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Addict aftercare: essence or afterthought?
by Stephen M. Pittel, Ph.D.
1977
Contemporary Drug Problems, 1977, 6, 491-513
Citation:   Pittel SM. "Addict aftercare: essence or afterthought?" Contemporary Drug Problems. 1977;6:491-513.
Let me begin by agreeing with almost everyone that people concerned with drug abuse are expected to disagree about almost everything. Disagreement about drugs is a national pastime that goes by many names. On the streets where drugs are abused, disagreements are called arguments and they result in fights; in laboratories where drug abuse is studied, disagreements are called hypotheses and they result in publications; in the upper echelons of power where decisions are made that affect the lives of countless drug abusers, disagreements are called policy alternatives and they result in the convening of conferences at which we are encouraged to politely disagree.

Yet, even in the contentious world of drug abuse I believe that there are some issues about which we cannot reasonably disagree, and I want to talk about what should be the most self-evident of these—the former addict's need for aftercare services designed to provide him with the means to live and work effectively as a law-abiding member of his community. In time, I will suggest some alternative ways of providing aftercare services about which we may disagree. But first, I will try to show why aftercare is the essence of successful intervention and why it must not come as a mere afterthought.

No matter how addiction is caused or how it is treated, the goal of all drug treatment is to return the former addict to the community. As every program director is reminded when the time for refunding comes along, the ultimate worth of treatment is measured by the former addict's ability to abstain from illicit drug use, to refrain from criminal activities, and to obtain a job that satisfies his financial needs.

To be sure, these are extremely modest goals. They are, in effect, no more than a token of what it means to reenter the life of the community. Those of us who work in the field of drug abuse treatment and rehabilitation would also like our clients to appreciate the advantages of a higher education, to treat their families with respect, and to have good telephone manners, high self-esteem, and clarified values. But, I will focus only on those tokens of reentry with which policymakers, evaluators and other keepers of the public trust are most preoccupied.

To achieve even a token reentry to the community, the former addict must perform a variety of tasks. To obtain a job, for example, he may have to acquire basic literacy skills, prevocational training, and job-skill training. He may have to alter his daily routine so that he can wake early enough to buy the morning newspaper or arrive in time for agency or job interviews. He will have to attend carefully to habits of dress and grooming to appear suitable to prospective employers, and he will have to prepare a resume and fill out job applications that present him in a favorable light. He will have to arrange transportation to get from home to prospective jobs, and perhaps, keep an appointment book to organize his schedule. And he will certainly have to deal with the anxiety of starting something new and the disappointment and frustration of being rebuffed until a decent job comes through.

Finding a job, however, is only the beginning. Next he must learn to stay employed, and this, according to Walter Neff, requires more than competence on the job:
"Different occupations not only require certain combinations of physical and intellectual capabilities, but also a set of social behaviors which, on the surface at least, may appear to be quite unrelated to the particular job. These social behaviors include details of dress and grooming, the style and content of speech, the ability to relate in certain standardized ways to peers, to subordinates, and to superiors in complex social hierarchies, and even the necessity of accepting (or at least appearing to accept) various systems of opinion and belief. To become a worker. therefore, one must not only be willing and able to learn the job, but one must also be willing and able to learn the "rules of the game." . . . both sets of conditions are essential to human work.1
To this list of requirements I would add that the ability to hold a job calls for the former addict to maintain a modicum of stability in other aspects of his life. He must, for example, have a decent place to rest and sleep when work is done, to store his clothes and other possessions, and to attend to daily routines of toilet and nutrition. He must be able to manage his personal finances, to purchase food and other essentials, and to maintain himself in adequate health. And, if (he former addict is to receive any gratification from his life as a worker, he must also make new friends and take up new leisure-time pursuits that will insulate him from the pressures and temptations of old acquaintances and old pursuits.

Before proceeding further, let me reiterate that I have not yet begun to discuss community reentry except in its most limited sense. The former addict must be able to perform all of the tasks I have enumerated thus far, merely to satisfy the minimal reentry goals. Nor have I alluded yet to any of the problems that might make accomplishment of these tasks especially difficult for the former addict. In effect, I have only stated what any person must accomplish to participate in the world of work.

To go a bit further, let us ask what other skills the former addict—or any person—must have to be successful in the many and varied roles a full-fledged member of the community performs. What skills are required, for example, to be a successful friend and neighbor, spouse and parent, householder and consumer? What emotional reserve or coping skills are required to deal with situations in which we experience frustration, embarrassment, separation, anger, failure, pain, tenderness, love, joy, or grief? What personal and familial resources must the former addict—or any person—have to compete successfully for status and prestige? What other inner strengths and social supports must a person be able to draw upon in times of stress and crisis? And lest we slight the other tokens of reentry that society holds so dear, what skills and wherewithal does the former addict—or any one of us—require to keep from committing crimes or resorting to the use of drugs?

Like the centipede who becomes paralyzed when asked to describe the coordination of his many legs, it is virtually impossible for any one of us to identify all the skills we use to navigate our daily lives. Nor is it possible for us to specify when or how we learned the skills we have. But, we can be sure that the majority of former addicts do not possess these countless skills and we can be sure that they will not acquire them automatically merely because they have learned to refrain from the use of drugs.

Let me suggest by way of an analogy what it must be like for the former addict at the time he is ready to leave treatment. Instead of focusing on what he needs to become one of us, let us imagine instead what we might need if we were faced with the challenge of entering his former world.

As a newcomer to the world of addiction, we would need to know the lore and language of the streets; how to "cop" and "fix," to find a "connection," to avoid overdoses or getting "burned." We would have to learn to forego many material comforts and conveniences; to live in abandoned tenements, to sleep on lumpy mattresses, to "maintain" and "take care of business" even when we're sick or scared. We would have to learn the rules by which the "cops and robbers" game is played; how to recognize a "narc," when to resist and when to yield to pressures to become a "snitch," and when to fight conviction on a "bust" and when to "take a fall" or "cop a plea." We would have to learn the "hustles" by which to earn our daily bread, and the games that must be played to get services from social agencies, or to convince our "P.O." that everything is "cool." We would need to forego checking accounts and credit cards and be prepared to deal in cash, thereby exposing us to risks of "rip-offs" by friends and foes alike. And we would have to learn to take our pleasures when and where we can because tomorrow is unsure, and survival is the only value that cannot be compromised.

For most of us, I expect that even this scanty catalog is enough to inspire fear. The terms are familiar, but it is difficult to comprehend that we could ever transform our lives so radically, or learn to do so without failing miserably. Even if we were sincerely motivated to take this path—by promises of great rewards, or escape from greater strife—we would know that our chance of success is slim. Even if we were taught the rudimentary skills by sincere and friendly counselors who encouraged us to try, we would intuitively recognize that our experience has not prepared us to become an addict on the streets, that it would take months or years of a different kind of socialization to master this treacherous terrain. At the time of transition, we might have second thoughts, our confidence might waver, we might be paralyzed with fear. And all during the transition, and especially when things went wrong, we might dream of returning to the world we already know so that we can demonstrate competencies we have already learned, rather than take this awesome step into a world for which we have not been adequately prepared.

The point I have attempted to make through this analogy might have been made less dramatically by illustration of the difficulties anyone might have when he is called upon to alter drastically his entire way of life. But, it is important to recognize that the transition I have described is—in reverse—no different from the one that former addicts are expected to perform. The addict—no less than a member of any social group—has already been socialized to survive in a complex and demanding society; he has already acquired a repertoire of skills, habits, values and attitudes that have allowed him to enjoy innumerable rewards. For just as if the tables were reversed, the addict leaving his world for ours is not merely escaping from a life of misery and despair. Instead, he is forced to give up something he values dearly in exchange for an intangible and perhaps unattainable reward. At the very least, he is giving up the chance to prove his competencies in the way he knows best. As I have argued elsewhere:
[A]ddicts are forced to test themselves against the greatest odds each day. To sustain his need for drugs and his status on the streets, the addict must demonstrate over and over again his mastery of the harsh world in which he lives. To be a "righteous dope fiend" requires considerable competence in a multitude of job and social skills, and the addict receives direct proof that he is competent each time he scores—each time his hustle is converted to the heroin he craves. Whether or not he is actually addicted, the addict's perceived need for heroin provides a context in which he can (or must) repeatedly prove his worth.2
From all of this I hope you will agree that there can be no reasonable disagreement about the former addict's need for aftercare services. Drug abuse treatment may suffice to free the addict from his need for drugs, and it may even inspire him to seek a new and better life. But there is no reason to assume that treatment alone will suffice to keep the former addict on this path. Even after a decade of intensive search for new and improved treatment techniques, the results of drug abuse treatment per se, have not been impressive. Virtually all treatment modalities yield short-term benefits, but none of them appear capable of ensuring that a majority of former addicts will be able to survive in our complex and demanding society. And there is no reason that they should. Most treatment programs do their job quite well. But it requires far more resources than any treatment program has—or can ever expect to have—to ensure that their clients make the grade. Helping to transform the addict into a former addict is a treatment task; helping him to remain a former addict is the task of aftercare, and that is where our analysis of policy alternatives must begin.

Without stopping to recount the history of previous attempts to provide addict aftercare—or to comment on the dismal failure of those largely ill-conceived and poorly planned efforts of the past—I would like to quote some of the conclusions I reached in a recently completed review of the aftercare literature. From this you will see why I refer to current aftercare practices as an afterthought, and you will be better prepared to understand the policy recommendations I will make.

[ The following is from S.M. Pittel, "Community Support Systems for Addict Aftercare" (NIDA 1977). ]

"... [I]t appears that the primary gap in aftercare services is a general non-responsiveness to the former addict's aftercare service needs, particularly his needs for concrete and tangible services and for experiences that will allow him to become socialized to the community in which he is expected to live. In turn, this primary gap in aftercare services can be traced to a number of underlying biases prevalent among workers in the field of drug abuse and to a variety of more specific causes.

"1. The myth of addiction as a cause. Virtually all drug treatment modalities are based on the assumption that the addict's major problems result from his use of drugs. Other problems that the addict may have are viewed as secondary, and services provided to deal with these other problems (if they are provided at all) are viewed as merely 'ancillary' or 'supportive.' There exists among workers in the field an almost magical belief that curtailing the addict's use of drugs will make other problems simply disappear. Both in treatment and aftercare, acceptance of this belief results in a primary emphasis on maintaining abstinence to the disregard of the other, perhaps more critical concerns.3

"2. The myth of the addict as a unique sub-species. Closely related to the above is the belief that addiction to heroin is. so powerful an influence on the addict's personality and way of life that it obviates individual differences among those who become addicted. This results in the adoption of more-or-less uniform treatment and after-care strategies that draw frequently upon only a limited repertoire of available therapeutic and rehabilitative techniques. It results also in the development of encapsulated and parochial treatment programs whose internecine combat with alternatively encapsulated and parochial programs results inevitably in disservice to each of their clients.

"3. The myth of therapeutic infallibility. Another belief closely related to those above is that counselors and caseworkers guided by program philosophy know best what their clients need. In part, this results in a failure to assess directly clients' actual or perceived service needs. It results also in a tendency to slight or ignore clients' requests for services that do not correspond to therapists' views or to established service delivery protocols.

"4. The myth of the unmotivated client. When clients refuse treatment or aftercare services recommended or mandated by program staff, or when they fail to improve in response to these services, this is most frequently taken as a sign of insufficient motivation. In effect, services are held to be sacrosanct and above criticism; responsibility for failure rests entirely on clients' unwillingness to benefit from what is offered. The alternative position, that treatment and aftercare programs should take responsibility for instilling motivation in their clients by providing them with meaningful services, is rarely considered seriously.

"5. The myth of the sufficiency of vicarious learning. In their emphasis on counseling to the relative exclusion of other direct services, it seems clear that treatment and aftercare service providers assume that clients can effect a successful re-entry to the community without having to master specific skills. Yet, if my analysis is correct, quite the opposite is true. Counseling may be an effective means to reduce the former addict's ambivalence about re-entry, to encourage his persistence, and to identify problems that need to be worked on, but there must come a time when the efforts of a 'generalist counselor' give way to the services of specialist who can teach the former addict specific coping and survival skills.

"6. The myth of cure as a prerequisite for care. Because of their typical involvement with criminal justice agencies, there exists a curious anomaly in the delivery of treatment and aftercare services. In effect, the addict must be cured as a condition of his receiving services. To the extent that he manifests those behaviors (e.g., illicit drug use, criminal activity) that characterize his status as an addict, he is in continual jeopardy of being returned to jail. In part, this may explain the great emphasis placed on clients remaining abstinent, and the alarm that attends their occasional use of heroin. But it also creates a difficult treatment paradox, because all therapists know that change is a gradual process, not an all-or-nothing phenomenon; that change does not take place without occasional regression and without occasional testing of previous limits.

"7. The myth of the unregenerated junkie. To complete my list of factors underlying gaps and biases in aftercare services I must add that a majority of social agency personnel do not believe that the addict can be rehabilitated, and that most do not wish to work with addict or former addict clients. To borrow a term used by Segal, Baumohl and Johnson4 in their analysis of social service delivery to a young vagrant population, the addict or former addict has little 'social margin' on which to trade. Social margin ... is a relational matter consisting of the good will of potential benefactors. As we will see, the good will of potential benefactors ... is often dependent upon the ''applicant's" compliance with certain pivotal role expectations. When expectations between benefactors and recipient are incongruent; i.e., when behavioral expectations on either or both sides cannot or will not be met, the benefactor is rejected and/or the applicant is outcast.

"Even when addict clients meet agency expectations, their stereotype does not, and it is not the exception but the rule that addicts are denied services in agencies that have the choice, and treated poorly when they cannot be turned away."5

With the understanding that neither you nor I have ever been guilty of believing in these—or any other—myths, let me proceed to discuss some of the policy issues that bear most directly on the design and delivery of effective aftercare services. To begin with a programmatic issue upon which all other considerations rest, I would like to suggest that we can do no better than to adopt Gerald Caplan's notion of a community support system as an exemplary model for the delivery of aftercare services. In an early discussion of this concept, Caplan focused on the community support system as a means of improving communications between actually or potentially disenfranchised persons and the larger community. Thus, he defines a support system as:
. . . continuing social aggregates (namely continuing interactions with another individual, a network, a group, or an organization) that provide individuals with opportunities for feedback about themselves and for validation of their expectations about others, which may offset deficiencies in these communications within the larger community context.6
With its emphasis on improving communications between an individual and his community, this definition allows explicitly for the resocialization experiences I have alluded to as necessary in the reentry process, and Caplan comes close to suggesting the desirability of an apprenticeship relationship of sorts when he goes on to say that:
. . . the characteristic of these social aggregates that act as a buffer against disease is that in such relationships the person is dealt with as a unique individual. The other people are interested in him in a personalized way. They speak his language. They tell him what is expected of him and guide him in what to do. They watch what he does and they judge his performance. They let him know how well he has done. They reward him for success and punish or support and comfort him if he fails. Above all, they are sensitive to his personal needs, which they deem worthy of respect and satisfaction.7
And as if he were aware of the problems encountered in previous addict aftercare projects, Caplan notes that:

Such support may be of a continuing nature or intermittent and short-term and may be utilized from time to time by the individual in the event of an acute need or crisis. Both enduring and short-term supports are likely to consist of three elements: (a) the significant others help the individual mobilize his psychological resources and master his emotional burdens; (b) they share his task; and (c) they provide him with extra supplies of money, materials, tools, skills, and cognitive guidance to improve his handling of his situation.8
Although he is well aware that the ideal support system is more likely to exist in a natural family network9 and in informal, nonprofessional organizations (such as religious denominations, fraternal organizations, mutual assistance and self-help groups) than it is to be found in community-wide professional organizations or service delivery systems, Caplan insists that ". . . we professionals must learn to appreciate the fortifying potential of natural person-to-person supports in the population." Moreover, he proposes that the model of a support system be used to guide innovations in mental health and social service delivery, particularly for individuals ". . . made vulnerable [by] acute crises, life transitions, or chronic privations."

While it is probably fanciful to believe that public policy will shift significantly away from agency-based delivery of services to encourage Caplan's vision of informally organized community support systems, the National Institute of Mental Health received the go-ahead just last year to initiate a comprehensive community support system program based on a more congenial definition of the term. In the NIMH version, a community support system is defined as "[al network of responsible people and coordinated resources committed to the goal of assisting a vulnerable population to meet their needs and to function as normally as possible in the community." And to this is added the practical proviso that "there must be legislative, financial, administrative and other arrangements which will guarantee that these needs are met.".10

With its emphasis on the coordination of resources on legislative, financial and administrative arrangements needed to guarantee the delivery of comprehensive services, this working definition of community support systems provides a needed base for our examination of a variety of programs and systems that might be adapted for addict aftercare. But before proceeding to that task, let me digress to consider why I view community support systems as constructive alternatives to existing service delivery systems.

Except, perhaps, in the higher reaches of the bureaucracy where decisions ultimately are made, there exists among all those who come in contact with health and social service agencies an almost intuitive understanding of the need for services integration. Although they are probably unacquainted with the terms, clients understand the need for "integrated social service delivery systems" or community support systems every time they fill out an application that calls for the same information they have given countless times before; every time they wait in line to be served and are then sent elsewhere to wait again; every time they try to justify themselves to one caseworker who refuses to accept what another caseworker, probation officer, counselor or therapist has counseled them to do previously.

Similarly, caseworkers (particularly those new to their jobs) understand the need for services integration whenever they perceive the need to deliver services over which they have no control; whenever they are accused of interfering with another agency's autonomy as they attempt to intervene on a client's behalf; whenever they have to refuse a riskier case because they only have resources available to serve clients with lesser needs. Even program administrators (particularly those who are most vulnerable) understand how much nicer it would be for them if they didn't have to compete with other agencies for clients (when they are in demand) or for limited funds (that are always in demand). And I suspect that even the most insular groups whose strength is perceived to lie in their unique ability to serve a particular client group might be willing to concede the advantages of working cooperatively with other agencies to serve clients who "fall between the cracks."

In the parlance of the social services, these intuitively grasped problems fall under the headings of ". . . fragmentation of services . . . inaccessibility of services. . . lack of accountability of social delivery agencies. . . discontinuities of services . . . dispersal of services. . . wastefulness of resources, ineffectiveness of services, [and] short-term commitments."11 Each of these has been the subject of repeated political scrutiny, and collectively they have been viewed as: **. . . symptoms of fundamental barriers, such as organizational autonomy, professional ideologies, conflicts among various client interest groups, and, perhaps most critical, conflicts over who is to control resources."12

In principle, almost everyone agrees that a major overhaul of social service delivery systems is necessary, but no one is particularly enthusiastic about reorganization plans that might interfere with his autonomy, jeopardize his job or cause him, rather than his counterpart in other agencies, to make radical changes in the accustomed way of doing things. Thus, there emerges the paradoxical opposition to services integration even among workers who—on clinical grounds—are firm supporters of the idea.13

Perhaps as a way of postponing services integration at the level of service delivery agencies, many workers in the field believe that local adjustments cannot be made without substantially new legislative mandate and bureaucratic reorganization at all levels of government. Thus, I have heard dedicated vocational rehabilitation counselors, for example, say that they would like to serve addict clients but cannot either because they are not eligible for services or because the counselor cannot afford the time to work with a client who needs extensive help until he is freed from the responsibility of "closing" an already great number of cases each month or year.

In spite of the opposition from local quarters and a "lack of support for a broad reform policy" among federal legislators,14 the services integration movement has attracted considerable attention in recent years, primarily through the efforts of professional critics of existing practices.15 Moreover, it has resulted in a number of executive proposals to facilitate services integration at local levels through federal administrative reorganization, and in a number of federally sponsored services integration research and demonstration projects.'16

But, if the truth be known, there is little evidence that either casework practices, neighborhood service centers, central intake or referral units, umbrella agencies, diversion programs or any of a score of other services integration models have been effective in overcoming the territorial imperatives, apathy and red tape that interfere with effective service delivery. Nor do any of these models have the capability of creating services where none exist.

Yet, the community support system model has at least the potential to succeed where other models have failed. First, because it centralizes responsibility for both direct delivery and coordination of client care, and second because it provides—at least in principle—the legislative, administrative and financial clout to develop a network of community resources that are obliged to provide for all their clients' needs. To put it differently, the community support system concept emphasizes the wedding of two essential features of effective care: comprehensiveness and continuity of care. And these are the features that must be present in whatever programmatic policies we adopt for any disadvantaged client group.

While there is much more that needs to be said about services integration, client access to needed services, agency responsiveness to perceived and assessed client needs and continuity of care, from the standpoint of public policy it is sufficient to say that these are the minimal requirements for effective client care. As chess masters are often heard to say, once the proper opening has been made, winning the game is just a matter of technique.

Thus, let me move on to consider two other policy related themes. First, I would like to call your attention to the fact that I have not referred to aftercare per se, from the time that I began to discuss community support systems. Nor have I, since then, referred to former addicts as a client group that requires any special consideration. By no means is this an unintended lapse. Quite the contrary, I have avoided using those terms to suggest that the concept of aftercare has no precise meaning, particularly as it is used in the field of drug abuse. From a policy perspective what is essential is that clients receive the services they need. Determining the proper timing and sequencing of services delivery is a clinical decision that should be made by the most highly qualified staff. But it is inconsequential whether those services are provided under the rubric of prevention, treatment or aftercare. At best, the concept of aftercare is merely imprecise; at worst, its continued use may lead to further internecine squabbles among drug treatment programs and other social agencies when both of them should be preoccupied with more important things.

My avoidance of the term "former addict" is to make a second point that I have alluded to before. Namely, that once the addict is detoxified—or perhaps shortly thereafter when he begins to take his first tentative steps toward reentry—his reentry or aftercare needs are not substantially different from those of the former alcoholic, the former mental patient, or the ex-convict. Indeed, his so-called aftercare services needs are not all that different from those of the returning Vietnam veteran or of anyone who is entering a strange and perhaps alien world or who is returning to a place that has changed dramatically since he first went away.

I do not mean to suggest that we should disregard differences of ability or disability among these groups, or that each of them requires the same kind of clinical management. But, there is no reason either to disregard the similarity of their needs. Again, from the standpoint of public policy this is a crucial issue because it relates directly to the level of funding required to provide for client needs. Clearly, it is considerably less costly to fund a single agency to serve the needs of diverse client groups than to duplicate the same service delivery capability for each supposedly unique client group. A common reentry facility for ex-convicts, former addicts and former alcoholics, for example, might be funded amply enough to maintain a staff of specialists to serve clients' diverse reentry needs. But, it is highly unlikely that any program designed to meet the needs of only one of those target populations will ever be funded well enough to serve its clients well.

In the parlance of planners and policymakers, I am referring of course to the issue of noncategorical eligibility for services, and, lest there be any doubt, I am opting strongly that it be tried. I have no illusions that it will be an easy task for workers committed to each group to set aside their differences, or for clients who view themselves as uniquely stigmatized to eat from a common loaf. But the point must be made that the former addict is no longer an addict and that the former alcoholic is no longer an alcoholic when it comes to their needs for such things as decent housing and meaningful work. While I am not particularly sanguine about the prospects of taking addicts and alcoholics off the streets into an integrated treatment program, I see no reason that they need to remain apart once the process of reentry has begun.

As a final matter of policy, I would like to comment on the costs of funding effective aftercare delivery systems. To provide a framework for my remarks, consider the following quote from The Road to H:
Given a society without unlimited resources, the amount of money and effort that can be invested in an attempt to cope with a problem depends on how grave it is in comparison to other problems which also demand money and effort. As a first approximation of (he justifiable investment, we might allocate the available resources proportionately to the assessment of the gravity of the problems. . . . [If| the resources thus allocated to some problems [are] less than adequate . . . [w]e must then confront the question of whether the returns to be expected from an inadequate investment justify any investment at all. That is, the returns are not necessarily proportionate to the size of an investment, and the expected returns from an inadequate one may be so disproportionately small, either in absolute terms or in relation to the magnitude of the desired effect, that a sound businesslike approach would compel us to concede failure in advance [emphasis added].17
Although Chein and his associates go on to argue persuasively that the worth of (some) social problems should be assessed in different terms, there is no escaping the fact that the cost of providing comprehensive aftercare services to a substantial number of former addicts will be a serious consideration in shaping federal policy in this regard. Using estimates based on programs I have designed, for example, the annual cost of providing aftercare to the approximately 210,000 addicts currently in treatment or in jail (according to a 1974 SAODAP estimate) would be between 700 and 900 million dollars, or about three-fourths again the current annual cost of providing treatment services (estimated at 1.1 billion dollars in 1974).

Two questions follow from this analysis. First, is the federal government prepared to invest the full amount required to develop comprehensive community support systems for addict aftercare on a nationwide basis? And second, if it is not, how significantly will expected outcomes suffer from a reduced or less ambitious federal effort?

While we can do no more than speculate about the second of these questions, a relatively firm answer to the first is indicated in the 1975 White Paper on Drug Abuse prepared by the Domestic Council Drug Abuse Task Force.18 Here we are told that recommended federal strategy for demand reduction (i.e., prevention, treatment and rehabilitation efforts directed at reducing the demand for drugs) includes plans for stepping up the delivery of rehabilitation services to supplement currently extensive treatment services. Yet, before advocates of addict aftercare take encouragement from this, two provisos are added to qualify this recommended strategy. First, only vocational rehabilitation services and the former addict's need for related schooling, vocational counseling, skill training, supported work and jobs are mentioned in this regard, and second, it is assumed that all necessary services can be provided by ". . . existing community manpower services." Thus, the recommendations for federal policy conclude with the statement that "[s]ignificant progress can be made without requiring the commitment of substantial additional resources [emphasis as in the original]."

Without stopping to debate either their exclusive focus on vocational rehabilitation and employment services or their assumption that existing manpower programs are sufficient for the task,19 it appears that the Domestic Council Drug Abuse Task Force has overlooked the substantial investment of funds required merely to direct former heroin addicts to make use of existing community resources! Unless they presume, in face of considerable evidence to the contrary, that former addicts and stabilized patients in treatment will seek out and make use of community resources on their own, or that treatment programs can coordinate this effort on their behalf, it is hard to understand the Task Force's conclusion. To put it differently, their estimate of no significant increase in costs, and my estimate of substantial costs are both based on the assumption that existing community resources can suffice (more or less) to provide needed services.

To the extent that the White Paper on Drug Abuse recommendations continue to serve as a token of the current administration's policies, there is little reason to expect that any major federal support is forthcoming for comprehensive addict aftercare programs.

To return, therefore, to the question of reduced expectations based on limited federal financial support and services integration initiative, I can only conclude that it is better that addict aftercare programs not be started at all, than that they be attempted without adequate support. That little has been done in the area of addict aftercare following the disappointing results of earlier efforts most probably reflects the assumption that aftercare has been tried and it has failed. Rather than perpetuate the legacy of these flawed attempts, my own preference is to opt for systematic research and demonstration efforts based on the comprehensive community support system mode. If it can be demonstrated that providing comprehensive services in a manner responsive to former addicts' needs does make the difference, as I suspect it will, then we may expect to find support for a broader federal program that has an opportunity to succeed.

Instead of ending with the conventional disclaimer that I have failed to touch on many of the significant issues and that much more needs to be done to resolve the dilemma of addict aftercare, I would like to end on a more personal note.

First, to reiterate a point I have made elsewhere,20 virtually all of my beliefs about the treatment and rehabilitation of addicts are summed up in the words of a traditional African proverb: Before a man is asked to give up a thing he cherishes and holds most dear, he must be given something of value to take its place.

And, as I have also argued before, it is not clear to me that we are prepared to provide this common courtesy to the heroin addict in exchange for his sacrifice. In large part, I suspect (hat this is due to the prevailing belief that the addict is enslaved by heroin, and that he suffers a life of misery and despair because of its demands on him. Thus, our approach to the heroin addict has focused on freeing him from the clutches of heroin and offering him, in exchange, freedom from social stigma, freedom from arrest, and freedom to compete on equal terms for whatever rewards motivate the rest of us to lead more decent lives.

I think this argument is flawed in two essential ways. First, because it ignores the many gratifications that the addict derives—not so much from heroin itself, because even the "righteous dope fiend" can barely get enough heroin to keep from being sick—but from his mastery of the streets, from his ability to survive in the only world he knows. But even if I am wrong about this, the argument is flawed in another essential way because it rests on the assumption that the former addict can compete successfully for the rewards society holds in reserve for those who toe the line. Perhaps this is so—and in this rests my faith in aftercare—but it is not so merely because the addict is no longer enslaved by heroin. Before the former addict can be expected to compete successfully, he must be given the chance to learn and to experience an entirely new way of life. Until he does, the rewards are precious few; his new life may seem no better and perhaps worse than the one he left.

Yet, because addiction is a crime, the former addict is expected to lead his new life to the hilt, immediately and all at once. He is not given the opportunity to assimilate gradually into a foreign and alien world. There is no tolerance for delay, no room or time to turn back once or twice to compare the relative merits of the new and the old, or to make a choice. So far as society is concerned there is no choice to be made.

I am not sure that I could make so abrupt a change successfully. Perhaps I could if the immediate rewards were great enough or if the long-term stakes were high and I thought I had a chance of winning them. But no matter how bad things might be, what reason is there to take up something new if the chances of success are slim and neither the short-term or long-term payoff is worthwhile?

Perhaps what I have described here as a comprehensive community support system for addict aftercare can provide the incentive and the opportunity that treatment alone does not. If it docs not, then apparently nothing will, or at least nothing that can be reasonably imagined. The attempt is certainly worthwhile. But only if well-made.

This brings me to my second point. There is a world of difference between what Caplan describes as an optimal support system and the NIMH working definition of a community support system. Quite simply, there is no way that an artificially created system of service providers can be equated with a naturally occurring caretaking relationship that exists among members of a family or clan. There is no way that a continuum of services designed to solve a social problem can be equated with a helping relationship built on the strength of friendship, love, devotion, respect and mutual trust. Nor must we ever confuse the two.

At the very best, the most comprehensive community support system of the kind that I have described is but a pale substitute for the kind that has the best chances of success. To compromise it any further by reducing services or by the introduction of dehumanizing practices that are all-too-common in other ostensibly helping agencies would be a mockery.


AUTHOR'S NOTE: Parts of this paper are taken or adapted from the author's monograph, Community Support Systems for Addict Aftercare. (National Institute on Drug Abuse, 1977), Its preparation was supported by a grant from the National Institute on Drug Abuse (H8I DA 01901).


References #
  1. W.Neff, Work and Human Behavior {New York: Atherton, 1968).
  2. S.M Pittel, "Addicts in Wonderland: Sketches lor a Map of a Vocational Frontier," 6 Journal of Psychedelic Drugs 231-241 (1974). For a further discussion of the rewards of the addict culture see: H. Feldman, "Street Status and Drug Users." 10 Society 32-38 (1973); E. Preble and JJ. Casey, "Taking Care of Business: The Heroin User's Life on the Streets," in It's So Good Don't Even Try It Once: Heroin in Perspective, D.E. Smith and G.R. Gay (eds.) (Englewood Cliffs, N.J.: Prentice-Hall, 1972); A.G. Sutter, "The World of the Righteous Dope Fiend," 2 Issues in Crimi­nology 177-222(1966).
  3. For extended discussion on this issue see Pittel, supra note 2.
  4. S.P. Segal, J. Baumohl and E. Johnson, "Falling Through the Cracks: Mental Disorders and Social Margin in a Young Vagrant Population." 24 Social Problems 387-400 (Feb. 1977).
  5. S.M. Pittel, Community Support Systems for Addict Aftercare (National Institute on Drug Abuse, 1977).
  6. G. Caplan, Support Systems and Community Mental Health: Lectures on Concept Development (New York: Behavioral Publica­tions, 1972).
  7. Id.
  8. Id.
  9. G. Caplan, "The Family as a Support System," in Support Systems and Mutual Help: Multidisciplinary Explorations, G. Cap­lan and M. Killilea (eds.) (New York: Grune and Stratton, 1976).
  10. National Institute of Mental Health, "Comprehensive Community Support Systems for Adults with Chronically Disabling Mental Health Problems: A Working Paper," unpublished manuscript, 1976.
  11. M. Aiken, R. Dewar, N. DiTomaso, J. Hage and G. Zeitz, Coordinating Human Services (San Francisco: Jossey-Bass, 1975). See their bibliography for omitted references.
  12. Id.
  13. I suspect that some clients would object to services integration also, because it would necessitate their devising new strategies for maneuvering and manipulating the system to their advantage. Sometimes, having a number of caseworkers to play off against each other is more a boon than it is a hindrance.
  14. R.W. Gage, "Integration of Human Services Delivery Systems," 34 Public Welfare 27-33(1976).
  15. R.E. Boettcher, "The 'Service Delivery System'; What Is It?" 32 Public Welfare 45-50 (1974); S.M. Butrick, "Present Shock: The Future of the Social Services," 31 Public Welfare 41-66 (1973); F.J. Kahn, "Public Social Services: The Next Phase—Policy and Delivery Strategies," 31 Public Welfare 15-24 (1973); M.S. March, "The Neighborhood Center Concept," 27 Public Welfare 97-111 (1968).
  16. Gage, supra note 14; S.B. Kamemnan and A.J. Kahn, Social Services in the United States (Philadelphia: Temple University Press, 1976).
  17. 1. Chien, D.L. Gerlad, R.S. Lee and E. Rosenfeld, The Road to H; Narcotics, Delinquency and Social Policy (New York: Basic Books, 1964).
  18. Domestic Council Drug Abuse Task Force, White Paper on Drug Abuse (Washington, D.C.: United States Government Printing Office, 1975).
  19. For a different opinion see I.I. Goldenberg and E. Keating. "Businessmen and Therapists: Prejudices Against Employment," in Vocational Rehabilitation of the Drug Abuser: The State of the Art (Volume IV, Gainfully Employed), H. Liebowitz (ed.) (Washing­ton, D.C.: Youth Projects, Inc. and U.S. Social Rehabilitation Service, 1973).
  20. Pittel, supra note 2.
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