[Music] [The U.S. Department of Health, Education, and Welfare Public Health Service presents T-1701 MCMLXIX] [A National Medical Audiovisual Center Production] [Daniel H. Casriel, M.D.] [Casriel:] I'm Daniel Casriel from New York. I'm the co-founder and Medical Psychiatric Superintendent of Daytop Village. From my five years' experience it is my opinion that drug addicts are curable. [Jerome H. Jaffe, M.D.] [Jaffe:] I'm Dr. Jerome H. Jaffe of the University of Chicago's Department of Psychiatry and the Department of Mental Health of the State of Illinois. I believe that narcotics users are a heterogeneous group and that there is no one treatment approach that is appropriate to all of them. [Frances Gearing, M.D.] [Gearing:] I'm Dr. Frances Gearing, Division of Epidemiology with the School of Public Health of Columbia University, I'm involved in developing evaluation criteria to measure success of narcotics treatment programs so that their results may be compared. [Music] [concepts and controversies in modern medicine] [Current trends in the therapy for narcotic addiction] [Host:] Welcome to the exploration of concepts and controversies in modern medicine, one of a series of programs dedicated to examining the uncertain, candidly recognizing that much of today's teaching is necessarily based upon opinion, and that the opinions of eminent physicians in a given field vary widely. The National Medical Audiovisual Center believes that openly airing such opposing views is a basic responsibility of medical communications. Dr. Frances Gearing, assistant professor of epidemiology at Columbia University School of Public Health and Administrative Medicine, will act as moderator of this presentation. [Gearing:] We have two approaches to this problem of the treatment of narcotics addict, both of which have their proponents and opponents. Dr. Casriel, what is Daytop Village and why do you think it works? [Casriel:] Daytop village is a halfway house, better still a therapeutic community. It is a non-profit corporation, basically subsidized by the State of New York, also having its own funds available through its own resources. It is basically a collection of people, black, white, Puerto Rican, young and old, with or without their children. They all have one thing in common. They've all been hardcore addicts and addicted to heroin. They have all, they all have one goal in common and that is to help each other and themselves, cure themselves and rid themselves of the problem and the symptom of drug addiction. In my experience, I find that what has happened in Daytop, through the amalgamation of the hostile confrontations developed by places like Synanon and the supportive emotional understanding approach that has been classically used by psychiatrists, there has evolved in Daytop a new dynamic which is extremely effective, and is very exciting because it leads not only to the solution to the problem of drug addiction, but in my opinion leads to the solution of the problem of the character disorder in general. [Gearing:] Dr. Jaffe, what is the approach to narcotic, treatment of narcotics addicts in, in the State of Illinois. [Jaffe:] Well, a little over a year ago we had no treatment facilities for narcotics users in the state, and our task was to develop treatment programs. In doing so, we decided to look around at the various programs being proposed throughout the country, ranging from civil commitment programs in California to methadone maintenance in New York and programs such as Synanon and Daytop Village. We felt that the claims of all of these programs were worthy of exploration and we have evolved a program which establishes all of these treatment programs in a context which permits us to compare each to the other, so that we can develop a program which is best suited to the needs of the community, mainly the, the urban area around Chicago. [Casriel:] Doctor, I think in answer to your second question, why does it work or how does it work, I think to explain it I've had to change some of the psychodynamic theory. Mostly it states that people react to stress by flight and fright, fear and anger. To really account what happens in Daytop, we've... I've had to hypothesize a third way of reaction, and that's by withdrawal and encapsulation. Now, the encapsulating shell that a person utilizes may be heroin or it may other some, some other characterological shell such as homosexuality, the shell of inadequacy, the shell of criminality, etc. But if you take this as a hypothesis, then the treatment to the character disorder in general, and the treatment of the drug addict in particular, becomes very understandable and very obvious. In Daytop there are two cardinal rules: no chemicals of any kind, of course, and no physical violence, of course. Now when we say no chemicals, there are no other shells under which to hide. Once we remove the shell of the chemical, we prevent the individual from running into other types of encapsulating shells where they cannot or will not communicate with significant others. So that the individual in Daytop can only react to stress or danger in one way and that's through anxiety. He can't fight in anger and he can't withdraw into isolation. He has only one method of coping with stress and that's through fear. Now with fear, he can either run out of the house, never to return, or sometimes very frequently to return, or he can stay to fight his fear, to resolve his fear. If he stays, the problem is basically a reeducational one, not only emotionally, but also behaviorally and attitudinally, vocationally, educationally, morally, ethically, culturally. We have to reeducate this rather primitive antisocial human being into a culturally acceptable adult, and this is what we're able to do in about a year and a half, currently. I hope to improve the process so that we will be able to reduce this time in the future to about a year. [Gearing:] You're, you're implying then that a, a treatment modality that has a drug maintenance in it is not a treatment modality. Would you like to discus that Dr. Jaffe? [Jaffe:] Well, I'm not sure if this what Dr. Casriel is implying. [Gearing:] He said no chemicals to hide behind. [Jaffe:] Well, that's obviously one approach. I wonder whether chemicals are always hiding, because I think that there are two issues here, one of which is Dr. Casriel, Dr. Casriel's inference about what is the nature of narcotics addiction, and what you're saying is narcotics addiction is basically a, a withdrawal behind a chemical as a response to stress. [Casriel:] That's right. [Jaffe:] And other people have made other inferences from other approaches, for example, [?] have proposed based on their observations of what happens when they treat people with high doses of methadone each day, that in fact the narcotics user isn't respond, isn't withdrawing, but he is responding to some metabolic difficulty, specifically a kind of a narcotics hunger which has been induced by the repeated use of narcotics, so now when he stops using narcotics, he never feels normal again; he has this persistent hunger, at least it persists for many, many months beyond the time that he has used narcotics. So they make the inference that in fact, this is not a withdrawal, but this is a response to a metabolic difficulty, Correct that, specifically with the use of a drug like methadone, and many of these individuals require no further treatment. Obviously some will need social and vocational rehabilitation and characterological change. They will need to be resocialized, but that is something that would happen to any delinquent, not specific to narcotics users. [Casriel:] I don't think the hunger is metabolic. I, I see no difference between the hunger of an addict which lasts for months after he stopped the physiological addiction. and the hunger of a homosexual who is now developing a heterosexual way of life. Every time a homosexual gets anxious, he feels homosexual and he seeks a homosexual outlet. Every time a drug addict in the process of getting well gets anxious, he seeks the heroin to resolve his anxiety. [Jaffe:] I think the alternative interpretations other than metabolic disorder, one could talk about a, an overlearning, a conditioning process, such that what has so the narcotics user doesn't, doesn't have an actual hunger but is conditioned to make a drug-using response in preference to any other kind of response to handle the internal difficulties and the process required to cure this is, number one, a reeducational one or a process of extinction. What I am trying to say is that it's one thing to talk about the inference from the data about the nature of the disease, it's another to talk about, what is the outcome of certain therapeutic operations. I would say that one has to seriously consider the data. They have, of course, treated almost a thousand people with large daily doses of methadone. They say that about 750 are successfully treated, meaning that they are working, that they've a very low re-arrest rate, a very low rate of relapse to narcotics use and that although about 10 to 15 percent of them are using alcohol or amphetamine, that still leaves them with a very, very respectable percentage of individuals who are making satisfactory social adjustments, and given that kind of data, and given the small number of graduates of therapeutic communities to date, from the social point of view or the public health point of view, it's of real significance as to whether or not we go along with what will help solve the social problem of narcotics use, and what should we do about our inference about the cause of narcotics use. [Casriel:] I think, I think as the social problem that narcotics users cause, there's no question that methadone can alleviate a great deal of the crime immediately, because it's true, once they're on methadone there is no desire for heroin, they're just overwhelmed with the methadone. But, and I have no complaint about a 10 to 15 percent failure, we have about a 10 percent failure rate now with our graduates, so that is in keeping I think with, I'm perfectly happy with that. What I question is their statement of the level of social and vocational integration and emotional integration while being sustained on methadone. How many of those 85 percent are truly functioning in a capacity that they would otherwise function in if they weren't narcotics addicts and on methadone? [Jaffe:] Well, I think that what we have to look at is, what percentage of people in a therapeutic community would be truly functioning at a high level if they weren't in a therapeutic community? Now if you then compare your graduates, and the overall percentage of people entering a therapeutic community, and the percent graduates and say now how are the graduates doing, that might be a reasonably fair comparison. And the real question here is one of attrition. Of the hundreds of people who come in to therapeutic communities, and I think would be unfair to imply that every therapeutic community has the same holding power or the same recovery rate as Daytop Village. There are number of these, as you well know, and the attrition rate of some is such, that of a hundred people making initial contact, only 15 actually enter the therapeutic community. So that even if all 15 were to become successful graduates with a zero rate of relapse, you would still have to deal with the fact that somewhere in the community, there are 85 people who for one reason or another have been unable to benefit from this treatment process. [Casriel:] I agree, I think any treatment has to be rated on its effectiveness. Now, I think it's taken Daytop five years to really zero in on the effective process, and I feel that we do have one now. In the last four months, our holding power of all those coming in is 85 percent and we're taking in about a hundred a month. [Gearing:] You mean 85 percent of those who applied to you stay. [Casriel:] Right, stay, stay. They might split, but they come back. [Gearing:] Is there any, are there any that are, that come to you that are rejected by you as not, uh...? [Casriel:] Very rare, very rare, less than one percent I think. [Jaffe:] This is an interesting contrast to our experience thus far in Chicago, and brings us into the question of compulsory treatment. We have a system in which people are offered an opportunity to enter a therapeutic community. They are told if they will simply go to the interview, and are either rejected or decide not to enter, they can come back to the intake center and would be offered another treatment. The response to this situation is such that well under half of the people given this opportunity will not even participate in an interview. In other words, they would rather never come back and never have any opportunity for further treatment than to go simply for the interview, so this is, this must reflect differences in the population. [Casriel:] It also reflects differences in the law. In, in New York now, you know there's a heavy, heavy hangover if you get caught as a drug addict, you know you have to go and you are incarcerated in the state program. I think this is a motivating tool to get the person into Daytop. We assume when they come in, they truly have no real motivation and one of the things we do very early is to motivate them, so that if they stay over several weeks, our holding power, again, for the last four months, has been 97 point some percentage. It's very exciting now what is finally being jelled. But I agree with you, you have to push the addict into treatment and you have to assume that he is not motivated when he gets into the treatment modality. [Jaffe:] This is, this is of course the great paradox, that although you have to push them into treatments that we designate as being curative, we have a waiting list of several hundred people who want to participate in a methadone treatment program. Now, when we say methadone treatment program, we don't mean simply substituting methadone for the heroin. As a condition of participating in this program, they do attend the group, they are required to take a look at themselves, unless they can make a case that says I do not require this because I am working, I have not been arrested, I am not using drugs. And all I require is this medication each day. If somebody can say that, I think the burden is on us to, to say why he should be forced into participating in group therapy This...I assume it is, is a philosophical position. Those people who're not working, those people who are in fact still showing some form of drug use, whether it be alcoholism or barbiturate or amphetamine use, or who don't have any legitimate means of support, and we suspect that they're engaged in some kind of antisocial activity, are required to participate in groups just as if they were totally abstinent, and furthermore some of them we start on methadone do elect after a period of several months to be withdrawn from methadone, after which they participate in a totally abstinent program based on a Daytop model, or may actually elect at that point to enter a therapeutic community. My, my point is that when first confronted, when you know with the idea of immediate entrance into a therapeutic community, the number of people who will reject that totally is rather high. [Casriel:] I'm not pushing for the first and only step to rehabilitate an addict must be a therapeutic community, What I'm objecting to is the use of methadone as a total maintenance dose, you know, for indefinite periods of time. Now if you want to use methadone to control and contain and try to wean a person into therapy, whether it's a therapeutic community or group therapy, of the type has evolved in Daytop or similar types of groups which are effective, fine, I have no objection. I'm not on a witch hunt for methadone anymore than I was on a witch hunt for heroin, but I do feel that these people need to be forced into a treatment process, and I think it behooves the doctor to force the community to take responsible action, just as the community has taken responsible action for any communicable disease such as leprosy or all the various communicable diseases. To me an addict on the street is a, is a contagion and he will introduce his contagion, his, his symptoms to his friends. [Jaffe:] You consider a, a human being who was once a heroin user, who now works and takes methadone each day or some drug similar to methadone, do you consider him to be a contagion? [Casriel:] I don't think he is the contagion that a heroin addict is because he is now law-abiding and attempting to function, but I think he is a very poor role model for others who could otherwise be completely free of methadone and I can't really buy the concept that a person on methadone is a healthy human being emotionally, I just can't conceive of it. [Jaffe:] Well, you know it, it's interesting. We could, we could talk about the relativity of all of these things. Clearly, he is a poor role model for people who have the capacity and the interest and the potential for becoming totally independent of all medical support, as you claim that people who go to Daytop Village will become. He's a fine role model walking around the streets to people who have not yet made a commitment to give up intravenous heroin, and as a matter of fact, one of the great advantages of methadone, which people have not emphasized sufficiently, is that people who enter a therapeutic community like Daytop Village who've disappeared into the bowels of this organization for a year, never go back to a neighborhood to tell people there's another way of life. [Casriel:] Well that's not a - [Jaffe:] People on methadone, at least in our program which requires no hospitalization, are almost transformed immediately into non-drug users and go back and carry the word to the community. [Casriel:] But your statement isn't quite true, because one of the things in the rehabilitation of the person at Daytop is to go back into addict communities, and by example prove to others who are still using drugs, that you don't have to be a dope fiend anymore. We have three storefronts right now in high-density addictive areas where we are sucking, literally vacuuming, the streets of the addict by confrontation. Many of these boys used to shoot dope with these kids that are still on the street, and they say, "Look Johnny, you don't have to do it anymore, you know, you don't have to be a dope fiend." It isn't metabolic you know, you're not some peculiar, enzymatic, defunct human being. You've just had a problem that you've never been able to face, and that problem is emotional, cultural, social, vocational, etc. and we will be able to help you. And it's a very hard... [Gearing:] How, how long after they start at Daytop do they get back into the community? [Casriel:] Right now between 15 and 18 months, and I hope within the next year to cut that down by at least three months and perhaps six months. [Gearing:] Now then, then Jaffe's statement was correct, for a year, they're, they're off the streets, they're off the streets, whereas in an ambulatory program, they're back on the street almost immediately, and even with the, and even with the, the inpatient induction, they're, they're out within four weeks. [Casriel:] But their cultural values, their social values, their moral values, their ethical values, none of these have changed. [Jaffe:] Well, that's an assumption. One important thing is that... [Casriel:] Don't tell me the change is within the day. [Jaffe:] No, it does not change within the day, that's quite true. The real issue is can, can we afford to, to change that slowly, or can it be changed slowly as an ongoing process after they've started methadone, or is it necessary to make a total break with the drug-using subculture and to live in a therapeutic community for a while? I submit that this is a question for further research. I have seen people switch from illicit narcotics to methadone and behave in a totally reliable law-abiding way. They do have a certain amount of super-ego, they do have a sense of commitment to other people, a sense of honesty in spite of the many myths to the contrary. [Casriel:] Now I don't want you to feel that we can only cure a drug addict in, in a therapeutic community, because Daytop has an outpatient setting in these storefronts which we call SPAN, where we take what we call the softcore addict who's been used to heroin less than a year and in my own private practice I've taken a middle-class addict who might have had heroin for many years, but have something going for them like a job or family, and we've been able to hear them on an outpatient setting. And I use the word cure as it is used medically, so that the underlying problems are no longer existent, which give rise to the symptom, and although it is conceivable that once you cure a person's pneumonia, five years later you can get pneumonia again, I think it's also conceivable that once we cure a drug addict, the social, realistic stresses that confront all of us might reproduce a, a reversion to his primitive earlier symptoms, because although we can cure him of his symptoms, we don't remove the memory, you know, you never forget your past. You don't have to act on it. But I think that the, in the light of the program and the rehabilitation process at Daytop, to settle for anything less than a total psychodynamic personality change is, today, anachronistic to the best of what medicine can offer. [Jaffe:] Well, I still submit that there are two issues, one is a social issue and one is a theoretical medical issue, and the social issue requires that we look at what is the capacity of the thing we call therapeutic community to get into treatment the large numbers of heroin users as opposed to the feasibility of establishing a large-scale methadone treatment program. Now, you might argue that you would accept that program so long as people did not support the idea that this was a permanent kind of thing, but I would submit the idea that for those people who are functioning on methadone, as long as they are functioning in a socially acceptable way, I would be rather reluctant to see them forced arbitrarily to stop using methadone to undergo what we are calling a cure, but would reserve that for those people who elect to do so or who are not functioning adequately while on methadone. I also, there's one other point, you keep referring to kids, you know, these young people, and it's very interesting that this must be the case in New York and it must indicate that the problems are different in different communities. The average age of people seeking treatment in Chicago is 35 years and that they've been on heroin for an average of 14 to 15 years. Now, it may well be the reason that we are not seeing people seeking out or accepting treatment of therapeutic community as regularly as you do, is because we're seeing a different spectrum of the narcotics-using population and that therefore methadone is for us something different than it is for you. [Casriel:] Well, I think if a person used heroin for 14 or 15 years, his, his whole personality has been so frozen that he really feels there is no other way except perhaps to use methadone instead of heroin. But I question seriously the difference between when you say a person is functioning on methadone, is he functioning on a borderline peripheral way, like he's an attendant in a gas station, or I shouldn't even say that...like he's a make-type of job, you know, just one level above welfare, or is he really doing something significant, and what percentage are really capable of doing something significant while on methadone? I don't know that answer. [Jaffe:] Well, I think this is a matter to be looked at when the data is in. When...we are looking at this, we are categorizing jobs and the earnings and we're comparing this to the output, to the kinds of jobs held by people who passed through our own therapeutic community, and it's when we have all this information, we might be able to answer the question a little bit more objectively. [Gearing:] Well, we presented two sides of the problem and two varying approaches to the problem of the treatment of narcotics addiction. Obviously, there is much more to be done before all the answers are in as to what part each one of these may play in the total narcotics addiction problem. [Host:] We thank Dr. Jerome Jaffe, Dr. Daniel Casriel, and Dr. Frances Gearing for their interesting analysis of a critical problem in patient care. In subsequent programs we shall continue to record equally significant concepts and controversies in modern medicine. The opinions expressed on this program do not necessarily constitute endorsement by the Department of Health, Education and Welfare, the Public Health Service, or its constituents. [Music] [Daniel H. Casriel, M.D., Medical Psychiatric Superintendent, Daytop Village, New York] [Jerome H. Jaffe, M.D., Director, Drug Abuse Program, State of Illinois, Dept. of Mental Health] [Frances Gearing, M.D., Ass't Professor of Epidemiology, Columbia University School of Public Health & Administrative Medicine] [concepts and controversies in modern medicine] [The End, T-1704, MCMLXIX]