The failure of the standard addiction treatment modalities—detoxification and aftercare counseling—and the explosive increase in identified addicts in urban areas in the 1950s and 1960s spurred the search for alternative treatment methods. Methadone maintenance was one such modality. Another was the so-called "therapeutic community."
WHAT RESIDENTIAL TREATMENT IS
Residential treatment programs for heroin addicts were an integral part of the Nixon administration's comprehensive "multi-modality" rehabilitation strategy and served to counter the claim that the government was relying solely on methadone maintenance. Residential programs have made extravagant and unsubstantiated claims about how they could "cure" most addicts.' Today these programs constitute only 6 percent of the total addiction treatment "slots" available in metropolitan areas, but a "therapeutic community movement" has developed, and these programs have generated publicity out of proportion to their numbers.
Called variously "therapeutic communities," "residentials," "half-way houses," "recovery houses," or simply "TC's," they can be defined as twenty-four hour, nonmedical residential care facilities designed to reform heroin addicts. Therapy is generally based on the medical model: addicts are presumed to be sick, suffering from an underlying personality disorder, of which compulsive heroin use is but a symptom.
Residential programs differ from each other primarily in their internal discipline structure and required length of stay. There are two kinds of disciplinary structures: programs with relatively demanding (high) or relatively undemanding (low) internal structures.2 Length-of-stay requirements range from fourteen days to a lifetime, depending on whether the program is a short- or longer-term residential.'
HISTORY AND DEVELOPMENT OF THE RESIDENTIAL MOVEMENT
The term "therapeutic community" was coined first by British psychiatrist Maxwell Jones to describe a unique kind of ward milieu for hospitalized psychiatric patients where each patient is at once a therapist and a patient.4 Most residential programs are based on some variant of this "milieu therapy" model.
Residentials also borrowed heavily from the philosophy developed by Alcoholics Anonymous, a variant of Christian redemption'," built around the concept that alcohol or drug addiction reflects certain inherent psychological instabilities and character deformations. The pattern is as follows: the weakness, the temptation with heroin, the self-indulgence, the rise and fall, and the redemption through recognition and perception of oneself as a child of original sin. To be sure, weaknesses are spoken of in psychological rather than religious terms (except in religious residentials), but the whole religious journey of self-degradation, self-negation, the trip through hell, the public confession, the self-abasement, the blinding insight, the revival and the salvation is evoked.
Synanon was the first residential in the United States to gain wide publicity and academic attention.5 Since it began in Santa Monica, California, in 1959, Synanon has addressed the problem of overcoming supposed ignorance among its clientele through a process of "mutual self-education." Its founders and residents insist that it is not so much a community of students or teachers as a community of "scholars," each learning and teaching at the same time. Residential programs tend to see themselves as simultaneous therapeutic and learning environments.
Synanon, however, differs from most residentials in three respects. First, it takes the position, almost unique among these programs, that the ambient society is so deficient, corrupt and unfeeling that the most authentic and rational choice for program "members" is to continue as residents of Synanon for the rest of their lives. Second, Synanon has moved away from strict focus on the drug-alcohol misuser toward a kind of "sensitivity" program for nonaddicts as well. Third, Synanon has never accepted government funding, because it does not want to be tied to government rules and regulations. Financial support comes mainly through client fees and various business enterprises that Synanon has spawned over the years.
Synanon has not shown much interest in outcome studies. Some informal evidence indicates that their recovery rate is low, especially among those who "split" and leave the facility. Charles Dederich, the cofounder of Synanon (and arrested in 1979 on an attempted murder charge), is said to believe that the relapse rate is 90 percent and that roughly one in ten has stayed "clean" outside the facility.° More comprehensive follow-up studies are not available for Synanon. The various Synanon spin-off residentials such as Daytop, Phoenix House and Odyssey House have taken more interest in evaluation studies, probably because they receive government grants and feel a need to "prove" their merit.
PHILOSOPHY OF RESIDENTIAL TREATMENT
What exactly is the philosophy of these residential treatment programs for heroin addicts? Upon what kinds of problems do they focus? Residentials adopt the medical model and focus on the client's inner life rather than on factors external to the individual that might stimulate and perpetuate opiate dependence.
Residentials, like most drug treatment programs, see addict-clients as arrested in their emotional development, as persons who have not yet grown up, in other words, as "babies." Programs thus operate on the standard medical assumption that addicts suffer from underlying personality defects. That their clients are sick and must submit to "rehabilitation" is the sacred, universal tenet of residential programs. In this pathogenic view, addicts are looked upon as "weaklings" and "snivelers" who cannot cope with life on its own terms without resorting to self-medication. Thus, the residential dogma does not presuppose sickness in the strict medical /physiological sense so much as plain stupidity and character weakness on the part of the habitue. Residential programs take the medical model of addiction as irrefutable gospel, and staff flaunt their newly acquired facility to "diagnose" clients in case records as "passive-dependent" personalities with "sociopathic tendencies."
"Therapy" in residential treatment programs consists of a varied set of individual and group transactions including focused individual and group counseling in addition to free-wheeling, unstructured group interactions, all conducted under a loose system of "behavior modification." The ultimate goal is to get the client to stop using drugs. Jr. most residentials, behavior defined as desirable is rewarded with privileges, while infractions (or inertia in the program) are punished by removing privileges previously granted or by imposing tedious and disagreeable work assignments. Behavior modification is thus the operative underlying principle. One moves up the status hierarchy in the residential by proving to be "capable of positive change," as defined by staff and senior residents.
Residents, especially new ones, are immediately cut off from all contact with outside persons, including family. Clients are generally on restriction from several weeks to several months, unable to leave the facility and sometimes even forbidden to converse with fellow clients, especially those of the opposite sex. Most residentials see sexual maladjustment as a common problem among heroin addicts, and sexual relationships are usually denied. These are privileges to be "earned" through "good behavior."
The new enrollee is subjected to "degradation ceremonies"' of various sorts to erase outward manifistations of a sense of personal identity, especially a self-image as "junkie," "dope fiend," or "con."
Shaved heads or self-deprecating signs hung around the neck for rule infractions or "nightcreeps" by senior residents and staff to terrorize the new arrivals and keep them off guard are techniques employed by residentials to break down the client's self-concept. Total and complete role dissociation from former street life is attempted. Program staff insist clients should accept this kind of "reeducation" without complaint or even feeling that any injustice has been committed. Enrollees who oppose role disassociation (often harder-core addicts with longer addiction and prison backgrounds) are looked upon as demonstrating that they are still suffering from an internal "character disorder" and are "emotionally immature."
The Synanon Game
High-discipline programs usually employ the confrontive "Synanon game"—a leaderless group encounter session to create aggressive and provocative interchange, using ridicule, cross-examination and hostile attack. During these group assaults on individual residents in the "hot seat," especially newcomers, any castigation and ridicule appear to come from the whole community of clients. Facing this, it is difficult for the subject of attack to resist or defend himself. At this point, the resident on target must confront and be confronted with the "real reasons" for heroin use: a weak, rotten being, the black depths of "shithood" as a "dope fiend." In such sessions a client can demonstrate to staff that he is "learning" the cause of the "irresponsibility" that led to narcotic delinquency in the first place. That one is irresponsible is never open to question. One either plays the game and is rewarded with privilege and favorable discharge, or one "splits" from the program.
Staff members and senior residents usually facilitate these group encounter sessions, as well as provide individual counseling. Experience indicates that when these counselors use an especially intrusive, aggressive approach, frequently debasing and harshly confronting clients, they may do more harm than good. Counselors, many of whom are ex-addicts, tend to be impatient, authoritarian and demanding, usually insisting on immediate self-disclosure, emotional expression and attitude change from clients.
This intrusive, assertive therapeutic style works well for a few clients but may injure many more. Neurotic addicts, especially, tend to question their own judgement before questioning that of staff and resident leaders. A number of clients, yearning for a sense of belonging and something to believe in after removing the heroin from their lives, relinquish all independence and subjugate themselves to these staff and senior residents, accepting humiliation and total control over their lives even to the extent of accepting complete direction of their sex lives, outside work, incomes and, when permitted, medication.
Quite simply, the so-called "therapy" and "rehabilitation" practiced in most residentials are somewhat out of control. Thousands of untrained staff and residents in hundreds of residentials nationwide, many hardly off heroin themselves and under no legal or professional oversight, unleash their own brands of "therapy" on addicts, many of them under court-ordered mandatory treatment. These so-called therapists have catchy titles like "head counselor," "group leader," "game leader," "expeditor," and so on.
I terminated one such "head counselor" at a federally funded residential who forced female clients to engage in fellatio with him while he "pled their cases" to parole or probation officers over the telephone. The women complained, and the staff member later overdosed on heroin in his office after he was fired. The male "founder" and assistant director of another large federally supported all-female residential was having intercourse with an unkwnown number of his clients, most of them young heroin addicts, scared and unable to resist his advances. This came to my attention when one of them, a retarded fifteen-year-old, told me (and I later verified) that he had taken her to a motel, "screwed" her then "dumped her" beside the road with no money and no way back to his "therapeutic community." Incidents like these are not unique in residentials.
Funding sources like the National Institute on Drug Abuse, central state drug abuse agencies and county health departments, especially their monitors and "project officers," are unequipped to monitor closely the therapies and therapists in residentials twenty-four hours a day for effectiveness and ethical practice. Although the unproved claims of residentials are being challenged, dangerous practices still prevail in many of them. In 1975 not one of the four large residential programs in one California county operating under the aegis of the federal government had a bona fide psychologist or psychiatrist on staff, though they all waved the banner of formal psychology. Similar situations abound throughout the country.
RESIDENTIALS AND THE MENTAL HEALTH POWER ELITE
A number of residential program staff members, especially founders of such programs, are charismatic. These ex-addicts are politically adept and have a self-serving interest in the proliferation of residentials. A number of these people have mobilized considerable community and political support by promising to reduce drug misuse among youth. They have become skilled at manipulating the news media and do not hesitate to play on the natural fears of parents concerning drug abuse by their children. By offering parents and civic leaders simplistic, client-centered solutions to a complex problem like addiction, some residential -programs have managed to accumulate a significant amount of political influence. They manipulate local, state and national government officials to utilize and expand their facilities by enlisting community drug hysteria. Eventually, some programs and their leaders have created situations where they are answerable to no one—licensing bureaus, housing or health regulations, fiscal auditors or scientific evaluators.
DO RESIDENTIAL PROGRAMS WORK? RETENTION AND OUTCOME
Are residential programs able to reform their addict-clients? Reform is generally defined as: (1) postdischarge narcotic abstinence, (2) reduced criminality, and (3) employment or school involvement. Scientific evaluations of residentials are few, since only a small minority of those responsible for residentials seem concerned about client follow-up and evaluative research.' Most residential program staffs lack the methodological and analytical skills to perform such evaluations. Moreover, they know that the briefest investigation would show failure to achieve overt goals.
RETENTION IN TREATMENT
Retention in treatment is a major process goal for residential programs, as it is for methadone maintenance, detoxification and aftercare centers. Are residentials able to hold their clients? Studies of residentials have found attrition rates over 80 percent prior to formal program completion or "graduation."9
In a typical study, Glaser found eighty-six of every hundred admissions to a large residential program terminating themselves against advice of staff. Most of them "split" within thirty days of admission.1° Brill studied 2,110 consecutive admissions to Phoenix House, a residential in New York, and found a 96 percent drop-out rate. Of the 4 percent who finally "graduated," 25 percent had become paid staff members. As a result, Brill doubts that residential programs can ". . . return large numbers of residents to the community as rehabilitated or 'cured.' "11
The inescapable conclusion is that residentials are unable to retain substantial numbers of addict-clients in order to "treat" them. Those who do remain are highly motivated, and might have discontinued heroin use without the intervention of the program.
Retention in treatment is an important goal in any addiction treatment modality; everything else depends on it.12 DeLeon and colleagues found that at Phoenix House, the longer a client stays, the larger the post-discharge reduction in arrests. Addicts with any time in Phoenix House, even those who "split," showed "sharp reductions" in criminal activity ". . . during and after leaving the program."13
Retention rates seem to be affected by two factors: program approach (high- or low-disciplinary structure) and client background variables. The more strict the program, the lower the percentage of clients retained in treatment.14 Young, white, shorter-term addicts appear to stay longer in treatment than older, black/ brown, longer-term addicts with more extensive histories of institutionalization.15
With high "split" rates and numbers of untreated street addicts running low in some communities, residentials are now concentrating on the youthful "multiple-drug abuser" or "polydrug abuser," the person who is using heroin sporadically in combination with other drugs or perhaps not using heroin at all. These clients are more likely to be retained in residential treatment than hard-core heroin addicts. A federally sponsored residential program in California was funded to "treat" the "adolescent and young adult, middle-class soft-drug use syndrome." Whether or not large sums of money should be spent on treating "soft drug" users is questionable. Should the federal government be funding Synanontype residentials for pot smokers and occasional heroin users? To hold the newer "lightweight" clients, some programs have somewhat altered their treatment approach. No longer is the hard-attack encounter the primary therapeutic tool. A "softer," less confronting approach, designed not to scare clients away, prevails."
Retention rates at New York's Odyssey House are instructive, for this program was heralded as the "Tiffany" of therapeutic communities. The program's founder, Judianne Densen-Gerber, calls her project ". . . the country's most successful program for curing drug addiction."17 Is it? Or is there a vested interest in the background?
At Odyssey House only a quarter of all admissions stay longer than thirty days. After six months the figure falls to 9.7 percent retained. At one year the Odyssey retention rate is 5.6 percent. After eighteen months, the program's required length of stay in order to "graduate," only 2.8 percent of all admissions are retained. This is a 97.2 percent "split" rate." Obviously, only the most motivated clients complete the prescribed treatment regimen. Could the same results have been acheived without the intervention of Odyssey House, where the cost per "graduate" is more than $20,000?
With high attrition rates like these, residential programs, especially since their overexpansion during the Nixon era, constantly need new addicts to fill their beds, meet contractual client matrices and keep their grants. Since they have difficulty keeping clients, and because methadone maintenance poses a serious threat to their continued existence, many residentials actively solicit clients, called "body snatching" in the trade, or more respectably, "outreach."
For example, residentials seek the court-ordered "diversion" client, since clients who have been diverted into residentials in lieu of jail or prison are more likely to stay than voluntary ones. The reason is obvious: Such a resident stays because he tries to "beat a case" by making a favorable impression on the court or the staff members who ultimately provide feedback to the court—especially feedback on whether or not the client is still in treatment. Thus, preferential loading of residential client populations with diverted addicts can effectively boost retention power.
Virtually all residential treatment programs have formed and nurtured close alliances with various elements of the criminal justice system, and consider police, courts and corrections excellent sources for potential clients.'9 A large residential program in Pennsylvania, for example, says that ". . . in the past 2 years the majority of our clients have been admitted as a result of some immediate and direct action by one part or another of the criminal justice system."2°
The largest addiction treatment intake unit in Los Angeles has a legal department which focuses primarily on diverting addicts out of jail into its in- and outpatient services, including two residentials. The program says its legal office is ". . invaluable in bringing [program] clientele into treatment and keeping them there. . . .',21 (Emphasis added) In the words of The Godfather, diversion offers the addict a choice he cannot refuse: remain in jail or ','-voluntarily" request release, which is conditioned on entering and remaining in a specified residential program. This can be bad when the program is bad.
In such diversion cases, is the residential program the agent of the client, the court or the community? Voluntary addiction treatment involves a therapeutic relationship in which the primary responsibility of the program or therapist is to the client alone. In an involuntary treatment setting (diversion), the program's primary responsibility is to some third party, usually a criminal court.22 The objectives of most residentials who go to the criminal justice system for clients extend beyond simply "rehabilitation." Their aims include self-perpetuation and social control over addict criminals.
Addict diversion is particularly invidious when applied to the pretrial addict prisoner who pleads guilty at the preliminary hearing phase. It is, in effect, a plea bargain. Pretrial diversion clients are given the "choice" of treatment prior to being offered a trial. Thus they forfeit the opportunity to prove their innocence by accepting treatment in lieu of a trial. Addict-defendants in such cases are really forced to accept treatment that they generally do not want for a "disease" they often believe to be nonexistent. They are thus denied due process.
There is near-unanimous support for this kind of diversion among residential program directors and staff. Their motto appears to be: "Keep the beds full, at any cost." Some programs have used "bounty hunters" to find diversion clients who "split" prior to formal discharge. Others will pay a "finder's fee" for each new client brought in. One program paid $10 a head, and a former ex-addict staff member there had a stable of "recruiters" on the streets and in the jails looking for potential clients.
A 1974 survey found that most residential program directors see themselves as moving closer and closer to the criminal justice system as a source of clients.23 Residential program staff and directors are thus quite frank about their commitment to perpetuate residentials through close alliance with the criminal justice system, particularly where the bulk of the staff are recovered addicts themselves. They have, like aftercare program staffs, found a niche and understandably are determined to hold it. When criticized, they staunchly defend goals of their programs, client recruitment methods and treatment results.
THE RELATIONSHIP OF TREATMENT TO OUTCOME
Recruiting and holding onto clients is one thing. In the end do residentials succeed in benefiting clients they manage to retain?
Success critieria in client follow-up studies of residential programs vary. Drug use, criminality, social functioning of some kind and health are areas in which client status on follow-up is consistently examined. Closer scrutiny, however, reveals that while the categories are similar, the definitions of these outcome measures vary wildly.
In drug use, for example, some studies examine the use of illicit and licit drugs after discharge, demanding abstinence from the use of both as a criterion of "success." Another viewpoint holds that only reduction in the use of illegal drugs is evidence of "successful" residential treatment outcome.
In the area of subsequent criminality most outcome studies focus on arrest histories and arrest rates. Few studies examine wider criminal involvements. Where some studies utilize official records, others rely on client self-reported drug use, arrests or other pertinent data. Similar disparities at this level are evident in every category of outcome measurement.
Outcome Studies of Dropouts
Some studies attempt to demonstrate that residential programs are so successful they even achieve some success with dropouts. DeLeon and his colleagues determined the percentage of arrests for a sample of 254 clients who failed to complete the Phoenix House program. Even the dropouts, they concluded, ". . . showed sharp reductions in criminal activity during and after leaving the program. These changes relate to the rehabilitative aspects of the program." 24
There are severe methodological problems with such studies. First, to conclude that postdischarge reductions in arrests were due to the rehabilitative aspects of the program is a self-serving assumption, since no control group or other standard of comparison was used to determine independent program impact on postdischarge arrest rates.
Second, postdischarge "arrests" as the only indicator of "criminality" is an inadequate measure. Victimization surveys, for example, which measure the true crime rate by asking population samples if they have been victims of crimes, indicate that reported crimes are not reliable indicators of total crimes committed. Arrests would seem to be an even poorer indicator, since most crimes are never cleared by an arrest. One victimization study found that 50 percent of all crimes in the nation's five largest cities were unreported to the police.25 Was an unknown amount of lawbreaking, unknown to him and his colleagues, going on among DeLeon's study sample? In substance, a lower reported arrest rate does not mean a lower actual rate of crimes committed among the discharged clients interviewed.
A third glaring methodological error of the DeLeon study was that the New York City Narcotic Registry was used to validate client self-reported arrests. Arrests among the study group outside New York City did not appear in the registry.2 6
True, an unexplained relationship exists between residential treatment and positive outcome, even among dropouts. But untested assumptions, unreliable criminality indicators, and all the pitfalls of client self-reported data (no friends or relatives were interviewed to corroborate self-reported information) characterize the study.
Chambers and Inciardi, in a comprehensive residential follow-up study, used the following postdischarge behavioral variables in examining a group of clients who dropped out of Phoenix House between the third and eighteenth month of treatment:
1. Abstinence from drug use since discharge.
2. Arrest history since discharge.
3. Employment status at follow-up.
Was Phoenix House so effective that it even achieved some success with dropouts? "Twenty-seven percent of Phoenix House splitees can be considered as complete successes, 43.5% can be considered as marginally successful and 29.3% can be considered as failures."27
As with most similar reports, however, methodological problems beset the Chambers and Inciardi study. It was nonexperimental; no matched set of controls was compared with the treatment group to determine independent program effect. Nor was any other form of comparison used. Although it admittedly was a study of "dropouts," only clients in the program at least three months were included in the study group. Thus, early dropouts (the great majority of all admissions) were specifically excluded from the sample. Conclusions deduced from remaining rather than total starting samples are speculative and highly questionable. Of 182 individuals in the sample, only 92 were found and agreed to be interviewed. So almost one-half of the original group were unavailable for interviews. Generalizations from this small group applied to the total number of dropouts are tentative and conjectural. Those clients who could be found and agreed to be interviewed may have been the very ones who were most "successful," as evidenced by their availability and willingness to be interviewed. Further, all data for the study were self-reported by the ex-clients and therefore unreliable. There was no cross-checking to validate this information. Thus, the conclusions drawn from the Chambers and Inciardi study are scientifically unsound and, to a degree, self-serving.
Outcome Studies of Graduates
Another often-quoted residential treatment program follow-up study confined follow-up interviews to "successful graduates" of New York City's Daytop Village and predictably found a majority no longer "abusing drugs" or "committing crimes." Most were also working or in schoo1.28 Behavioral measures of success employed in this study were:
1. Postdischarge drug use.
2. Postdischarge alcohol use.
3. Arrest history since discharge.
4. "Prosocial involvement," defined as in school or working at follow-up.
The Collier and Hijazi investigation of Daytop Village concluded that the program had an independent, positive impact on the postdischarge behavior of program graduates, but this conclusion is marred by four methodological errors.
First, the study sample was biased and therefore unrepresentative of the total discharge population. The sample excluded all dropouts and focused instead only on program "graduates." Since most admissions to Phoenix House drop out prior to graduation, this is the same commonly repeated flaw of generalizing from remaining samples. Casriel and Amen, in their study of Phoenix House "graduates," committed this same error.29
Second, the Collier and Hijazi study was nonexperimental: No matched controls were used to determine if indeed it was the "treatment" that accounted for the ex-clients' success or if extraneous variables, particularly client characteristics like age, race or addiction history, accounted for the observed "reform." Some addicts undergo "spontaneous remission" of their addiction. Sick and tired of being sick and tired, they naturally begin to "mature out" of heroin addiction in their thirties without the ministrations of professional helpers.3°
Third, arrests were utilized as the sole indicator of client criminality. The pitfall of this indicator is obvious. Fourth, follow-up interviews were conducted only nine months after program graduation. This is a very short period of time in which to make generalizations regarding the durability of observed behavioral change. Detoxified addicts should not be considered a "success" after only a few months of drug-free existence ". . in view of the well-known relapse potential of detoxified addicts."31 Vaillant suggested that at least five years is a more realistic minimum period to determine the persistence of client change.32 This may be an unnecessarily stringent requirement. Nevertheless, the probative aspects of the Collier and Hijazi study taint its weak conclusions.
Pin and his colleagues studied three hundred graduates of Horizon House, another New York therapeutic community. Only 164 were actually found and interviewed; the rest were lost to follow-up. Of those interviewed one year after discharge, 64 percent had a job or were in school, 69.9 percent were "abstaining from drugs," and 64.5 percent had not been arrested.33
Like other studies, however, this one also omitted dropouts from the sample, interviewed only 164 of 300 clients in the original study group, used arrests as the sole indicator of subsequent criminality, relied exclusively on self-reported follow-up data, and interviewed clients within a year of discharge—a short period of time not comparable to the clients' more extensive drug-using histories prior to admission to treatment. The "success" rate that Pin and his colleagues found is thus debatable on methodological grounds and tells us virtually nothing about the overall success rate that the program achieved. Such is the case with almost every other residential outcome study.
CLIENT FACTORS AND SUCCESS
Reform observed in clients after discharge may be more attributable to client characteristics and research designs than to program impact. For example, the absence of detoxification procedures using methadone or other drugs at residentials may encourage only those addicts with weak heroin habits to seek admission. Further, many of the recorded postdischarge "successes" of residentials may never have been addicted to narcotics at all. A large number of them are middle-class pot smokers and runaways, not really disadvantaged, long-time heroin addicts.
It remains to be demonstrated whether therapy in drug-free residential programs is more effective than ". . . that found in the coercive or custodial types of facilities in terms of eventual rehabilitation of residents and return to the community."34 In effect, residentials probably are no more effective than jails, prisons or community-based corrections such as probation.
CRC: A JAILHOUSE THERAPEUTIC COMMUNITY
Do- jails and prisons reduce heroin use among addict-inmates after release? Incarceration and the cold turkey withdrawal that usually accompanies it is at least a negative reinforcer. The jail experience brings home to the addict the physiological consequences of repetitive heroin use. Perhaps this reinforcement is best summed up by the phrase, "if you want to play, you have to pay." The analysis here is confined to the California Rehabilitation Center (CRC) at Corona, on the outskirts of Los Angeles. It is representative of nationwide "civil commitment" programs for addicts.
In 1958 California pioneered civil commitment procedures for court-declared heroin addicts. In this way government authority can force an addict to take treatment, regardless of his wishes. The civil commitment program in California was an updated version of the old Lexington—Ft. Worth model: establishment of a "therapeutic milieu" within a locked custodial facility (CRC is a decommissioned World War II naval hospital).
In 1961 California opened the CRC facility amid much fanfare and high hopes of breaking the cycle of heroin addiction. By 1978, thousands of addicts later, CRC had come under fire from all directions and was itself suffering from severe withdrawal symptoms:
. . . the CRC program is removing relatively few addicts from the streets of California. Only a small percentage of those committed to the program are being successfully rehabilitated. CRC is not preventing the spread of addiction [and] the elimination of the . . . program should be considered in view of its burden to the taxpayers."
Although the stated purpose of CRC is to provide an enforced drug-free therapeutic community for the "psychological rehabilitation" of "criminal addicts," the institution is really a prison. This reduces the effect of what little the institution has to offer the committed addict. Labeling inmates "residents" and the institution a "rehabilitation center" does not alter the fact that CRC is, following Goffman's usage, a total institution, admission to which can only be described ". . . as a leaving off and a taking on, with the midpoint marked by physical nakedness."36
Entrance to CRC is what Goffman calls a "degradation ceremony": the new inmate is completely stripped, buttocks spread and a finger probing for narcotics is inserted into the anus (or vagina). Then the "resident" is gowned in prison garb. The result is total and complete role dispossession. Such skin and internal searches do not keep drugs out of CRC or other prisons. J. J. Johnson, a former "N-number" parole agent ("N-number" means a caseload of addicts only) said, "You can make a connection in CRC easier than you can on the street ."37 Howard McGarrey, a state parole supervisor in California's San Bernardino County, told the press, "Sure, we've got heroin [in CRC]. It is a constant source of concern to us. . . . as long as you run a minimum security institution, you're going to have the problem of drugs coming in."38
Edward Bunker, a brilliant addict-writer who served time in a therapeutic community at the Federal Correctional Institution, Terminal Island, said:
Heroin is cheaper in Terminal Island than on the streets of Los Angeles. Narcotics is the number-one problem in this institution. . . . At least 40 inmates at Terminal Island are "hooked." Another 150 or more use heroin as they can afford it. . . . [I] spent $12,000 on narcotics within six months while imprisoned [at Terminal Island]."
Inmates no doubt use drugs to calm their anxieties while in institutions like CRC or Terminal Island. John Lopez, a former CRC resident, said: "Some of those cops at CRC are sicker than the inmates. You talk about hysteria and anxiety, man, CRC is full of it. I think the place should be fully exposed. "40 The guards in such institutions, said Bunker, have ". . . fixations on punishment [and] spend all their time trying to get some poor addict to urinate in a bottle."'"
The drive to "get loaded" within such institutions leads inmates to use forbidden drugs, whether it is pruno, a sickening alcoholic concoction made from sandbagged breakfast prunes, or heroin, barbiturates or cocaine. I have interviewed a number of individuals who first developed heroin addiction inside prisons and jails, not an uncommon circumstance. Bunker says, "My first 'fix' was given me in jail. For every addict cured in jail, two dozen are created."42
"THERAPY" AT CRC
InMates soon learn to despise CRC, like all prisons, and everything it claims to be doing for them. As a result, the so-called "therapeutic" aspects of the program, CRC's raison d' etre, are dramatically curtailed by the very context of the institutional setting. CRC's tall wire fences and operative norms place a barrier between the addict-inmate and the outside world to which he or she one day is supposed to return "cured."
Inmates, many of whom have been there before, know the quickest way out of CRC: "If you wanna walk, you gotta talk." The normal prison stance of "hold your mud," and "fight, fuck or hit the fence," is forgotten at CRC in order to impress counseling staff that one is "rehabilitated" and ready for release.
Group therapy sessions at CRC, which have their moments in terms of impact, are a standing joke among residents. Residents are well aware that one of the most important criteria for being released is to demonstrate in group sessions that one is aware of the "psychic disturbances" that the staff feels caused the narcotic addiction and, more important, that one is able to express in some kind of searching, groping or perhaps articulate fashion that this is the case. Group counseling provides one of the few occasions for serious dialogue between inmates and staff, but reports suggest that spectacular results should not be expected from such "therapeutic" encounters."'
The approval of the treatment staff is critical for early departure from CRC, and this approval comes primarily from "good behavior" in the "therapeutic community." The manifest function of CRC is to make the addict's reentry into the non-heroin-using community smooth and successful. However, the very existence of CRC as a separate institution for addicts and the group sessions for addicts underscore the inmate's self-concept as a separate kind of person. By a kind of suggestion process, addicts eventually come to view themselves as sick. This creates an unanticipated and very undesirable side effect in CRC and other treatment programs as well: The addicts are trained to percieve themselves as a class of men and women apart. Commitment to CRC or any other treatment program automatically and retrospectively effects crucial modifications in the individual's self-identity. Labeling the inmate an addict-criminal is a positive step in his progress toward a true criminal career.44 The effect of this stigma on addicts is such that their behavior becomes a self-fulfilling prophecy. Such treatment programs, especially in prisons, undermine the goal of reform.
STAFF PERCEPTIONS OF THE ADDICT WORLD
Though most inmates at CRC are working- or lower-class and half are Hispanic, the treatment staff is solidly middle-class and Anglo. The white, middle-class treatment counselor at CRC has the dominant and commanding view of the way "normal" life should be lived when the resident is released. The counselors have highly class-biased views on what constitutes "appropriate" behavior in the community of "normal" men and women, and the readiness of the inmate for release is based on these class-biased judgments. Most counselors have never seen the sprawling barrios of East Los Angeles or seen Watts at close hand, nor do they have a very sharply etched conception of pressures these communities exert on their returning citizens.
What benefits have been reaped by the millions of dollars poured into CRC and other civil commitment programs around the country? Few reviewers defend CRC. According to CRC's own figures, 20 percent of the addicts committed between 1961 and 1971 achieved a "success" accreditation: at least two drug-free years on the outside.45 John Kramer, former research chief at CRC, said the program ". . . has had very little success in rehabilitating clients . . ."46 and that "CRC does not help very many people stay away from heroin. . . . On the average CRC delays by perhaps a few months the return to heroin addiction."47
The majority of addicts in CRC are high school dropouts and do not possess the rudimentary qualifications for employment. Their parole agents do not spend much time seeking job opportunities for them upon release. A close friend of mine, who died from a massive heroin overdose several days out of CRC, was a three-time "graduate" of the institution. The "vocational training" he received in gardening at CRC was nothing that could have developed into a decent job on the outside (he was an excellent musician). CRC itself does not have much of a job development/placement program; residents are turned out to find employment on their own after release.
After the state of California spends more than $20,000 a year for each inmate at CRC, he is given about $100 at the gate and told to go home and report to his parole agent. Go home to what? To San Francisco, Los Angeles or San Diego where less than 20 percent will stay relatively "clean" during their first two years out of the institution? After release to middle-class parole agents holding bottles for urine samples and after standing cap-in-hand before wary employers unwilling to take a chance, the paroled CRC addict sees society as clothed in persistent harassment if not cruelest persecution. Relapse to heroin under such conditions is almost certain and understandable.
Clearly, then, CRC, like most non-custodial therapeutic communities, removes relatively few heroin addicts from the streets, and only a miniscule percentage of those committed to such treatment programs are successfully rehabilitated as measured by reduced drug use, reduced criminality and increased "stability."
Most "scientific" outcome studies of residential programs are narcissistic and self-aggrandizing and have the primary funciton of legitimating program continuation. Many therapeutic communities conduct self-serving measurements of themselves, using research strategies crafted to prove that their particular programs "work." Outcome research on residential programs is so shoddy or, if carefully designed, so unkind to program impact, that funding sources have tended to overlook outcome altogether and to focus instead on treatment process—numbers of admissions, client-counselor contacts, discharges, and so on.
It would be surprising if objective evaluation showed that more than 5 percent of those who come into contact with residential treatment programs are enabled to lead a reasonably drug-free, socially productive life as a result of the programs. No residential program has ever graduated more than an insignificant fraction of those admitted. Under such conditions, most therapeutic communities could be eliminated without great loss, considering their minimal direct benefits (and possible harm) to clients and the high costs of their services.
1. As examples see Paul A. Henningsen, The Role of Therapeutic Communities in the National Plan to Treat the Drug Abuser (Racine, Wisc.: The Johnson Foundation, 1973); and Judianne Densen-Gerber, We Mainline Dreams (New York: Penguin Books, 1974), the story of Odyssey House in New York City.
2. On classifying internal value structures of therapeutic communities, see Henry L. Lennard and Steven D. Allen, "The Treatment of Drug Addiction: Toward New Models," International Journal of the Addictions 8 (June 1973): 521-35; Jerome S. Miller, John Sensenig and Johnathan S. Raymond, "Value Structure as a Predictor of Type of Discharge Among Residential Addicts," International Journal of the Addictions 9 (January 1974): 127-36; Steven G. Cole and Lawrence R. James, "A Revised Treatment Typology Based on the DARP," American Journal of Drug and Alcohol Abuse 2 (January 1975):37-50; and Reginald G. Smart, "Outcome Studies of Therapeutic Community and Halfway House Treatment for Addicts," International Journal of the Addictions 11 (February 1976): 143-59.
3. William S. Aron and Douglas Daily, "Short- and Long-Term Therapeutic Communities: A Follow-Up and Cost Effectiveness Comparison," International Journal of the Addictions 9 (October 1974): 619-36.
4. Maxwell Jones, The Therapeutic Community (New York: Basic Books, 1953); see also his later work, Beyond the Therapeutic Community: Social Learning and Social Psychiatry (New Haven, Conn.: Yale University Press, 1968).
5. For the story of Synanon's early years, see Lewis Yablonsky, Synanon: The Tunnel Back (Baltimore, Md.: Penguin Books, 1967).
6. Edward M. Brecher and Consumer Reports Editors, Licit and Illicit Drugs (Boston: Little, Brown and Co., 1972), pp. 135-39.
7. The term is Erving Goffman's, from Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (New York: Anchor Books, 1961).
8. Stanley Einstein came to this conclusion after surveying residential directors. See his "Methadone Treatment: Views of Program Directors," in Fifth National Conference on Methadone Treatment: Proceedings, 1973, ed. National Association for the Prevention of Addiction to Narcotics (New York: National Association for the Prevention of Addiction to Narcotics, 1973), pp. 718-22.
9. For typical studies demonstrating high "split" rates, see Leon Brill, "Some Comments on the Paper 'Social Control in Therapeutic Communities' by Dan Waldorf," International Journal of the Addictions 6 (March 1971): 45-50; Dan Waldorf, "Social Control in Therapuetic Confmunities for the Treatment of Drug Addicts," International Journal of the Addictions 6 (March 1971): 29-44; Deborah Colburn and Kenneth Colburn, "Integrity House: The Addict as a Total Institution," Society 10 (May-June 1973): 39-45; Frederick B. Glaser, "Splitting: Attrition from a Drug-Free Therapeutic Community," American Journal of Drug and Alcohol Abuse 1 (December 1974): 329-48; David J. Bellis, "Jericho Home Evaluation," (Ontario, Calif.: West End Drug Abuse Control Coordinating Council, Inc., 1974); Vitali V. Rozynko and Kenneth B. Stein, "Social and Psychological Factors Associated with Length of Stay in a Drug Treatment Facility," International Journal of the Addictions 9 (December 1974): 873-78; and George W. Joe and D. Dwayne Simpson, "Retention in Treatment of Drug Users: 1971-1972 DARP Admissions," American Journal of Drug and Alcohol Abuse 2 (January 1975): 63-72.
10. Glaser, "Splitting," pp. 329-48.
11. Brill, "Some Comments," p. 48.
12. Time in treatment, for example, seems to be associated with client performance after discharge. See Emile Jean Pin, John M. Martin and John F. Walsh, "A Follow-Up Study of 300 Ex-Clients of a Drug-Free Narcotic Treatment Program in New York City," American Journal of Drug and Alcohol Abuse 3 (September 1976): 403-7.
13. George DeLeon, Sherry Holland, and Mitchell S. Rosenthal, "Phoenix House: Criminal Activity of Dropouts," Journal of the American Medical Association 222 (November 6, 1972): 686.
14. S. B. Sells et al., "A National Followup Study to Evaluate the Effectiveness of Drug Abuse Treatment: A Report on Cohort 1 of the DARP Five Years Later," American Journal of Drug and Alcohol Abuse 3 (October 1976): 545-50.
15. A number of studies explore the relationship between client characteristics and retention, including Aron and Daily, "Short- and Long-Term Therapeutic Communities"; George W. Joe and D. Dwayne Simpson, "Retention in Treatment of Drug Users: 1971-1972 DARP Admissions," American Journal of Drug and Alcohol Abuse 2 (January 1975): 63-72; and Rozynko and Stein, "Social and Psychological Factors Associated with Length of Stay."
16. On the change in treatment approach to hold "soft-core" opiate users in treatment, see Herbert J. Freudenberger, "The Therapeutic Community Revisited," American Journal of Drug and Alcohol Abuse 3 (January 1976): 33-42.
17. Densen-Gerber, We Mainline Dreams, p. 196.
18. Odyssey House retention data reported in "Is Odyssey House the Tiffany of TC's7" The Journal, (June 1, 1974), p. 5.
19. "Junkies are becoming a scarce commodity," say Thomas McCahill, Karen N. File, and Leonard Savitz, "On Counting (on) Addicts in the Criminal Justice System," in Developments in the Field of Drug Abuse: Proceedings of the National Drug Abuse Conference-1974, ed. Edward C. Senay, Vernon Shorty, and Harold Alksne (Cambridge, Mass.: Schendman Publishing Co., 1974), pp. 886-91.
20. Vincent J. Rinella, "Rehabilitation or Bust: The Impact of Criminal Justice System Referrals on the Treatment of Drug Addicts and Alcoholics in a Therapeutic Community (Eagleville's Experience)," American Journal of Drug and Alcohol Abuse 3 (January 1976): 550.
21. Narcotics Prevention Project, "Methadone Maintenance Letter of Intent," (Los Angeles: Narcotics Prevention Project, 1974, mimeographed), P. 3.
22. For the implications of diversion relevant to therapist-client relationships, see Robert G. Newman, "We'll Make Them an Offer They Can't Refuse," Fifth National Conference, 1973, ed. National Association for the Prevention of Addiction to Narcotics, pp. 96-99; Roger C. Smith, "Addiction, Coercion, and Treatment: Reflections on the Debate," in Developments in the Field of Drug Abuse, ed. Senay, Shorty, and Alksne, pp. 852-62; and Barbara Underwood, "The Conflict Between the Criminal Justice System and Addiction Rehabilitation Systems," American Journal of Drug and Alcohol Abuse 3 (January 1976): 59-61.
23. "Recommendations Designed to Help NY Programs Fulfill Their Stated Goals," The Journal (July 1, 1974), p. 1.
24. DeLeon, Holland and Rosenthal, "Phoenix House," p. 686.
25. See Kurt Weis and Michael E. Milakovich, "Political Misuses of Crime Rates," Society 10 (July/August 1973): 29; and the victimization survey reported in "Study Bares Profusion of Unreported Crime," Long Beach Independent Press-Telegram (April 27, 1972), p. A-18.
26. For a history and analysis of the New York City Narcotics Register, see J. J. Fishman, Donald P. Conwell, and Zili Amsel, "New York City Narcotics Register: A Brief History," International Journal of the Addictions 6 (July 1971): 561-69.
27. DeLeon, Holland and Rosenthal, "Phoenix House," p. 127.
28. Walter V. Collier and Yasser A. Hijazi, "A Follow-Up Study of Former Residents of a Therapeutic Community," International Journal of the Addictions 9 (December 1974): 819.
29. Daniel Casriel and George Amen, Daytop: Three Addicts and Their Culture (New York: Hill and Wang, Inc., 1971), chapters 1-3.
30. On spontaneous remission of narcotics addiction with onset of maturity, see Charles Winick, "Maturing Out of Narcotic Addiction," United Nations Bulletin on Narcotics 14 (January 1962): 1-7; and M. Snow, "Maturing Out of Narcotic Addiction in New York City," International Journal of the Addictions 8 (December 1973): 921-38. In fact, this is how most addicts "clean up," not through the ministrations of some program, but on their own.
31. This methodological warning comes from an experienced outcome researcher, Paul Cushman, Jr., "Detoxification from Methadone Maintenance," Journal of the American Medical Association 236 (November 8, 1976): 2171.
32. George Vaillant, "A 12-Year Follow-Up of New York Narcotic Addicts: III. Some Social and Psychiatric Characteristics," Archives of General Psychiatry 15 (March 1966): 599-609.
33. Pin, Martin and Walsh, "A Follow-up Study of 300 Ex-Clients," pp. 400, 403.
34. Brill, "Some Comments," p. 348.
35. Howard A. Katz, "California Rehabilitation Center: A Critical Look," International Journal of the Addictions 6 (September 1971): 550-51.
36. Goffman, Asylums, p. 18.
37. "California Rehabilitation Center," Long Beach Independent Press-Telegram (April 6, 1972), p. A-20.
38. McGarrey is quoted in ibid.
39. Edward Bunker, "Methadone in Prisons?" The Nation (November 8, 1975), p. 454.
40. Lopez's testimony appears in U.S. Congress, Senate Committee on Labor and Public Welfare, Alcoholism and Narcotics, 92d Cong., 1st sess., Pt 1, p. 110.
41. Bunker, "Methadone in Prisons?" p. 454.
43. On the failure of "counseling" in prisons, see Leslie T. Wilkins, Evaluation of Penal Measures (New York: Random House, 1969); Richard J. Carlson, "Rehabilitating Criminals," The Center Magazine (July/August 1973), pp. 27-31; Robert Sommer and Barbara A. Sommer, "Showcase Prisons: The Best are a Waste," The Nation (October 1974), pp. 369-72; Bunker, "Methadone in Prisons," pp. 454-55; and Robert Martinson, "What Works?—Questions and Answers About Prison Reform," The Public Interest 35 (Spring 1974): 22-54.
44. On labeling theory and its relation to heroin addiction, see Edwin M. Schur, Crimes Without Victims (Englewood Cliffs, N.J.: Prentice-Hall, 1965).
45. J. E. Berecochea, R. A. Bass and G. E. Sing, "Narcotic Addict Outpatient Program: One Year Followup," Research Report #33 (Sacramento, Calif.: California State Department of Corrections, 1971), pp. 6, 11, 33.
46. U.S. Congress, House Select Committee on Crime, Narcotics Research, Rehabilitation, and Treatment, 92d Cong., 1st sess., Pt. 2, p. 642.
47. This Kramer quote appears in "California Civil Commitment Program," Los Angeles Times (May 9, 1971), Pt. I, p.B.