatment,
so it gets subsumed under that. That's the point.

QUESTION: Basically what you're saying is that you have an aggrega-
tion of perhaps different causes for this phenomenon and there is
nothing you do to try to determine which specific cause might be
bringing about, say, the catatonia? You are seeing a symptom or sign
and you are treating that rather than trying to determine what it is
that caused it.

21

DR. BIASE: That's a very fair way of putting it. The modality con-
tinues to deal with the person as the person. It is less concerned
with the fact that the individual used the drug 200 times, may be
ignorant of the actual physiology; and begins to deal with this indi-
vidual who is not feeling well at all, who is modestly delusional, who
can make contact and then breaks contact. But we'll support that
individual along until the individual basically returns to a range of
normal behavior.

QUESTION: I have a couple of comments to make. One, Charlie, you
talked about the therapeutic community as family and you talked about
brothers and sisters. I hope that the people in the group here don't
allow that to slide because of the fact that there is an awful lot of
institutional jargon going on in terms of talking about facilities and
treatment models and aberrant behavior and that sort of stuff.

So I want to emphasize the fact that supplements the notion of the
therapeutic community, the family environment of the people here,
which I'm feeling today in spite of the fact that I have seen three
pe0ple here today whom I know.

The second thing is, I would hope the people who are looking at us
recognize that this group is a very special group, and since I have to
leave tonight and will miss what I assume will be the usual feedback
process tomorrow, I want to say to the members of the CCG that I have
found this conference to be very meaningful and I think probably the
best we have had so far, and I'm taking a lot away from it.

QUESTION: To follow up with that, I was wondering, among Daytop
graduates is there a high degree of bonding, of getting married, or
becoming roommates or just general old boy getting together?

MR. DEVLIN: We find that there is a definite closeness. Daytop sort
of becomes the surrogate family. Daytop is sort of their home away
from home. When a person graduates from Daytop they will drop in and
keep ties with us pretty well.

Also, what will seem to happen-—I don't know if it's out of choice or
out of economics-—a lot of the graduates room together because they
just can't afford the apartments in New York by themselves. So a lot
of them double up. A lot of them will share and then move out
together. There is a lot of positive reinforcement that goes there,
and they are not in a situation where they are alienated and very
alone. So it's positive.

Relationships, male—female relationships, they don't develop that

much. There are some, but not really. I tend to find that most of
the graduates who go out meet “square" partners, and they tend to do

22

that more than having relationships from within. Most of the rela—
tionships that develop between a man and woman in the program and move
on and graduate and get married fail.

MR. ARROYO: Some of the graduates are concerned with forming a
graduate alumni association. We are trying to get off the ground.

QUESTION: Just as annchair theorizing at the moment with the question
about the establishment of relationships between individuals who have
gone through the program, you develOp such a strong family concept of
brothers and sisters that perhaps for many of the individuals who go
through the program, they don't view each other as potential mates
but, rather, as just family members. The relationship is established
in that context rather than a mating context later on when they leave.
That's just armchair theorizing.

MR. DEVLIN: We have one of the residents, or sombody who can speak to
that, who can tell you what their experience was, how they view it.

DR. BIASE: The question was, because individuals see themselves some-
what or really in the spirit of brothers and sisters might that reduce
the chance of them getting together as lovers, as mates, as partners.

QUESTION: Does that reduce the chance?

RESIDENT: I grew up in Millbrook and the ratio of girls and guys was
much smaller and a lot of my friends were guys because I shared a lot
of my past experiences with them, went through a lot during treatment
with them, and I wouldn't look at them that way--maybe briefly. Yes,
I would say that closeness reduces that chance. Also, you know each
other so well that you are really not looking for any other type of
relationship.

DR. BIASE: The other part of that is that many of the experiences are
exploratory, so persons are beginning to feel good about themselves
and may find somebody attractive, and they develOp the relationship
and while in the program and under the support of the program, they
have an Opportunity to examine some of the motivations that they might
not examine elsewhere in life.

They begin to find out that they really have eyes for another person
for maybe not the most positive, motivating reasons. It may be less
than helpful to continue the relationship with that person. That
becomes public information for them both to learn about, to undergo
the discomfort. If they do, in fact, separate, they have learned
about how they themselves (a) select persons, and (b) what they expect
and want out of relationships.

23

MR. ARROYO: Also, if I may add, if they want to have a relationship,
they can, in fact, have a relationship. But we encourage all of the
residents in reentry to go out and socialize in the greater world
because most of them are afraid. They don't want to deal with the
fears, so we want them first to prove to themselves that they are able
and that they can. We put them through that process first. When they
graduate and are away from Daytop they have to be able to have rela-
tionships. They can't be afraid to interact with people.

QUESTION: If your objective is to facilitate independence, perhaps
relationships established between the brothers and sisters would be a
promotion of a dependency relationship. They would find relief or
comfort in each other because they can identify, and as a result would
not become as independent as you would prefer.

My concern is that because of the reparenting that you, in fact, do,
what is the relationship between the graduates and their natural
parents over a period of time, especially since you are applying sound
psychological and parenting techniques to train the individuals to be
able to handle themselves?

When you find a person or one of your students from a natural family
where this was not possible because the natural parent didn't know how
to properly rear a child, what does this do in this relationship
between the student now and the natural parent when the student has so
‘much more on the ball than the natural parent?

MR. DEVLIN: Well, remember we mentioned about our Parents' Associa-
tion. We have a very large number of parents who come to groups them-
selves and come for orientation and want to learn more about
themselves. We found they complement each other very well. We find
that when the parents are involved in groups, the resident stays.
There is a holding power that helps in that area. We find that they
do get together and they do learn to relate and have a more honest and
open relationship. It doesn't necessarily mean they are going to go
back home and live with mom and dad. Most go on their own. But at
least now they are able to communicate and get out some of the hos-
tility that's there. There is a lot of hostility to be dealt with
that the resident feels about the parents. They have to get that out
and then they can continue on with their relationship.

MR. ARROYO: We have some individuals who have come from broken
families and their families did _not care to get involved. Now those
individuals who have graduated from our program know, and they are
told upon graduation, this is your family. Any time you want to come
back you are quite welcome. As a matter of fact, you can visit any of
the Daytop facilities. So these things are also encouraged for those
individuals you are referring to.

24

QUESTION: Have you done any followup studies on treatment outcome,
like when they graduate and leave the program; after six months or a
year have you done any followup studies to see how they are doing?

DR. BIASE: We have done one study several years ago to follow up
those who completed the program in its entirety. It was extremely
favorable in both its direction and result. Since that time we are
providing a variety of strategies. We don't feel there is only one
way, namely, the posttreatment followup interview assessment of an
individual that is appropriate. For that reason we have been doing
the street studies I mentioned. We are now conducting this pre
post employment study with the Department of Health, Education and
Welfare and the Social Security Administration. He will be conducting
a followup study with the Miniversity students and their controls, and
we have also looked at a variety of ways to access those individuals
then.

Since the last published study several years ago, we have not com-
pleted a single followup study using individual interview, post-
treatment.

QUESTION: Do you have any approximate figure on annualized treatment
costs per client?

MR. HYJHAZI: For the residential it's $7,805 a year, and for the out-
reach day care it's $2,600.

QUESTION: We have talked somewhat about PCP, heroin, and polydrug
abuse, etc. I'm curious about what patterns have you seen over the
years in terms of increasing use of alcohol-in-combination with drugs,
and what kind of treatment approaches you have for those kinds of
clients and if they are different from the typical drug only client.
Secondly, what kind of facilities or modalities do you have for
clients with serious emotional problems as well as drug abuse?

DR. BIASE: I think the street phenomena precede individuals getting
into treatment. When we did the street study the presence of alcohol
in situations that would be unheard of eight to ten years ago was
certainly blurred. As the methadone swig bottles were passing, so was
the vodka bottle and the midnight rider. It's an insidious problem.

Definitely as the interdiction and reduction of heroin and other drugs
of abuse are successful, I see a proportionate increase in the amount
of alcohol abuse.

We are seeing alcohol used by persons where years ago they would not
have used it, just because they can't get their hands on enough
dmg&

25

We are seeing the ready combining of alcohol with opioids, barbitu-
rates, stimulants and a variety of other substances as an enhancing
chemical, so to speak, and one that's easy to get.

If you look at the troika of the drugs, alcohol stands as number three
in tenns of its frequency within the treatment center population, and
it stands as the second most prominent drug with the day care. The
average age of the day care clients is 16 and 17 year olds.

The next part of your question, the philosophy and the programmatic
intervention, has not been radically different for the alcohol abuser.
It appears that this person has elected to use this substance because
it's available, along with the others. It changes mood, it changes
state. We do not see the kinds of individuals who, in fact, have to
be dried out. Individuals who have to be dried out are referred to
hospital services and some followups will be made. If it's appropri-
ate, they will be offered an Opportunity to come to the program. But
it's usually alcohol as the secondary or tertiary drug that we see
more frequently. That's not to say that in a little while we won't be
seeing alcohol as number one, supported by barbiturates and illegal
methadone.

So a new intervention strategy has been taken. Brian Madden, who is
responsible for all mental health services, may want to speak to the
issue of any particular need for services that he has witnessed within
the mental health arena concerning alcohol abusing residents.

MR. MADDEN: There are three particular emotional problems when the
resident first comes in the induction unit. The staff in induction
evaluates the resident coming in. If staff feel that there is a
particular problem and there has been an extensive psychiatric
history, any suicide gestures, they will refer to our department for
further evaluation. Our psychiatrist will do an in-depth evaluation
whether or not that person is appropriate for treatment. Our main
concern with people caning in is that if a borderline personality were
sent upstate in the treatment center, which is a stressful environ-
ment, that stress might precipitate a psychotic episode.

But if somebody is in the outreach facility or in reentry and the
facility director feels that some one to one therapy might be bene—
ficial in conjunction with the treatment going on at the facility,
they will make a referral to us and we might see the resident on an
ongoing basis in conjunction with the treatment.

MR. ARROYO: We take the stand that the drug that person abuses is
only the symptom of the problem, and that the problem is the
individual, so we treat the individual. We don't focus too much on
the alcohol or the pills or the PCP from a treatment sense. We focus

26

on the problems and the behavior of that individual and what he or she
is demonstrating.

QUESTION: The square world of people in their 205 and 305, in San
Francisco, at least, and I imagine certainly here, would involve
minimal use of most drugs but a very great use of marijuana and also
wine and beer. I wonder how your graduates adjust to this out of the
use of zero drugs of any sort within the program. In other words,
they go out and they interact with perhaps square people, marry them,
who use vast quantities of marijuana.

MR. DEVLIN: I think they adjust very well. They can socialize with
people and I guess not get very hung up if they go to a party and
people are smoking marijuana. They stay and they just don't indulge.

When it comes to alcohol, our graduates are told that if they want to
make a decision to drink, it's their decision to make. Most of them
do make the decision to drink alcohol. We encourage them to wait
awhile until they get their apartment, until they get a social life
going and pass those hurdles before they indulge. Most elect to drink
and most abuse alcohol and then they come to us and say, “Listen, I'm
not drinking too good; I'm having a problem with this." At least they
are able to come back and talk to us about the fact that they're
having the problem. Then many decide not to or they will "dig" them-
selves, as we say.

But we are concerned about alcohol abuse among our young graduates. I
guess we are more concerned about alcohol abuse and use more than
marijuana use and abuse because they have have been pretty well con-
ditioned that marijuana is bad and it's against the law. It concerns
me a bit that they will go to drink instead.

At this point we will conclude our morning session. After lunch we
will convene for the panel discussion.

27

AFTERNOON SESSION

The Role of Drug Abuse Treatment
over Time -- Response to Changing
Trends and Changing Characteristics

moderator

DR. PIERRE RENAULT

panelists

MSGR. WILLIAM O’BRIEN
MS. ANITA KURMAN-GULKIN
DR. GEORGE DeLEON

DR. BENY PRIMM

DR. HAROLD TRIGG

28

DR. RENAULT: Let me start by introducing myself. I am Pierre Renault
and I'm sitting in for Dr. Pollin who couldn't be here. I'm a psychi-
atrist and work in the Division of Research at the National Institute
on Drug Abuse. My primary area of interest has been treatment
research of a fairly specific kind. It's more medical, and it
involves a more experimental approach to treatment research. NIDA has
a large commitment to treatment research and it ranges everywhere from
looking at innovative treatments and trying to provide some kind of
very early evidence of whether or not innovations are worth pursuing
from a public health standpoint as a response to particular problems
in the drug abuse community.

We also have a drug development program and we have a large commitment
to field studies, looking at the effectiveness of the treatment pro-
grams that we support. The Institute is organized really in such a
manner that all of those are different parts of the Institute and I
probably represent a more limited or a more specialized area in the
medical aspects of it.

As far as this panel and what we are undertaking this afternoon, I
think one of the principal interests I have, and I think I reflect a
good deal of the interest at NIDA, is in what's happened to treatment
over the last five to ten years, whatever frame of reference we have,
how has it changed, what's happening to the clients, our p0pulation,
have they changed in any way? And what kind of perspective can we get
on the future?

When NIDA set up a treatment program there were treatment programs
that arose without Federal support, all to meet a need that existed at

29

a point in time, and I think at least one major goal that I would have
is to try to understand to what extent that need has changed over
time.

As far as the format, we have kind of discussed this among ourselves,
and it seems to be agreeable to the panelists just to start off and
have each panelist describe very briefly their area of interest and
then for me actually to go through a few questions and ask for
responses from the panel on these issues. When we have gotten through
a certain amount of that we will open it up to more general discussion
from the audience around the issues that have been raised by the
panelists.

DR. DeLEON: My name is George DeLeon. I'm wearing two hats today.
One is as Director of Research for Phoenix House, a large traditional
therapeutic community born in the mid—60$, somewhat similar to the
Daytop Village.

Phoenix House has been engaged in a continual systematic or program-
matic research effort since 1970, focusing on two or three of the cen-
tral treatment issues from a research perspective: treatment outcome,
short-term outcome and long-tenn outcome. In this regard we have
recently completed a fairly major series of followup studies which was
NIDA funded and about which a complete report is now circulating in
both large and small forms for those of you who are interested.

The second activity we are engaged in is the treatment process, and I
guess we feel now is a program based effort. There is a unique per-
spective or vantage point in studying treatment process from within
the treatment setting.

The second hat that I'm wearing is as principal investigator for a
very important and innovative research effort which is being sponsored
by Therapeutic Communities of America, the National Association for
Therapeutic Communities, and NIDA. It is a several year effort, and
it's focusing on a central matter about research and treatment and
treatment develOpment, which is helping programs establish a self-
evaluation capability. It is moving a lot of the burden of examina-
tion, objectivity, accountability to the treatment base level and
program base level. We think in therapeutic communities that person-
nel can be trained to be sophisticated and self—critical and objective
if they have some simple skills. They can gather important data about
client change and composition in treatment and report on that data on
an ongoing basis if pr0perly supported.

So this particular two-year NIDA funded project is very innovative as
a demonstration project to show that programs can learn a self-
evaluation approach and put out regular reports which contain useful
data in an ongoing basis. We are in the second year of that project.

30

A lot of the data that have been gathered over the years at Phoenix
House and some of the data at the National Therapeutic Communities of
of America may be relevant to some of the discussions today. If we
have an Opportunity I would like to report on that.

MS. KURMAN-GULKIN: I am Anita Kurman-Gulkin. I am Executive Director
of Greenwich House. Greenwich House is a 77-year old settlement house
in Greenwich Village and the first settlement house in the United
States to Open its doors to drug abusers. -

We started working with drug abusers as a result of the fright in the
Village during the Kerouac era when everybody thought everybody looked
like they were stoned. We received a three—year NIMH grant for a
demonstration project. At the end of the three years, what we knew
then is probably what we know now. We didn't have to spend all that
money, and that some people were smoking pot during that period and
some people had access to a variety of drugs. But it's not the big
deal it appeared to be.

Over the course of the past 20 years we have developed what I consider
to be the leading outpatient psychiatric clinic for drug abusers and
their families. We involved everyone, if at all possible, who is now
living with the drug abuser. We work with an older population. We
also work with peOple nobody else is interested in working with,
pe0ple who were clearly psychotic, people who were self-medicated
because they couldn't handle a number of different situations, people
who were kicked out of therapeutic communities, people who were the
fallen position patients who were kicked out of hospital situations.
We did this over a period of years and in 1972, because we consider
ourselves a very purist kind of clinic, gave absolutely no medication
whatsoever.

We realize there was a certain percentage of the population that could
not be helped with our treatment process and we then opened a
methadone maintenance clinic. We now have two methadone maintenance
clinics in the city, but we have continued doing the counseling por—
tion. Methadone patients are also the recipients of the same kinds of
treatment we do in the counseling center. We work with abusers of not
only drugs but of battered children. We have started a new center,
one of the clinics for battered wives and battered children. This is
the latest thing for us and we are finding that alcohol and drugs are
very, very much a part of that whole scene, much more than we had
suspected in the first place.

We have approximately 1,000 patients who come through the program in a
given year and we have a very professional staff. That was the other
thing. We were sort of damned and praised for exactly the same kind
of approach. We were not asking people to come to the clinic

31

after they had kicked their habits. We were accepting people who were
still using drugs. The philosophy, as I understand it when the clinic
first started, was that if a stutterer called up a speech clinic, you
said to them, "Look, once you have taken care of your stuttering, then
you could come and see us.“ We really feel that was a kind of inap-
propriate response to people having difficulty in other treatment
areas.

I would particularly like to respond later on this afternoon to the
community responsibilities since we are now in a very ugly situation
in trying to relocate the clinic in the community. We had thought
things were tough 20 years ago. They are just a bit more sophisti-
cated in confronting the idea of having drug addicts, methadone
patients and abusers on any given block.

MSGR. O'BRIEN: You have heard all about Daytop this morning, so I
think I will speak about Iran or something like that.

I was originally associated with a program that you might never have
heard of, maybe should not have heard of, called Synanon. We started
in the 19505. There was a huge drug problem in New York and we looked
everywhere. We went to the professional sector, the governmental
sector and no one knew what to do. It was by accident that we dis-
covered a Synanon Hospice, an induction house in Westport,
Connecticut, towards the end of 1958. I drove up there just on a
hunch and going up the steps that night I met a psychiatrist from New
York by the name of Castrio. It was mind blowing, really, to stay
there all night, in fact, to say Mass the next morning without any
sleep. It was so fascinating. It was mind blowing to discover for
the first time that drug abuse was essentially not a drug abuse prob—
lem, and Castrio and I were associated with Synanon for the next five
years. We were pumping New York addicts to the West Coast. Nestport
eventually closed that house. It was an affront to that fine com-
munity. I don't know whether in 1979 it's still true, but I know in
1976 it was true that the highest per capita incidence of drug abuse
in the whole state of Connecticut is in Nestport, if that doesn't tell
you something.

Synanon was extremely successful, and we had organized a group, the
supporters of Castrio. Castrio was writing the first book on Synanon.
In 1963, the fifth year of that first therepeutic community, as most
of you know, was the crisis year when Chuck Diederich woke up one
morning and decided that the vision that he had during the night
demanded that he radically change Synanon, and we did not accept the
radical changes. They were really fivefold:

The first was that Phase III reentry was to be knocked out; that soci-
ety (Chuck's words) was irreversibly corrupt and, therefore, no one

32

was to return to it and Synanon was the pristine antiseptic community.
We took strong exception to that and we knew that Chuck's agenda was
really an economic agenda, that he needed those people to work on the
industries.

The second objection we had was they were imposing a $1,000 entry fee,
at the same time refusing to take money from the Government. They
would take money from the Government, but they would just take a blank
check with no reports back. As you know, that's not a responsible
posture.

The $1,000 entrance fee required most of the dope fiends we knew to go
out and rob another bank or rip someone off, or the family, if they
were still relating to the family, to mortgage the house. We felt
that that was a huge obstacle.

The third item was that the basic hostility that went back a number
of years between the addict, the ex—addict, and the professional was
elevated to a grotesque degree in Synanon's posture towards the pro-
fessional community. We felt that in order for us to, over the long
pull, lick the problem we should have a marriage between what we would
call the paraprofessional, which would be the lay approach (which was
in Synanon at that particular time), and the professional.

The fourth item was that there was no question that Synanon had
pioneered a breakthrough and that they should open their doors to
research.

We met with the old man and with the late Reed Kimball in Dr.
Castrio's apartment in September of 1963 and made our case. Their
response was to play a tape in which they had residents attempting to
blackmail Dr. Castrio and David Dietz, who was the director of the
Westport House, who was with us, the three of us. They didn't respond
to any of the issues. I stayed at the meeting for only about 15
minutes and left. I couldn't believe it. But I think that was the
beginning of the cancer that has emerged subsequently. We left and
the following day we met with the Mayor of the City of New York. We
told him about the drug-free, self-help approach. He showed us 34
years of reports that he had received from his health experts and his
predecessors had received, and said they weren't worth the paper they
were written on. If we could incorporate, he would get us funding
immediately.

We went around the corner to Chock Full O'Nuts and designed a thera-
peutic community. We took the acronym DAYTOP, which meant Drug
Addicts Treated 0n Probation, at that particular time and which we
subsequently changed to Drug Addicts Yield to Persuasion, and we
incorporated Daytop. We committed ourselves to the resolution of five

33

issues: (1) accepting reentry at the earliest possible time to their
families, to their loved ones, to the community; (2) realizing that
the professional sector has a tremendous contribution to make to our
treatment process, at the same time that we have a contribution to
make to that whole revolution in psychiatry; (3) the importance of
objective research, extramural research and professional intramural
research; (4) and I think one of the most important factors is a
healthy partnership between the private and public sectors; and (5) we
felt that the treatment program should be tailored to the needs of the
clients and that those harsh, repressive measures which we objected to
in Synanon were totally unnecessary and would be purely vindictive.
So we have tailored our particular process to the client in need.

Currently, our emphasis is on the client. I think in New York City we
have a very exciting revolution. We discovered some years ago, much
to our dismay, that we are not the answer to everybody's drug problem.
There are probably six to eight characterological patterns out there
in terms of drug abuse, and there have to be fielded six to eight
responses. So we developed through the people at the table, Harold,
Beny, Anita and George, Phoenix House, and other therapeutic com-
munities and the treatment sector in New York banded together to field
a complementary, cohesive force so we can refer one to another, and
that's where we are at present.

DR. TRIGG: My name is Harold Trigg. I'm clinical chief of the
methadone maintenance treatment program at Beth Israel Medical Center
here in New York.

Just a little bit of backgroud, description of services. In 1961 Beth
Israel Opened up an inpatient drug detoxification service. At present
that service still exists. It has 154 male beds, 35 female beds; a
medical unit serving the addict population, 38 beds; an alcoholic
treatment ward, inpatient service, 50 beds; an alcoholism outpatient
program, and 24 methadone maintenance clinics containing about 6,800
patients.

Those clinics are located in four boroughs of New York City. We have
nothing in the Bronx. There is something there, but it's not under
the auspices of Beth Israel Medical Center.

I'm very happy and proud to say that Beth Israel Medical Center opened
the first methadone maintenance treatment program on a service basis
in February 1965 and, since this is an informal gathering, people are
usually asking me, why Beth Israel. The answer is very simple. One-
half of the team which did the original research on Methadone Main-
tenance, Dole & Nyswander (Dr. Nyswander and I were residents in
psychiatry at Bellevue), and I shouldn't say this, I was there in
1948. We lived across the hall from each other on the ninth floor

34

Bellevue Psycho Hard, and during the initial phases of the research on
methadone maintenance at Rockefeller in 1964, and since Dr. Nyswander
and I had known each other for so many years and she knew that I was
chief of the Inpatient Detoxification Service, we supplied Dole &
Nyswander with countless urine samples from patients who were being
detoxified and samples of blood.

As you probably know, a couple of years after methadone maintenance
started, Dr. Dole and Dr. Nyswander got married, and I suppose that is
the original effect, side effect of methadone maintenance. It has
been a very happy one. I'm delighted to be here today.

DR. PRIMM: I would like to apologize to the group for being a little
late. Being a New Yorker you are supposed to be well-infonned. I did
not know until today that from 59th Street to 47th Street, uptown to
downtown and from Lexington East to something Nest, you can't make a
right turn, so I just kept going, going. Finally I wound my way back
and began to look for garage spaces that were open. None were open in
this immediate neighborhood so I had to park up on 44th Street and
walk back.

Again, too, I would like to take this opportunity to thank you for
inviting me here to present my statements to you. I don't know what
the format has been. I didn't get here early enough to hear you
explain it, Pierre. I know it's supposed to be informal and, indeed,
I had gotten a whole lot of things in my head I was going to say but
after hearing some of my colleagues speak to you, it's mostly a
history of their program. I imagine we will get into other things
later.

I'm a physician, an anesthesiologist by Specialty. I began working in
substance abuse at Harlem Hospital Center in 1966 and 1967. At that
time I was prompted or attracted to this field because I was always
assigned to what was the most difficult and traumatic shift at Harlem
Hospital, where we did most of the traumatic surgery, the 4 to 12
shift. I also always worked the weekends and as a consequence I began
to see a number of emergency surgical cases that came in the hospital
that were directly related to the problem of narcotics addiction. One
particular night there was a young fellow who came into the hospital
who had a stab wound near the heart and he had just about exsangui-
nated. He almost bled completely out. You can imagine the state he
might have been in.

We rushed him to the operating room and, of course, I got his old
chart because he had a previous admission to the institution. As I
was doing anesthesia, I perused his old chart and a year almost to the
day, he had had a gunshot wound in the chest that had been repaired
in the same operating room and here he was, back again.

35

I said to myself, you know, doctors are awfully stupid. What we do is
have our coronaries constrict like the devil, force ourselves into
situations where we have to save people, etcetera, etcetera, but never
do anything about the etiology of why they might be here.

I began to do research at Harlem Hospital and I found out that 75 per-
cent of all the traumatic surgery done in that institution was either
directly or indirectly related to the problem of narcotics addiction
in New York. That's amazing. When I presented that to the Medical
Board, they were shocked because they had never realized the same
thing. In other words, people who were either robbing or stealing
would get shot by the caps or get stabbed or cut or shot by each other
while making deals for narcotics. People who were shop merchants
would be shot in a robbery. That's the kind of problem it was, and I
went home that night and I couldn't rest. 50 I sat down and wrote a
paper about how to get involved with the problem of narcotics addic—
tion when we have a patient admitted to the institution with a diag-
nosis of, say, a gunshot wound or stab wound, and to do something in
relation to his secondary diagnosis while he was vulnerable or
amenable to some intervention in his lifestyle that led to his prob-
lem. The paper was read by Mel Yarr, who was then the Dean at
Columbia. He immediately pulled me off anesthesia and said, "Beny,
you have got to do that in this hospital," and from that day on I have
been working in narcotics addiction.

Now, as a result of some of the work I had done earlier at Harlem (and
I became kind of well-known as a fighter in New York City for addicts
for doing something about their care) I run a large addiction rehabil-
itation center. We treat approximately 1,500 patients. We have 300
employees in six centers in Harlem and Bedford-Stuyvesant and East New
York. We also have a skills training center in East New York that is
a support service where we vocationally train people who don't have
any skills or who have lost those they did have. We also remediate
peOple from the community other than the addict population I treat.

Years ago I wanted a supermarket of services where a person who found
himself addicted to a substance would walk into the addiction research
and treatment corporation and just like it was a big A&P supermarket,
take off the shelf whatever that person might need to rehabilitate
himself. It was very Utopian. Initially, funding was provided for
legal services, educational services, a therapeutic community for
those people who found it difficult even on methadone maintenance to
be ambulatory and needed a place to be.

I had the second therapeutic community for methadone-maintained

patients in the city. There was one other out in Chicago that was run
by Dr. Jaffee.

36

Some of those services have been cut now because of funding cuts and I
don't have them any more. I think in the present climate of things,
with the socioeconomics as they are, with the racism as it is, with
New York being what it is, what should I say to be kind to both?
Msgr. O'Brien said when I came in, "Beny, you have blessed our house
with your presence,“ and we exchanged kisses and I don't know what to
say about our fair city at the moment, especially driving through it,
coming through Harlem and seeing what I saw today, and seeing the
drastic change between Harlem and what's downtown, et cetera, et
cetera.

I think we do quite well to get people to stop participating in crime
and to be functional, at least here in New York City, without crying
or screaming and doing a lot of hurrahs about a great deal of suc-
cess.

As we talk informally for the rest of the afternoon, I can fill you in
on some of the thinking that I have in terms of what's happening in
substance abuse, trends of drug taking, responses to treatment, hope-
lessness, disenfranchisement, and all the kinds of things that affect
what we are about in this field, and I just await that time when I can
speak again.

DR. RENAULT: Before you came in I tried to give a little structure to
what we were supposed to do, and I think it's really an excellent
beginning so we have an idea of where to go. What we agreed upon was
that I would try to ask a few questions and try to be specific, not as
broad as that letter of invitation you received.

As it gives me a sense of power here, I can ask a lot of things. It's
very difficult to choose. Where I would like to start, I think, is
with the clients. Of all the things that filter down to Washington,
the thing that has struck me the most is a persistent refrain that the
drug abusing client who comes for treatment has changed radically over
the last few years. Now what I have heard out of that might reflect
my professional orientation. But I have heard that the degree of
psychopathology has increased a lot and that it has caused some change
in program orientation and in the kinds of services, the kinds of
needs that the clients are bringing to treatment. I have no firsthand
knowledge on that particular phenomenon. I would really like to hear
from the panel on what their perceptions are of any changes, any per-
ceptual change in the treatment client.

DR. TRIGG: As far as I'm concerned, the only change in the client
population that I can see is the tremendous number of polydrug
abusers. I don't think that there is any more psychopathology. When
I look at the six original methadone patients, for example, one of
them was a paranoid schizophrenic who had delusions, ultimately
threatened to kill Dr. Dole. I don't think things can get much worse
than that, aside from an actual killing.

37

I certainly do remember when methadone patients were started on an
inpatient basis, a six-week inpatient basis. It was very easy to see
a great deal of psychopathology. I remember probably one of the first
20 patients developing a delusion centering around the head nurse, who
was about three times his age, and in correSpondence with her he
carried on a torrid love affair and became exceedingly jealous when
she even administered medication to other patients.

I do think in the early days, when Dr. Nyswander and I both screened
patients, all patients had two interviews. In 1965, those patients
who appeared for an interview in a suit and tie with a crewcut--in
case you have forgotten those days, long hair wasn't in yet--those
patients were almost guaranteed admission just because of the way they
looked. And some of them turned out to be really terrible patients
and were discharged, and some poor slob who showed up in a leather
jacket without a shirt or tie (and if he made the mistake of having
two tattoos on each ann), he was automatically rejected as being a
psychopath.

Now that doesn't happen any more. That's ridiculous. Dr. Nyswander
and I learned a great deal when we saw that some of our Harvard Ivy
League appearing patients had a great deal of psychopathology.

I don't think people have gotten any crazier. I also don't think they
have gotten any saner.

MS. KURMAN-GULKIN: I find it very interesting that that is what is
filtering back to Washington. I think that is what happened. I abso-
lutely agree with Harold. I think the patients haven't changed. I
think the treatment people have changed. We have a great need to
justify some of the things that we do and I think we start looking for
things. Because we were a psychiatric clinic we always found
pathology that nobody else seemed to find, and it has been consistent.
The thing that has changed for us over the course of the 20 years is
the polydrug abuse because we started treating only heroin addicts and
then became very realistic about the fact that, certainly, in the
19705 there was no such person as a pure heroin addict. But the issue
for us was that people seemed to be getting into drugs younger and
younger, and that's where the pathology seemed to be much more preva-
lent.

DR. PRIMM: I would like to take a crack at that, too, certainly
caboosing on what Anita says in saying the psychopathology has always
been there.

The treatment people have changed, and we are fortunate enough now
to have some good mental health specialists, psychologists and psychi-
atrists in our program who are picking out some of this pathology and
making more mention of it than previously.

38

My client population is about 87 percent black, maybe 7 percent
hispanic, and the other 6 percent would be caucasian or oriental
mixed, very few orientals, maybe one or two. The incidence of suicide
among blacks, not only in the nation but primarily in the urban areas,
has risen precipitously. I don't know whether you might not be aware
of that. It's because of a great deal of psychopathology and stress
within the black and hispanic communities, whereas before, blacks
hardly ever killed themselves. There is a lot of mania. There is a
great deal of schizophrenia. As a matter of fact, heroin itself,
methadone, and other substances of abuse are being used primarily to
self-medicate, to treat their own pathology, to treat the
schizophrenia, the depression, etc. I don't think there is any better
drug than heroin to treat some of the schizophrenic kinds of processes
that go on.

The biggest killer in New York City, including those of us sitting at
this table, is cirrhosis of the liver secondary to alcoholism, and in
most major or urban areas in the United States the third biggest
killer is, indeed, that.

We self-administer alcohol and I think the rise in alcoholism,
especially in the large cities, is because of all the stress that is
associated with living in a large city. People self-medicate them-
selves by using alcohol in great amounts and end up becoming alco-
holics and, of course, damage their livers. Eventually it's a
contributory factor in their deaths. That in itself would indicate
that the psychopathology we are seeing now was omnipresent, surfacing
more now because of the high technocracy that we see in the cities,
the inability of migrants (meaning southern blacks, Puerto Ricans,
Europeans and all others, in a gross melting pot) to cope with this
kind of society. Unquestionably it creates psychopathology.

DR. DeLEON: It's a very critical question that hasn't really been
researched enough. We have, I think, some very sound clinical
opinions as we have been hearing at the table. We do have some very
systematic data now that tells us something about the changing psycho-
pathological profile over time. Remarkably, there is no greater inci-
dence in frank psychosis in the therapeutic community in Phoenix House
than there was in 1970.

When you compare it to 1974 admissions, psychological profiles which
we.get routinely show relative invariance of measured psychopathology.
It doesn't mean that there aren't still important indicators of
psychopathology or its change, but on an objective basis you don't get
striking statistical differences. In fact, it's paradoxical. The
1974 pathology scores on admission tend to be statistically lower,
that is, less deviant, than the 1970 pathology scores on admission.
We think we understand that, though, and I will address it if there is
a question.

39

In 1970 and 1971 at Phoenix House and most therapeutic communities, 83
to 90 percent of the population in treatment were heroin addicts and
the rest were something else, but you shouldn't ignore the myths.
Heroin addicts in 1970-1971 were polydrug abusers. The only differ-
ence was that their chief and primary abuse of drugs was heroin. The
change from 1970 to 1973 in heroin addicts, its so-called decreases, I
don't think is well understood. But one factor for the therapeutic
community was that heroin addicts, a large proportion of them, moved
away to other modalities as those options opened up. Thus, in Phoenix
House and other therapeutic conmunities, we get a very wide range of
drug abusers now. In 1973 at Phoenix House, for example, 53 percent
of our clients were primary opiate abusers versus all others. That
percentage, I think, has increased further in our most recent census
to around 40.

When you get off the primary heroin addict, you then run into a wide
range of psychological and social problems that to me and people in
our business seem to reflect the social, psychological climate of the
times. The population is a younger, a little bit more anomic, a
little bit more without a value system, a little bit more existen-
tially disturbed. One doesn't necessarily see in our psychological
data a frank classical pathological upset. One does see something
else, which is much more drifting, much more low-energy individual,
much less motivated, much more absent of a value system--this is
therapeutic community clients, now——and much less highly directed
toward a change in lifestyle.

50 our understanding of the relative constancy of the pathological
picture is that the heroin addict who was in treatment in 1970 was
disturbed. Incidentally, all those scores were disturbed. The fact
that we didn't show a great cohort difference didn't mean they weren't
disturbed. They were all disturbed. It just didn't change very much
from 1970 to 1974. But the heroin addict who came in 1970 who had a
disturbed profile also showed it was a disturbance which was classi-
cally associated with an antisocial type of profile: high schizo-
phrenic peaks and antisocial characteristics, lots of anger, lots of
blocked hostility. The treatment planning and approach was based on
that kind of energy level and you could get a conversion in the thera-
peutic community based on that.

In 1974 you get the same antisocial peaks because they are engaged in
antisocial activity. You get the same schizophrenic signs because
they are confused and fragmented, but the reasons are different. They
don't seem to be as hostile, energetic. You are not dealing with a
client who has high boxed-in energy that needs to be relieved through
either a conversion approach in the therapeutic community and reso-
cialization or some other psychotherapeutic lifting of that problem.
You have a much more difficult picture even though the profile is not

40

dramatically different. Therapeutically, you have a much different
mandate, which is not only to rehabilitate many of these individuals,
which implies a previous lifestyle rejected, but to habilitate a large
proportion of them, which implies no firm lifestyle implanted.

The Therapeutic Communities of America research has now generated a
psychological profile of over 700 clients who have been admitted into
treatment in the past year across seven therapeutic communities. I
think the analysis of that data will be carried out over the next
months. We are very, very interested in looking at the regional dif-
ferences in which they are putting communities. We want to see
whether really these profiles differ by program and by region and per-
haps over time.

MSGR. O'BRIEN: From the therapeutic community corner I see more
change. I would say since we started in 1963, or largely in the last
ten years. There is a reliance in the early phase of treatment on
pressure from without, "I'm always going to do something about myself
tomorrow.“ The intervention of an arrest, family pressure, pressure
from the wife--to do it today and to pull with the treatment decision-
-is vital to the therapeutic community, especially during the first 90
days.

There has been a dramatic change in the environment out there. George
referred to the changes on people having other Options, so that we
were picking up people who originally belonged with us later. At the
same time from the other end, we were discovering that people who did
not belong with us--the other, older addict that we should have refer-
red to Beny or Harold earlier--that we had waited too long to do
that.

The second thing is that the whole picture changed in 1972 in New
York, in particular, when for political reasons there was manipulation
of the scene out there to create the impression that we had turned the
corner on drug abuse in New York. Can you believe it? The Mayor was
running for the White House and under the guise of qualitative
arrests, the hassling on the streets really stopped for drug abusers.
That meant a lot especially when we were dealing with the hard-core
addicts.

We just had a meeting and Cardinal Cooke has set up a new commission
under the retiring chainnan of IBM on youth, drugs and alcohol. The
head of the narcotics squad in the New York Police Department testi-
fied that over the ten—year period from 1969 there were 283,000
arrests for narcotics related crimes in New York City. When I pressed
him, we discovered that 210,000 of that figure were before 1972.

41

So there has been pretty much a release of pressure on the streets
relative to enforcement which, in our particular area of the shop,
affects an earlier decision made by clients in pursuing treatment.

We see from the Daytop corner a vast shift towards polydrug abuse in
young peOple. I think they might have covered it this morning. Our
emphasis is on keeping the youngster in the family if the damage is
not irreversible. We want to bring the family in the evening for
groups to rebuild that unit. We work from ambulatory to residential.

We see a marked shift towards polydrug abuse, a socioeconomic shift
upwards and to younger people, and I'm contrasting it with 1963 and
the early 19605 when we started in this ball game. I think the shift
has been effected by the change in the environment that's out there,
and a lot of other factors which have nothing to do with treatment
whatsoever.

DR. RENAULT: I guess I'm surprised in a way to respond to this
because it sounds like you all agree that there really is no quantita-
tive difference in psychopathology. There might be a qualitative dif-
ference in some redistribution of patients which sounds’ like an
appropriate redistribution, given increased options and the response
of the treament community to the psychopathology that has existed all
along.

I guess the next question then, since the Washington myth exploded
there, is what about treatment? That implies to me that we have done
pretty well. We have responded to the need. Perhaps we have not
responded quantitatively, we could do more. But we have responded
appropriately to the kind of clients who have come in, and that the
future of treatment, I guess, would be pretty much as it is, would be
to continue as we have been doing it.

DR. TRIGG: I'm not sure I'd go that far. The New York City Methadone
Maintenance Treatment Program operated by the Health Department is the
largest in the world and does not employ a single psychiatrist. My
boss started that program.

I think that psychiatry has become too deemphasized in the program.
There was a time where we had a nice mix. Now we can't have it any
more, primarily because of inadequate funding. For example, you can
hire physician—assistants to help out the doctor, but the doctor who
supervises him has to be an internist. Well, you can't afford an
internist and a psychiatrist. So it's one or the other, and I don't
think there are enough mental health professionals in the field,
frankly. I don't think the treatment is as good as it was ten years
ago.

42

MS. KURMAN-GULKIN: You don't think 50?
DR. TRIGG: No.

DR. PRIMM: I think it's much poorer. We have turned in order to
satiate that need at ARTC to what we have chosen to call the mental
health specialist. A person who might be a psychologist or a person
who has a Master's in social work with an emphasis on psychology is
generally chosen for that position. It is also very, very difficult
to attract a psychiatrist now to work in drug treatment programs.
They are beginning to come back. On the front line level it's dif-
ficult. On a higher level, where pe0ple are doing research, etc., you
get a lot of psychiatrists doing psychopharmacology. etc., in this
field. But at the actual treatment level where we are, it's very dif-
ficult to attract them.

Not only that, when you refer the patients who have a gross psycho-
pathology, psychiatrists are reluctant to take them, reluctant to
treat them, and they are terribly prejudicial to this kind of a
patient. Frankly, I find that repulsive. I have found some psychia-
trists who would accept and might treat an isolated case or two. We
end up placating people with psychotropic drugs--maybe some Mellaril
occasionally or some Elavil for depression. That combined with
methadone and all the other substances of abuse might be accomplishing
just what the patient wants to accomplish, a state of pharmacological
euphoria, a cocktail that they wean out of you.

So it's a big problem, Pierre. It's a big problem on the front
lines.

MS. KURMAN-GULKIN: I think also it makes a statement about the salary
expectations of treatment people. We have always insisted on having
psychiatrists in each of our clinics. We really feel if something
else had to be cut, so be it. But we feel that's an imperative. I
feel comfortable that the standard of treatment at Greenwich House has
been very consistent, that we have gone the other way in that for ten
years we never had paraprofessionals, and we learned a great deal.

I think people have priced themselves out of the market. We are
totally dependent upon Government funds. As a result, we run the risk
of dancing to their music and we run the risk of also designing lines
to cover treatment expectations. However, you can diminish the
integrity of treatment and the whole treatment pattern by backing into
your budget, and we really feel that no one should have to give that

up.

I absolutely agree with Harold. I think that the treatment has dimin-
ished. The service areas are there, but the deeper treatment levels
have really been diminished.

43

DR. PRIMM: I agree with Anita and certainly I agree with Harold. Not
only has the treatment diminished in tenns of actual treatment given,
but there is an emphasis on documentation; on what the regulations
require you to do more than an emphasis on actually doing it. People
are hell-bent for compliance so that the programs won't be put on pro-
bation or dissolved because they did not comply with regulations.

The quality of health care itself is much better because the followup
by state monitors and FDA monitors within programs makes sure that you
do a physical examination yearly, that you do followup care if you
find an abnormal hematological finding, or that kind of thing.

It's lacking in the mental health area, but in the pure health part of
it, quality remains about the same.

DR. RENAULT: I would like to contrast that with therapeutic communi—
ties because it has been my impression, at least, that therapeutic
communities have not been that involved in delivering psychiatric ser-
vices. I know the therapeutic community involves a program that deals
with psychopathology to some extent.

MSGR. O'BRIEN: We have central services and the role of central
service psychologists, psychiatrists, and social workers is to deal
with the problems as they arise and are referred by the the director
of the center and, secondly, to train the paraprofessional staff. In
many areas we refer to a more suitable setting for a serious incidence
of psychopathology.

The therapeutic communities generally have central service to provide
this type of service.

Treatment centers start from a position totally different from where
Beny or Harold are coming, though we complement what they are doing in
terms of the service that we attempt to provide through central pro-
fessional service. But our rationale is a different starting point.
So we are talking about apples and oranges here.

DR. DeLEON: I would like to pick up on that. I quite agree that in
order to understand or approach the question of treatment, more
specifically, let's say the Federal response to treatment needs, has
it been adequate? I don't know if you can answer that question
without some good, careful modality distinctions of the kind that have
been raised here. I would like to just restress something about that
question here. One is that traditional therapeutic communities, for
good or bad, proceed from a social, psychological model of the drug
abuser and the causes of drug abuse, whether you agree with it or
not.

44

The long standing enduring programs like Daytop, Phoenix, and Gateway
and other places around the country operate pretty much the same,
remarkably in the same approach, with striking invariance in staff
attitude and preparation. There are changes, and I will talk about
them in a moment, but from the philosophical, psychological, techno-
logical points of view, therapeutic communities have been quite con-
sistent, at least the long-standing ones, in the approach to the
client, even though the client has changed and the range of the prob-
lems has changed and the particular needs of the client have varied
along some one vector or another.

So I would say, in answer to Pierre's question, from where we sit the
Federal response to meeting the range of client differences has been
adequate. I think since the introduction of a variety of options from
outpatient and detox and long-and short-term therapeutic communities,
residential centers and various shades of methadone maintenance, from
our view the Federal response has in its way recognized the diversity
of the clients over time.

The problem has not been in whether we should increase a quantitative
diversification of treatment. I don't think we need that any longer.
I think the problem is something else. It's really now focusing upon
the diversity of the client in treatment. Recommendations for treat-
ment planning would be more in the direction of recognition of
individual differences, and that what is associated in terms of policy
around it. What's associated? More staff training, more recognition
that there are modalities which proceed from a social, psychological
model. There should be greater familiarity with the model so that
when that model requests, for example, certain assistance or help or
demonstrational efforts to improve the quality of treatment, funding
of such a model is done much more sensibly and rationally because the
model is understood.

The same thing happens in the methdone maintenance approach. A well-
managed umbrella of methadone maintenance clinics as we have had here
in New York has been undercut because the basic understanding of that
approach, we feel, has probably not been grasped fully by funders and
outside observers.

If I were going to speak specifically now towards this question from
the therapeutic community, I would say that the direction should not
be in greater diversity of treatment options but greater improvements
in the options within treatment settings and within modalities.
After-care has to be better, whatever that is going to take, whether
it's in the form of reentry models and demonstrational programs for
reentering the client. They should be examined and funded.

Staff training and upgrading approaches which relate not to simply
trying to teach staff general principles of human behavior (which is

45

useful), but staff grading and upgrading which, in fact, upgrades the
particular approach that they are using. There are second and third
generation staff in therapeutic communities who actually lost their
roots and principles before they do what they do, even though they do
it well. That's a whole group of workers who need a good, sound con-
ceptual upgrading.

I think that some nits in Washington about some cost benefits get in
the way of treatment quality. For example, to talk about long-term
residents as being expensive and then running us through all modali-
ties, through some hoop of comparative treatment effectiveness, cost
benefit studies just wastes our energy. When in reality we know if
you have a diversity of clients, some need long—term residence, and
some do better in shorter-term residence. If anything, it helps to
enlighten us on how to clarify those client differences and to improve
our program to respond to that.

I have looked at the literature cross-culturally and nationally, and
therepeutic community literature, which is my bias. In therapeutic
communities it is remarkable to me as a scientist that success rates
are remarkably the same, particularly when analyzed by time and pro-
gram. This is a residential treatment. The difference is not more
than ten percentage points, not only in program by program like
Phoenix House, which has done studies over and over and the success
rates go on. The longer they stay in treatment, the better the suc-
cess is. It is not only true for Phoenix House but it's true on the
shorter-term communities that have published nationally and cross-
culturally; the English studies, the Dutch studies, and now some
Swedish studies.

What does that tell me? Not that the therapeutic community is great,
but there is something lawful here despite client changes. We have
probably the effects of some kind of model that works for whatever it
is doing. As long as it stays a coherent model, it's able to roughly
compare data in terms of outcome statistics over the years.

I just throw this out because it's very striking and it should really
be known as literature and considered in any discussions up here.
What do we do about treatment and what do we do about the diversity of
the clients?

MSGR. O'BRIEN: I would like to pick up and echo what George said. We
have three large centers in the country. We began diversifying,
responding within the program setting to the variables that are out
there in tenns of client needs. A few years ago in our smallest
center in Dutchess County we attempted to respond to the needs of
women in particular because we were reflecting generally in the popu-
lation the ratio of the streets, which is about four or five to one,

46

male over female. It is most difficult for a female in a large set-
ting on Swan Lake or Parksville to respond to her needs with the
family when she is so overwhelmed in tenns of the ratio.

So we shut up a population in Millbrook on an experimental basis for
two years with a 50-50 ratio. It was an artificial ratio in terms of
the street, but very valid in tenns of testing the particular needs of
women in a setting where they were on par with the men and the staff.

Surprisingly, one of the outcomes of that particular study on a
special dynamics in our Millbrook Center was the women in the center.
Rather than feeling better because they had equal action, equal repre-
sentation and equal opportunity, they felt it was much harder than the
other two centers because women, both staff-wise and fellow residents,
were much stricter on women than the men were in the centers where
they predominated.

Since then, we have moved Millbrook into an adolescent center. We
have zoned our Swan Lake Center for the older addict who has tried a
number of concepts and is coming back to us later in life. Our
Parksville Center is accented for those who have higher educational
potential and the Miniversity is there.

So I think what George has said within the therapeutic community, we
are focusing more on responding more effectively to that whole variety
of client profiles.

DR. RENAULT: One thought that occurred to me as you were talking is
that the Federal perspective, particularly at NIDA, is based primarily
on the questions that we get asked by the Oversight Committees and the
relative success that we have in defending the drug abuse treatment
programs that exist, and explaining, dealing with what you said,
George--trying to explain to Congressmen and to investigators from the
General Accounting Office, what have you, about what goes on in drug
abuse treatment.

I think we are most successful, really, in doing that when it comes to
methadone maintenance and when it comes to therapeutic -3mmunities
because, obviously, there we have got the best kinds of data. We have
the DARPS study. We have some Phoenix House studies. We have a lot
of information that is developed. We also have the trials looking at
methadone. What we don't do very well at defending, it seems to me,
is the other modalities, particularly drug free, outpatient drug
treatment, for example, or how about detoxification? How does that
figure into treatment in general? How do they respond to a need? Do
they respond to a need?

Just to give the feedback that we get, for example, in detoxification,
most patients in a 21 day detox, which is obviously an artificial

thing anyway, don't last 21 days, let alone become heroin free,
upstanding citizens, which I think is often the expectation, or an
outpatient, drug free.

We are very often hard pressed to even account for what happens within
the outpatient, drug free modality. It's a much looser concept than
methadone maintenance or the therapeutic community.

MS. KURMAN—GULKIN: Not for us, because we were the first outpatient
and we have been very consistent. I think the difference that I have
found over the past several years is the kind of openness and recogni-
tion that other treatments do work. I know that when I first came
into the field the treatment centers were over here and drug free was
over here and, God help us, they added a third called methadone main-
tenance. It was like the Tong Wars. I must say this in relation to
Daytop because they were really first to come forward. When there was
recognition that it was inapprOpriate to have someone go into a
treatment center, they called. We, in turn, referred out all of the
younger people who came who we felt very strongly could not make it on
the streets if they didn't get into a therapeutic community. We had
to learn very carefully to give up this vested interest which was very
related to the statistics and contractual capacity. We really learned
early on that you have a responsibility to get people into the appro-
priate setting for them.

For the outpatient drug free concept, we used a very classic
psychiatric, mental health model. It was appropriate for people who
were managing their lives up to a certain point. Lots of our people
were still working. Lots of our people were still in school and would
not identify themselves as dope fiends, would not give up everything
in order to get into a therapeutic community. We had firemen, nurses,
teachers--people who ran a very, very high risk of losing their
income. They were really narcotizing themselves to a certain point
and controlling it all at the same time. They were able to perform.
For the most part, we saw lots of people who were blitzed from Friday
night to Sunday night and then somehow managed to clean up their act
and get to work Monday; and we saw lots of people who were just smok-
ing.

If someone had a taste of a therapeutic community and couldn't handle
it, had tried everything, and this was the last resort and if he
couldn't make it in our clinic, it justified his reason for continuing
to use heroin.

We feel that we maintain patients over a longer period of time. I
think that causes funding sources some problems. You don't have the
24-hour investment in a drug free setting that's an outpatient
setting. You have someone who may come in for an hour and a half a

48

week for group, an hour for individual and then there is involvement,
if you are lucky, with the people who are living around and close to
the person who is abusing. So we involve more than the individual and
that causes some problems.

People have difficulty in measuring success. I think that must be
true of private factors. I think that it would be very hard for an
outside source to come in and look at a psychiatrist's files and
figure out from a very clinical and scientific point of view if they
are getting the same results that he thinks he's getting with indi-
vidual patients. So again I want to stress, we feel there is a
tremendous need for our kind of drug free counseling environment.

We also know that in the past ten years we have picked up graduates of
therapeutic communities and people who have withdrawn themselves from
methadone maintenance. The danger that we saw in tenns of the people .
who were graduates of therapeutic communities was that they felt they
had to really hit rock bottom before they could come in and ask for
help. The whole concept of red flagging just seemed to go down the
tubes. There is a tremendous fear that they would be put back to step
one if they went back to the therapeutic community, and many of them
had worked in therapeutic communities and served as role models, and
so they had the double burden of the fallen person and then the old
street junkie. So alcohol became a big issue for graduates, and then
going back into the drug scene.

I think as we have develOped a more cooperative relationship with
therapeutic communities, we have been able to set up systems whereby
people know now that they don't have to go all the way down to come
back up again.

DR. PRIMM: You had spoken about the response of the Feds to the prob-
lems in a sense. Let me just talk about that for a minute. I think
it's really important from an online perspective and from someone who
has a chance from time to time to give input on Federal policy, like
myself.

I often see the Federal Strategy. I don't know how many of you have
seen the Federal Strategy that comes out, but it's very duplicative.
Many things that are said in this year's Federal Strategy would have
been said in last year's and the year before, and since 1972 when the
first Federal strategy for a long time had been written on drug abuse.
It's incredible that the people from the White House might get that
Federal Strategy out and the Advisory Committee to the President,
which is composed of Joyce Lowinson and Vernon Jordan and a few other
people would have some input into it. And somehow it seems as though
the Office of Drug Abuse Policy (I don't know what it's called now,
something else) doesn't at all communicate with NIDA or doesn't get

49

behind Congress enough to see that Congress apprOpriates the money to
carry out its very lofty, utopian Federal Strategy. It bothers me.
It bothers me greatly. It's not that the Feds failed. I think
failure is built in on the part of, say, the National Institute on
Drug Abuse by the very people who have set it up to satiate the prob-
lems by not giving it the money, the staff, not allowing enough of
this kind of interaction between people from the trench level to
pe0ple who actually supply the trenches with what they need, and that
is most important.

You are not to take this either, by the way, as a critique, because
let me say this. I think as a public health deliverer or purveyor of
services as we are in the drug abuse field, no other field in public
health has been as successful. I pause for just a second so you could
swallow that one and see how you could digest it. For example, in New
York City in 1969-l970, the time when we got into drug abuse and the
emphasis was on building programs, there were over 1,000 deaths in
this town secondary to narcotics overdose. Today, just ten years
later, there are far less. I don't know the exact number, but I hear
it's below 300.

That's incredible for the amount of drug abusers that we supposedly
have in this town. I just saw some statistics and it's estimated we
have around 200,000 addicts in this town. It's also estimated that
within this state, only 22 percent are in treatment and 78 percent are
not in treatment. Here we have in this field diminished, just getting
22 percent of the people in treatment, the death rate by 2,000 or
3,000 percent. That is fantastic. It's got to be written about.
It's got to be sung loudly from all the highest points in New York
City, and it's been a joint effort. It's been an effort on the part
of the therapeutic community, an effort on the part of the methadone
maintenance programs.

That's not to say that the job is being well done. We certainly are
getting the peOple off drugs in many instances onto maybe methadone,
but certainly not returning them back as functional citizens of soci-
ety. They are not functional. They are dysfunctional. We return
them. We are not rehabilitating them. We are just habilitating them,
maybe getting them ready to do something, and then we have nothing for
them to do at the end of the pipeline.

So my point to you here is, NIDA should use that when they go to talk
to Congress. I don't think they do. That strategy has not been used.
I think we should help NIDA in relationship to the Office of Drug
Abuse Policy, that, hey, don't write this nonsense unless you are
going to give us the money to carry it out, and then we have got to
tell NIDA, don't you expect us to carry out what you expect us to
carry out if you don't give us the money to do so.

50

I could go on and on on that subject.

I think programs are underfunded, for example, terribly underfunded.
For example, in New York State there are programs that deliver the
same services across the board, yet are funded quite differently in
terms of the reimbursement formula, $300,000 and $400,000 less for the
(same services. That's incredible. That creates a kind of feeling
among treatment prsonnel of elitism, that divides the field. It
creates such divisiveness that people don't talk to one another.

All of these nice things that we are saying, sure, Msgr. O'Brien and I
talk, sure, Mitch Rosenthal and I talk, and George DeLeon and I talk,
and Anita Kurman-Gulkin and I talk, kiss and do other things together
in terms of programs, but when we have a meeting, like there was a
meeting going on concurrently with this very meeting here, the
National Association of Drug Abuse Problems (it met just here in New
York with the leading figures in this nation present in that forum
talking about new research) I didn't see one person from the Thera—
peutic Communities of America in that audience, not one.

Here they are giving out all the information on which a lot of policy
is going to be based, a lot of direction is going to be based, and
here my friends are not there. Let me tell you something else. I
want you to hear that-~when a majority of people in treatment are
blacks and hispanics, and two of the blacks I brought there personally
myself-—I didn't get invited until the Friday before the conference
was to begin on a Tuesday. I want you to hear that.

If there is anybody well—known in drug abuse because of his mouth and
because of some of the actions taken, it's Beny Primm. Especially in
New York City, there is no question about it. My point is that
despite what you see on the surface, and at the expense of not being
invited back to talk to you next year or whatever, I am taking the
chance to say what I want to say-—Msgr. O'Brien made sure I was
invited to the Therapeutic Communities of America's conference or the
International Therapeutic Communities conference. He made sure of
that. We have got to make sure of things like that so that this com—
munication flows freely and we will even do better than miracles that
we have already done underfunded.

MSGR. O'BRIEN: I would like to pick up on something that Beny is
pointing out, and I think we should get it out there and then move on.
I think that whole spectrum that we have in New York City is a very
important thing to understand in tenns of refering a graduate or staff
person, as Anita said, to Greenwich House for the reasons that Anita
enunciated. We might refer someone to Harold or Beny or we might
refer to Phoenix House or Odyssey or one of the other programs for a
reason that we feel that program best responds to their needs. It

51

might be outpatient, as Greenwich House does it extremely well and we
have referred many people in that particular way. But that whole
spectrum construct of referral that we have because of what we dis-
covered some years ago and began to realize that none of us should or
can reinvent the wheel is a very important concept for NIDA to
understand when looking at New York City.

The second thing is, we talk about responding 'to client needs. I
think you should know that just the 16 years we have been in business,
we have had 16 commanders. If you were enterprising right now, you
would be filing proposals for elderly people who are female who might
take drugs, so you can move into prevention money; that that partic-
ular responding to the needs of the shifting leadership in our field,
NPD and T, we have had six chiefs in Albany, six chiefs in New York '
City, and we have had some beauts in New York City. All of them had
priorities, all had needs, psychological and programmatic, personal
and communal, that we have all had to respond to besides trying to
deal with clients.

Within that frame of reference, as Beny said so well, I think we have
done pretty damn well. That figure Beny was referring to, I remember
1,458 overdose deaths in New York, I believe in 1970 or 1971, and now
we are down below 300. I think that's an achievement. But I think
that is largely an achievement from this type of referral construct
that we have in New York City.

DR. DeLEON: I thought I heard your concern, how do we tell Congress
about the drug-free outpatient, how do we tell them about detox? We
seem to have good data on methadone maintenance and therapeutic com-
munities that talk about treatment effectiveness. My understanding of
this is that other than the DARPS studies, you don't have very well-
designed, extensive evaluation studies for drug free outpatient
clinics, so I think you are going to be a little bit tongue-tied until
you can generate some more carefully designed studies of that modal-
ity.

Number two, I would recanmend in the design of those studies that they
both be from external evaluation teams and internal evaluation teams
so that you don't regress us back to the era of simply trying to do
research when it really means programs are viable because you are
really trying to get programs to generate good data to evaluate how
they are doing.

Third, I would heartily recommend researching the modalities so that
you would have some data to go with it. Despite the data, though, I
think one problem is in the rationale for both detox and drug free
outpatient. The fundamental rationale for those two modalities
rested on an implicit distinction between the words "service" and

52

“treatment“ even though a lot of people who work in drug free out-
patient honestly feel that they are heavily involved in this treatment
business, and they are. But their rationale initially, their original
funding rationale, was to provide service to the widening range of
drug abusers out in the field, some of whom would not be in residen-
tial treatment and some of whom it was not appropriate to be in metha-
done maintenance. Well, who were they? They were people who needed
certain kinds of contact or service.

I said this would be controversial because the statement I want to add
to this is that when you have a service oriented approach, and detox
incidentally is a classical example of a service, and if detox service
peOple accepted with equanimity that they are providing a 21-day
service with no implications about treatment, with no implications
about long-range change, then at least they would rest easy in terms
of the work they are doing and you would have smarter things to say to
the Congressmen about well, listen, we are meeting needs. Not all of
them are treatment or rehabilitation needs. Some of them are contact
service needs, and then your evaluations would begin being premised on
simply assessing whether those contacts and services are being
delivered.

Then you will come to the Congressional people because they will want
to know,'well, what good is that. You know what I mean? If you pro-
vide a contact and you provide a service, you will then have to
rethink again, understanding from the standpoint of the rationale, is
it good to do that, should we really compel the field in the direction
of actually bringing about fundamental changes in people's behavior,
and if that is so, can you do that on a current outpatient basis. The
answer is you can, but you can bet you won't find that client without
a lot of evaluation.

In the end, a small, hard-core group of certain people out there will
benefit enormously by outpatient contact, but you are going to have to
spend the money and the time evaluating who that client is and identi-
fying him. It is the oldest problem you are having, but it's coming
out most heavily in drug free and detox.

0n the service side, the drug free outpatient people, like all of us,
are getting so egocentric they want to provide to everybody. Treat-
ment centers did and they continue to make that mistake. I want to
reach everybody, and you don't know that you are in business with
certain kinds of clients. Drug free outpatient, by simply declaring
them drug free outpatient, doesn't mean they are appropriate for
everybody. Patients, particularly large drug abusers who, inci-
dentally, never want to be locked in with residents and don't want to
go through disciplines and don't want to go through rigorous daily
routines, and everybody would like to be an outpatient.

53

0n the service side, drug free outpatient workers have to be told and
have to be encouraged that there is a certain client and it isn't only
defined by middle-class. It isn't defined by the drug abuse, but it's
defined by characterological patterns, the history, and I'm sure a
number of other psychological parameters. It's a certain client for
whom they are most appropriate and they should not be spreading their
doors wider and they need help in that kind of delineation. 0n the
other side, the funding side, they have to redefine the goals of drug
free outpatients and I think if you do that you will have a better
case in terms of looking at it yourself and then coming back and mak-
ing the statements.

One thing on detox that to me is the grimmest of all businesses, here
we are going to detox you and we are going to give 21 days and the
prima facie contract between you and the client is you have your life,
do what you want to do. We have made a place available for you to
come in and then thereafter everything else you do is on your own.

In other words, the contract is, I have no big hopes of any large
impact, and however many times you come back to detox you know that's
a very high revolving rate and the moral question in that seems to me
to be very great, and the rethinking about whether that's a viable
approach, I think, is very demanding.

DR. PRIMM: I think some direction should come from the National
Institute on Drug Abuse on the 21-day thing who are collectors of all
this data, research data, and ideas that say, “Hey, if you've got a
person who has been on drugs for a year and a half or two years, how
in the world are you going to get him off drugs, get him nondrug
dependent in 21 days"? It is impossible, both pharmacologically and
certainly psychologically. Certainly with an overall feeling of well-
being they are even going to have any chance of success. You might
reduce their tolerance so that they can get high out there in the
streets on a lot less money and continue to add to the problem, but
not much more.

For example, in a program in which I'm the medical director and
actually lay hands on patients, I will not take a patient on 21-day
detox. I will take a patient who wants to ease the withdrawal syn-
drome who might be going into Renaissance or to a Daytop or going to
jail. I'm going to see him again in another two months and I m going
to have to 21-day detox him and then at that point I'm going to say to
him, you either have got to go on maintenance or you have to do some-
thing about your life, and he ends up as a 19 or 20 year old male who
has never been in treatment before except for detox on a methadone
maintenance program. Fortunately my program, which is a low dose
program, which I don't like, so that has to be changed and some
clarity has to be given to the field in that.

54

They've even got a program here in Harlem at d01nt Uisease Hospital
where they do a 7-day detox and right back on the street. They do it
and it's just cyclical and it's nothing but generating an income for
seven days on a Medicaid reimbursement rate that builds up that out-
patient department's capital.

MSGR. O'BRIEN: Are you referring to heroin detox or methadone main—
tenance detox?

DR. DeLEON: Heroin detox. It's a much longer time.

DR. PRIMM: We penalize our patients. Let's say our patients are on a
methadone maintenance program. He gets into an altercation with the
staff member. So you have rules and regulations. The patient is
taken before the interdisciplinary team and a decision is made. The
whole team may decide that this patient ought to be put off the pro-
gram. Instead of abruptly discharging that patient from the program
with zero dose the very next day, we are kind and we give him a 21-
day detox. That 21-day detox is not adequate for somebody who might
have been on the program a year and a half, who has built up to a
tolerance of 50 and sometimes 60 mg. of methadone. We know that this
patient is going to undergo protracted abstinence syndrome six or
eight months or a year later. We actually know it's quite possible 26
weeks later. It's punishment, undue punishment and too harsh,
Draconian in nature and certainly should not be practiced.

DR. DeLEON: Is it within the bounds to check on how you are reacting
to all of this? What are you hearing?

DR. RENAULT: One of the things that is going through my mind is the
transcript. This is going to be a useful document that we can take
back to Washington. I think there are some particularly quotable
segments in it where we could use the information and just directly
transmit that.

The other thing that I have about it, too, is what we have in
research, particularly, just as a policy, we have taken on those
things that are the easiest. We have taken on those populations that
are easiest to study and we have measured those outcomes that are the
easiest to measure and our field is really blessed, in a way, that we
have things such as heroin taking or drug taking that can be verified
by urinalysis. It's a researcher's dream, especially in the mental
health field where we have such a clear-cut outcome.

Where we haven't done as well is in these other modalities or even
other patient characteristics life cycle pathology, where we have
fallen way short from a policy point of view in terms of encouraging
that kind of research, encouraging research into outcome measures that
are poorly defined, and in modalities that are poorly defined.

55

What I have heard today, one thing that's of interest to me, is that
modalities, perhaps, can be defined in tenns of the client population
that is most characteristically served by that modality. Even that
would be a starting point where we could look at that to try to define
that population even better, even as guidance, say, to drug free pro—
grams, but also in feeding it back to the funding sources. That is
what we are doing in outpatient drug free, and this is the kind of
treatment or service we are providing.

I think the same is true with detoxification. One of the problems
with detoxification is that although it doesn't provide a treatment-
and I think that's been quite clearly stated—-it does provide a ser-
vice. I think for a lot of patients one of the fears that we have
had, and we have discussed this a lot at NIDA, has been that it can
provide a sham treatment; that it can convince people they are doing
something for themselves when, in fact, they are not. They are going
through the motions and setting themselves up for failure, and I don't
have to go on from that. You know the problems that most of the
clients really have, lifelong problems of failure, and detoxification
fits right into that.

The idea of providing a service, even if patients were given that as
the goal, "I'll detoxify‘you as long as you realize it's not a treat-
ment," this is whatever definition we could come up with as to what
kind of a service it would be, I think even that would provide clarity
to the field and might even actually improve the modality.

Finally, as far as the service that we are providing in these two
modalities--let's take detoxification, for example--in a way, that
could be seen as a humanitarian service, it still escapes me. What
are we actually doing for somebody? I don't mean to say that we are
not doing anything. That's not my position. I'm just trying, in my
own mind, to understand better what is the service we are providing
when we are doing that? There are people who definitely want this
kind of a modality and will come back and will come back repeatedly
for it.

MS. KURMAN-GULKIN: If it were successful, they wouldn't have to.
DR. RENAULT: That's right.

MS. KURMAN-GULKIN: I am very pleased. I feel like I have heard it
all, and I think I have heard something today that's impacting in a
very different way. It's George's statement of separating out service
from treatment and not feeling defensive about it, but making sure
that you understand that this is what you're doing and that you will
not be held accountable for doing more than you are expected to do,
and that you accept your limitations.

56

The issue of detoxification as it is set up now has a kind of
mutuality to it and that is that it's delusionary for the person
coming in, and to Beny's point, it's also a ripoff for both parties.
In one area, the facility is able to collect and the other, the
patient deludes himself that they are doing something.

I think ideally--and I stress "ideally"--that the service is one that
can be used appropriately if it's related to something else. Just to
go in is not enough. I see it as being important. For instance, when
someone is on pills, I would hate like hell to have someone withdraw
on the streets, especially from amphetamines, if there were a facility
that could handle the situation during a very trying time, and the
whole barbiturate situation. I think that is a real need, but it
doesn't Operate in a vacuum. Detoxification does operate in a vacuum
as it stands now. It usually is a source available when somebody's
wife is ready to check him out, when parents are really pounding on a
kid to get him out and the kid can say, "Okay, I'll go into Bernstein,
I'll go into this, I'll go into that,“ and it's a stopgap measure. I
see it as nothing more than an interruption to a cycle that immediate-
ly is relived the minute they get out the door because there is
nothing at the end of that 7—day, 21-day.

I also think we all agree that 21 days is arbitrary and it's much more
relevant when you are doing statistics and billing than it is for an
individual.

DR. PRIMM: Could I make a comment here, I seem to have been in my
dissertation completely opposed to 7-day, 21-day detox. Medically it
doesn't make sense. That's the bottom line. There is something good
about it, and what is good about it is that it introduces a person, .
many people who have never cone in before, to treatment. One thing it
does is get them registered in the network of being a narcotics
addict. -

The other thing is that while that person is in the detox program, he
decreases the demand for illicit drugs on the street by one. Yet that
demand will go up precipitously once he goes back because he then will
be building back up another tolerance before returning. The addict
becomes less contagious when in detox because we know the more people
we have out there an the street, the more the contagion factor,
especially in heroin abuse. While they're in that network, that con-
tagion factor is reduced.

For those reasons it is good, especially with people in New York City
who have a 78 percent not intreatment addict population. We need to
reduce the demand out there as much as possible. We need to keep them
from, for example, having an overdose phenomenon, and we know that
methadone, if it's used for detox, sort of gives in a defense mechan-
ism against the overdose phenomenon.

57

I think, though, we are getting a lot more people on drugs and a lot
more people are having problems with drugs. We are not seeing as many
deaths related to substances because methadone creates a greater
tolerance for individuals who nonnally would not have that tolerance.
They would not have been able to get the methadone either through
illicit channels that were diverted from licit programs or through 7-
day or 21-day detox exposure.

If we are not going to provide the money for sociological changes
necessary to create independent behavioral change, it might be good to
keep them intact.

DR. RENAULT: It's obvious that everybody has a lot of questions, and
I think the discussion has covered a lot of issues. It has been, of
course, provocative for all of us. I have had the monopoly on being
able to ask questions. I think what we will do is throw it open and
have questions from any of you.

QUESTION: At the risk of maybe climbing up on the soapbox, there
were some comments at the beginning of the responses to your
second question, should treatment change because pathology is the
same?

Some of the initial responses to that indicated that psychiatrists at
one time were very seriously involved in the treatment effort, and for
a number of reasons were no longer quite as involved. This, according
to various members of the panel, was to the detriment of the treatment
attempt. There is a problem which I have with that kind of attitude
because I'm not so sure that the types of treatment provided today by
psychiatrists, psychologists, social workers, or the corner bartender
in delivering helpful behavior to an individual who has certain prob—
lems is all that different. I'm not a clinician, I'm a psychologist
in research, so I don't have any personal vested interest, but there
was one statement I must admit I was especially irritated about.
Because psychiatrists have priced themselves out of the market, deeper
treatment levels have been diminishing. I'm not even sure what deeper
treatment levels are, and that various other mental health workers,
which was a quote I heard for psychologists and social workers, are
any less deep, given the same virtual training. Psychologists, social
workers have gone into psychoanalysis and are psychoanalyzing and
today perhaps the lines of demarcation between the professional indi—
viduals of different schools of thought are not as clear as they once
were.

Personally, I think in many respects if you want to look for a real
line of demarcation between psychiatrists and other professional
deliverers of mental health care might be the ability to deliver medi-
cation to a client and for many of our clients, that's not what we

58

want to do--add more medication to what already has been going on
in their lives.

So I do feel that I have to take some exception to those statements
and as the conversation at the table continued, I noticed we have got
to have all different kinds of modalities because we have to recognize
the diversity of our client population.

In the recognition of the diversity of the client population we recog-
nize that we need a diversity of treatment modalities. I don't under-
stand why we don't recognize the need for a diversity in professionals
who are attempting to help our client population.

DR. DeLEON: I'm not sure what I heard in that, but I think somewhere
in there you might have been reacting to something that I did, too,
that maybe points about professionalism and professionals and psychi-
atrists which were not really clarified. Therapeutic communities, you
know, have been a special modality which are remarkably absent of
professionals for good and bad reasons, and I can give you just some
current update on the role of the professional in the therapeutic
communities, psychiatrists and psychologists. Maybe that will bring
you a clearer view of that modality.

In the early days, professionals were certainly anathema to thera-
peutic community workers because they were the founders of their own
treatment system, which was self-help. Both had a real and imagined
beef against the professional hierarchy which had not helped them in
the past.

But that has changed over the years and therapeutic communities are
now handling the diversity of individual differences internally. The
whole issue of the professional, the paraprofessional, the use of the
the professional has been overloaded by stereotypical perceptions of
each. Maybe we should drop the notion of professional and simply talk
about individuals who have certain kinds of useful skills, and where
those skills could be merged with an ongoing program or with other
people who have other skills. In Phoenix House and Daytop and other
large treatment centers, there are no real, deep problems of inte-
gration of professionals and nonprofessionals because of the recog-
nition of the differentiated skill and their utility. What has hurt
us has been professionalism, and the aura of that I think, hopefully,
is going away.

QUESTION: That's not what I heard happening. I agree with what you
just said. That's the kind of thing I was trying to say, and what I
heard up here was that professionalism was again-~well, it seemed like
there are only certain people who can help other people and no one
else can, and I was objecting to that kind of thrust that I heard at
the beginning of the response.

59

DR. PRIMM: I think you may have heard what you wanted to hear and
oftimes we do a lot of selective listening. I talked about the mental
health specialists as a way that we have satiated our need within the
corporation because we could not attract psychiatrists. As you very
well know, our society is very polar. It's polar in tenns of sociali-
zation, in tenns of economics, and especially in tenms of race. Many,
many of the patients in the program that I run, and in other programs
that I happen to be a consultant for or know something about, are
minorities. They feel that a majority of professionals in many
instances do not have the cultural background or enough exposure to
their particular culture to help them through a number of problems
that they might have, and this is becoming more and more pronounced.
Even black and white psychologists and psychiatrists are writing about
it.

It's difficult at first to get a black professional to come to com-
munities where I work because it's below the level that they think
they should be involved——both in terms of patients and surroundings.
There is very little good to come out of his involvement there anyway.
He knows that, and if he's smart he doesn't come to work there.

As a matter of fact, in Harlem alone it is so bad that Congressman
Rangel and Mr. Califano did a whole binding thing together to do some-
thing to get some better delivery of services and get some profes-
sionals in. They could not attract black professionals from Harlem
Hospital itself, so they went to the U.S. Public Health Service and
they will now be assigning to the Harlem community to increase the
doctor population ratio, U.S. Public Health Service physicians to
serve out their commitment to the Public Health Service to that com-
munity so that we could have some service.

You are not going to get a black psychiatrist or a white psychiatrist,
unless he's particularly interested in this field, to serve in any one
of those communities. Therefore, we at ARTC began to satiate the
regulatory need to have psychological evaluations by using the mental
health specialist. That could be a social worker who has a particular
emphasis in the background in psychology or a psychologist. In no was
was I demeaning that source of professional help that I'm able to
attract. As a matter of fact, my division director, deputy director
of Human Services, came out of the mental health service specialty
ranks from the corporation and could very easily run the corporation.

So my point is, they cannot write for psychotropic drugs. Many of
these people do need psychotropic drugs, particularly with the new
evidence that has been uncovered that many of our problems in drug
addicts and substance abusers derive from a chemical imbalance or a
lack of homeostasis in our own body chemistry. We do need these sub-
stances there to block receptors, for example, opiate receptors,

60

antianxiety receptors, PCP receptors, barbiturate receptors, right on
down the line, and especially the diamamine receptors.

My point is that we are penalized and handicapped if we just have a
psychologist or psychosocial worker and not a psychiatrist who does
know psychopharmacology and, therefore, can give us the kind of thing
we need.

I don't know of one black psychopharmacologist in the nation. I want
you to hear that. And the one that I did know who was black worked
for a drug firm and is now back in Nigeria. He was a Nigerian who had
come to this country to study. Not one do I know, but we do need
black psychopharmacologists, hispanic psychopharmacologists who have
some knowledge of the background and culture of these special groups.
That is the point I was making.

QUESTION: During the discussion, the information that we have heard
over the past several days has suggested that there has been a tremen-
dous decrease or, shall we say, a significant decrease in the
incidence of heroin abuse among young people. It seems that for what-
ever reason the supply is down. Have people just decided that heroin
is not the "in" drug any more, or beginning to decide this, and they
are going to other drugs.

With this in mind, and recognizing that we have now built up an insti-
tution of methadone maintenance and methadone treatment facilities,
what roles do you see for this institution if what the statistics that
we are getting happen to be true, say, of heroin dosages fading out,
will they go the route of LSD?

DR. TRIGG: I don't know where you heard that heroin was fading out.
I think that it is probably safe to say that the prevalence remains
rather static, as far as I know. The incidence may have peaked, but I
don't think heroin is fading out. Methadone maintenance treatment
programs are in jeopardy because I don't think heroin is fading out.
We see new cases every day.

In terms of the inpatient detoxification service at Beth Israel: if
you call down to get a patient in there you probably get a bed date
two weeks from now. That place is solidly booked, like the Waldorf-
Astoria. It's harder to get a bed in there than it is to get a hotel
room these days.

DR. PRIMM: There is some diminishing in my own program. I don't see
new people. I see people that might have been in Harold's program or
might have been in Anita's program who are coming back into treatment
after they have dropped out, or they have been successfully treated
and had a fall. However, in suburbia, in Nestchester County, for
example, within the last week and a half, just to give you an idea,

61

and I know you are not an epidemiologist, there have been 12 admis-
sions to the program. Seven of those admissions have been young,
middle-class whites, averaging in .age from 19, say, to 22. As a
matter of fact, the first time in the last three years I have seen
anybody shooting drugs in their feet were the young, middle-class
whites who came to the program, who were employed, and good family
life, etc. One such middle-class white had been using drugs seven
years and he died last week after he was put on the methadone program
for three days.

My point is that you do see some new admittees to programs who have
never been in treatment before, whose primary substance of abuse com-
ing in the program from suburbia is heroin. I was talking to some
people today about why that is so. In the black community, for
example, those people who would normally be migrating into heroin
taking and so forth are not. They are migrating into a great deal
more marijuana smoking, which has replaced heroin among the younger
age group in Harlem. But it's just as bad and just as deleterious to
the person, and particularly to our racial group, than it is to the
other racial groups because they are amotivated and they don't do any-
thing but smoke pot from one minute to the other and are in great
trouble and drink alcohol. So we are seeing that replacing it, but
out in suburbia we are not seeing that.

Another reason for a statistical downgrade may be that methadone is so
available illicitly. There have been in my own program two robberies
at gunpoint where a great amount of methadone was taken from one
clinic, and where a nurse probably inadvertently did not lock the safe
completely and another great amount of methadone was taken from that
clinic. That methadone is out on the street in enough .supply that
people don't need to take heroin. They can get just as high off that
oral methadone.

I would like to say something else here and caboose on your question
to talk about missing methadone and its effect on lowering the heroin
trends, so to speak, and it's a pseudo-effect, really. You report
that to the DEA and you even report the possible suspects to the DEA.
They will come and will rip your clinic apart and tell you all the
things you are not complying with, but in tenms of enforcement and
followup on leads, given either by clinic personnel or whomever they
question, they don't do it. They turn it over to the New York City
Police Department and you know what happens then. They probably go
out and find the methadone and keep it themselves and sell it. We
just found a case of that a few days ago.

So my point is this. It's a plethora of things that are happening out

there that give this trend a false kind of positive goodness when
indeed there is heroin available. If David Kennedy can go up in

62

Harlem, the nephew of a Senator can buy drugs right on the streets,
one block from where the demonstration was last night at the church-—
I was invited to that Presidential campaign kickoff. I drove one
block from there and there were people four deep on that corner wait-
ing for a dr0p. So heroin hasn't diminished at all. It's available.
We are not getting a lot of young people shooting up. But I would
guarantee you, if the socioeconomic conditions of this country don't
change within another six months or a year, we are also going to see a
lot more heroin takers and a lot more ripoffs of methadone maintenance
programs to get the methadone out.

QUESTION: You don't feel, then, that the methadone treatment program
is threatened?

DR. PRIMM: Not at all.

QUESTION: My question was, not that drug abuse is reducing, but that
there is nothing currently that a methadone treatment program can do
for the person who is on marijuana. That requires another kind of
institution.

DR. PRIMM: There will be illicit methadone people out there who are
taking the illicit methadone. Methadone is a primary drug of abuse
for a number of people right now.

MS. KURMAN-GULKIN: We have very stringent methadone hours at our
clinic. I remember the person for whom I worked, the director of the
program at the time I came to Greenwich House. One of the patients
came late and became really menacing, really violent, screaming and
yelling. My boss came out and said, “What's going on?“ The patient
said, “They won't give me my methadone." He said, "Well, you are
going to have to come back tonight when the clinic opens again.“ The
guy kept screaming at everybody and he turned around and said to my
boss, "I'm telling you now, the only reason that you have a job is
because I was a junkie. What are you going to do when methadone goes
out of style"? And without skipping a beat, my boss said, “There is
always alcoholism, there used to be TB. I'm sure they will develop
something else."

If that's really the thrust of it, if you are feeling it may go the
way of frontal lobotomies, I don't know. I think there is also a
sense, politically, that heroin is on the downswing because we haven't
a French Connection lately. We haven't had a big drug bust to get
everybody excited. In a crazy kind of way, that works against us.
People get lulled into it and then methadone becomes the issue for
awhile. But really, drugs do not feel like an issue unless they are
an issue for you.

63

DR. DeLEON: I don't think this is really a question at the moment.
Heroin exists and methadone treatment exists for that and there is
nothing in the near future to indicate that there is going to be a
dismantling of that treatment or that heroin will go away. New inci-
dence means the rate at which people are becoming hooked to heroin for
the first time in their lives.

Now we all can see clinically that more people are trying other drugs
than heroin. It says nothing to the already swollen pool of lifetime
heroin users that were established through the 19605 and the early
19705 and the fact that that pool, provided the new incidence trend
goes down, still must be served for many years to come in one way or
another. That's one thing.

Another statistical statement. I am not making the prediction of
what's going to happen to the new incidence trend. The other one is
from the street. Heroin is one of the most powerful drugs and one of
the nicest drugs that we have. What it provides for the individuals
is well documented in phenomenological counts for 50 years. It has
now been assimilated into the culture. While it was the drug of
rebellion in the 19605, it has now subsided as rebellious efforts do
and is now part of the culture. A large proportion of people will use
it and not use it in a way that doesn't symbolize rebellion but simply
what it gives them. We will have heroin with us. It is too potent a
drug to say that it will go away.

MS. KURMAN—GULKIN: It's also considered, by the way, the equivalent
of the health foods fad. It's a pure drug. So on the street look at
what they are doing with themselves. It makes me laugh. They talk
about not taking pills because pills are chemistry but heroin is
pure.

DR. PRIMM: When George spoke of it being acculturated, in a number of
the black communities, for example, because of socioeconomic condi-
tions the people have become so accustomed to seeing winos and drug
takers that the complacency that has come out of this does not any
more drive a lot of these people into treatment. So the only way we
know that they are out there is that when they come into treatment, we
don't go on to corners and count 40 or 50 people I saw standing there
last night because we go out every day and we might count some of the
same faces, but we would also count some new faces because we couldn't
count the David Kennedy types that would be up there copping from that
corner.

The point I'm trying to make is that there is a whole economic system
in our communities because of the distribution of illicit drugs, the
hot stuff that's sold on the streets, the hot stuff that's sold in
restaurants, beauty parlors and barbershops. You can't go into a bar

64

in Harlem and have a drink without being offered a new tweed jacket or
Burberry raincoat or whatever. We are supporting the whole drug econ-
omy by buying that type of thing. It has become a way of life, so
people pretty much are accepting it. They are against methadone
maintenance, even establishing themselves, not knowing that that might
eradicate some of the other stuff. But it takes away from their
economy.

QUESTION: I would like to thank the panel, first of all, at least on
my own behalf as a member of this group, for being a kind of sensiti-
zation process for a concern that we have had in the past about what
our data gathering efforts can mean to policy issues and program
development issues within our respective communities. It has been
very helpful.

But I have a question to pose based on the discussion that you have
presented so far. I think it has been founded on an assumption that
the system that's in place is adequate. There is a heritage of the
criminal justice system connection in terms of working primarily with
people who use illicit drugs. There is a-heritage in working with
people who are socioeconomically disadvantaged or disenfranchised.
I'm not belittling the need either to work with those particular kinds
of illicit drugs or that particular population. My concern is that
there is a much larger population using and abusing and dying from
prescription drugs. They are licitly produced, manufactured, and dis-
tributed drugs and there is a very different population of people who
are doing that. The question I would like to pose to the panel is
whether or not the treatment system, as now engaged and structured,
should expand to include that larger population; or whether another
institution should be developed. As I understand the system as it now
operates, as NIDA is now structured, has now structured it, it's mono—
lithic; it's rigid, and it won't. respond to the needs of those other
people who are doing those other drugs. It either changes, it seems
to me, or some other kind of institution needs to be generated to
respond to that need.

DR. DeLEON: You are, I think, talking about the large majority of
reasonably well-socialized Americans who are using varieties of drugs
which are not seriously affecting their taxpaying lifestyle. I'm just
trying to get the climate; you know what I mean.

I think your question is: Can NIDA, as it is structured both
philosophically, bureaucratically, fiscally, identify that population
and then does it have philosophical, medical rationale for handling
that and the personnel, and do they have specialized treatment
thrusts? I'm just trying to translate your question.

65

DR. PRIMM: I would like to answer the question under the reformu-
lation. New York State put out a booklet. Nice fancy package. It
talked about a report on the nonmedical use of drugs among the New
York State household population, quite different than the population
we treat. I have long since been concerned about that population,
particularly the black elderly and others who take nonprescribed drugs
in combination with prescribed drugs. It is possible to buy almost
anything you want over-the—counter and put those things together and
get the effect you want. As a matter of fact, I go around with a kit
filled with over-the-counter drugs and give lectures to senior citi-
zens' homes. I have been doing that for the last three or four years.
I submitted the proposal to NIDA to do a study of drug abuse among the
elderly, comparing four different cohorts; one in the urban area,
another from a rural area, another a rural-urban setting, and the last
from a retirement community. The project was designed to look at
the drug taking patterns of the black elderly and the folk medicines
that they take.

That proposal was not funded. We are now submitting it to the
National Institute on Aging. I got into this whole thing because of
my father who was sick. He took a shot of bourbon every day, and he
took his Darvon compound every day for his low back pain. It had been
given to him to take every four hours, and he took it all through the
night. He got up at night and took it every four hours whether he had
pain or not. It was PRN given as needed, but he took it all the time.
Then he took his high blood pressure medication. Then he took Simmons
Liver Regulator to keep himself regular every day. Then he gargled
with Listerine and swallowed a little bit to ward off colds.

So here was a man of great intelligence, who was addicted to pr0poxy-
phene, addicted to alcohol, addicted to Simmons Liver Regulator. He
made a mistake during the latter days of his life and mixed up some of
my mother's medication with his. She had died about six weeks before.
He began to take some HydroDiuril along with everything else. He was
drug oriented completely--and died at 78 years of age.

I think that not only the elderly, but the whole household drug user
population should be studied. I think you are doing something about
it, aren't you, Msgr. O'Brien, with the household drug users, the pill
takers? There ought to be be money set aside for special populations
and a concentrated effort to choose people who want to do this kind of
work and give it to them.

I don't think drug programs as they are set up now can be expanded to
take care of that population. You are not going to get an elderly
person to come into a methadone maintenance program center that she
has seen as a stigma on the block.

66

MSGR. O'BRIEN: I want to throw something out. You are talking about
the Barbara Gordons, you know, “Dancing As Fast As I can," who spoke
at our recent conference and said, "My doctor sent me back to my
apartment to detox. I was medically detoxified from Valium. But the
rest of it, I was to do all alone. I didn't know you existed." She
described the agony she went through for many months.

We have given a lot of thought to this and we have been dabbling with
it a little in the evening therapy groups. My own impression is that
there is too much of a stigma attached to it. We come from the
criminal justice sector. There should be a model out there with
wheels on it. It's a whole different ballgame, and if you are going
to get the housewife and the Barbara Gordons, you are not going to get
them into programs like this.

MS. KURMAN-GULKIN: I don't think it's appropriate. I think we are
tooled up for the things that we are doing best. But I do think that
the issue you raise is like the silent alcoholic pictured as the
desperate woman in the suburbs. We are not reaching those people, and
if we did we now have nothing to offer. I think we have to redesign.
I think that we have to be very careful as to how we set it up. There
is a very clearcut separation between the street addict and the person
who chooses to be prescribed to.

I am sort of stretching to hear the other part of that statement.
Most of those people are women, and clearly none of us are addressing
the issue of the women drug abusers who are abusing the things we know
how to handle. , When I talk about a 30-70 ratio, that's a hell of a
statement. I think that at Greenwich House we have done a great deal,
and we can only say 30 percent of those people in treatment are women.
We know for a fact that there are many, many more people out there.

When Beny talks about 22 percent in treatment, what's happening? I'm
concerned about the 78 percent.

QUESTION: One of the points I wanted to ask--and you have all given
me an ability, at least as I perceive it, a little bit more focused--
is picking up on something that Beny said, that NIDA ought to be
responding. I am not so sure that what I was interested in is having
necessarily NIDA respond to this population as recognizing and making
very explicit what NIDA's limitations are and that if the model you
have described as working in New York is the referral model between
programs and different kinds of modalities within the illicit drug
using population.

If that becomes a model that should be used nationally, it should be

described. One of my concerns in Philadelphia is that we have a great
deal of difficulty moving across from the drug and alcohol system to

67

the mental health system, to welfare systems, to all kinds of other
services that are appropriate in the population we are talking about,
or the illicitly using population as well as in the licit one. My
concern is that we be explicit about what we are tied into in terms of
the therapeutic system we have, accept the limitations. Then we must
determine where we go from here. I think part of our responsibilities
as data gatherers and analyzers of that data is to bring it forward,
to bring our data up to a point where we can begin to address the
issue very directly.

This group represents a lot of major drug using populations because we
are mostly urban people and we have a pretty good system developed in
reporting on those drug using behaviors in our respective communities.
We are stretching ourselves to try and find out some ways to record
"polydrug use." We haven't gotten very far, but I think we may be as
far along as anybody else is in this country. My concern is that we
need to be very explicit about what we can't do and then try to
address that need, and I would be interested in your response to
that.

MS. KURMAN-GULKIN: We don't know if we can't do it. We have never
attempted to do it and as we are structured, I think it would be
inappropriate. I think we have to think past where we are.

QUESTION: If given the resources, we could. I wanted to comment on
that. First of all, in clarifying Chris' question, I am not so sure
that all of these people--this is in response to George's
restatement--are in a good condition to pay their taxes. Some of
these people are debilitated.

A few years ago the anmy had what was called a Pentomic Division and
that division contained the basic structure so it could be modified to
respond as either of five divisions, depending on the need. I don't
know if the society is ready to allow the establishment of another
institution to deal with polydrug abuse similar to the methadone or
the institution that is set up to deal with heroin. If you've got the
backbone of a system, I think the best chances for dealing with poly-
drug abuse is to build in for flexibility so the same system might be
able to respond to either of these issues.

There is a program, again in Albuquerque, New Mexico, for instance,
where the one organization is responsible for the treatment of heroin
abuses and it has a polydrug abuse program.

Certain people are assigned to one program which is located in subur-
bia, where it is accessing the middle-class housewife who has this
problem. It's in a very sterile environment where this person goes
and is not associated with the stereotyped drug abuser. In certain

68

other areas there are the methadone clinics, but it is administered by
one program, and this is basically why I asked the question earlier.
I was concerned with what thought is being given now by the methadone
programs to realize that there is another problem out there that's
much larger than the heroin problem, and is any thought being given to
modifying the thinking so that this one institution will be able to
deal with this other problem if necessary. Otherwise I think it's
doomed to failure. The society can't afford an institution for each
kind of problem it has.

DR. TRIGG: I don't understand why methadone has to cure everything.
Methadone is designed to check opiate addiction, that's all.

QUESTION: That's what I am saying.

DR. TRIGG: Why should methadone programs involve themselves in bar-
biturate use. I am not saying they shouldn't. But I am fascinated by
the way you are phrasing it.

QUESTION: I am phrasing it from the standpoint that methadone is an
instrument. It has professional individuals who are directing and
implementing a program.

DR. TRIGG: But they don't know anything about barbiturate addiction.

QUESTION: I am saying why couldn't those individuals, for example, if
a psychiatrist is in a program why should he be limited only to deal-
ing with the opiate addict or the schizophrenic? Why can't he deal
with a set of problems?

DR. TRIGG: I could make an equally cogent argument that since treat-
ment centers now deal with non0piate substance abuse, why don't
treatment centers do it. I mean, if I have a 17 year old barbiturate
addict coming to me this afternoon in my office, I am not going to
refer him to a methadone program. He's going to a treatment center.

QUESTION: 50 vice versa. If one can do it, why can't the other?

DR. TRIGG: I am not saying both can't. I am saying it's more than
natural to me, given the structure and the history of things, to give
it to a treatment center. They have been doing it for years.

DR. PRIMM: That might be true, but what he's saying is that this net-
work of treatment is already tooled up to do a certain job, so you
expand the network a bit to include that kind of technology that would
be able to deliver that service.

69

DR. TRIGG: I can see expanding the network by drawing the treatment
centers and the methadone maintenance programs closer together so that
an applicant who really is not suitable for methadone maintenance
would go into another branch of the program. But that means that
Msgr. O'Brien and I both have to give up our empires, which isn't very
likely to happen.

MSGR. O'BRIEN: Speak for yourself.

QUESTION: What I think I am saying is that perhaps society cannot
afford to allow the two of you to have separate empires. If you are
dealing with substance abuse, the one empire should deal with sub-
stance abuse and the individual is referred to the appropriate com-
ponent. You can't break substance abuse down into several
institutions.

DR. TRIGG: You are talking about the organization of the thing. But
I can tell you that as long as there are Republican and Democratic
parties, there are going to methadone programs and treatment centers.

MSGR. O'BRIEN: I think you are referring to the Jaffe Chicago model,
aren't you, that whole spectrum of central induction and off on the
track that would suit the client most. It certainly makes a lot of
sense. Though we don't have central induction here, I think it makes
a lot of sense.

If you are saying that the secondary drug abuser, the middle-class
housewife, should be woven into the spectrum that's there, I agree.
What that particular treatment model will be, I don't know. But I
certainly think we should all be moving in this direction and with
NIDA's help, we should. Dr. Primm also mentioned that he had a pro—
posal in to address some experiments in this particular area. I
certainly think there is no question but what we should be giving
attention to it.

DR. PRIMM: I think that methadone maintenance programs, if they are
freestanding and hospital based and are out in the communities, are
under great jeopardy of being put out of business unless they are
diversified. We have the capability of diversification. For example,
it's one of the best health care delivery systems for primary health
care for that group of population than anyone knows.

First of all, they are lured into the program by the methadone and
then as you get them, you capture them and do a physical. So we could
deliver primary health care as an offshoot of what we are doing right
now. Unquestionably we could deliver sociological counseling. We
could also deliver primary mental health care and classification of
psychopathology so that it could be a triage. It would be no problem

70

to me to diversify my program enough so I would be able to take in
that special population you are talking about. I would be glad to do
it tomorrow. If you mention that to Bill Pollin or somebody down in
contracts, and just raise my fee a little bit, I will tool up.

QUESTION: The question that it brings up is rather disturbing because
it makes me think about my idealistic days. There are three levels to
health care. There is primary and secondary and then tertiary preven—
tion. Most of us here are talking about tertiary prevention, and you
bring up a problem that, to a great extent, can be addressed at this
first level.

There are causes for something to happen and then there are things
which facilitate. One of the things that facilitates the abuse of
prescription drugs is a lack of controls placed on these drugs by the
Government, the same Government which is represented here. It seems
that would be the first area where something would be done. I have
been reading the transcripts of several Congressional committees which
have been meeting on this issue. One of the things that they said was
that 80 percent of the psychotropic drugs prescribed in the country
are prescribed by general practitioners to patients who have never
seen a psychiatrist. That indicates to me right off the bat that
those people who are looking out for our good are not doing a very
good job. Just some elementary primary prevention measures could cut
down on some of the accessibility where patients are given unit doses
of 100 pills when they only need five or six. The pills are given by
a person who is not particularly well trained to assess the optimum of
this particular choice of drugs.

So a lot could be done on prevention, and since we have stepped into
this--this is where the idealistic thing comes--looking at the use of
drugs and we are talking about cycles, there was heroin and now we are
going into heavy marijuana use and PCP. At what point does the Federal
initiative take into account the overriding evidence of the policies
of the Federal Government that contribute to drug abuse?

We have just recently completed some studies on drug abuse as it
relates to social and economic conditions in this country and policies
initiated by the Federal Government. The Chairman of the University
of Illinois Economics Department did a graph showing a one—to-one
relationship between unemployment in black communities and infant
mortality. As unemployment rose, infant mortality rose. We have put
together our own chart dovetailing narcotic addiction over that same
period of time and we find a similar pattern. I think that somebody
who is a little less responsible than myself could say that when the
President calls for an eight percent or nine percent unemployment
level to stablize the economy, he's simultaneously calling for X num-
bers of black and hispanic children to die before the age of one and
for X numbers of young kids to start shooting drugs.

71

At what point does NIDA begin to address those issues and the impacts
of other social conditions on drug addiction and the possibility that
there is some prevention?

COMMENT: Let me come to the Government's rescue, at least to some
extent. Insofar as the 80 percent figures you are referring to, we
are quite concerned about that. But we must keep in mind that many
people get these drugs not because they are going to a doctor with a
primary condition that would cause them to ask for the drug. They go
for some other reason and on the way out they say, “Oh, doc, by the
way I can't sleep, can you give me something"?

A part of our job is to try to understand what is going on here and to
interact, communicate with physicians, to bring them--especially the
primary care physicians--related information on what is, in fact,
going on so that they are aware of this sort of thing.

With respect to the study or the type of study on the prescription of
drugs to older people, our office has recommended to PHS the study of
physicians prescribing psychoactive drugs to the elderly, and also a
study on the use of psychoactive drugs by the elderly. Now whether
these studies go or not, we don't know. We are asking for a national
survey, not a small study in a local environment. So we are very much
aware of this. We are very much aware of the lack of information that
primary care physicians have on psychophannacology and psychothera-
peutics, and we're trying to deal with this.

You may or may not have seen the study we cosponsored with the White
House on sleeping pills and other hypnotic drugs. There we were con—
cerned with how our hypnotic drugs, including the benzodiazepines, are
being used. The Government is not just sitting still. We are very
concerned with this. We are tracking it and when you talk about the
monies you received, believe me we have similar budgetary constraints.
So there are certain things that we can't do. But we at least trying
to make enough noise within NIDA and at the Congressional level to let
them know that there are things we need, certain things that we can do
for them if they will allocate it to the budget.

QUESTION: We have about 25 minutes left before this program ends.
My concern is that a bit more time be given for the problems of women
in substance abuse. NIDA mentioned that 30 percent of women who have
substance abuse problems are in treatment. This has been, I guess,
the decade of the woman, so to speak. I hope that women are becoming
more comfortable with their drug problem to the point of feeling free
enough to seek help.

I know frun my own program there has been some sensitizing, but there
is a need for much more sensitizing with regard to the treatment of

72

women. It is not just a symptom which is substance abuse, but there
are many underlying problems that are sociological as well as psycho-
logical and surely economical that lead to substance abuse.

My concern is that when we are talking about problems of substance
abuse, I think that traditionally we always think of the male who has
the problem with substance abuse. I, too, had had to sensitize myself
so that I incorporate into my own sensorium my sisters.

I would like to know if there have been some specific concerns among
the persons here from their cities or concerns within their cities
about the problem of treating women substance abusers. Is there any
need for a discussion? Has there been some satisfactory movement
towards treating successfully, or at least creating an environment in
which the woman can be approached from a more positive perspective
when it comes to treating? I would like some time given to that
because this is being printed and I certainly think its' an important
issue.

DR. TRIGG: I think it's an important point and just speaking for
myself, I would like you and everybody else to know that I have been
working very hard as a member of the Task Force on Drug Abuse for the
Second National Conference on Women in Crisis. We have had a number
of meetings. There is a lot of leg work. That conference will be
held at the Hotel Shoreham in Washington, D.C., June 5th to the 8th.
I think that in the meetings which I have attended a number of things
have come out. One could probably summarize in two pages what Freud
had to say about the psychology of women. So I think that the whole
field is probably way behind in whatever this is about a female
psychology. I'll point out one thing to you: they have managed to
survive, thank God, women that is.

I would guess that if this meeting were a year from now, you would
probably have heard a great deal more surface about women. Anita
knows that I have worked with women heroin addicts for many, many
years, have been fascinated by the fact that they find extreme diffi-
culty achieving the degree of rehabilitation on a methadone program
that the male patient achieves. I think, but I am not sure-~there is
no way I can document this scientifically--since most female junkies
support their habit by selling their bodies, that doing that for a few
years must be so degrading that the woman is unable to capture or
recapture her self-esteem. I don't know that she had it in the first
place, but if she had it, I think by the constant laying back, smiling
and saying, “50 bucks, 100 bucks," that she just irrevocably is
degraded. I don't know. Somebody should study that. Everybody tells
me I should. Well, I'm not about to do everything for everybody.

MS. KURMAN-GULKIN: But, Harold, what have you done for women lately?

73

 

DR. TRIGG: I told you I sit at that darn meeting and.get my head
chewed off.

COMMENT: I think within the state of Illinois, and more specifically
in Chicago, we have seen the rate of women entering treatment increas-
ing at a greater degree in proportion to men. My experience on the
streets has been that the number of women who are active in the youth
drug culture (heroin hangouts, copping areas and multiple drug distri-
bution and using areas) is roughly equal proportionally to women in
treatment. The great untapped population which you have mentioned is
the household prescription drug user. If any initiative really
remains to be open and more fully explored, it is that area.

QUESTION: Maybe that's one of the problems with what we were talking
about earlier, that flexibility that is needed in programs to bring
those people in. Maybe it's not the need for a methadone program but
the ability to bring a prescription drug user who happens to be a
woman into the program and be able to deal with her as well as we can
deal with the male opiate abuser.

MS. KURMAN—GULKIN: We have a problem with that. I really want to
respond to your statement before. It's like when a major bill
appears, when it goes through the whole system and there are riders
attached to dilute that bill. That's how I feel. If you are asking
if the present structures can dilute their services to adjust to a new
need, I think that we are terribly unsuccessful when it comes to
treating women for illicit drugs. What makes you think that by
extending ourselves even more that we are going to be successful with
a whole new breed that we don't even know how to approach. They are
having difficulty identifying themselves. We are having difficulty
bringing them in, and I would not like to see more of the same because
more of the same is a lot less than they are entitled to. I feel very
strongly about it.

QUESTION: So we set up many fiefdoms to figure out what to do?

MS. KURMAN-GULKIN: No. I am being incredibly patient and I am not
quite sure, and that's my own personal problem, that the two kingdmns
that were referred to were methadone maintenance and therapeutic com-
munities. All through this afternoon there has been, except for
myself, a complete avoidance of dealing with drug free. I really feel
that that's a very powerful treatment component that has been diluted
here this afternoon. But I do think that the whole counseling concept
is much more relevant to these people than either of the other two.

COMMENT: San Diego County funds regional drug programs, seven of
them scattered throughout San Diego County. These programs have not

74

been picking up much in the way of middle-class female prescription
drug abusers. The last year, recognizing that that was a need, a
separate program intended to be an information, educational, referral
kind of system was set .up to go out to women's groups, shopping
centers, get the message out what prescription drug abuse is, be a
center to refer anyone who would contact them to our regional clinic.

As the months went on they got more and more individual contacts, some
just for information on drugs. Some people who have a definite prob-
lem recognized they had a problem. These people were referred to our
regional outpatient programs. They never showed up. They would come
back to the referral program-—OPTIONS was the name of it--again and
again and use that as a counseling service. They would not go to our
outpatient programs because they didn't want to be associated with
drug programs even though these programs are basically programs for
soft drug abusers. They are not primarily heroin or coke clients
there. They are marijuana, amphetamines, glue sniffing, aspirin, any
excuse to get in there. But these middle-class, female prescription
abusers would not go to the programs.

COMMENT: I think that one of the experiences we have had in Dallas,
though, is location. We took that same type concept and put it in one
of the largest hospitals in Dallas, which happens to be a private
hospital. It seems to be working. It's the same basic outpatient
program when counseling is done. We put it in the Methodist Hospital
and that was our experience, let's not use the drug free slots in the
drug program. Let's move them into a hospital and see how that works,
just to draw on that one potential client that we were after.

COMMENT: I wanted to respond, Barbara, to what I think was your ques-
tion to the group in our individual efforts and also a little bit
about what we are doing in Philadelphia. Individually we have been
collecting and focusing on differences in intake to our treatment
services in our respective areas by sex. So we are increasingly aware
of and we have noted in previous meetings the increase in the number
of women coming into treatment services.

For instance, part of our more general concern has been how we respond
as a group to some of these things that clearly have policy implica-
tions. I think we have no unanimous sense about that. But we
certainly are focusing on the difference between data gathering,
analysis and the needs of policy development.

In Philadelphia, specifically, we have a somewhat regrettable record
of attracting some ten percent less women into our treatment system
than is the national average. As a part of our response to that, we
will be fielding a symposium and I am working very closely with the

75

pe0ple at the Women in Crisis Drug Task Force. But I think we will
probably be the first effort in the country to focus on women abusers
of legal drugs at the national level, and we are projecting that con-
ference in February. We are trying to again do some data gathering in
a sense. But we are also bringing together people who will provide
some direction perhaps, if not regulations and guidelines, some possi-
bility for political change in development.

COMMENT: I need to respond a little bit on the concept of prostitu-
tion among female addicts and how devastating it must be to go into
treatment with the burden of being a prostitute in order to support a
habit.

I think that most of the burden we carry with us is that part of our
defining process of who we are and what we are comes from our social
environment, and I have a little problem with that. I am not sharp in
terms of my statistics with regard to the number of women who have
become prostitutes to support their habit versus becoming other
things to support their habits. But one of the things that is most
important, and I have been asking about responses to treating women-
-one of the things that we don't talk about a great deal, we are talk-
ing about bricks and mortar and we are talking about money--one of the
most important things that we don't deal with too much is attitude,
value system, judging versus nonjudging. I think perhaps a lot of the
problems we incur with regard to trying to treat women is the atti-
tudes that prevail in a treatment situation with regard to women,
their needs and their position in society. Probably a lot of what
leads women to use drugs, legal or illegal, has to do with the kinds
of problems women encounter on a daily basis in trying to be a person
in our society.

In looking at my program and doing a bit of studying of the women we
are treating in our special women's center, most of the problems we
are dealing with now have to do with polydrug abuse or just the abuse
of pills. I think the major difference between the women we treat who
abuse Valium, Thorazine and other such "helpers," as opposed to their
going directly to the physician, is that they have a street physician.
They go to a second in .command, and maybe the middle-class woman can
go directly to the physician's office and be a little bit more com-
fortable with her prescription, and I think that difference is kind of
important.

MSGR. O'BRIEN: In our experience, even a more grotesque problem our
women face is being sexually abused by a relative that they trusted,
going back into childhood, and all of the tremendous emotional scars
that surround same. We have been trying for two and a half, three
years to address the problems of women adequately. We haven t suc-
ceeded to our satisfaction but we were successful enough that our

76

director of women moved up to Stamford, Connecticut, to head up a
small program. But in the women's dynamics, the women's program, all
of this deep emotional pain, even more deeply rooted, because that's
pretty much accepted as the way of the women drug abusers, there is
really pain there which is much more intense than the male client and
takes much more of a sophisticated approach. We have a hell of a long
way to go at Daytop in tenns of addressing it properly, but it's a
,number one problem. I am glad you brought it up.

DR. DeLEON: We don't have enough data on women and one pitch I want
to make to this group, maybe one of the things that Pierre could take
back, is that we have got to embark on a very, very energetic and
systematic data gathering fonnulation, problem formulation phase if we
are going to say anything sensible about women, and that's just a
little preamble to a little propaganda I have for you.

Treatment centers, as you may or may not know, have to my mind been as
a microcosm social setting heavily involved in the role relationships
between the meaning of drug abuse for men or women. I am not saying
successfully curing it or clarifying it, but very sensitized to it
from the origins of the treatment itself which was male dominated,
hierarchical, authoritarian, so that our problems with female "split—
tees" were all quickly sensed to be related to the sociocultural
dynamics of the treatment center itself. It brought us very close to
the problem of women. In our all day conference we have been very
heavily involved about having injured the women and are the women
reacting. We are still trying to dig out. One thing that I want to
sell to this group now is that we have recently finished a followup
study of females which is very rare in the literature indeed. This
looked at the psychological status of women early on at admission,
captured them again during treatment about six months later, and then
at least two years after treatment. I hope it replicates. It was a
small sample, merely 100 women.

Here is the finding. It's very clear. This is now a heterogeneous
group of females, which means heterogeneous by primary drug. About
half of them are heroin addicts, half were other kinds of drug users.
We are talking about what we consider the socially deficient women
more or less, although there were higher proportions of females in the
sample who came from the middle class than a corresponding male sample
from Phoenix.

We have analyzed the data in complex ways and defined success in tenns
of social adjustment. Those who stayed beyond six months in treatment
make a good social adjustment in terms of not going back to their
primary drug abuse, in terms of not engaging in criminal activity or
antisocial behavior, although they may continue to go on and drink or
use pills, not heavily use them, not abuse them, but use them to some
extent.

77

Remarkably, however, psychologically the women make a significantly
better improvement at followup. The women looked sicker when they
came in and looked psychologically healthier two years after treat-
ment.

Almost consistently across every psychological measure women looked
psychologically better than the males with corresponding time in the
program, whether they were dropouts or whether they were graduates.
The female psychological adjustment after they leave the therapeutic
community, if they had been there at least six months, was signifi—
cantly better.

It even argued against some-~my own published knowledge-—about the
meaning of sickness in drug abuse and the female drug abuser being
sicker. We have explored some of the explanatory parameters and you
might be interested in this one. The key change in the women was in
self—esteem. That was the key measure that changed. When we looked
at what might have been the reasons for that change, when program time
was controlled between males and females--and women incidentally still
hadn't had as good an employment record two years after treatment as
did the males, which seemed to be related to the employment climate
around females--why was it that they were still psychologically
significantly better, did not feel the need for treatment, and there
was no measure to indicate that they needed to continue treatment?
What was it?

In the therapeutic community there is a great emphasis upon developing
self-esteem through a variety of tactics. One of the ways that they
do it in treatment centers, particularly with females, is role
reversals, role relationships and so on, very heavy emphasis on break-
ing the role condition factors that existed outside.

What we have concluded is that if the women catch on in treatment,
particularly in the therapeutic community, there is a sharp change,
removal of what we think now is the largest component of their
pathology, namely self-stigmatized, poor self—esteem. So if they are
retaught by whatever techniques we use to remove the self-stigma com-
ponent of their maladjustment—~now they have maladjustment, but we are
saying in a kind of quantitative sense, a disproportionate contri-
bution to that maladjustment is their self-stigma. If you can teach
them not to self-stigmatize, usually through advancement in the
vertical ladder of the treatment center, through role reversal
approaches, through other parity making techniques. When that goes, a
very significant shadow of pathology leaves them and they simply feel
better and see themselves better. A lot of what I have been calling
psychological sickness in drug abusing women has been self-
stigmatization. If there were some way to crack it, then you would
have the famale paradoxical who would look like the kind of runaway
advancer in treatment conpared to the males.

78

Now go to the male data and you will see what I am talking about. In
the male data they made good social adjustments and they had better
jobs, but psychologically they didn't look as well. These were drop-
outs or graduates and it now appears to us that in tenns of the males,
since a smaller contribution to their increase in pathology and
maladjustment is related to social stigma factors, we have less of an
impact on their psychological status.

In other words, the contrast from their outside social stigma situa-
tion to the inside treatment social stigma situation is not very
great. So it's telling us now, in fact, psychologically we are not
doing that much for the men but we are doing a lot for the females.

It's a pitch for treatment, but in terms of science, what I want to
sensitize you to is the importance of this finding. It has led us to
make an implication: any treatment system which hammers away at the
self—stigma cunponent in females, by whichever array of techniques
that they have, will make a very, very big impact on these females in
terms of their later adjustment. I would like to see this repli-
cated. '

QUESTION: Slightly more than a decade ago there were very few people
involved in the field of drug abuse, either in treatment or in preven-
tion or education. The panel represents some of those few who were
‘involved in that time. It was also characterized by incredibly
limited amounts of funding.

At that time, too, the stereotyped image of drug addicts or drug
dependent persons was as a marginal person, somewhere in the shadows.
We began to make contact with the person and when we brought him into
the light, we realized that the person was a neighbor or a friend, or
in some cases a family member. The result of that recognition was an
expenditure of a great deal of money. If the expenditure of public
funds, the amount of public funds that are expended, is a reflection
of society's concern, then society was indeed very greatly concerned
about the drug problem at that time.

We might have at that point, though, kind of lulled ourselves into a
sense of false security because very shortly after that we began to
enter an age of almost panic level economic concern and the reaction
to that was a kind of Proposition 13 mentality. One of the first
heads to roll when we started cuting back was the drug abuse offices.

I am wondering what the future holds for the drug abuse field? Does
this reaction, this cutting off of the drug abuse programs in many
counties, in fact, represent a feeling of frustration on the part of
the public that we haven't been able to come to grips with the prob—
lem? Does it represent disinterest at this point, that we have kind

79

of legitimized drug use, or does it represent some kind of a shdrt-
coming on the part of the Federal Government, local governments,
private foundations that the lobby hasn't been that effective or it
hasn't been geared up to get into direct competition with other areas
that are demanding funds?

MSGR. O'BRIEN: I think there are a number of items in the picture. I
heard a very distinguished leader in the New York State Senate--he's a
key figure, he's on the Republican-Conservative side--who felt that
the public monies should be given to health needs that are not self-
inflicted and that drug abuse is self-inflicted and, therefore, that's
not a first priority. It took us a long while to explain drug abuse
to him. So you have that mentality.

Speaking to some heavyweights in Washington, their current mood is
paranoia about Proposition 13. They feel that they have put out what
the committee said the other day, $55 billion or something--they had a
figure the other day, the Waxman-Murphy crowd, that is a ten—year out-
put by the government. What do they have to show? All they have to
show is what Anderson brought up on NIDA and they are sore about it.
They want bottomline information on what they have to show in tenns of
the product that's out there.

It's our fault that we haven't gotten that to them, and they are
learning things for the first time. This is a wonderful committee.
They really don't know. They come from an investigatory corner and
they really don't know drug abuse from Shoelaces. Democracy doesn't
work--it hasn't worked yet. But in want of a better style, we will go
for it. They really need an education, but generally you go to
Charlie Rangel, you go to any of the other Congressmen who have been
in the field a long time and what they are saying is, "Will you get us
the message on the bottomline? What have you produced over ten years
from the Government outlay"? They have a right to ask it. We have an
obligation to give them the answer and we haven't. That's where I see
it.

DR. RENAULT: I feel like responding to that myself because I think
short of saying I agree with you, it's really too little to say
because I think NIDA is central in developing that message, too. That
has a lot to do with research policy and the kind of information that
we should be making priorities on acquiring.

One of the things that really struck me in this second session con-
cerns drug free treatment, which I guess has been on my mind, but I
see it in another perspective which has to do, I think, with the prob-
lem of female drug abuse, the problem of licit drug abuse, not as its
sole justification, but it's an added dimension. A lot was discussed
about the flexibility of our own treatment system and about our

80

inability and probably an apprOpriate re1uctance to take on other
prob1ems over and above those that were so poorly funded to dea] with

HOW.

With that I w111 just thank the pane] on beha1f of NIDA and the
group. - '

'U.S. Govmmm PRINTING OFFICE : 1980 o-sn-zus/eoug

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