International Journal of Group Psychotherapy
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Peer Group Psychotherapy with Adolescent Drug Abusers Arnold W. Rachman & Margaret E. Heller To cite this article: Arnold W. Rachman & Margaret E. Heller (1976) Peer Group Psychotherapy with Adolescent Drug Abusers, International Journal of Group Psychotherapy, 26:3, 373-384, DOI: 10.1080/00207284.1976.11491956 To link to this article: https://doi.org/10.1080/00207284.1976.11491956
Published online: 29 Oct 2015.
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Citing articles: 1 View citing articles
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Peer Group Psychotherapy with Adolescent Drug Abusers ARNOLD W . RACHMAN , PH.D., and MARGARET E. HELLER
PEER GROUP AFFILIATION is the hallmark of the adolescent developmental period, and meaningful peer group affiliation is one of the basic ingredients in successful resolution of an adolescent identity crisis. Adolescents increase their self-esteem by their actions in the culture of a peer group that is positive, meaningful, and ego·enhancing. Group psychotherapy that is intended to help adolescents with the identity crisis does well to take therapeutic advantage of this fact (Rachman, 1972). Peer group psychotherapy (PGP) has emerged in recent years from the example of self-help rehabilitation programs (Hurvitz, 1970; Mowrer, 1971), with two such programs being the prototypes for PGP: Alcoholics Anonymous (A.A .) and Synanon. Peer group psychotherapy involves several significant concepts related to identity formation: 1. Peers, not traditional authorities, are the helping agents in the healing relationship. 2. Peer role modeling is fostered. 3. Group identity is provided by membership in a therapeutic subculture whose participants all have similar problems and share the same belief system and values; a special, in-group language is often spoken.
Dr. Rachman is Consultant in Drug Abuse, New York, N.Y. Ms. Heller is Associate Director of Research, Addiction Services Agency, New York, N.Y.
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4. A sense of community and family life is provided. 5. A sense of purpose and direction is enhanced. Adolescent drug abuse, a problem which has increased to epidemic proportions over the last decade or so , is in some ways an example of negative peer group affiliation based upon identity confusion. Although the causes of adolescent drug abuse are varied and complex, it is almost certain that the attraction drugs have for young people goes beyond simply the chemical effect. Drug use not only substitutes for normal ego defenses but also alleviates the anxiety surrounding identity confusion. By supplying an entrance into a special identity-giving subculture, drug use has the symbolic and practical significance of providing adolescents with a sense of direction and purpose, a sense of belonging, and an identity role; e.g., "acid head ," "dope fiend ," etc. Encounter, Inc . , is a peer self-help drug rehab ilitation program for adolescent drug users founded by a former adolescent drug user. The program is group-oriented and is run by young adults who are invariably graduates of the program or of others like it. It is hypothesized that one of the basic ingredients in t.!lis program's effectiveness is the positive opportunity for ego identity formation. The program structure and function will be described to illustrate the influence of peer group affiliation in providing adolescents with a positive alternative to the drug subculture.
ORIGINS AND PHILOSOPHY OF DRUG REHABILITATION PROGRAMS Encounter , Inc., and other programs like it have been largely modeled after the "therapeutic community" concept first developed by Chuck Dederich at Synanon (Casriel, 1963). These programs were developed because of the perceived failure of traditional methods of psychotherapy to deal successfully with drug addicts. Addicts tended to mistrust "straight" therapists ; psychotherapists were easily "conned" by the manipulative personalities of addicts ; and addicts seemed to need peer role models in the person of reformed former addicts in order to give up drugs. In addition, Dederich and the early founders of the therapeutic community approach intuitively realized that drug use involved a total identity and life-style as much as it involved "getting high ." These leaders
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developed a treatment approach that in many ways comprises a substitute or alternate life-style to addiction. Therapeutic communities are 24-hour-a-day environments that are characterized by the following: 1. A strong sense of community, which is encouraged and fostered by administrators and staff members; e.g., friendships among program members are strongly encouraged; friendships outside of the program are discouraged; group activities are paramount; members who leave treatment are ostracized and are not allowed to talk to members who remain in treatment. 2. A strong, enforced belief system, frequently called "The Concept." This belief system extends beyond a theory of addiction and encompasses values about "healthy" and "unhealthy" behavior which are rather specific. 3. The almost exclusive use of ex-addicts as staff members rather than professional psychotherapists. 4. A therapeutic approach that is directive and behavioristically oriented and operates upon a system of rewards and harsh punishments. The staff of most therapeutic communities believes that addicts are immature personalities who learned impulseoriented and unrealistic methods of coping with internal and external pressures. The treatment for addiction is, therefore, literally a "re-education," the replacement of pleasure-oriented by reality-oriented coping mechanisms. The initial phase of treatment is intended to strip the addict of his defenses and "break him down" to the point where he will be ready to replace destructive habits with more mature ones. In summary, then, therapeutic communities strive to have the addict replace a negative peer-group-based identity with a positive peer-group-based identity. In the process of doing this, changes in behavior are stressed above the attainment of insight, and the use of rewards and punishments predominates. In the first years after the formation of Synanon, the therapeutic community approach was hailed as "the answer" to the addiction problem (Yablonsky, 1964). Hundreds of these programs sprang up across the country . For example , in New York City there are more than 60 such programs for the treatment of addiction. But in recent years, especially since the advent of chemotherapeutic forms of treatment like methadone maintenance , therapeutic communities h ave come under sever attack. Evalua tion of these programs has stressed that their rehab ilitation effects
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are counterbalanced by the following negative effects (Glasscote et al., 1972; Ford Foundation, 1972): 1. Therapeutic communities can work only with a narrow band of clients. The large majority of clients drop out long before completing treatment. 1 2. The relatively few clients who do complete treatment often have difficulty reentering society, and many tend to remain in the therapeutic community indefinitely as staff members, seemingly unwilling or unable to leave the protected environment. Synanon, in fact, now has a formal policy stating the belief that ex-drug addicts can never reenter society and remain drug-free and that Synanon will not attempt to prepare addicts for societal reentry. 3. Punitive techniques employed in therapeutic communities tend to be overly harsh and perhaps psychologically damaging to some individuals in treatment. Encounter, Inc., which resembles the traditional therapeutic community in many ways, although it maintains clients on an ambulatory as well as a residential basis, epitomizes many of the strengths and weaknesses of the therapeutic community approach. Although no formal follow-up study of Encounter's members has been made, many of its successfully terminated clients seem to remain relatively drug abstinent and become productive members of society. Encounter has, however, a high rate of drop-out. In 1971, the ratio of admissions to unsuccessful terminations was 1. 6:1, for a 60 per cent drop-out rate despite a fairly selective admissions procedure. Furthermore, successfully terminated clients tend to become overcontrolled and rigid as a result of treatment. Since a number of "graduates" seek professional psychotherapy after leaving Encounter, it could be argued that Encounter prepares drug abusers for more insight-oriented approaches. But to the extent that some clients do not seek further help, this tendency toward producing rigid personalities is counterproductive in that it can lead to an ultimate relapse into addiction or to a cross-addiction to alcohol when the artificial rigidity of the personality collapses and control of impulses is again lost.
1 There is some evidence, however, that even relatively short times in treatment benefit addicts ; i.e., that there is a "partialization of treatment" effect (Kneisler and Heller, 1973).
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Treatment failures are not unique to Encounter but are fairly characteristic of all programs using the therapeutic community approach and are the subject of much controversy in the drug-abuse field . It is hoped that the following discussion of facets of Encounter's approach will illuminate some of the causes and possible remedies of the treatment problems cited. GROUP EXPERIENCES AS THE SOLE TREATMENT MODALITY Drug rehabilitation programs recognize the positive aspects of group treatment. All forms of group interaction are fostered: therapy groups, residential group living, group decisions regarding the functioning of the program and its members, group recreation, group government, and so on. The fostering of interpeer communication, interpersonal relations, and interpersonal feedb ack are antidotes to the isolation, loneliness, alienation, and withdrawal that trouble many adolescent drug abusers. For many, such group interactions become the first experience in sharing feelings , thinking, and behavior with other adolescents . Adolescents with difficulties in peer relationships can discover through first -hand experience and direct confrontation why they h ave been unable to make and keep friends. For example, an adolescent who cannot get along with others because he is passive and cannot be appropriately assertive has an opportunity to exhibit this behavior in a therapeutic milieu and have it pointed out by staff and program members. He can then be encouraged in groups to express his anger directly. In short , a drug rehabilitation program can provide a place for an adolescent to make friends who are constructively supportive, warm , and open; opportunities for staff and peers to notice difficulties he has in relating to others; and opportunities in groups to learn how to modify his behavior so as to improve interpersonal relations. Although adolescents are generally best helped with an identity crisis in a group setting, there are adolescents who because of their psychopathology do not respond well to groups: they are self-absorbed, intensely withdrawn, feel paranoid in the presence of others, and cannot give of themselves to others. Rather than force these individuals into all kinds of groups immediately, gradual group experience as an adjunct to individual treatment would be
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preferable . It is probable t hat, were individual psychotherapy to be made available , therapeutic communities would be able to retain some people who are currently lost to treatmen t. As well as group membership , adolescents also need "private time, " time to muse by themselves about who they are and where they are going. Drug rehabilitation programs are "fishbowl living" ; the individual is always u nder scrutiny. Permitting periods of "creative withdrawal" m ight help addicts to integrate their group experience and obviate a detrimental side-effect of the exclusive use of group techniques, which is that many adolescents so treated develop a strong group identity but no personal identity, becoming totally "other-directed" persons with little cap acity to make decisions without the aid of a peer group . PEER SUBCULTURE AND PEER ROLE MODELS Drug rehabilitation programs of the type described here stress peer relationships as being more important than relationships with authorities . In addition , peers, rather than professionally trained authorities , are seen as the agents of change . To the adolescent or young adult, they appear less threatening and thus d o n ot evoke the instantaneous negative transference that adult professional authorities may. Peers can serve as examples of self-control and of being happy and productive . In many ways , ex -addict staff members become substitutes for a family . Ex-addict staff members present other positive aspects for role modeling. They are definite , organized, and decisive; they have "the answers. " Confused adolescents are easily impressed by someone who shows a strong sense of identity. They can gain direction and purpose from an individual who presents himself as "someone to grab onto and borrow a piece of." Peers , however , can be oppressive authorities in that they are often harsher with each other (e.g. , punitive , lacking in empathy, coercive , etc.) than a professional authority would be . Such coercive peer authority can produce superficial behavior change and adherence to rules in order to "beat the system ," while underneath the adolescent 's personality difficulties and basic conflicts are heightened rather than resolved. The peer subculture can foster a distorted , paranoid view regarding family and adult authority . Ther apeutic communities are
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relatively an ti-adult and anti-traditional authority. Parents and authorities are "out to mess you up , don't trust them , don't give them anything of yourself." Staff members often suggest cutting off ties with parents rather than trying to work through the problems. T he paranoid view of adult authority fostered by therapeutic communities can make ultimate reentry into "straight" society excessively difficult. Drug reh abilitation programs could benefit from encouraging mem b ers to explore and understand the derivatives of their p roblems with family m embers. Group and individual counseling sessions should include positive, empathic d iscussions of the history of an in dividual's relationship with h is family in order to discern repetitive neurotic patterns . These disturbed patterns could then be compared to the individual's behavior within the therapeutic community. The family of the therapeutic community, armed with an understan ding of and empathy for the individual's family confli cts , could better provide him with a positive alternative. "THE CO N CEPT" - A PHILOSOPHICAL BELIEF SYSTEM Therapeutic communities espouse a philosophy of life, human behavior, and a prescription for personality change. This philosophy is commonly referred to by staff and members of these programs as "The Concept ." It is a belief system complete with a prayer-like statement of philosophy recited by members , mottoes, and a p articular jargon. Such a belief system provides confused adolescents in the midst of an identity crisis with a sense of meaning, p urpose, and direction for their lives . It tells them what to believe in and how to behave. Everyone in the program is positive about what is right and what is wrong, which gives a strong sense of direction and purpose . This can be irresistible to someone who is lost and fl oundering . On the minus side, there is a rigidity, inflexibility, and dogmatism in espousing "The Concept." The staff decides what is "right" and "healthy" and proceeds to insist that everyone measure up to this standard . Democracy, freedom , and free will are confused in such an orientation. People are not oriented toward various ways of being-in-the-world. Respect for individual differences and the right not to conform are lost. O nly when adolescents are given judicious opportunities for "free
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role experimentation" can a true sense of personal identity emerge (Rachman, 1972). Adolescents and young adults in drug rehabilitation programs should be encouraged to explore their own philosophical notions regarding human personality and human destiny. Although staff members can provide a model for identification, the adolescent should be encouraged to make his own choice of beliefs based upon his ethnic, racial, economic, intellectual, and social background. CONFRONTATION Drug rehabilitation programs of this type have pioneered in the direct confrontation and sharing of feelings. Total and complete honesty is encouraged. Expressing and experiencing feelings makes an individual alive in his relationships, promotes genuine communication, lifts repression barriers, puts the individual in direct contact with others, and cuts through the intense facade, detachment, and isolation of an addict. "It gets you out of your own bag and makes you connected to others." However, direct confrontation has drawbacks that are seldom considered in its application in drug rehabilitation programs. One such aspect is the desirability of exploring the aftermath of confrontation therapeutically. The session following the direct expression and sharing of intense feelings of anger, affection, etc., would do well to focus on the group member's emotional reaction to the confrontation , so that the following points could be explored: 1. the fear and anxiety involved in translating feelings into action; 2. the translation offeelings into insight; that is, has the member been able to make "cognitive connections"; 3. the probing of material that still has not been expressed: latent feelings, thoughts underneath the outburst ; 4. the member's success at dealing with feelings of depression, loss, mourning for his "old self '; and 5. is the member able to cope with the insecurity of a "new identity"? The "wisdom of the mind" needs to be listened to when group members resist confrontation. People should be granted the civil
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liberty "not to confront," especially when the group leader senses that a fear of personal disintegration is the basic anxiety behind the resistance . In such an instance the leader should encourage the member to explore his anxiety and should discourage the group from pursuing direct confrontation. The practice of encounter and marathon group psychotherapy within drug rehabilitation programs tends to reinforce "attack therapy." Time-extended group sessions are conducted as "pressure cookers" in which individuals are forced to encounter themselves and each other. Although they can be meaningful aspects of the therapeutic experience, the issues of preparation, group formation, countertransference, therapist self-disclosure, and the humanistic encounter need to be incorporated (Rachman, 1976).
THE JUNKIE MENTALITY AND THE SEARCH FOR THE "GOLDEN HIGH" A therapeutic community, through its practices, can provide a "substitute high" for program members. The intense interaction of direct confrontation and sharing of feelings, the close community life in which people are always available, the excitement of an adolescent and young adult community, the missionary zeal involved in reclaiming human life; all of these provide an atmosphere that resembles a junkie's life. There are daily crises; people walk around either emotionally "high" or depressed; program members keep referring to how "fucked up" they are; everyone appears to be hanging around waiting for a "fix" (a new emotional high). Exploration of the psychodynamic causes of drug abuse is not a significant part of the peer group experience. Traditional psychotherapy is disavowed, to the detriment of the program's attempt to change basic personality patterns and foster identity formation and self-actualization. It is crucial that drug-oriented individuals explore the underlying dynamics of their craving for a magical solution to their problems if they are to be provided with the alternative of becoming connected to self-understanding through a struggle for self-identity.
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BEING A STAFF MEMBER IN A THERAPEUTIC COMMUNITY There are particular emotional difficulties inherent in the job of being a staff member in a drug rehabilitation program that is designed on the therapeutic community model. Perhaps the greatest strain is the "fishbowl" atmosphere. Because a family-life milieu is created , staff members do not have the professional distance from clients common to traditional residential environments such as hospital wards. Staff members are expected to , and do, reveal a great deal about their personal feelings and lives in the groups. They usually give out their home phone numbers and are thus subject to calls at all hours of the day or night. Since staff members and clients frequently socialize together, intimacy between staff and clients is not only encouraged, it is virtually unavoidable. This intimacy is more demanding upon the staff member than a normal peer intimacy . Staff members are expected to be role models for clients, and because their lives are common knowledge, the staff member must maintain exemplary living habits , not only while he or she is in contact with clients but even when work is ended. A staff member who, for example, is having marital difficulties or who is drinking too much after work is subject to strong confrontation and to possible loss of job. Essentially, there is little separation between one's work and the rest of one's life; work and "not work" cannot serve as refuges from one another. The pressure of this is tremendous and makes working in a therapeutic community very difficult. The staff members are usually young and are frequently still resolving their own identities. Because of the pressure upon them to be role models, they do not have the freedom of role experimentation that is open to other young adults. Clients often develop strong dependencies upon staff members. The relationship can become like a parent-child relationship, with all the responsibility of "parenting." It is a particularly heavy responsibility because some clients may be seriously disturbed. Being a staff member in a therapeutic community means, for example, knowing that if you do not answer the phone call of a distraught client who is dependent upon you, that client is in danger of committing self-destructive acts that could lead to his death. In a
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way, working in a therapeutic community is like working with suicidal patients. The intensity of the milieu and the nature of the problems of drug abusers create an environment in which there is little time for a staff member to reflect before making decisions and in which crises are never-ending. This atmosphere is emotionally draining, and staff members of therapeutic communities frequently become "burned out" in a few years. And, finally, the atmosphere within a therapeutic community, emotionally charged, crisis-oriented, intimate to the point of almost total lack of privacy, can make it as difficult for a staff member ultimately to adjust to the outside world as it is for a program graduate. Since a staff member working in a therapeutic community finds it difficult to have any life separate from the job, he or she is as insulated by working there as any program member is by going through treatment. Drug rehabilitation programs could benefit from an upgrading of personnel and the professionalization of staff. Some of the staff should probably be professionally trained mental health personnel, while those staff members who are successful graduates of the program should be screened for intellectual and academic potential. Many staff members of therapeutic communities are chosen only on the basis of their capacity for emotional confrontation , and often they are limited in their schooling. If staff members were to be chosen on the basis of intellectual capacity, they could be asked to pursue education and training in the field of mental health as a condition of employment.
SUMMARY AND CONCLUSIONS Much adolescent drug abuse is theorized to be an example of identity confusion and negative peer group affiliation (the drug subculture) . Peer group psychotherapy, as practiced in drug rehabilitation programs of the "therapeutic community" type, becomes a meaningful treatment model for the rehabilitation of the drug abuser the more it incorporates practices and concepts relevant to helping young people find a sense of ego identity. The clinical practice of peer group psychotherapy in a prototypical drug
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rehabilitation program, Encounter, Inc., is examined from the vantage point of traditional group psychotherapy , and recommendations for changes are made relevant to fostering ego identity formation, a humanistic therapeutic frame of reference, and self-actualization.
REFERENCES Casriel , D. (1963) , So Fair a House: The Story of Synanon . Englewood Cliffs, N .J. : Prentice· Hall. Ford Foundation Drug Abuse Council (1972), Dealing with Drug Abuse. New York: Praeger Publishers. Glasscote, 1., Ball, J. , and Jaffe, J. (1972), The Treatment of Drug Abuse. New York: Harcourt , Brace. Hurvitz, N . (1970) , Peer Self-Help Psychotherapy Groups and Their Implications for Psychotherapy. Psychotherapy: Theory, R esearch, and Practice, 7:41-49. Kneisler, T ., and Heller, M. (1973) , A Preliminary Study of Post-Treatment Arrest Rates of Clients in Therapeutic Communities. Studies in Addiction, 1(1). Mowrer, 0. H . (1971) , Peer Groups and Medication , the Best "Therapy" for Professionals and Layman Alike. Psychotherapy: Theory, R esearch, and Practice, 8:44-53 . Rachman , A. W. (1972) , Group Psychotherapy in Treating the Adolescent Identity Crisis. Internal . ]. Child Psychother. , 1:97-119 . ___ (1976) , The Humanistic Encounter. Psychotherapy: Theory, Research, and Practice (in press). Yablonsky, L. (1964), The Tunnel Back: Synanon. New York: Pelican Press.
Dr. Rachman 's address: 310 First Avenue N ew York, N.Y. 10009
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Peer Group Psychotherapy with Adolescent Drug Abusers Arnold W. Rachman & Margaret E. Heller To cite this article: Arnold W. Rachman & Margaret E. Heller (1976) Peer Group Psychotherapy with Adolescent Drug Abusers, International Journal of Group Psychotherapy, 26:3, 373-384, DOI: 10.1080/00207284.1976.11491956 To link to this article: https://doi.org/10.1080/00207284.1976.11491956
Published online: 29 Oct 2015.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujgp20
Peer Group Psychotherapy with Adolescent Drug Abusers ARNOLD W . RACHMAN , PH.D., and MARGARET E. HELLER
PEER GROUP AFFILIATION is the hallmark of the adolescent developmental period, and meaningful peer group affiliation is one of the basic ingredients in successful resolution of an adolescent identity crisis. Adolescents increase their self-esteem by their actions in the culture of a peer group that is positive, meaningful, and ego·enhancing. Group psychotherapy that is intended to help adolescents with the identity crisis does well to take therapeutic advantage of this fact (Rachman, 1972). Peer group psychotherapy (PGP) has emerged in recent years from the example of self-help rehabilitation programs (Hurvitz, 1970; Mowrer, 1971), with two such programs being the prototypes for PGP: Alcoholics Anonymous (A.A .) and Synanon. Peer group psychotherapy involves several significant concepts related to identity formation: 1. Peers, not traditional authorities, are the helping agents in the healing relationship. 2. Peer role modeling is fostered. 3. Group identity is provided by membership in a therapeutic subculture whose participants all have similar problems and share the same belief system and values; a special, in-group language is often spoken.
Dr. Rachman is Consultant in Drug Abuse, New York, N.Y. Ms. Heller is Associate Director of Research, Addiction Services Agency, New York, N.Y.
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4. A sense of community and family life is provided. 5. A sense of purpose and direction is enhanced. Adolescent drug abuse, a problem which has increased to epidemic proportions over the last decade or so , is in some ways an example of negative peer group affiliation based upon identity confusion. Although the causes of adolescent drug abuse are varied and complex, it is almost certain that the attraction drugs have for young people goes beyond simply the chemical effect. Drug use not only substitutes for normal ego defenses but also alleviates the anxiety surrounding identity confusion. By supplying an entrance into a special identity-giving subculture, drug use has the symbolic and practical significance of providing adolescents with a sense of direction and purpose, a sense of belonging, and an identity role; e.g., "acid head ," "dope fiend ," etc. Encounter, Inc . , is a peer self-help drug rehab ilitation program for adolescent drug users founded by a former adolescent drug user. The program is group-oriented and is run by young adults who are invariably graduates of the program or of others like it. It is hypothesized that one of the basic ingredients in t.!lis program's effectiveness is the positive opportunity for ego identity formation. The program structure and function will be described to illustrate the influence of peer group affiliation in providing adolescents with a positive alternative to the drug subculture.
ORIGINS AND PHILOSOPHY OF DRUG REHABILITATION PROGRAMS Encounter , Inc., and other programs like it have been largely modeled after the "therapeutic community" concept first developed by Chuck Dederich at Synanon (Casriel, 1963). These programs were developed because of the perceived failure of traditional methods of psychotherapy to deal successfully with drug addicts. Addicts tended to mistrust "straight" therapists ; psychotherapists were easily "conned" by the manipulative personalities of addicts ; and addicts seemed to need peer role models in the person of reformed former addicts in order to give up drugs. In addition, Dederich and the early founders of the therapeutic community approach intuitively realized that drug use involved a total identity and life-style as much as it involved "getting high ." These leaders
A doles cent Drug Abusers
375
developed a treatment approach that in many ways comprises a substitute or alternate life-style to addiction. Therapeutic communities are 24-hour-a-day environments that are characterized by the following: 1. A strong sense of community, which is encouraged and fostered by administrators and staff members; e.g., friendships among program members are strongly encouraged; friendships outside of the program are discouraged; group activities are paramount; members who leave treatment are ostracized and are not allowed to talk to members who remain in treatment. 2. A strong, enforced belief system, frequently called "The Concept." This belief system extends beyond a theory of addiction and encompasses values about "healthy" and "unhealthy" behavior which are rather specific. 3. The almost exclusive use of ex-addicts as staff members rather than professional psychotherapists. 4. A therapeutic approach that is directive and behavioristically oriented and operates upon a system of rewards and harsh punishments. The staff of most therapeutic communities believes that addicts are immature personalities who learned impulseoriented and unrealistic methods of coping with internal and external pressures. The treatment for addiction is, therefore, literally a "re-education," the replacement of pleasure-oriented by reality-oriented coping mechanisms. The initial phase of treatment is intended to strip the addict of his defenses and "break him down" to the point where he will be ready to replace destructive habits with more mature ones. In summary, then, therapeutic communities strive to have the addict replace a negative peer-group-based identity with a positive peer-group-based identity. In the process of doing this, changes in behavior are stressed above the attainment of insight, and the use of rewards and punishments predominates. In the first years after the formation of Synanon, the therapeutic community approach was hailed as "the answer" to the addiction problem (Yablonsky, 1964). Hundreds of these programs sprang up across the country . For example , in New York City there are more than 60 such programs for the treatment of addiction. But in recent years, especially since the advent of chemotherapeutic forms of treatment like methadone maintenance , therapeutic communities h ave come under sever attack. Evalua tion of these programs has stressed that their rehab ilitation effects
376
Arnold W. Rachman-Margaret E. Heller
are counterbalanced by the following negative effects (Glasscote et al., 1972; Ford Foundation, 1972): 1. Therapeutic communities can work only with a narrow band of clients. The large majority of clients drop out long before completing treatment. 1 2. The relatively few clients who do complete treatment often have difficulty reentering society, and many tend to remain in the therapeutic community indefinitely as staff members, seemingly unwilling or unable to leave the protected environment. Synanon, in fact, now has a formal policy stating the belief that ex-drug addicts can never reenter society and remain drug-free and that Synanon will not attempt to prepare addicts for societal reentry. 3. Punitive techniques employed in therapeutic communities tend to be overly harsh and perhaps psychologically damaging to some individuals in treatment. Encounter, Inc., which resembles the traditional therapeutic community in many ways, although it maintains clients on an ambulatory as well as a residential basis, epitomizes many of the strengths and weaknesses of the therapeutic community approach. Although no formal follow-up study of Encounter's members has been made, many of its successfully terminated clients seem to remain relatively drug abstinent and become productive members of society. Encounter has, however, a high rate of drop-out. In 1971, the ratio of admissions to unsuccessful terminations was 1. 6:1, for a 60 per cent drop-out rate despite a fairly selective admissions procedure. Furthermore, successfully terminated clients tend to become overcontrolled and rigid as a result of treatment. Since a number of "graduates" seek professional psychotherapy after leaving Encounter, it could be argued that Encounter prepares drug abusers for more insight-oriented approaches. But to the extent that some clients do not seek further help, this tendency toward producing rigid personalities is counterproductive in that it can lead to an ultimate relapse into addiction or to a cross-addiction to alcohol when the artificial rigidity of the personality collapses and control of impulses is again lost.
1 There is some evidence, however, that even relatively short times in treatment benefit addicts ; i.e., that there is a "partialization of treatment" effect (Kneisler and Heller, 1973).
Adolescent Drug Abusers
377
Treatment failures are not unique to Encounter but are fairly characteristic of all programs using the therapeutic community approach and are the subject of much controversy in the drug-abuse field . It is hoped that the following discussion of facets of Encounter's approach will illuminate some of the causes and possible remedies of the treatment problems cited. GROUP EXPERIENCES AS THE SOLE TREATMENT MODALITY Drug rehabilitation programs recognize the positive aspects of group treatment. All forms of group interaction are fostered: therapy groups, residential group living, group decisions regarding the functioning of the program and its members, group recreation, group government, and so on. The fostering of interpeer communication, interpersonal relations, and interpersonal feedb ack are antidotes to the isolation, loneliness, alienation, and withdrawal that trouble many adolescent drug abusers. For many, such group interactions become the first experience in sharing feelings , thinking, and behavior with other adolescents . Adolescents with difficulties in peer relationships can discover through first -hand experience and direct confrontation why they h ave been unable to make and keep friends. For example, an adolescent who cannot get along with others because he is passive and cannot be appropriately assertive has an opportunity to exhibit this behavior in a therapeutic milieu and have it pointed out by staff and program members. He can then be encouraged in groups to express his anger directly. In short , a drug rehabilitation program can provide a place for an adolescent to make friends who are constructively supportive, warm , and open; opportunities for staff and peers to notice difficulties he has in relating to others; and opportunities in groups to learn how to modify his behavior so as to improve interpersonal relations. Although adolescents are generally best helped with an identity crisis in a group setting, there are adolescents who because of their psychopathology do not respond well to groups: they are self-absorbed, intensely withdrawn, feel paranoid in the presence of others, and cannot give of themselves to others. Rather than force these individuals into all kinds of groups immediately, gradual group experience as an adjunct to individual treatment would be
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preferable . It is probable t hat, were individual psychotherapy to be made available , therapeutic communities would be able to retain some people who are currently lost to treatmen t. As well as group membership , adolescents also need "private time, " time to muse by themselves about who they are and where they are going. Drug rehabilitation programs are "fishbowl living" ; the individual is always u nder scrutiny. Permitting periods of "creative withdrawal" m ight help addicts to integrate their group experience and obviate a detrimental side-effect of the exclusive use of group techniques, which is that many adolescents so treated develop a strong group identity but no personal identity, becoming totally "other-directed" persons with little cap acity to make decisions without the aid of a peer group . PEER SUBCULTURE AND PEER ROLE MODELS Drug rehabilitation programs of the type described here stress peer relationships as being more important than relationships with authorities . In addition , peers, rather than professionally trained authorities , are seen as the agents of change . To the adolescent or young adult, they appear less threatening and thus d o n ot evoke the instantaneous negative transference that adult professional authorities may. Peers can serve as examples of self-control and of being happy and productive . In many ways , ex -addict staff members become substitutes for a family . Ex-addict staff members present other positive aspects for role modeling. They are definite , organized, and decisive; they have "the answers. " Confused adolescents are easily impressed by someone who shows a strong sense of identity. They can gain direction and purpose from an individual who presents himself as "someone to grab onto and borrow a piece of." Peers , however , can be oppressive authorities in that they are often harsher with each other (e.g. , punitive , lacking in empathy, coercive , etc.) than a professional authority would be . Such coercive peer authority can produce superficial behavior change and adherence to rules in order to "beat the system ," while underneath the adolescent 's personality difficulties and basic conflicts are heightened rather than resolved. The peer subculture can foster a distorted , paranoid view regarding family and adult authority . Ther apeutic communities are
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relatively an ti-adult and anti-traditional authority. Parents and authorities are "out to mess you up , don't trust them , don't give them anything of yourself." Staff members often suggest cutting off ties with parents rather than trying to work through the problems. T he paranoid view of adult authority fostered by therapeutic communities can make ultimate reentry into "straight" society excessively difficult. Drug reh abilitation programs could benefit from encouraging mem b ers to explore and understand the derivatives of their p roblems with family m embers. Group and individual counseling sessions should include positive, empathic d iscussions of the history of an in dividual's relationship with h is family in order to discern repetitive neurotic patterns . These disturbed patterns could then be compared to the individual's behavior within the therapeutic community. The family of the therapeutic community, armed with an understan ding of and empathy for the individual's family confli cts , could better provide him with a positive alternative. "THE CO N CEPT" - A PHILOSOPHICAL BELIEF SYSTEM Therapeutic communities espouse a philosophy of life, human behavior, and a prescription for personality change. This philosophy is commonly referred to by staff and members of these programs as "The Concept ." It is a belief system complete with a prayer-like statement of philosophy recited by members , mottoes, and a p articular jargon. Such a belief system provides confused adolescents in the midst of an identity crisis with a sense of meaning, p urpose, and direction for their lives . It tells them what to believe in and how to behave. Everyone in the program is positive about what is right and what is wrong, which gives a strong sense of direction and purpose . This can be irresistible to someone who is lost and fl oundering . On the minus side, there is a rigidity, inflexibility, and dogmatism in espousing "The Concept." The staff decides what is "right" and "healthy" and proceeds to insist that everyone measure up to this standard . Democracy, freedom , and free will are confused in such an orientation. People are not oriented toward various ways of being-in-the-world. Respect for individual differences and the right not to conform are lost. O nly when adolescents are given judicious opportunities for "free
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role experimentation" can a true sense of personal identity emerge (Rachman, 1972). Adolescents and young adults in drug rehabilitation programs should be encouraged to explore their own philosophical notions regarding human personality and human destiny. Although staff members can provide a model for identification, the adolescent should be encouraged to make his own choice of beliefs based upon his ethnic, racial, economic, intellectual, and social background. CONFRONTATION Drug rehabilitation programs of this type have pioneered in the direct confrontation and sharing of feelings. Total and complete honesty is encouraged. Expressing and experiencing feelings makes an individual alive in his relationships, promotes genuine communication, lifts repression barriers, puts the individual in direct contact with others, and cuts through the intense facade, detachment, and isolation of an addict. "It gets you out of your own bag and makes you connected to others." However, direct confrontation has drawbacks that are seldom considered in its application in drug rehabilitation programs. One such aspect is the desirability of exploring the aftermath of confrontation therapeutically. The session following the direct expression and sharing of intense feelings of anger, affection, etc., would do well to focus on the group member's emotional reaction to the confrontation , so that the following points could be explored: 1. the fear and anxiety involved in translating feelings into action; 2. the translation offeelings into insight; that is, has the member been able to make "cognitive connections"; 3. the probing of material that still has not been expressed: latent feelings, thoughts underneath the outburst ; 4. the member's success at dealing with feelings of depression, loss, mourning for his "old self '; and 5. is the member able to cope with the insecurity of a "new identity"? The "wisdom of the mind" needs to be listened to when group members resist confrontation. People should be granted the civil
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liberty "not to confront," especially when the group leader senses that a fear of personal disintegration is the basic anxiety behind the resistance . In such an instance the leader should encourage the member to explore his anxiety and should discourage the group from pursuing direct confrontation. The practice of encounter and marathon group psychotherapy within drug rehabilitation programs tends to reinforce "attack therapy." Time-extended group sessions are conducted as "pressure cookers" in which individuals are forced to encounter themselves and each other. Although they can be meaningful aspects of the therapeutic experience, the issues of preparation, group formation, countertransference, therapist self-disclosure, and the humanistic encounter need to be incorporated (Rachman, 1976).
THE JUNKIE MENTALITY AND THE SEARCH FOR THE "GOLDEN HIGH" A therapeutic community, through its practices, can provide a "substitute high" for program members. The intense interaction of direct confrontation and sharing of feelings, the close community life in which people are always available, the excitement of an adolescent and young adult community, the missionary zeal involved in reclaiming human life; all of these provide an atmosphere that resembles a junkie's life. There are daily crises; people walk around either emotionally "high" or depressed; program members keep referring to how "fucked up" they are; everyone appears to be hanging around waiting for a "fix" (a new emotional high). Exploration of the psychodynamic causes of drug abuse is not a significant part of the peer group experience. Traditional psychotherapy is disavowed, to the detriment of the program's attempt to change basic personality patterns and foster identity formation and self-actualization. It is crucial that drug-oriented individuals explore the underlying dynamics of their craving for a magical solution to their problems if they are to be provided with the alternative of becoming connected to self-understanding through a struggle for self-identity.
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BEING A STAFF MEMBER IN A THERAPEUTIC COMMUNITY There are particular emotional difficulties inherent in the job of being a staff member in a drug rehabilitation program that is designed on the therapeutic community model. Perhaps the greatest strain is the "fishbowl" atmosphere. Because a family-life milieu is created , staff members do not have the professional distance from clients common to traditional residential environments such as hospital wards. Staff members are expected to , and do, reveal a great deal about their personal feelings and lives in the groups. They usually give out their home phone numbers and are thus subject to calls at all hours of the day or night. Since staff members and clients frequently socialize together, intimacy between staff and clients is not only encouraged, it is virtually unavoidable. This intimacy is more demanding upon the staff member than a normal peer intimacy . Staff members are expected to be role models for clients, and because their lives are common knowledge, the staff member must maintain exemplary living habits , not only while he or she is in contact with clients but even when work is ended. A staff member who, for example, is having marital difficulties or who is drinking too much after work is subject to strong confrontation and to possible loss of job. Essentially, there is little separation between one's work and the rest of one's life; work and "not work" cannot serve as refuges from one another. The pressure of this is tremendous and makes working in a therapeutic community very difficult. The staff members are usually young and are frequently still resolving their own identities. Because of the pressure upon them to be role models, they do not have the freedom of role experimentation that is open to other young adults. Clients often develop strong dependencies upon staff members. The relationship can become like a parent-child relationship, with all the responsibility of "parenting." It is a particularly heavy responsibility because some clients may be seriously disturbed. Being a staff member in a therapeutic community means, for example, knowing that if you do not answer the phone call of a distraught client who is dependent upon you, that client is in danger of committing self-destructive acts that could lead to his death. In a
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way, working in a therapeutic community is like working with suicidal patients. The intensity of the milieu and the nature of the problems of drug abusers create an environment in which there is little time for a staff member to reflect before making decisions and in which crises are never-ending. This atmosphere is emotionally draining, and staff members of therapeutic communities frequently become "burned out" in a few years. And, finally, the atmosphere within a therapeutic community, emotionally charged, crisis-oriented, intimate to the point of almost total lack of privacy, can make it as difficult for a staff member ultimately to adjust to the outside world as it is for a program graduate. Since a staff member working in a therapeutic community finds it difficult to have any life separate from the job, he or she is as insulated by working there as any program member is by going through treatment. Drug rehabilitation programs could benefit from an upgrading of personnel and the professionalization of staff. Some of the staff should probably be professionally trained mental health personnel, while those staff members who are successful graduates of the program should be screened for intellectual and academic potential. Many staff members of therapeutic communities are chosen only on the basis of their capacity for emotional confrontation , and often they are limited in their schooling. If staff members were to be chosen on the basis of intellectual capacity, they could be asked to pursue education and training in the field of mental health as a condition of employment.
SUMMARY AND CONCLUSIONS Much adolescent drug abuse is theorized to be an example of identity confusion and negative peer group affiliation (the drug subculture) . Peer group psychotherapy, as practiced in drug rehabilitation programs of the "therapeutic community" type, becomes a meaningful treatment model for the rehabilitation of the drug abuser the more it incorporates practices and concepts relevant to helping young people find a sense of ego identity. The clinical practice of peer group psychotherapy in a prototypical drug
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rehabilitation program, Encounter, Inc., is examined from the vantage point of traditional group psychotherapy , and recommendations for changes are made relevant to fostering ego identity formation, a humanistic therapeutic frame of reference, and self-actualization.
REFERENCES Casriel , D. (1963) , So Fair a House: The Story of Synanon . Englewood Cliffs, N .J. : Prentice· Hall. Ford Foundation Drug Abuse Council (1972), Dealing with Drug Abuse. New York: Praeger Publishers. Glasscote, 1., Ball, J. , and Jaffe, J. (1972), The Treatment of Drug Abuse. New York: Harcourt , Brace. Hurvitz, N . (1970) , Peer Self-Help Psychotherapy Groups and Their Implications for Psychotherapy. Psychotherapy: Theory, R esearch, and Practice, 7:41-49. Kneisler, T ., and Heller, M. (1973) , A Preliminary Study of Post-Treatment Arrest Rates of Clients in Therapeutic Communities. Studies in Addiction, 1(1). Mowrer, 0. H . (1971) , Peer Groups and Medication , the Best "Therapy" for Professionals and Layman Alike. Psychotherapy: Theory, R esearch, and Practice, 8:44-53 . Rachman , A. W. (1972) , Group Psychotherapy in Treating the Adolescent Identity Crisis. Internal . ]. Child Psychother. , 1:97-119 . ___ (1976) , The Humanistic Encounter. Psychotherapy: Theory, Research, and Practice (in press). Yablonsky, L. (1964), The Tunnel Back: Synanon. New York: Pelican Press.
Dr. Rachman 's address: 310 First Avenue N ew York, N.Y. 10009
