1 Is Drug Rehabilitation Possible Through Out-Patient services? Efrén Ramirez Psychiatristv-Trainipg Consultant Drug Rehabilitation The answer to this question is a qualified yes! During my thirty years of clinical experience in the prevention, treatment and rehabilitation of addiction, I have come across a number of instances in which successful rehabilitation of drug-dependent individuals has occurred in non-residential community environments. As a result of careful study of the clinical material, several factors emerge as essential to understand these successes. In the first part of this chapter, I will enumerate and briefly describe these factors. In the second part I will advance an ambulatory treatment and rehabilitation model with the hope that it will be tried, commented, criticized and eventually adopted or adapted as a viable alternative to in-patient rehabilitation. PART I I believe there is consensus among substance abuse workers that the preferred method of achieving successful rehabilitation in drug addiction is that which is carried out, with variations, in professionally-supported residential therapeutic community [(TC) settings]. This model was pioneered by me for addicted individuals with varying degrees of mental illnesses and personality disorders in the CISLA (Centro de Investigacidn Sobre La Adicci6n [Addiction Research Center]) 1 Project at the Puerto Rico State Psychiatric Hospital between 1961 and This program was studied and adapted by Dr. Densen-Gerber in the Odyssey House Program in New York in and by SERA (now called P. R. O. M. E. S. A.), also in New York in ' FALCO, M.: The Making of a Drug-Free America: Programs That Work, Times Books, N.Y. (1992). 3 RAMIREZ, E.: "The Mental Health Program of the Commonwealth of Puerto Rico", Rehabilitating the Narcotics Addict. Vocational Rehabilitation Administration, U.S. Dept. of Health, Fon Worth, Texas, 1966, pp RAMIREZ, E.: "Comprehensive Management of the Addiction Problem", The Bulletin, New York State District Branch, American Psychiatric Association, Sept. 1967, Vol. 10, No. 2, p. 4. RAMIREZ, E.: "The Existential Approach to the Management of Character Disorders", Review of Existential Psychology and Psychiatry, Winter, 1968, Vol. 8: DENSEN-GERBER, J.: We Mainline Dreams, New York,
2 the mid sixties; While serving as the first Commissioner of the Addiction Services Agency during the John V. Lindsay Administration in New York City, I founded Phoenix House 4 which is now an international organization under the leadership of Dr. Mitchell Rosenthal. In 1968 I helped to establish the CISLA model on a community basis in Puerto Rico in the Hogares CREA Program, which now has 77 residential facilities in the island and several others in Latin America. 3 During the past 25 years, second, third and fourth generation TC programs derived from the original CISLA model, 6 have sprouted all over the world, most of them members of the World Federation of Therapeutic Communities. In spite of the fact that the residential therapeutic community movement has expanded greatly during these years, the number of addicts being treated in these facilities is still a small fraction of the population in need. There are several reasons for this discrepancy. In addition to the economic limitations which have restricted the growth of the number and quality of residential treatment and rehabilitation programs, we face a lack of adequately trained ex-ad-diets, professional and supportive personnel. In addition, we have to consider the perennial reluctance of addicted individuals to enter and stay in residential pro-grams. Residential rehabilitation is difficult, demanding, constraining of personal freedom and plagued with internal struggle and corruption. As a result of the relative paucity of high quality residential rehabilitation facilities, most addicted individuals are not receiving adequate treatment and rehabilitation. I believe this is an important factor in the worldwide explosion in the incidence and prevalence of drug-dependent behavior. Untreated drug-dependent individuals are forced by their biological and psychological disorders to recruit new addicts to maintain their personal drug consumption. If unchecked, this infection process could approximate a geometric growth curve limited only by the prevalent inclination of the human population towards addictive drug use. That predisposition can only be guessed at in terms of percentage of the general population. My own educated guess, 4 RAMIREZ, E.: "The Problem of Narcotics Addiction in New York City", Office of the Mayor White Paper, City Hall, New York, October, RAMIREZ, E.: "Help for the Addict", American Journal of Nursing, Nov. 1967, Vol. 76, No. ii, p RAMIREZ, E.: "The Dome Model in the Management of Addiction", Major Modalities in the Treatment of Drug Abuse, (Brill, Ed.), New York, Behavioral Publications, RAMIREZ, E.: "The Addiction Services Agency of the City of New York", Major Modalities in the treatment of Drug Abuse, (Brill, Ed.), New York, Behavioral Publications, ' RAMIREZ, E.: "Fundamentos del Programa de Hogares CREA", Proceedings, First Dominican Congress of Psychiatry, Ed. Emilio Guille'n Matarranz, Editora Taller, Republica Dominicana, Cap. I, Part 3, pp (1976)... * RAMIREZ, E.: "Recent Advances in the Therapeutic Community Movement in Puerto Rico and Latin America", Proceedings, Eight World Congress of Therapeutic (communities), Rome, Italy, Sept. 1984, Vol. I, pp , RAMIREZ, E.: "Status Report on Drug Addiction in Latin America", Proceedings, First Scientific Symposium on the Prevention of Drug Abuse, Dominican Hogar CREA, Inc., Santo Domingo, Dominican Republic, April 26-28,
3 based on the prevalence of impulsive, compulsive and sociopathic behavior disorders culled from mere analysis of a Variety; of worldwide mental and personality disorder prevalence studies, is that about 20% of the general population (one of every five individuals) is vulnerable to pathological drug and substance dependence and addiction. If this estimate is accurate, the potential worldwide target population for prevention, treatment and rehabilitation services is more than a billion people. Clearly, with a potential clientele of this magnitude, residential facilities will never be able to cope with the problem. Non-residential (out-patient) models and programs must be created, tested, perfected and implemented in a massive, world-wide fashion. Still, the professionally supported residential therapeutic community continues to be, not only the treatment and rehabilitation model of choice, but perhaps more importantly, the basic training structure for the preparation of ex-addict, and professional substance abuse workers and volunteers to man the needed out-patient effort. A much stronger political commitment would be needed by governments of all nations to give priority to the residential treatment of drug dependent individuals. "The World Federation of Therapeutic Communities should attain NGO (Non-Governmental Organization) status in the United Nations, like the Red Cross, t o a c h i e ve a t r ul y i n t e r n a t i o na l l o b by h i t his direction. In the meantime, drug dependence and its devastating consequences: massive loss of human productivity, catastrophic disruption of family and neighborhood life, crime, high death risk, AIDS and social decay continue to take its awesome toll in human misery and social disruption. Until the world community of nation s wakes up to these facts, the burden of absorbing the responsibility of dealing with the drug dependence pandemic lies squarely on the shoulders of the families and the neighborhoods of the affected communities. We are able to identify five social structures that have to be studied, understood and strengthened to enable them to cope with this problem: the family of the addict, the church, the schools, the workplace and the street subculture. These social structures have played a significant part in those instances where outpatient rehabilitation has proven effective. In my experience, the following factors are essential: a) Family Support: In most of the cases known to me, the families of drug-dependent individuals are either broken suffers multiple psychosocial problems are not religiously oriented or at least one family member is either addicted or involved in criminal activities. In cases where rehabilitation has been successful, the addict's family has participated actively in fundamentally changing patterns of dysfunctional behavior. In other cases, the successful ex-addict has been "adopted" by a functional family. b) The Church: Significantly, most addicted individuals have never had a relevant spiritual experience. In some cases, childhood indoctrination has been negated by unpleasant memories of punishment, rejection and strict discipline. In most cases, however, church participation has been absent or perfunctory. On the other hand, I have not seen a single successfully rehabilitated addict who has not experienced a spiritual renaissance. c) The School: A clear majority of addicts are school drop-outs. Most suffer from unrecognized learning disabilities, mental problems and personality disorders. Rehabilitation successes are significantly correlated to educational enhancement of their treatment programs, particularly through the participation of caring, skillful teachers who find ways of overcoming the almost universal oppositional attitude of addicts towards learning and self-improvement. d) The Workplace: More often than not, the workplace of the addict or the ad diction-prone individual is an environment where substance abuse is encouraged and actively sponsored by those fellow-employees who are users or dealers. Office
4 parties are more drug-oriented than ever. Successful out-patient rehabilitation of workers usually requires an active prevention and treatment program in the work place sponsored by the employer. More often than not, a job change to a drug-free workplace is essential. c) The Street Subculture: Since childhood, addiction-prone individuals tend to gravitate towards "the street" as a favorite habitat. This is a frequent complaint from parents. In the streets of inner cities all over the world, children, adolescents and young adults become victims of older addicts to serve as couriers, small-time dealers and prostitutes. Successful outpatient rehabilitation is practically impossible unless the addict is removed and protected from the pull of the negative street subcultural environment. PART II In reviewing the five social structures that are firmly associated to the process of addiction, we must remember that social structures are not the sole cause of addictive behavior. My thirty years experience with addicts in three continents has told me that the person who is negatively influenced by his social milieu has a personal predisposition towards addictive conduct. This personal predisposition can be defined in the context of eight existential parameters: 1) psychiatric disorders, 2) a vulnerable inherited psychological make-up, 3) medical conditions, 4) inability to tolerate stress, 5) an oppositional attitude towards supportive socio-cultural values, 6) undeveloped talents, 7) spiritual alienation and 8) character immaturity. 7 7 RAMIREZ, E.: "La Evaluaci6n Octagonal" (The Octagonal Evaluation), Proceedings, 10th National Psychiatric Congress and the First Transandean Psychiatric Symposium, Lima, Peri, Oct. 30, RAMIREZ, E.: "La Evaluaci6n Octagonal coma Instrumento Fundamental de Diagndstico y Plani-ficaci6n de un Sistema Comunitario de Salud Mental" (The Octagonal Evaluation as a Fundamental Assessment and Planning Instrument for the Implementation of a Community Mental Health Program), Magisterial Lecture presented at the Pontificial University of Salamanca, Spain, April 4,1989. RAMIREZ, E.: "The Octagonal Evaluation System (OES): The Clinical Team-work Search for Precision in the Psychiatric Diagnostic Process and Intervention Plan", Internal Paper published in the Assistant Secretariat for Mental Health, Department of Health, Commonwealth of Puerto Rico, San Juan, October The professionally supported therapeutic community model creates an environment where all these factors are identified and treated with the final objective to strengthening the addicts' personalities to the point of maximum immunity possible to the social pressures that wait for them upon their return to community life. Out-patient treatment and rehabilitation must have the same final objective. The main difference is that the process has to be carried out, instead of in a structured, controlled environment such as that of a TC, in the open, difficult to contra environment of the community at large. Nonetheless, in my experience, success out-patient treatment and rehabilitation can be achieved following a model that takes into careful consideration the five social structures and the eight personal p r e - d i s p o s i t i o n p a r a m e t e r s m e n t i o n e d a b o v e. T h i s m o d e l consisting of (I) INDUCTION, (II) DETOXIFICATION, FAMILY-CENTERED TREATMENT, (IV) REHABILITATION THROUGH CASE-MANAGEMENT, and (V) LONG-TERM FOLLOW-UP (RE-ENTRY). I. INDUCTION: Induction is defined as a process of persuasion by which an individual who is dependent on the effects of a mood-altering substance is helped to recognize the harmful effects of his/her dependence on him/her, family members, and society in general. To the extent that this recognition happens, personal motivation towards change is enhanced. On an out-patient setting, induction is effective
5 only if the family of the addict participates fully in the process. Family counseling sessions are carried out by a therapist trained to identify the problem as a family problem and to recruit the collaboration of all significant family members, especially those who, through their behavior and attitudes have contributed to the individual's addictive behavior. To the extent that the whole family (which may include close friends) accept the problem as a family problem, persuasion is made easier. An essential component of this family-centered induction process is the obtaining of an integral personality profile of all family members actively involved, have developed an eight-angle personality assessment method called the Octagonal Evaluation System (published elsewhere - see note 7) through which the addict and his/her family members participate in identifying the status of the eight predisposing factors mentioned before, and briefly explained in the following paragraphs: a) Psychiatric factors: According to prevalence studies done in several nations, psychiatric disorders as identified by interviewing methods based on the American Psychiatric Association Diagnostic Statistical Manual third edition and third edition (revised), one out of every five persons is suffering from psychically diagnosable disorders. Many, if not most of these disorders have a genetic (inherited), component in family induction work, this is frequently found to be the case. High psychiatric co-morbidity in the addicted individual is accompanied by Atones of psychiatric disorders in one or more members of the immediate family. When this knowledge is openly discussed in family groups, the recognition of the situation as a Caning G. et al: "Prevalence of Psychiatric Disorders", Archives of General Psychiatry, 1984.
6 family problem eases the family's burden of guilt. Other family members frequently follow the addict into induction to treatment and counseling to resolve the guilt feelings stemming from supposed responsibility for the addict's disorder. b) Innate Psychological Makeup: All addicts have some form of personality disorder. Personality disorder, in the Octagonal Evaluation System (see note 7), is defined as a problematic level of intensity in one or more of the following inherited traits: 1) aggressiveness, 2) callousness, 3) impulsivity, 4) irritability, 5) melancholy, 6) sensibility, 7) sexuality and 8) shyness. During family induction sessions, it becomes abundantly clear that the personality profile underlying the addict's behavior patterns can be traced genetically to many family members, who have personality traits in common with those of the addict and who have varying degrees of difficulties as a result of these traits. Awareness of the coincidence of the negative personality traits in the family helps in reducing the "scapegoat" phenomenon which separates the addict from his/her family. c) Medical Factors: The most frequent medical factor in addiction is physical dependence to the addictive substance. Induction can often be advanced by the identification of the medical nature of this aspect of addiction and by the discussion of its medical management. The participation of an addictologist or a physician specialized in the management of substance dependence as a consultant is highly recommended at this point. With some frequency, other medical factors play a part in addictive behavior, particularly, the manic-depressive (bipolar disorder) tendency, which is widely recognized as a biological imbalance, and not as a primary "mental" problem. Many addicts have this imbalance, inherited from one or both sides of his family and all can be readily helped by the judicious use of lithium carbonate. Likewise, neurological, metabolically, immunological, gastrointestinal and musculoskeletal conditions can play a role in the addict's behavior pattern and those of his/her family members. Appropriate medical treatment is frequently a significant factor in this initial stage of out-patient rehabilitation. d) Psychosocial Stress: Different families have different patterns of coping with stress. In out-patient induction, the addict's family pattern of handling stress has to be identified and discussed fully. Family therapy techniques are very effective in identifying and reducing the stress patterns prevalent in the family which usually are contributing factors to the reluctance of the addict to engage in serious rehabilitation efforts. During the Octagonal Evaluation process, stress reactions are assessed in different psychosocial settings: couples, family, peers, work, school, neighborhood, church, etc. For the addict to accept treatment, the identification of stressful settings which provide excuses for substance use is the first step in making a personal commitment to treatment e) Cultural Support: Most addicts and then- families are surprisingly ignorant of, or indifferent to their cultural value support systems. This is most dramatically perceived in families that have moved to a different cultural setting. Transcultural shock and alienation can happen within a country or even within a city, when the 76
7 person moves from a familiar cultural surrounding to a hostile or a less familiar one. A reaffirmation of the natural cultural value system is very often essential in achieving acceptance of treatment towards rehabilitation. Assertiveness group therapy techniques are extremely useful in this respect. f) Vocational Development: Most addicts are talented individuals who have misdirected their natural abilities towards successful drug-seeking behavior. A surprising number of them have no idea of how to channel their talents in a socially acceptable way to achieve success and a satisfying lifestyle. Traditional educational systems are usually neglectful in helping students develop their talents beyond intellectual achievement. Other talents, such as artistic, athletic, intuitive, manual, sensory, social and verbal/expressive abilities have a relatively low priority in standard school curricula. The recognition and cultivation of these alternatives through talent workshops, especially if strongly supported by the family, opens up realistic avenues of motivation towards rehabilitation. The eight talents enumerated here are the natural outlets for psychic energy. If they are not cultivated, the person's energies can be easily deflected towards morbid behavior and "street skills". ; g) Spiritual Relevance: A straight-forward discussion about the relevance of seeking spiritual support in limit situations has been the turning point in many induction processes. A renewed recognition of the importance of spiritual guidance, support and strength is a sine qua non in the process of treatment and rehabilitation in most, if not all, successful attempts. The recruitment of a competent spiritual advisor is an important addition to the out-patient therapeutic team. h) Character Development: In both the addict and his/her family, the most con system psychological finding is character immaturity. This model utilizes Erik Erickson s Eight Stages of Man adapted by me into an eight-fold path towards personal maturity through the acquisition of learned capacities such as trust, autonomy, initiative, industriosity, identity, commitment, altruism and transcendence. 9 i) The acquisition of these capacities is the operational core of the residential Therapeutic Community which I developed in Puerto Rico in the early 60's. It is also the core of the out-patient rehabilitation model. The understanding on the part of the addict and his/her family that character building is the best way to overcome addiction and all its causal factors, is essential in achieving a true conscious commitment to treatment and rehabilitation. II. DETOXIFICATION: The induction process initiates a process of gradual detoxification in most addicts. Once the individual and his/her family have made the commitment towards treatment and rehabilitation, full detoxification is clearly mandated. A substantial number of addicted individuals will achieve detoxification by ' RAMIREZ, E.: 'Te'cnicas Basicas de Intervencidn Usadas en la Comunidad Terapeutica", (Basic Intervention Techniques Utilized in the Therapeutic Community), Proceedings, First Congress of Psychotherapy, Puerto Rico Psychological Association, San Juan, Dec. 2,1989. RAMIREZ, E.: "Character Development", Training Manual for parents and case managers developed for the institute of Personal and Professional Development,
8 themselves as a result of their commitment. This is usually aided by one or more family members, who through the induction process have shown a natural inclination to serve as therapeutic aides. Detoxification is possible at home with the participation of these therapeutic aides under the supervision of a physician or an addictologist. Sometimes, a short-term hospital detoxification process is desirable, when the physical dependence is very strong and/or when the family support system is not adequate. III. TREATMENT: Treatment on an out-patient basis depends on several crucial factors: a) A successful induction and detoxification. b) The identification of a case manager system, composed of family members and/or friends who have participated in the induction and detoxification processes and who are willing to undergo the necessary training and supervision to provide for the addict an around-the-clock support system geared to achieve a drug-free life style that will permit treatment of the personality factors responsible for the individual's addiction. c) Identification of an adequate treatment team. According to the personality profile of the addict, professionals capable of treating the most abnormal factors have to be recruited under the supervision of a therapist.in charge. Sometimes one therapist can do the necessary work. More often than not, a number of professionals and paraprofessionals are needed to help the addict overcome his/her personality disorders. d) The simultaneous training of case manager(s) to help in the treatment process by the therapist in charge or by a specialized Personal and Professional Training Program. 10 The case manager(s) will eventually take over most of the rehabilitation work. IV. REHABILITATION: Rehabilitation is defined as the recuperation of pre-ad-diction capabilities, values and performance. Many times rehabilitation must include habilitation, when the individual started his addicted lifestyle at a young age, before he/she could develop such capabilities. Rehabilitation overlaps treatment. The main therapist, at least, must continue to give follow-up counseling and supervision to prevent relapses. If there is a relapse, which frequently happens, the therapist makes sure they are handled adequately, to prevent loss of motivation on the part of the addict and his/her support system. The most significant factor in the rehabilitation process, apart from the continued support of the main therapist, is the case manager. As stated before, the case manager can be a family member, a friend or a hired paraprofessional (preferably a 10 Such as the one provided by the Institute of Personal and Professional Development, #804 Ponce de Lean Avenue, Suite #304, San Juan, Puerto Rico, 00909, TeL/Fax (809) , Efren Ramirez, M.D., Clinical Director and Principal Trainer. 78
9 trained former addict) who follows the person being helped throughout the whole process, from induction to full re-entry to autonomous living. The case manager is trained in the techniques of therapeutic dialogue, management of temperament, character formation, family mediating techniques, and interagency brokerage. The first four techniques are variations of the therapeutic armamentarium of the main therapist who adapts them to the personality and skills of the selected case manager. In my experience, rehabilitated ex-addicts make the most effective case managers. Interagency brokerage is an essential component of out-patient rehabilitation. Through this activity, the case manager helps the addict take legitimate advantage of the services available to him/her in the community, eventually leading to the final stage of the process. V. LONG-TERM FOLLOW-UP (RE-ENTRY): Once the addict has successfully overcome his/her inclination to resort to substance abuse as a coping mechanism, a life-long process of re-entry into normal society begins. The process, like personal development for all of us, whether or not previously addicted, is a life-long endeavor. To stop being part of the psychosocial problems of our society and become part of their solution is a never-ending task for all of us. For the ex-addict it is no different. The ex-addict, having had' the experience of falling into one of the most devastating states that human beings are prone to, can become effective witnesses for change, both at the individual and at the collective levels. As individuals, former addicts constitute an ever expanding human resource pool as case managers, counselors, therapists, and role models. Collectively, the ex-addicts constitute an essential component in the development of the needed community-based movement to strengthen the five social structures which are identified at the beginning of this chapter as breeding grounds for addiction. A long-term follow-up of a former addict is both a responsibility and a bonus for his/her family. Having had an addict in their midst is a sobering experience for most families. If the addict has achieved rehabilitation with the help of the family, it could only have happened as a result of a change for the better in the family structure and collective health. The younger members of the family benefit from the experience. Educational leaders and managers have to realize that the school room can be either the ejection mechanism for youngsters whose behavior is heralding a high risk toward addiction or a natural catchments area for the early manifestations of addiction prone personalities. At present, most schools, at least in America, have unacceptably high drop-out rates, of precisely those children who because of their learning disabilities (40%) and/or their mental, social and personality problems are rejected by the system. As former addicts return to school as students, counselors, teachers or administrators, they have proven to contribute positively to a collective awareness of the golden opportunity that schools have of catching addiction-prone individual on time. It will only take the training of teachers, administrators and parents in the same techniques that are described above for induction, treatment and rehabilitation, adapted to the school setting. This has been done successfully in pilot projects in Puerto Rico and the United States." A. fundamental component of long-term follow-up in the rehabilitation of former addicts is his/her participation in church activities. Churches can either reject the addict and the addiction-prone individual or tram their religious and lay personnel to become a massive support system for hundreds of millions of individuals at risk. Imagine it! Every church in the world, through a simple training and supervision program, can become a substance abuse primary prevention and long-term rehabilitation follow up center as a complement to treatment and rehabilitation programs in the community it serves! The workplace is also an essential component of long-term rehabilitation follow-up programs. Rehabilitation is meaningless unless the former addict has the opportunity to work. The work has to be commensurate with his/her skills. The workplace has to be drug-free. In a recent study of work performance by former addicts graduated from the CREA program in Puerto Rico, their productivity, performance, and punctuality 12 was better than a control group of employees who were not addicted and who had never gone through a rehabilitation process. Although there is a large job opportunity avenue for the former addict in the case manager business, that still remains a future opportunity, depending on whether the model proposed here will be adopted on a large scale. Besides, in my experience, only about 15 to 20% of the former addicts develop the vocation to be case managers. The majority of the
10 rehabilitated addicts will have to be absorbed by the traditional professions and occupations. Brokerage with employers by case managers will be an essential on-going goal for long-term follow-up. Finally, the street sub-culture plays an undeniable role in long-term follow-up of successfully rehabilitated former addicts. The temptation will always be there. Drug dealers, consistent with their psychopathic way of thinking, will tempt the former addict as a potential client. Many times they succeed, since they have adapted psychological and marketing techniques to spread their "business". This is the final challenge to long-term rehabilitation. Will the political leaders of nations give priority to clean the streets of drugs, drug dealers and drug-profit motivated crime? We have to remember that addiction-proneness is inherent in human nature, at least in about 20% of us. Maybe all politicians should receive the basic training that I have described in this chapter. After all, they get elected or chosen to be the case managers of our society. They should learn how to do it well. " The Peer-Power Program, carried out in the Archdiocese of Brooklyn School System between 1971 and RAMIREZ, E.: "The School Therapeutic Community Project", A three-year pilot project carried out in five intermediate and high schools in Pueno Rico between 1986 and Repon to be published by the Puerto Rico Department of Education. " Personal communication by the Director of Rehabilitation Programs of Hogares CREA, Pueno Rico, 1986.