Rational authority and the treatment of narcotics offenders

Abstract

The recent enactment of legislation in New York, New Jersey and California, as well as federally, for civil commitment programmes, has forced our attention increasingly on one of the components of all such legislation; namely, the use of "compulsion ", "coercion ", "constructive coercion" 3 or "rational authority" in the treatment of narcotics addicts. Whatever one may term this element, in its simplest form it involves the rehabilitation of addicts on an involuntary rather than voluntary basis. We prefer the term "rational authority" 4 because these programmes derive their legitimate coercive powers through the authority of the courts and are rational in the sense of utilizing this authority in a humane, constructive manner, relating the means of authority to the ends of rehabilitation.5

Details

Author: Louis LIEBERMAN , Leon BRILL
Pages: 33 to 37
Creation Date: 1968/01/01

Rational authority and the treatment of narcotics offenders *

Louis LIEBERMAN1
Leon BRILL2
Washington Heights Rehabilitation Center, New York City

The recent enactment of legislation in New York, New Jersey and California, as well as federally, for civil commitment programmes, has forced our attention increasingly on one of the components of all such legislation; namely, the use of "compulsion ", "coercion ", "constructive coercion" 3 or "rational authority" in the treatment of narcotics addicts. Whatever one may term this element, in its simplest form it involves the rehabilitation of addicts on an involuntary rather than voluntary basis. We prefer the term "rational authority" 4 because these programmes derive their legitimate coercive powers through the authority of the courts and are rational in the sense of utilizing this authority in a humane, constructive manner, relating the means of authority to the ends of rehabilitation.5

This use of authority in the rehabilitation of offenders is not, in itself, a new technique; since, for many years, persons have been placed on probation as an alternative to imprisonment, while others have been released from prison on parole before completion of their sentences. What has been changing recently is the emphasis on the use of authority as a punitive end-in-itself within the large caseloads of probation and parole officers, to the use of authority as a means for intensive casework within smaller caseloads for rehabilitation purposes. As a consequence, probation and parole officers are increasingly able to use the authority of their office as a lever to structure the supervisor-supervisee relation ship and firm up the probationer's or parolee's emotional supports in order to effect desired behavioral changes. The officers may accomplish this through their greater involvement in the addict's day-to-day activities because of the smaller caseloads and opportunity for more intensive help. Evaluations of such programmes for narcotics addicts in California, New York State, Philadelphia and elsewhere indicate that, when addicts are thus supervised, there appears to be less likelihood of their return to full addictive behaviour and criminality [1] .

* This paper is the first of a series describing the rationale and methodology of the Washington Heights Rehabilitation Center. Subsequent papers will present the statistical findings concerning the effectiveness of the variables used.

1 Social Scientist at the Center.

2 Project Director of the Center and Research Associate, Albert Einstein College of Medicine.

3Soden, Edward W., "Constructive Coercion and Group Counseling in the Rehabilitation of Alcoholics," Federal Probation, September 1966.

4 This term has been used in a similar sense, though in a different context, by Eric Fromm in Escape from Freedom, Religion and Psycho-analysis and other writings.

5Although other forms of the use of authority, both personal and professional, have been utilized by public health nurses, social workers, and others in the helping professions in hospitals, courts, Departments of Health, this is not the type of authority dealt with in this paper, which emphasizes court authority.

The Washington Heights Rehabilitation Center, which has been investigating the use of rational authority during the past five years, evolved out of one of the authors' experience as Director of the New York Demonstration Center, sponsored by the National Institute of Mental Health from 1956-1961 [2] ; and an earlier follow-up study of dischargees from the Public Health Service Hospital in Lexington, Kentucky, sponsored by the Bureau of Medical Services of the U.S. Public Health Service between 1952-1961 [3] .

The Washington Heights Rehabilitation Center was a five-year programme in narcotics addiction jointly sponsored by the National Institute of Mental Health of the United States Public Health Service, the New York City Department of Health, and the New York City Community Mental Health Board. Its organization is rather complex: funding was through a contract negotiated between the National Institute of Mental Health and the Department of Health through its Medical and Health Research Association. The project was operated under the supervision of the Project Director, who was immediately responsible to the New York City Narcotics Coordinator, as well as to the Chief of the Community Services and Research Branch of the National Institute of Mental Health. Staff included four social workers of whom one was supervisor; four public health nurses, including a supervisor; a Research Unit of two sociologists, research analyst, interviewer and coders; a psychiatrist-consultant and physician to insure full medical evaluation of patients; as well as clerical staff, with full use being made additionally, of the health, welfare and vocational resources of the City.

Generally stated, the goal of the programme was to learn how the Department of Health could co-operate with a court agency to manage the narcotics addiction problem in a circumscribed area of the City - in this case, Washington Heights. The rationale for the programme derived from the cumulative experience in various parts of the country that the use of compulsion plus case-work help in the local community appeared to constitute the best known means, at that time, for rehabilitating addicts. The Center worked exclusively with male probationers of all ages referred by the Office of Probation of the Courts of the City of New York. The programme was constructed as a neighbourhood-based, service-action project, with provision for built-in evaluation and research.

What was unique about the programme of the Washington Heights Rehabilitation Center was the kind of co-operation, i.e., "joint-management" envisioned between the Probation Office and a community-based agency offering intensive services. This "joint-management" was used in the experimental exploration of selected techniques such as "reaching-out" and "use of authority ". What was also significant about the Center programme was our emphasis on socio-cultural studies in the local neighbourhood and use of a public health approach; and, among other aspects, not the least, emphasis on research and evaluation, and study of addicts in their own environment.

As noted earlier, the Washington Heights Rehabilitation Center was an outgrowth of two earlier studies. It had been concluded from these studies that one of the problems in the treatment of drug addicts was the apparent inability of addicts to sustain prolonged relationships with a therapist or caseworker on a voluntary basis and to involve themselves meaningfully in treatment on a regular basis. In order to overcome this problem, a solution was proposed, based on the possibility of using probationary supervision of drug addicts as the central holding and treatment technique. Consequently, the programme of the Washington Heights Rehabilitation Center was designed to demonstrate and test the value of combining the use of authority by a probation officer with the more intensive techniques of social casework including reaching-out to addicts and their families. By reaching-out, we mean the following: narcotic addicts have been found to be "not motivated" in the sense of middle-class patients. They often come from multi-problem, lower-class families too apathetic to seek help. Their so-called "lack of motivation" may actually be the different way of life of lower-class groups, focused around their immediate impulsive needs rather than long-term goals. They do not come to agencies of their own accord (nor are agencies always ready to receive them), or on a regular basis, but rather at times of crisis. It was therefore assumed that we would need to reach out to them, follow them into their homes and into hospitals and jails, wherever they were to be found, in order to maintain the treatment relationship, involve them more consistently in the rehabilitation process, and observe the impact of our intervention on treatment.

This "aggressive case-work" was viewed as an ancillary form of the use of rational authority, the fulcrum and primary variable in our programme. It was felt that reaching-out efforts coupled with the use of rational authority might help us cope successfully with the addict's "lack of motivation", apathy, and overcome his resistances to changing his deviant way of life. It was conjectured that rational authority, in the sense of providing a firm structuring of the treatment relationship, setting limits, controls, and a graduated series of sanctions, might minimize the addict's actingout behaviour, help him grow within this structure, internalize the controls he lacked, and hopefully give up his destructive way of life in time.

In considering further what components were involved in our use of rational authority, we noted the following elements:

  1. First, the concept of authority as a holding device, i.e., a means of holding the patient in a therapeutic setting. This was accomplished for us by the fact that our cases, approximately 95 in all (with an additional control group of 95 cases carried by Probation alone), were male addicts who had been convicted by the Court of a criminal or drug-related act, and had subsequently been placed on probation. As part of the conditions of probation, the probationer was required to come to the Washington Heights Rehabilitation Center and co-operate with a Center worker and probation officer in their "joint-management" decisions. The holding function of rational authority proved to be of great importance since we know that addicts are often caught up in a life of frequent crises, where the impulse to run from the therapeutic setting and act-out is often overpowering as soon as their anxiety or depression is mobilized. Consequently, by holding the addict to the treatment setting through his perennial crises, we provided the basis for building a meaningful relationship between the addict and worker.

  2. Rational authority was also employed as a structuring device: immediately after the addict was placed on probation, a joint conference was held with the probationer, probation officer, Center worker and, if possible, members of the probationer's family. At this meeting, the probationer was reminded of the conditions of probation to which he had agreed before being placed on probation, and the consequences of violation of these conditions. He was further informed that all decisions made in his behalf (hopefully, also, with him), would be made jointly between the worker and the probation officer. As indicated, this decisionmaking process was termed "joint-management". The addict was informed that contrary to the kinds of relationships he might have experienced in the past with other agencies, there prevailed a full sharing of information between the worker and probation officer at the Washington Heights Rehabilitation Center; that the usual notion of confidentiality of data would thus not be maintained here. The rationale for this kind of sharing was derived from previous experience with drug addicts; namely their tendency to manipulate the probation officer and worker, and play them off against each other (" wedging "), in the service of the addicts' impulsive needs, as they had formerly played one parent against the other.

  1. By rational authority, we also meant communication to the addict that the worker represents an extension of the authority of society, in that the addict was expected to conform to certain behaviour such as abstinence from drug use, criminal as well as anti-social behaviour; and that the violation of these standards could not be tolerated.

The central focus of the use of authority was to devise a series of graduated sanctions or coercions which would brake the addict's acting-out behaviour, help him internalize controls and be rehabilitated even, and often, in spite of himself. In practice, the rehabilitation worker, either a social worker or public health nurse, attempted to utilize the authority derived from their association with Probation in any number of ways at a point in the relationship prior to the addict's slipping back into his old behavioural patterns. Workers thus employed varying degrees of personal and professional authority, ranging from mild disapproval, through acts indicating disbelief in the addict's statements, to the ultimate of returning him to prison if this was therapeutically and practically indicated by virtue of the seriousness of his deviant behaviour. Fortunately, this was not found necessary in most cases.6 To cite some illustrations, when the worker felt that the addict was beginning to use drugs again, she might tell him that he must submit to a thin-layer chromatography urinalysis test. The addict did not take this test voluntarily, but was compelled to do so as one of the conditions of probation. He was not given prior warning and thus had no opportunity to prepare himself for it by abstaining from drug use for a few days. If the test results showed up "questionable" or "positive", the worker would then attempt to determine the extent of drug use; and, if it approached the level of heavy or continuous use or if the probationer appeared readdicted, the worker could then compel him to be hospitalized. Refusal to go into a hospital could con stitute a violation of the conditions of probation. The worker might also, under other conditions, insist that the addict seek employment, or avoid association with other addicts or refrain from any other behaviour the worker felt detrimental to the probationer's recovery at this point.

6With the programme terminating within a month and the average time in programme being 18 months, only 9% have thus far had to be returned to prison as a consequence of the use of rational authority in our programme.

It should be re-emphasized that the addict had been told, at the initial structuring conference, that he must co-operate with the worker and probation officer in any decisions made in his behalf; and this was reinforced in many of his subsequent contacts with the Center when he, from time to time, tested limits by refusing to co-operate or come to the Center. At such times, the worker employed various devices, depending upon her own creativity and professional skill, in utilizing authority to meet the challenge of the patient's testing-out and resistance or weakness. For example, the worker could make the authority more visible by bringing the Probation officer more closely into the picture: the probation officer and the worker might go together into the patient's home and talk to him and his family about his current acting-out behaviour. The worker might also remind the probationer, by showing him the card on which his conditions of probation were outlined, of what he had agreed to when being placed on probation. The worker could take a very firm stand, when necessary, by making it clear to the addict that he was losing control, and his behaviour, unless checked immediately, would ultimately lead to violation of probation and remand to jail. The worker could further force him to take certain actions she felt indicated, such as hospitalization, by using her derived authority as a lever.

While it may be argued that what we have presented here thus far is not very different from the customary practices of probation or parole officers, it should be reiterated that these methods were for the first time being employed by the Center workers themselves, who shared the authority obtained from their association with a probation officer and the Courts. It was an important function of this project to demonstrate how a private agency, by working in joint-management with probation officers, could utilize this borrowed authority in the case management of offenders, and work conjointly with probation officers to help reinforce the goals of supervision and rehabilitation.

As a result of our preliminary clinical experience at the Washington Heights Rehabilitation Center, we believe that the firm structuring of the relationship which was developed, the setting of limits, the direct confrontation with the realities and legitimate requirements of society, as represented with the therapeutic context we offered, has relevance for all offenders and "character disorders" and can be of specific benefit in the rehabilitation of narcotics addicts.

We know from past experience that all the addicts we encountered had problems in relating to authority and authority-figures. All too often, however, their initial confrontations with authority-figures and institutions followed upon earlier traumatizing experiences with either punishing and rejecting or weak, over-indulgent and inconsistent parents; or later still with the, to them, depersonalized abstract laws of society, which reflected the distance from their own parents. These laws might be crystallized in the person of the policeman, who, in carrying out the dictates of society, was seen by the addict as punitive, irrational, dishonest, corruptible, impersonal, and uncaring. For many of our patients, then, it becomes possible for perhaps the first time, in spite of their initial fear of closeness, to relate to another human being who cared for them yet did not use them as their parents had, and could be rational, helpful, and non-destructive.

We have not thus far discussed our success - a question that is, of course, of the highest interest when operating a demonstration programme, yet difficult to specify. As mentioned previously, the primary purpose of the Washington Heights Rehabilitation Center was to test the effectiveness of utilizing the two treatment variables of "reaching-out" and "rational authority" in working with addicts. We therefore built into the programme detailed provision for research and evaluation. While we cannot now by any means claim that we have found the answer to the treatment of narcotic addicts, we do know that this approach works for some. We have been primarily interested in learning for whom this particular kind of programme works; and, obversely, what types of addicts do not respond to the use of rational authority. There is a great need at present to learn how to match addict types with treatment types, and in time to develop a typology for the differential diagnosis of addicts. We are interested in elaborating techniques for the use of authority through a series of sanctions or coercions; so that, in designing future programmes for those addicts for whom we find it applicable, we can develop a greater battery of treatment tools with which to offer our traditional services within a firm framework which "potentiates" or maximizes the use of these generic services.

In considering what one may appropriately deem "success" in the field of narcotic addiction, we have been quite clear about the need to modify our traditional insistence on total immediate abstinence for addicts as the single criterion of success. Our programme is predicated on the belief that it is better for a person not to be using drugs than to be using them. We have no quarrel with other programmes which attempt to stabilize the addict on a methadone-maintenance basis (one of the authors has, in fact, helped conduct such a programme at the Albert Einstein College of Medicine [5] . We believe these should be tried and properly evaluated a s to their usefulness for certain kinds of addicts. We at the Washington Heights Rehabilitation Center have been more concerned, immediately, with exploring the possibility of enabling addicts to function in the community without the aid of narcotics. At the same time, we realize that it is unreasonable to expect an individual who has resorted to narcotics as a means of adapting to the community and coping with severe emotional problems and social pressures to surrender, totally and immediately, a vital defense and mechanism which has helped him function for years. Just as a considerable period of time was required before he became fully involved in the "addiction system ", during which time a tolerance was built not only for the physiological effects of drug use, but also for the negative self-image of the "junkie" and the associated way of life, the "hustling syndrome"; so we believe that an undetermined period of time must elapse before the addict can free himself of his chronic illness and its associated activities and behaviour, and function in the community without leaning on drugs [6] . We have elsewhere described this period as the interval during which the addict must build up his tolerance for abstinence. It is through the holding function of rational authority that we can engage an addict long enough to develop his tolerance for abstinence.

As part of this process, we need to understand that addicts will experiment with the condition of being abstinent without always being successful. It takes time to grow out of the addiction system just as the addict needed to go through a series of stages to get into it. Thus, when we discover that he is beginning to use drugs again or that he is involved in criminal activity, we neither reject him nor automatically drop him from the programme. Instead, we anticipate these slips as occurrences to be expected; and, further, as warnings to the worker that the addict must be brought closer into the relationship, and the use of authority made even more explicit to prevent his slipping back into his old patterns, since he is himself unable to check his antisocial behavior without the aid of strong outside supports and controls.

During the past two years, our impression of the value of a rehabilitation setting utilizing the kinds of structures and techniques we have devised has been overwhelmingly positive. As part of our original design, the final evaluation will not be completed for another half year; and a further evaluation of post-agency community follow-up will be required to determine whether or not the behavioural changes which occurred while the patient was in the Center programme continue when he is no longer a probationer and in treatment. Preliminary analysis of our data indicates that the number of those who reverted back to their old negative adaptations is very low. The majority of patients are working or in school, or both, at the present time. We feel quite certain that our early impressions will be sustained through the final evaluation of the programme.

We feel it important to point out, however, that, even if we had not been successful in the majority of cases, we would still feel we had accomplished a great deal in learning for whom this kind of programme does or does not work. We believe that service is not enough. One of the serious failures in most prior work with addicts has been the tendency to offer service without any attempt to evaluate systematically the effectiveness of the programme and relevancy for different types of addicts. It is this sort of evaluation which will help us accumulate the scientific data we need to develop criteria of treatment and a typology of addicts and treatment programmes as well as a systematic collection of demographic data, uniform or comparable instruments, valid interchanges of information, replication of studies, co-ordination, and, hopefully at length, primary prevention.

In our discussion, we have not, thus far, stressed the need to devise programmes in which the cost of the programme is justified in terms of the numbers of successfully rehabilitated persons. If a thorough cost analysis of all programmes were to be made today, we might find it difficult to justify the existence of many of our agencies. Yet from a public and private standpoint, cost analysis is a primary consideration in programme planning. The anticipated assumption of far greater help by New York and other states and the Federal Government in connection with the recently enacted civil-commitment programmes makes this point especially compelling.

To conclude, the use of rational authority will, in future, be of increasing importance in two ways. First, the greater emphasis on civil-commitment programmes makes it inevitable that some sort of probationary supervision will be demanded for the majority of addictpatients. In this connection, what we have learned at the Washington Heights Rehabilitation Center and will report over the next year, should have great relevance. We further believe that the use of authority as a central structuring and holding device can be employed in a variety of programmes including chemotherapy programmes such as methadone-maintenance and cyclazocine. (One of the authors has, in fact, used it successfully as a cornerstone for these programmes at the Albert Einstein College of Medicine) [4] . Similarly, Daytop Village, a Synanon-type facility, has used rational authority as a holding technique for approximately half of their patients. We believe that, for many programmes and treatment modalities, far smoother programme operation, sustained contacts, and maximization of the services offered are bound to ensue if rational authority is established as a fulcrum of treatment.

The authors wish to thank the National Institute of Mental Health for its support of this project through contract No. P.H.43-62-454 with the Medical and Health Research Association of New York City.

References

001

Diskind, Meyer H. and Klonsky, George, Recent Developments in the Treatment of Paroled Offenders Addicted to Narcotic Drugs, New York State Division of Parole, Albany, 1964; Burkhart, Walter R. and Sathmany, Arthur, Narcotic Treatment Control Project, Research Report No. 19, Phases I and II, Research Division, Department of Corrections, State of California, Sacramento, 1963; Konietzko, Kurt, "Interim Report of the Philadelphia Parole Narcotic Project", Commonwealth of Pennsylvania, Board of Parole, presented at twenty-fifth Meeting of the Committee on Drug Addiction and Narcotics of the National Research Council, February 1963.

002

Duvall, Henrietta J., Locke, Ben Z., and Brill, Leon, "Followup Study of Narcotic Drug Addicts Five Years after Hospitalization", Public Health Reports, Vol. 78, No. 3, March 1963.

003

Brill, Leon, "Rehabilitation in Drug Addiction", Mental Health Monographs, U.S. Department of Health, Education and Welfare, Public Health Service, National Institute of Mental Health, Maryland, May 1963.

004

Lieberman, Louis, "Current Trends in the Rehabilitation of Narcotics Addicts", to be published in Social Work, Journal of the NASW.

005

Brill, Leon, and Jaffe, Jerome H., "The Relevancy of Some New Treatment Approaches for England", to be published in The British Journal of Addiction, Spring 1967.

006

Alksne, Harold, Lieberman, Louis, and Brill, Leon, "The Life-Cycle of Addiction", to be published in the International Journal of the Addictions.