|
GENERAL STATEMENT
Odyssey House, Inc, is a voluntary nonprofit agency which began as a pilot research program at Metropolitan Hospital in January, 1966. At that time, Dr. A. Ronald Sorvino was assigned the task of evaluating the use of the maintenance drug, cyclazocine. Based on his prior unsuccessful experience with methadone drug maintenance alone, Dr. Sorvino asked me as resident psychiatrist assigned to the ward, to develop a long-term psychotherapeutic setting in which the narcotic addict might be more responsive to psychiatric intervention.
Subsequently, in early January 1966 I visited with Dr. Efren Ramirez in Rio Piedras, Puerto Rico. Impressed with his work, I agreed to try to adapt his method to the New York City milieu. Odyssey House is the successful outgrowth of that project. We now serve fourteen American states, two in Australia, and the countries of New Zealand and Israel in the field of drug and substance abuse.
Historically, in August 1966 the patients influenced the doctors in charge of the program to conclude that continuance of the maintenance concept gave the antitherapeutic message that the patients were crippled and unable to function normally without drugs. The patients requested discontinuance of cyclazocine. However, a drug-free project, no matter the promise it showed, was incompatible with Metropolitan Hospital's commitment to drug testing. Therefore, the patients were discharged from the hospital in October 1966.
Seventeen of them elected to continue the work of the therapeutic community. Their dedication to the belief that they could function without drugs, that they could be successfully treated by psychiatric intervention, and that they had a responsibility to prevent, through education and example, the spreading and continuation of addiction, rallied many members of the community to aid and assist them. Three psychiatrists volunteered their services free of charge in the initial interim period. At the same time, a small seven-room building was loaned to them. Until June 1967 the group was self-sustaining, supported minimally by donations.
In March 1967 Odyssey House was incorporated and soon received tax-exemption from the Internal Revenue Service. Its strong belief in the therapeutic community method of treating addictive diseases, based on the statistics of the Rio Piedras experience and its own high success rate, committed Odyssey House to the expansion of its program to meet the compelling needs of the community. A voluntary agency has the important ability of being sufficiently flexible to develop, test, and modify its ideas and methods. The small professional staff is dedicated to the observation, recording, and analyzing of the treatment data accumulated. Every session in the community is recorded for future research evaluation.
In order to expand, in May 1967 Odyssey House rented a building at 309-311 East 6 Street in Manhattan. These quarters have facilities for approximately sixty persons—forty males and twenty females—plus eight resident ex-addict staff. Odyssey House occupied these premises in early June 1967.
Within the next year Odyssey House grew quickly, responding to the desire of more and more drug addicts to enter treatment. A motivational facility was opened in Harlem and a "re-entry house" in the Bronx was leased to Odyssey by the Roman Catholic Church for $1 per year.
By March 1969 Odyssey House had facilities for 130 residents and was continuously overcrowded. One of the causes for the overcrowding was the great number of teenagers seeking admission to the program. It was at this time that the Odyssey staff spearheaded the public outcry against the rising number of teenagers becoming addicted to heroin in New York City. The Deputy Chief Medical Examiner of the City of New York grimly confirmed this trend as he reported almost one teenage death daily in New York City from heroin.
Reluctantly, governmental officials decided to recognize the problem, but not before Odyssey House took the initiative and opened an adolescent treatment unit totally dependent on private funds. Technically, this was illegal, since Odyssey House did not possess an appropriate Certificate of Occupancy and the Odyssey House Charter did not allow for treatment of patients under 16.
In 1971 the Odyssey Method was adapted to treat addicted parents in addition to adults and adolescents. The outgrowth of this project is the Parents Program—the only treatment facility in the United States where children up to the age of five can be in residence with their parents: the children have round-the-clock supervision, medical care, and a diversified school/play program; the parents take part in a traditional Odyssey treatment program, but which emphasizes learning child nurturing skills. The major goal of the Parents Program is to break the multigenerational cycle of drug abuse and child abuse/neglect.
The Odyssey method of treatment is unique in that it is an easily understandable and teachable process of changing a person's behavior and basic attitudes. The flexibility of the Odyssey Method is demonstrated in its successful application in such diverse social milieu as Louisiana, Maine, Michigan, New Hampshire, and Utah, as well as in Australia, New Zealand, and Israel.
In spite of rather phenomenal growth, Odyssey House has been able to maintain high standards of excellence in therapy because of close supervision by an independent team of specialists four times a year, both for program control and modification.
The rehabilitation service program is divided into three phases: (1) pre-treatment or induction, (2) intensive residential treatment and (3) posttreatment or re-entry. Induction is divided into three stages; first, awareness of the program's existence; second, the motivation of the street addict to enter treatment accomplished while he remains in the community; and third, the first in-residence challenge, the candidacy-in, to determine the sincerity of his motivation.
The treatment phase is divided into three levels discussed more fully (see also Program Flow Chart, pp 218-219). The post-treatment phase is also divided into three stages: the in-residence one of level IV, during which time the patient begins resocialization; candidacy-out, accomplished in the community with the patient's return for after-care only; and finally, discharge to out-patient status. This concept is known as the rule of three upon three.
INDUCTION: PRE-TREATMENT PHASE
The initial presenting problem after the addict learns about the program's existence is that the raw street addict has a tenacious hold on street values called the code of the street. It represents to him the only code for survival remaining to follow. This hold not only supports him in his rebellion against organized society, but also strangles any effort of his to seek and benefit from conventional treatment. He is unable to interact in a patient-doctor relationship, even if his initial indifference, skepticism, and negativism can be overcome.
The pre-treatment phase is designed to motivate the street addict to enter into a meaningful therapeutic endeavor. Its primary function is to pave the way for the future doctor-patient relationship. The extreme importance of this is obvious to any professional who has been the object of the reactive contempt the addict initially shows towards the non-addict world, because of his own psychopathology of isolation, loneliness, and low self-esteem. However, within most addicts is the faint, but real, desire to return to functioning in a positive manner.
Therefore, the first constructive therapeutic relationship is, by necessity, that of an ex-addict group leader to a raw street addict.
The street addict, called by Odyssey the raw addict, may enter treatment on his own initiative or be sent from another referring agency, either private or public. The Induction Supervisor screens and accepts for admission addicts who are in prison, on the request of their counsel, by court order, or through the parole division of the Department of Correction. He has secured special permission to enter the facilities of the Department of Correction. The source of referral is unimportant, as long as the raw addict is exposed to the first motivational phase. However, the Induction Supervisor reserves the right to refuse admission to any applicant. The overwhelming majority of drug addicts are not psychotic. They are legally and psychiatrically responsible for the consequences of their actions and should be held accountable. Experience has shown that those addicts who are incarcerated by the law, or who feel incarcerated, or who are unwilling to accept treatment voluntarily, will be amenable to treatment when a proper pre-treatment phase is instituted.
The youthful addict or drug abuser under the age of 18 is accepted immediately into the program at any time, regardless of whether he has used drugs within the past few hours. The older addict must show sufficient (although quite minimal) motivation before he will be allowed to enter treatment. This is achieved by displaying a cooperative attitude, appearing on time for induction, and decreasing his addiction to a point where he can enter the residence without requiring detoxification. No addictive substances are permitted or prescribed within the residences.
For most patients detoxification has not been found to be necessary. Severe withdrawal is a rarity; all residents spend their first seventy-two hours in the program with a "buddy" and are closely watched by physicians and registered nurses as well as trained ex-addict supervisors.
When the raw addict is considered by the ex-addict team ready for admission to the community for the second stage of induction, the candidacy-in, he is sponsored by the level IV co-leader to the ex-addict and medical treatment supervisors of the intensive treatment unit. Either one can refuse admission, returning the applicant to the beginning groups for further motivational work.
In addition, the previously described method of admission is therapeutic for the level IV residents. It exposes them to the confrontation of the street values, beyond which they have now grown. This confrontation or challenge occurs at the beginning of their own resocialization and re-entry into the general community, the initial weaning from the protective isolation of the residence. The Induction Supervisor is continuing not only his confrontation with the addicts in the street, but also, he is assuming the responsibility of training others, the level IV residents, to undertake responsibility. He is increasing his sphere of authority. His staff is responsible for summarizing all the contacts with the patients during this first stage and beginning the resident's individual chart.
Within twenty-four hours of admission to Odyssey House, the second phase of induction is begun, "The Candidacy-In." This is initiated by an Inquiry-In, which is conducted by the House Coordinator in conjunction with representatives from the entire community. The functions of this meeting are to familiarize and acquaint the resident-patients with the proposed new member, to take a complete. history, and to afford him a constructive sense of belonging. An additional purpose is to identify, as quickly as possible, any major problem areas which later may complicate the interpersonal in-residence relationships.
The Inquiry-In is for the benefit of both the patient himself and the community, not only to enable the group to function better therapeutically, but also to be protected from and to cope with the inevitable gaming and testing behavior which has a unique flavor with each resident. The Inquiry-In openly confronts the patient with the expectations and demands of the community upon him as regards his behavior, and the consequences which will ensue from negative behavior. That such consequences must ensue without the possibility of mitigation is essential to the growth of these patients.
The breaking of any of four cardinal rules means immediate expulsion from the residence. These are: the use of contraband; stealing; a threat or act of physical violence; and any sexual acting out, whether heterosexual or homosexual in nature. The latter three rules are enforced by the senior patients and staff. The first is not left to the clinical evaluation of the other patients and staff.
In order to ascertain with certainty that the residents and staff are drug-free, their urines are analyzed on a daily basis and certified to be free of all substances such as opiates, barbiturates, hypnotics, and amphetamines, by an independent laboratory.
The Inquiry-In constitutes the first formal community challenge to the addict. It tests sincerity and motivational drive. It is a clear demonstration of the positive constructive functioning of the therapeutic community. The patient is shown dramatically that the community means business. A copy of the Inquiry-In, plus comments from the resident-patients present, are appended to the chart. The patient is now a candidate-in.
The candidate-in is responsible for the major manual work within the community. He is supervised by a level III resident. The candidate-in has four and one-half hours a week of group work with a therapist and a senior level III in his facility.
The residential day is structured from waking in the morning until bedtime. Little opportunity for leisure time is afforded. Between three and six hours a day is allotted to group meetings. The candidate-in has no voting rights or voice in the running of the community.
The candidate-in is given a complete medical work-up within twenty-four hours, including not only a routine history and physical but also complete blood and serological testing, urinalysis, chest X-ray, TB skin testing, and EKG. All female residents are given a PAP test. There is a licensed physician and a registered nurse assigned to each facility. All medical problems are worked up under the direction of the full-time Medical Director. The Medical Director also sees that each resident receives a complete psychiatric evaluation by a qualified psychiatrist within seventy-two hours of admission. Psychological testing is part of the general psychiatric evaluation. A complete medical and psychiatric report is appended to each resident's chart.
The Probe constitutes the next formal challenge to the candidate-irr. When suitable progress has been made by the candidate-in, he may be sponsored by the treatment staff to become a full participating resident. The sponsorship must have the endorsement of the group leaders in charge of the proposed patient. The probe usually occurs within three to six weeks after the Inquiry-In. A candidate-in is entitled to one probe a week after his initial week within the community, or a single probe by default at the end of six weeks if he has not been sponsored. The probe is conducted by a member of the treatment staff and is attended by selected representatives from each higher in-residence level as well.
The function of the probe is for the candidate-in to prove to residents as well as the professional staff, by both word and deed, that he has a usable understanding of the concept of the house, and a commitment to live by it while in residential therapy. In reality, this means that the patient accepts the doctor-patient relationship that he is willing to look into himself for the answers to his problems, that he will accept responsibility for himself and his actions, and finally, that he will submit to authority and discipline of the community.
If he passes the probe, the candidate-in moves to level I. If there is one negative vote, in a sponsored probe, he remains a candidate-in; if the probe is by default, he is returned to the street addict groups for additional motivational work and future application for readmission to the House.
It is important that the program have value to the patients participating and to those considering admission. It must be preserved as an entity above and beyond any individual member. Therefore, there are times when a resident must be excluded from the community. It has been repeatedly demonstrated that confrontation and actualization of discharge have rededicated the majority of the persons affected, causing subsequent improved functioning on readmission.
If the candidate-in passes the probe, he is accepted as a full participating member. He now begins the intensive treatment phase per se. A copy of the probe, including comments by all those participating, is appended to the patient's chart.
TREATMENT PHASE
Now the addict begins in earnest the process of personality reorientation, or reconstruction. He comes relatively quickly to the realization that he is not a chronically sick person in need of drug maintenance, but rather that his way of life, or orientation towards functioning, is sick or distorted. It becpmes very evident to him that his behavior is a result of free choice. No matter how deviant the past behavior of an addict has been, he has the innate capacity to function positively when properly challenged. The energies which before were destructive in nature are directed constructively in accord with those of society.
Acceptance by peers constitutes the prime force available in beginning therapy to the professional and ex-addict co-leader treating a group of sociopaths. Once deviant behavior is no longer rewarded by his group but has become grounds for exclusion, the speed with which new members are oriented to and accept positive, affirmative attitudes towards treatment, and adopt the senior members' judgment as to the therapist's qualifications is amazing. The therapist is an expert participant-guide in therapy meetings, but the patient participants are considered primarily responsible for the success or failure of any single endeavor. It is their work that counts, only they who stand to benefit from treatment or to lose if they game.
From its inception, the Odyssey House program is designed to create receptive peer-group relations, thereby permitting residents to relate to each other and the staff without fear of reprisal. There is no contraband in the house, no threat or actualization of physical violence, and "no contracts of silence" or "defending each other" in group therapy. The residents have assumed sole responsibility for the enforcement of the rules that they have instituted. This permits the treatment staff to devote full time to therapy rather than enforcing police or security methods. Thus, they are maximally able to utilize their training with minimum waste of effort, talent, or money. This prevents much of the frustration and depression often seen in professionals who treat addicts.
The emphasis in therapy is no present behavior, interpersonal relationships, and attitudes. The use of the past to excuse current behavior or to avoid present responsibility is discouraged. The past, for many of these patients is one of extreme deprivation, cruelty, and loneliness, at best. Much cannot be analyzed into acceptance through understanding and interpretation. It is explored and evaluated when of clear relevance, such as in incest trauma or unresolved oedipal conflicts. Stressed is resignation to the unchangeable reality of the patient's early life, a "now what" posture, coupled with an examination of what resources are present in the patient which he can tap to cope effectively in the here and now. The patient is challenged to begin today!
Excuses for poor functioning are not tolerated. The therapist is forcefully judgmental in his attitudes. To consider the patient, rather than his way of life, as sick, serves to reinforce the pathological defense of dependency on the part of the addict and the need of the professional to mother him.
The original Odyssey House core group of 17 addicts had "golden arms" worth one million, two hundred thousand dollars ($1,200,000) in illegal cost to society. This supported their actual yearly use of four hundred thousand dollars ($400,000). It is obvious upon reflection that they had the capacity to find room and board, to make and keep appointments, and hoodwink the most well-meaning, attuned professionals.
The inevitable conning, gaming, and manipulation is combatted by permitting group work only, and refusing all demands. This insistence on group work exclusively subjects each resident to the constant scrutiny of, and open confrontation by, his peers. No single resident can play one staff member against the other or against the community or vice-versa. This forces openness in therapy and prevents informing and gossip gathering. The only demands met by the staff are those of guidance and therapy. The professional is no longer a symbol of authority, police, or pill givers. There is a constant refusal to "do for", such as find jobs, education, or homes, but only to help them find themselves and group identity.
Thus, many of the basic pathologic features in the addict, his loneliness isolation, dependency and low self-esteem, are overcome. To recapitulate, the two cardinal prohibitions for the professional are no individual work and no demand meeting. It cannot be too greatly emphasized how little help the ex-addicts require. They take pride and "grow behind" doing for themselves. Whatever is accomplished has much more meaning and value to the patient under these circumstances and affords him the necessary stimulus for the required maturational growth. The Odyssey House techniques, though effective, have been difficult for many professionals to accept. They necessitate a relinquishing to the senior patient population, authority and responsibility, as well as according them respect. For it is respect for themselves and others that they must develop. This can be accomplished only through supervised, structured practice. The goal is positive, full functioning, independent people. It is difficult for many professionals to survive in the therapeutic community environment, because acceptance and status are accorded by the patients to a professional on the basis of his functioning as a real, warm, capable person, and not, on title per se. No one, neither patient nor worker, can demand respect, but each must earn it.
The concept of earning position and emotional growth through positive social interaction is deeply engrained in all the work. The residents are continually evaluated and re-evaluated bi-weekly by each other and monthly by the staff. It is partially on the basis of these evaluations that a resident will move from one level to another. The day of evaluation and phasing, is one of the most significant of the week. This minute subdividing or hierarchy creates additional incentive for positive growth, in accordance with the socially acceptable norms. The desire of an individual resident to win the approval of his peers and favorable recognition from an authority figure is clearly demonstrable.
Due to the severity of the psychopathology of drug addiction with its attendant social disruption to the lives of the addicts, it is felt that an in-residence setting is a prerequisite for successful treatment and that psychiatric intervention be intensive. All activities in the House are considered to be part of the therapy which is directed to returning the addict to normal living patterns. The residents are responsible for all the maintenance, laundry, cooking, office work, etc, which living demands of the rest of society. Nothing is done for them that they can do themselves. This serves three purposes: one, it teaches them that they can do for themselves; two, it gives them future job training such as typing, switchboard operation, bookkeeping, printing, etc; and last, but not least, it greatly reduces the cost of running the program.
In the past few years, several new group therapy forms have been developed, as well as the expansion and alteration of already existing methods. The attitude has been to test anything that seemed to offer promise, to discard nothing without a trial, to alter as deemed necessary and to accept on an empirical basis, if positive change occurred. There is a tacit commitment to being open, inventive and willing to learn from professional, ex-addict and resident alike.
Meeting forms which have evolved are as follows: business and general administrative meetings; concepts, either visual or verbal; special visitors meetings; regular group therapy sessions with a psychiatrist and alternates without; supervision of ex-addict co-leaders; encounters general, special, or marathon; orientation sessions for candidates-in, inquiries and probes; and phasing and evaluation with "feedback," to list only a few. It is impossible within the confines of this paper to describe the above in detail, but a representative from Odyssey House, if requested, would be glad to discuss any aspect of the program.
POST-TREATMENT OR RE-ENTRY PHASE
Reentry is divided into three stages. The first is that of level IV, then candidacy-out, and the last is discharge to out-patient status.
The transition from the protection of the resident unit, with its 16 hours a day therapeutic structured environment, to functioning within the community at large, is accomplished in supportive stages. It is begun by a level IV resident being proposed by his peers to the candidates-out and staff for an Inquiry-Out. This usually occurs after the resident has lived within the house for a period of twelve months and he is deemed by his peers to have experienced sufficient behavioral change and growth to cope with the demands of the street.
By referring to the therapy challenges at the different levels, one can see a slow developmental process unfold with increasing responsibilities and privileges. The candidate-in does most of the physical work, and has only motivational therapy. He must affirmatively answer the question: "Do I accept myself as a person needing help?" In level I, the number of therapy hours is doubled, with voting rights and a voice in the community afforded. He must learn the therapeutic techniques to help himself. He accepts that change will occur. In level II, the shift from predominately physical labor to office work is made with the development of certain vocational skills. He learns self-discipline by successfully completing tasks assigned to him. Supervised family visits are permitted. In level III, authority and leadership towards other residents is undertaken. He is permitted to travel alone on house business and receive unopened mail; he has earned trust when within the confines of the house. He attends therapy not only as a participant, but at times begins to assume co-leadership. He can head a small department. He learns to accept authority by being an authority figure. He is responsible for people.
Level IV begins with exodus out. He spends increasingly more time out of the house, meeting with the public, both formally at speaking engagements and informally whenever representing the house. He accompanies the Induction Supervisor in confronting and motivating the raw street addict in prisons, storefronts, or hospital settings. He assists the Treatment Supervisors in the running of the house by supervising general departments, and by co-leading candidate-in groups. He may with permission leave the house for personal reasons or business and may occasionally spend an evening out. He has begun to assume authority not only over others within the house, but the even more difficult task over self in the world at large. After he is observed to be functioning at a mature level, he may be sponsored for the candidacy-out or the second stage of re-entry. He must affirmatively answer the question: "Will I leave the protective shelter of Odyssey House for the community at large?"
The Inquiry-Out is a meeting before his own peer group, the one above, and the staff. Here, the proposed candidate-out discusses his future plans, presents a reintegration program, and is questioned in detail as to the realities of the outside world in relation to himself. He must consider and choose alternatives in the social and work areas. If the plan is considered complete and realistic, he is voted a candidate-out. At this level he may begin to put it into effect.
In the period of the candidacy-out, the resident acts upon and effects his reintegration plan. He may start school or formal vocational training. He must have obtained a High School Equivalency diploma as a level IV if he is not a high school graduate. He must hold employment outside of the field of drug addiction. He spends increasing time with his family, spending overnights or weekends with them. He may marry or divorce during this period. He must answer the question: "Will I succeed?" in the affirmative.
The candidate-out lives outside the program as an independent, functioning, useful citizen. He is salaried and a taxpayer. If he is employed at Odyssey House, his involvement with the program becomes more intense and demanding. If he works in other fields, his contact with Odyssey House is limited to weekly candidate-out groups in the evening which are geared by a physician or the Director of the Program. He continues to give up urine on a regular (but unscheduled) basis.
The last challenge to the candidate-out is the Probe-Out, which constitutes discharge to outpatient status.
This is the most important evaluation in the program because once the candidate-out becomes an outpatient, he is considered independent of the program except for occasional urinanalysis. The only therapy requirement will be a periodic group session, for approximately two or three years after discharge.
In about 30 percent of the residents, problems of a neurotic nature are unmasked when the sociopathic behavior patterns are lifted. Just prior to or at the time of re-entry, if one of these patients requests, he will be referred to individual therapy, but this must be in addition to the continuing group work. Individual work is permissible and desirable at this time. These patients now have the prerequisite anxiety to make them amenable to therapy, they can form the necessary transference relationships, and they can control their behavior sufficiently to keep appointments. Once salaried, they will independently negotiate on a fee-for-service basis with the treating psychiatrist.
The last phase needs no further discussion as the participant, except for the reservations listed above, functions as any other member of society. He has become a full-functioning, independent, constructive member of society. Most have chosen lives independent of their past drug usage; others have chosen employment within the field of drug addiction and prevention.
Since most of Odyssey patients are under no external pressure to completing the treatment process, many decide to leave Odyssey prior to graduation. Nevertheless, even those patients who do not complete the treatment program are impressively influenced. Follow-up studies have shown that 75 percent of the former patients go on to lead drug free, crime free, and productively employed lives. Of the many who do graduate the program, success is significantly higher, including those who go on to pursue careers in health care, medicine, law, finance and business.
The concept under which the community flourishes has been expressed in the following ways by its residents:
(1) Positive growth occurs in the soil of self-knowledge which is best seen in the mirror of peer group interaction.
(2) We see ourselves best in the eye of a brother. Therefore, the brother must open his eyes and speak honestly what he sees.
(3) The basic concept of our program is continual open confrontation with the reality of ourselves, our peers, and our environment.
(4) By open confrontation, and the experience of the concern of others for me, for the first time in my life, I have learned first to trust and then to cope positively. First I coped a little, now big.
(5) And finally, it is the rule of three. First by doing, I proved that it can be done. The second doing followed with ease, and the third slipped by unnoticed. I had a habit of living.
|
