From chaos to a structured therapeutic community: Treatment programme on Emiliehoeve, a farm for young addicts

Sections

Introduction
History
Preliminary results
Summary

Details

Author: Martien KOOYMAN
Pages: 19 to 26
Creation Date: 1975/01/01

From chaos to a structured therapeutic community: Treatment programme on Emiliehoeve, a farm for young addicts

Martien KOOYMAN Psychiatrist, Department of Preventive and Social Psychiatry, Erasmus University, Rotterdam

Introduction

Although exact data do not exist, frequent readmissions and referrals of young addicts to outpatient clinics after discharge from psychiatric wards of mental hospitals at The Hague suggest a failure in the current treatment programme similar in range to the 90 per cent or more found in the Public Health Service Hospital at Lexington, Ky., U.S.A. (Hunt et al., 1962 [1] ; Duvall et al., 1963 [2] ; Vaillant, 1966 [3] ). In February 1972 a new treatment centre for young addicts was opened in Emiliehoeve, a farmhouse situated in the grounds of the "Bloemendaal" mental hospital in The Hague. The project was started as a therapeutic community where, in accordance with the ideas of Maxwell Jones [4] , the ability to maintain stable relationships with others and the ability to find one's proper place in society were considered important factors preventing a relapse to drug abuse. It follows that they are the main focus of attention.

History

The history of the centre can be divided into five stages:

Stage 1. At the outset the programme was not strictly applied. Group therapy sessions and community meetings were the only obligatory activities, the former being held three times a week, mainly on the lines of psychoanalysis. Tranquillizers and sleeping pills were administered during a period following detoxification. In most cases detoxification from illegal drugs or methadone was carried out in award of the adjoining mental hospital and not on the farm. Working in the garden and in the house was encouraged by the staff. Some time was spent on recreational activities such as painting, woodcarving and sports under the guidance of a part-time staff member. The initial group consisted of eight boys who had a history of multiple drug use, amphetamines being the main problem. All plans were discussed by the entire community. Decisions were taken collectively by the staff and patients in a democratic way. After four months of experience the staff arrived at the following conclusions:

  1. Motives for seeking admission to the centre could be other than the wish to stop using drugs, for instance, to stay out of prison, to be able to pay off debts out of social allowances still received after admission, to become clean in order to start a cheaper habit, to continue using drugs with a holiday in the country.

  2. Boys not admitted on a voluntary basis continued using drugs and proved to have an adverse influence on the group. On occasions when one member of the group went out to buy drugs, nearly all the others also relapsed to drug use upon his return.

  3. When the group had not been participating in daily activities, the tendency to take drugs was far greater than on work days.

  4. The programme on the farm had to be more strictly structured. After two months a token economy system was introduced in order to stimulate activities on the farm, and it was thereupon found that relapses to occasional drug use decreased.

  5. Cohesion within the group appeared to be necessary in order to obtain worthwhile results from the therapy programme.

  6. In order to appraise the success of this form of treatment, a follow-up study is necessary.

Early in June 1972 the group was dissolved as the treatment system was seen to be ineffective. Using drugs in the comfortable setting of the farm had become a mere substitute for using drugs in the streets. One positive outcome for the staff was a definite lesson in "what not to do"; it helped the staff to get a clearer idea of the direction in which a treatment centre for addicts must be run.

Stage 2. On 13 June stage two began. A new group was formed comprising one member of the initial group and new members that had to pass a stricter selection procedure. Girls were also admitted. New members selected for admission to the centre were first seen by a psychiatrist at the outpatient clinic for drug addicts at The Hague. Only if they seemed genuinely interested in breaking their drug habit were they given a chance of visiting the centre on special appointment. Upon introduction to the centre members had to be drug-free. If necessary, they were sent for a few days or a week to a general psychiatric ward for detoxification. People not joining of their own accord were excluded. Final selection was made following an interview at the end of the first day the addict had been taking part in the programme. If he still wished to stay, conditions for his sojourn were discussed and measures agreed upon that would be taken if he relapsed into his drug habit, or if he left without consent of the group. So began the second stage, gradually leading to the present mode of treatment. Group therapy was still carried out in the conventional way. Residents were encouraged to discuss their problems, but in this period there were still many incidents of physically violent behaviour, occasional drug abuse and a general lack of discipline.

From the outset staff had only reacted to positive behaviour, not at all to negative behaviour. As a result there was an escalation of violence and negative behaviour generally. Eventually this method was discarded as ineffective and even destructive. The fact that staff did not react to destructive behaviour was interpreted by the residents as rejection or lack of concern for them. Individual therapy sessions for residents were also discontinued as residents tended to manipulate the staff and avoid group confrontation.

Controlled medication was still continued; residents were given tranquillizers and sleeping pills, without any change becoming apparent in their behaviour. A lesson was learned that casual sexual intercourse between residents was an easy way out for them to avoid genuine concern for each other; so a decision was made that sexual contact would only be tolerated in more meaningful relationships.

The turning point for the treatment centre was the participation by three members of the staff in a marathon encounter group, led by Denny Yuson, an ex-addict and former director of a Phoenix House in New York and of Phoenix House, London, which are therapeutic communities for ex-addicts (M.S. Rosenthal et al., 1969 [5] ). This led to the introduction of encounter groups instead of conventional group therapy, and was the beginning of stage three.

Stage 3. In the second half of July 1972 all medication was stopped and the community was proclaimed drug-free. All conflicts were voiced in encounter groups where the residents were allowed to confront each other in a strong positive way on negative behaviour and attitudes. For the first time they began to explore their own feelings, accept them, learn to express them and cope with them in times of stress. An incessant demand was made on the individual through the encounter group to be honest in his relations with others. After introducing programme encounter group meetings three times a week, overt destructive behaviour, physical violence and suicidal attempts that had previously occurred-especially after group therapy meetings-gradually disappeared. Before the adoption of encounter group techniques, feelings were discussed instead of being merely expressed. Primal scream techniques were introduced in September 1972, after the visit of staff members to groups led by Dan Casriel, one of the founders of Daytop Village in New York (Casriel, 1971 [6] ). Traumatic experiences from the past can be emotionally relived and dealt with by screaming (Janov, 1970 [7] ). At the same time the staff made an effort to obtain the maximum information from people working in drug-free communities; visitors were invited from Phoenix House and Daytop Village in New York and from communities in England. Speaking engagements by residents were introduced, while older residents were allowed to follow evening courses.

In August 1973 a foundation called Maretak was established to provide funds for a halfway house in The Hague. Here residents from the therapeutic community could prepare their re-entry into society after completing the treatment programme and after making headway in terms of a job-whether on the farm or away from it, or in the form of further education. At the centre visits and telephone calls from friends and relatives were prohibited until residents had followed the programme for four months; a similar condition applied to a person's first day away from the centre: he was not allowed to contact his old friends or parents, or to visit his old haunts. This measure was introduced once it was discovered that there was a high risk of relapse when a relatively new member was confronted with his recent past or with his parents.

Residents on the farm were given more responsibility. A co-ordinator in charge was elected jointly by the staff and residents, and made responsible for the delegation of all household tasks and activities, such as biological dynamic gardening and furniture making. Heads for these projects were selected in the same way. Although this measure had a marked positive effect, some residents used the democratic system as a device for escaping responsibility. They would for example vote in a co-ordinator from whom they could expect very few demands. It was noticed that decisions taken jointly by staff and residents in a democratic way could prove to be anti-therapeutic, for instance in allocating the work, approving week-end leave or keeping pets. When work assignment was largely left to the decision of residents it led to the formation of sub-groups on the farm. Residents appeared to hesitate to cancel week-end leave requests from their fellow residents, since their own requests might be similarly treated on another occasion. Pet animals were used as a means of avoiding contact with fellow residents.

Although decisions were taken by the whole community, residents tended to decline responsibility for the daily activities on the farm. It was felt that more pressure was required for residents to learn to take responsibility and change their attitudes, behaviour and life-style, so that they might cope with stress and the demands of society after discharge from Emiliehoeve. In September 1973, during a visit to the community by Denny Yuson, who had been engaged as a consultant to the staff, a marathon encounter group meeting was held under his guidance, with staff and residents present. This experience brought about the present structure.

Stage 4 and Stage 5 (present situation). Stage four began with the elaboration of a detailed work programme as described below, leading up to the present situation (stage five). Stage five started with the opening of an induction centre in The Hague on 15 January 1974. The programme as so far developed, can be seen as the product of learning from numerous errors. Many approaches and methods were adopted only to be discarded in favour of more meaningful concepts - concepts designed to make firm positive demands on the addict to change, while providing a structured environment where he can explore, learn and grow. The token economy system was abolished as it had turned out to be a means of avoiding direct confrontation of staff members and residents, in disregard of the philosophy of the encounter groups. The system set up in September 1973 was based on new insight and experience gained in the earlier stages of development. It is worth mentioning them in detail:

1. The Work Programme with a hierarchical structure is intended to achieve two things:

  1. To give a resident the opportunity of exploring, accepting or even seeking more responsibility for himself and others; to permit him likewise to take part in the running of his home.

  2. To give a resident the opportunity of creating stress situations where he can experience his own problems and he and others can use the information gathered to heighten awareness in encounter groups, thus making them dynamic.

A new resident enters the structure at the bottom of the hierarchy; his progress in the structure and the responsibility he acquires are a measure of his personal growth. The resident has a full working day in one of the departments in the community. If he fails in responsibility or abuses his position in the structure, he is fired by the staff and starts again at the bottom. (For structure pyramid, see figure A.) The structure, also permits of the formation of other departments as the community grows larger so as to give the same kind of learning experience to others. As a resident becomes more responsible with time and effort, he may become co-ordinator, with responsibility for the entire community, accountable only to the staff.

Decisions of a therapeutic nature like job changes and weekend allowances emanate from the staff and are carried out without questioning. The situation is balanced through the encounter groups where there is no structure, and staff as well as residents are open to questioning and confrontation.

Finding work to occupy the departments is not a problem at Emiliehoeve. There are calves, sheep, horses, pigs, goats, chicken and rabbits to be cared for. Biological dynamic gardening comes within the sphere of the farming department, in which emphasis is laid on growing clean food, creativity and learning how to live within, and improve, the natural environment rather than destroying it. The household department prepares all food and keeps the house clean. The construction department does maintenance work and repairs buildings and installations. It is also employed in construction work and furniture making. The administrative department does the typing and tries to obtain articles for the farm cheaply from outside firms and individuals. An opjutter (expediter) supervises all department heads.

2. Discipline: Staff members are responsible for higher levels of discipline such as job changes, withdrawal of privileges or the decision to discharge someone from the programme. But at the residents' level members apply their own discipline by making each other aware of negative behaviour, using encounter groups to express their negative feelings for each other or recommending serious measures to be taken by the staff. The core of the disciplinary system is care and concern, without which most similar systems fail. If a resident did not very clearly see that what was being done was done in an endeavour to make him see "himself" and get him to change his life-style, he would probably leave, which is a possibility open to him at all times. What keeps people in a programme like this one is the feeling of care behind the decisions taken and the learning experience provided thereby.

3. Group therapy: In the encounter group a resident receives most of his therapeutic experience. Using methods from Synanon and Phoenix House the encounter group could be said to be the "soul of Emiliehoeve". Here residents learn how to explore their problems in relation to themselves and other people. They learn to discover and explore emotions and to cope with them. This occurs through confrontation of their behaviour by the rest of the group. The confrontation is forceful and the value system learnt helps the resident to discard previous ways of behaviour in favour of a much more positive approach to life (Yablonsky, 1967 [8] ; Lieberman et al., 1973 [9] ). In addition to this experience residents can participate in Primal Scream groups if they apply for admission and if the staff think that it is appropriate.

4. Seminars: These constitute the intellectual balance to the primarily emotional experience of encounter groups. Residents are encouraged to teach each other all they know about anything - and also to invite speakers from the outside world to talk to them on subjects they are interested in. The staff also use seminars to transmit to residents some of the information they are presently acquiring.

5. Other activities: The clinical staff, the director and 2 assistant directors of whom one is male and one is female, use the services of specialist advisors (begleieders) in arts such as painting, sculpturing and drama as well as in agriculture. Apart from being involved in these areas residents take part in sports, games and yoga lessons. Cultural outings to museums and theatres are another feature of the programme.

6. Rehabilitation and prevention : Seen as a whole the programme consists of two parts: one deals with rehabilitation and the other with prevention. In order to be rehabilitated a resident undergoes:

  1. A strict screening procedure before he may enter the community;

  2. An intensive treatment period in the community;

  3. A re-entry period in which he "detoxifies" from the intentional "addiction to the therapeutic community" and learns to cope mainly on his own. During the reentry period the resident lives in the halfway-house "Maretak" in The Hague.

For prevention purposes the programme keeps in touch with the local community by:

  1. Accepting speaking engagements about the programme in front of professional bodies, schools, colleagues and parents;

  2. Forming a group of "Friends of Emiliehoeve", who support the programme.

  3. A group of parents of residents has also been formed who meet fortnightly to become aware of the fact that their own behaviour is usually part of the problem.

7. Extension of capacity: In the beginning of 1974, when ex-addicts could be added to the staff and more than one encounter group held at the same time, it was possible to increase the number of residents to more than 10. Since the 15th January the induction programme is being operated more intensively than before. The induction and information centre is run on a daily basis and its object is two-fold:

  1. To increase the number of residents from 10 to 20;

  2. To employ senior residents in the task of confronting the "addict in the street" and providing information to anyone interested in joining the programme.

Detoxification takes place as the addict visits daily the induction centre which is accessible to inmates from hospitals and prisons. In most cases, however, the addict detoxifies in his parents' or friends' home where he is sure drugs are not offered to him. No medicines are used to alleviate withdrawal symptoms. On 1 December 1973 an ex-addict was added to the staff as an adviser; he is the former director of a therapeutic community in England and his job is largely to train senior residents in their future responsibilities as staff members in the community and on the re-entry programme.

8. Re-entry. The first resident entered the halfway house "Maretak" in February 1974; a comprehensive programme was started for all those ready to begin life in the re-entry halfway house, aiming at:

  1. Continued education in the form of day school or evening classes.

  2. Financial independence by way of acquiring a job outside or inside Emiliehoeve.

  3. Community commitment by returning occasionally to run groups or seminars for residents at the farm.

  4. A commitment to social life by encouraging relationships with persons outside the community.

  5. Staff training for those who wish to work as staff in the community.

Preliminary results

A follow-up study is being carried out on all residents who attended the programme since its inception in February 1974. Their number, originally restricted to 10, was increased to 20 during the first half of 1974; this is the maximum the building can take. From February 1972 to July 1974 a total of 64 addicts was admitted; most left the programme before the halfway house was functioning. So far it can be stated that residents who stayed for more than six months on the farm did better then those who left early. As the evaluation is still in progress, detailed follow-up results will be published later. The high rate of attrition apparent during the first three months after admission, dropped during the later stages (see figureB ). Four of the five residents who recently left the programme returned within a fortnight asking for re-admission. The age range of addicts at Emiliehoeve so far varied between 15 and 39 - 39 being one single exception, the mean age being around 23. Generally the ratio of boys to girls was 2 to 1. Weekly urine specimens are taken by the staff on irregular days for the identification of drugs of abuse. According to the results of these tests it can be asserted that Emiliehoeve is the first treatment centre for drug addicts in the Netherlands where no drugs or alcohol have been used on the premises since 31 August 1972. This means that after admission the addict realizes that life in a drug-free community is possible. He experiences an atmosphere of hope and trust that makes him stay in a programme, even though some of the demands made on him seem difficult to meet. During the re-entry phase he is learning to face not only the stress and frustrations of life, but to look for positive opportunities that society equally offers.

Summary

Within two years a centre for young addicts emerged; from a chaotic situation where drug use was frequent a drug-free therapeutic community developed with a solid structure; encounter group techniques were the major therapeutic tool. The community is located on a farm providing a great variety of work situations. The evolution in this direction is described, pointing out the failings of several approaches attempted during the different phases of the programme.

FIGURE A

Full size image: 0 kB, FIGURE A

FIGURE B

First 3 months of stage 1,(from 15-2-'72)First 3 months of stage 2,(from 11-7-'72)First 3 months of stage 3,(front 15-1-'74)
Number of residents admitted
151014
Number of residents still in the programme 3 months after admission
569
Percentage of residents that left the programme in the first 3 months after admission
674036

References

001

G.H. Hunt and M. E. Odoroff - Follow-up study of narcotic drug addicts after hospitalization, Public Health Reports , vol. 77: 1, 41-54, 1962.

002

H.J. Duvall, B.Z. Locke and L. Brill - Follow-up study of narcotic drugs addicts; Five years after hospitalization, Public Health Reports , 78: 3, 185-193, 1963.

003

G. E. Vaillant - A twelve-year follow-up of New York Narcotic addicts: 1. The relation of treatment to outcome, Am. Journ. of Psychiatry , 122, 727-737, 1966.

004

Maxwell Jones - The Therapeutic Community, New York 1953.

005

M.S. Rosenthal and D. V. Biase - Phoenix Houses: Therapeutic Communities for Drug Addicts. Hospital and Community Psychatry , 20, 26-30, 1969.

006

D.H. Casriel - The Daytop Story and Casriel Method. In: Confrontation, Encounters in self and interpersonal awareness (Ed. by L. Blank, G. B. Gottsegen and M.G. Gottsegen), 179-193, 1971.

007

Ph.D. Janov - The Primal Scream (1970). Publ. in Great Britain by Garnstone Press Ltd., London in 1973.

008

L. Yablonsky - Synanon: The Tunnel Back. New York, 1967.

009

M.A. Lieberman, E. Yalom and M. B. Miles - Encounter Groups, First Facts. New York, 1973.