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C Drug Treatment Programs and Research: The Challenge of Bidirectionality Benjamin P. Bowser California State University at Hayward INTRODUCTION The charge of this committee is to recommend ways to increase the bidirectional flow of information and science between drug treatment providers and drug treatment researchers. The first major difficulty we had with this charge is defining the term "community" in community-based drug treatment. A subcommittee was formed to address the problem. Our response was to study the sociological and anthropological literatures on community and members of the overall committee talked at length with directors and staff in "community-based" programs that do drug treatment. Based on treatment program interviews and presentations before the committee, a sense emerged of the challenge before us. The non-utilization of research findings by community-based practitioners is not simply a problem of more efficient technical transfer of information between professional communities. There is a continuum among all drug treatment programs. At one end are programs that are vigorous consumers of research, and at the other are programs that do not use nor understand research, and are suspicious of researchers' intent. Programs are not evenly distributed across the continuum. The vast majority are nonresearch consumers. There is also a similar continuum among treatment researchers. Some have experience working with community-based treatment programs that are not research consumers, while most others have little experience with programs not affiliated with universities, hospitals, and now health maintenance organi-
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zations. The majority of drug treatment providers and researchers are organized into vastly different worlds, have different missions, cultures, histories, and information needs. With some exceptions, each has distinct ways of formulating, assessing, processing, and disseminating information. What both groups have in common are: (a) drug abuse and treatment are issues of primary concern, and (b) reducing drug abuse is their primary goal. Bidirectionality must be built on these two common points. We have come to realize the relationship between drug treatment providers and drug treatment researchers is more problematic than we thought. To call for bidirectionality between treatment providers and researchers has at least four requirements. First, treatment research has to be produced for practitioners and must be useful to them. Second, practitioners must want to work with and provide information to researchers. Third, researchers must be interested in what practitioners know and want to know. And fourth, we assume that better information exchanges between practitioners and researchers will improve client outcomes. The testimony from practitioners and researchers before our overall committee challenged all of these assumptions. The exception is the current attempt of NIDA and CSAT to bridge the gap between drug treatment practitioners and researchers. This is because the context for mutuality between practice and research has yet to be achieved. The work of this committee and the necessity to bridge the gap between practice and research are made all the more timely by congressional and public criticism of the perceived ineffectiveness of drug treatment. This criticism threatens funding for practitioners and researchers alike, and provides motivation for collaboration. In this paper, we do three things. First, we review how community has been defined in the sociological and anthropological literatures. Second, we define what is meant by "community-based" drug treatment as distinct from other treatment contexts. Third, we discuss strategies for bridging the gap between practice and research. WHAT IS COMMUNITY AND WHAT DIFFERENCE DOES IT MAKE? Community Defined There is an extensive literature on community that is useful to our committee's problems with defining community-based drug treatment. The two most commonly repeated descriptors of community are: (1) social land use—those who share common residence within specific geographic boundaries; and (2) social identity—those who identity with one another regardless of shared land use. Shared land use without social identity is not sufficient to define community, while shared identity is. Social identity is
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the essential factor in working definitions of community. George Murdock (1949) gave us one of the earliest definitions of community. Social land is combined with social identity as ''groups of people who normally reside together in face-to-face association." Community is both place and identity. A third descriptor of community is social identity through temporal periods. In this third definition, community consists of a social identity unfolding through time (Arensberg and Kimball, 1965). Examples are secret societies, age cohorts with distinct life courses, or people who share a decisive historic event such as war, the Great Depression, the "Sixties." There are two variations of social identity defined in time. The first is with a shared place and the second is without. A fourth descriptor defining community is function. Community is having a specific basis for a shared identity such as an occupation, a profession, common mission or common craft. In sum, the classic definitions of community are social identities bound (a) by place; (b) by time; (c) by time and place; (d) by function; (e) by function and time; and (f) by function, time, and place (Arensberg and Kimball, 1965). These types of community are not mutually exclusive, nor are they single dimensions. Different kinds of communities can coexist simultaneously, and of course, individuals can be members of multiple communities at the same time. We are all in some community—our clients come from community, our programs regardless of sponsorship are set up in community, and drug treatment researchers are a "community" as well. At first, the definitions of community appear to have little to do with this committee's deliberations. But in fact they have a lot to do with our mission and highlight the major challenge to bidirectional communication between drug treatment practitioners and researchers. Professionals who work in institutional settings are more apt to define community by function as did our full committee at our first meeting. We defined eight descriptors of community with regard to drug treatment. "Community-based" treatment programs were defined by (1) treatment modality, (2) setting, (3) service units in large organizations, (4) accountability, (5) profit-nonprofit, (6) residential or outpatient treatment, (7) source of funding, and (8) client catchment area. Furthermore, treatment programs are sponsored by hospitals, universities, health departments, corporations, and prisons. These descriptors corresponded with only two classical definitions of community—place (setting) and function. We have not considered temporal period nor have we addressed the most common of all descriptor of community, social identity. Essentially, we have taken the legal and formal organization of treatment programs as bases for community. By focusing on only setting and function, we miss what is "community" for most drug treatment programs. Given our review of community definitions, what then does "community-based" mean?
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The Meaning of Community-Based In 1929 Congress recognized that drug addiction was primarily a medical and social problem and that treatment of addiction by incarceration was illogical (NIH, 1995). The Lexington, Kentucky, and Forth Worth, Texas "narcotic farms" were set up by Congress to confine and treat persons addicted to habit-forming drugs. After congressional recognition of drug abuse as a social and medical problem, alcohol rather than drug treatment and support programs were started all across the country by community-based social service programs and by ex-alcoholics through organizations such as Alcoholics Anonymous (Bill W, 1967). The alcohol drug problem was much more pervasive until the 1960s. Then the epidemic of heroin use sparked a second community response. The "narcotic farms" and a few drug treatment programs expanded rapidly as an adjunct to community social services, and with government financial support (Musto, 1973). The expansion of alcohol and drug treatment into community settings was very much in keeping with popular institution building social movements. Local schools, health clinics, community policing, and cooperative grocery stores (Cox, 1994) are a few examples of an ongoing movement in American life (Anner, 1996; Fisher, 1994; Hoffman, 1989; McCarthy and Zalder, 1973). The establishment of needle exchange programs is an example a recent movement among community-based AIDS activists (Bowser, 1993). Local agencies that provided housing, children, and food services in residential neighborhoods started drug treatment programs. Churches with social missions started drug treatment programs. People who were themselves in recovery, started programs. All of these programs have come out of specific racial, social class, ideological, and residential social identities and places. Despite the fact that drug abuse is a chronic relapsing disease, the movement has had visible successes. There are many people who are now clean and sober due to these programs. What is particularly important for our purpose is that their successes have come without a scientific basis. With government funding and regulation of drug treatment, the distinct histories and missions of community-based drug treatment has been obscured. At the same time the Department of Veterans Affairs, county hospitals, university medical centers, and now health maintenance organizations have also rapidly expanded their own drug treatment programs. These are "institutionally based" treatment efforts. The following table gives a sense of the scope of each type of treatment base. In the SAMHSA (1996) survey, "community-based" programs are called "free-standing outpatient" programs. Table C-1 shows that "community-based" or free-standing programs treat 53 percent of all drug abusers seeking recovery. Clearly, university based treatment programs exist to advance research and knowledge about drug abuse. The hospital programs are responding to local public health
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TABLE C-1 Estimated Clients in Specialty Substance Abuse Treatment by Institutional Setting, 1994 Institutional Setting 24-Hour Care Outpatient Total Percent Free-standing outpatient 1,460 501,853 503,313 53.3 Community mental health center 4,178 136,420 140,598 14.9 General hospital (includes VA) 13,937 81,830 95,767 10.1 Specialized hospitals 8,714 14,045 22,759 2.4 Halfway house/recovery home 18,912 5,416 24,328 2.6 Other residential facilities 47,214 23,140 70,354 7.5 Correctional facilities 18,369 19,960 38,329 4.1 Other/unknown types 7,855 40,320 48,175 5.1 All types 120,639 822,984 943,623 100.0 SOURCE: SAMHSA (1996). needs. Corporations have started programs to address employee's drug abuse. But in comparison, there are many more community-based programs that have arisen in response to the drug treatment needs of people with specific area or residential race, ethnic, and social class bound identities. In the mission of community-based drug treatment, people come to abuse drugs not simply as individuals, but as members of some constellation of social identities. How they became addicted, what sustains them in their addiction, and the major source of motivation for "recovery" lies in their relationships and changing relationships with communities of people having similar social identities. The assumption of people who start programs within a community framework is that their specific social community is the best agent to address the cultural content of the abuser's drug abuse problem, treatment and recovery (Joe et al., 1977; Peyrot, 1982). For example, firefighters who became addicted to drugs as firefighters and who are going to remain firefighters are best treated by those most familiar with firefighting and who have respect among firefighters. Chinese-American heroin abusers are best treated by people who share the same social identity, are from the same regional and provincial culture, and who have the same generational immigrant experience—time- and place-bound. The same is true for business executives, and celebrities who go to discrete "retreat" programs, for New York Puerto Ricans ("NewYorRicans") and for African Americans from the South, who are culturally distinct from African Americans from southern Louisiana and the Caribbean. People and organizations emerge in varied communities to address drug abuse within their commu-
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nity (DHHS, 1989; Smith et al., 1971). What makes these programs "community-based" are their history, mission, focus on location, social identity around neighborhood, service to people in the neighborhood, and accountability to local residents and institutions. Whether one agrees or not with the centrality of community in treatment, community is central to their mission and treatment efforts. An example of the most successful model of community-based drug treatment are Alcohol and Narcotics Anonymous Twelve Step programs. They began as community-based treatment, and continue as such. The legal and formal organizational structure of Twelve Step programs is only part of what makes them "community-based." What is more important to their identity and what they do is their world view that values locality, their method for the social support of recovery, and their social identity as part of the twelve step recovery movement (Stephens, 1991). The same is true for drug treatment programs started by churches, Afrocentric organizations, woman's recovery groups, labor unions, and university-based treatment programs with missions to advance teaching and research. They define themselves by their mission and location, social identity and place. Program accountability comes closest to capturing the essence of social identity in the definition of community-based. Accountability tells us what interests, mission, and social setting the program serves. Drug treatment programs accountable to health maintenance organizations (HMOs) serve HMO clients and the profit or not-for-profit (time and function) mission of the HMO. Drug treatment programs accountable to university hospitals also serve teaching and research missions (time and function). Drug treatment programs accountable to local citizens (place) with a particular residential allegiance (identity) exist primarily to serve people in the local area. In other words, there are university-based, health department-based, hospital-based, HMO-based, and community-based drug treatment programs. If we investigate all bases of accountability, there are, undoubtedly, additional ones. It is likely that each of these types of drug treatment outposts have both common and unique informational needs, interests, and priorities based on their differing identities and accountabilities. As we have already seen; however, the community-based programs are the most numerous, and the most diverse. They are also as a group furthest from science and the use of science. The core of our committee's expressed mission is to address the problems of these community-based programs in utilizing science. But the definition what is "community-based" is not without relevance to their openness to using research in the future. WHITHER COMMUNITY? One of the reasons why community-based drug treatment is unrecog-
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nized as a social movement and as having a distinct identity is the fact of its overwhelming government funding and regulation. Any program that is going to treat more than a few individuals with a paid staff must have a source of regular funding. Private foundations avoid funding direct services, leaving drug treatment to city, state, or federal governments. But the money comes with regulations and guidelines that make community-based programs virtual adjuncts to government social services. Funding has obscured differences and standardized programs in how they are reported. Anyone who has worked in local government to fund community-based drug treatment programs knows of the tension and the potential for conflict in the annual funding process. What is at stake is not simply funding to run generic services. Programs want to treat clients in ways that they feel will work best and are most effective, in line with their mission and purpose. But more often, they are not able to because of funding regulations. For example, there are some community-based programs that offer methadone treatment, but would prefer not to. The idea of maintaining drug abusers on an alternative drug is against their specific view of drug abuse and their mission to reduce drug use, regardless of the drug. But methadone maintenance is a source of funding that can bring more drug abusers into their services and cannot be easily overlooked. In recent years, drug treatment dollars are in decline and there are increasing calls for evaluation and demonstrations of effectiveness. An undetermined numbers of community-based programs are in crisis. They do not have the human resources to conduct their own evaluations, nor do they have the fiscal resources to hire someone else to do so. Institutionally based programs in hospitals, universities, and HMOs have vastly more human and fiscal resources to meet the new demands for program accountability and evaluation. So larger and more successful community-based as well as institutionally based programs are more than happy to absorb smaller, well managed community-based programs and their support dollars. The rest will simply wither. We are now witnessing a consolidation and shaking out of community-based drug treatment. Community-based drug treatment programs are not the only community institutions shrinking in number and influence. The possibilities and resources of residential and neighborhood institutions are themselves in transition (Southworth and Owens, 1993; Wellman and Wortley, 1990). The historic centrality of residential community is itself in decline as is evident from a century of community studies (Abu-Lughod, 1994; Seeley et al., 1956; Spectorsky, 1958; Stein, 1960; Vidich and Bensman, 1958). We are now in the third generation of community research in the United States. The first and classic period was in the 1920s and 1930s, when teams of investigators spent years in the field studying Chicago, Illinois, Newburyport, Connecticut, and Natchez, Mississippi, as representative
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small cities. The post-World War II period was the second period, where smaller and shorter community studies were conducted because of the rapid expansion of survey and marketing research techniques (Stein, 1960). The third period began in the 1960s with a focus on understanding specific social problems in community context. Part of the reason for renewed interest in community studies today is because of drug abuse and AIDS prevention. NIDA realized in the mid-1980s that large-scale AIDS intervention efforts could not be mounted among injection drug users (IDUs) to slow the spread of HIV without qualitative knowledge of drug abusers and their communities. To reach IDUs would require accessing them where they congregated. Knowledge of IDUs in their social context was literally "a black box." In addition, AIDS activists argued that one could not mount a community-wide AIDS prevention effort if you knew little about community in the first place. Gay and bisexual activists insisted that their successful effort to reduce HIV infections in their communities was based on knowledge of the community and sensitivity to its cultural differences. As a result, NIDA's National AIDS Demonstration Research Projects required presurvey ethnography to "ground" the research in community. Despite the methodological and theoretical differences over three generations of community research, analysis of almost 80 years of work have noted consistent trends: 1. Residential communities have become increasingly dependent upon outside institutions to sustain their existence and quality of life (Clark, 1993; Stein, 1960). 2. The industrialization of work and the bureaucratization of institutions have reduced community autonomy and distinctiveness (Stein, 1960; Wellman and Wortley, 1990) . 3. Social affiliations based upon kinship, ethnic ties, and proximity (neighboring) are being replaced by affiliations based on friendship, work, and social class, diffused in locality and marked in time (Fischer, 1982; Pilisuk and Parks, 1986). 4. Self-identification by residential community is increasingly temporary as more and more Americans move. Residential communities are becoming increasingly segregated by social class, and multiclass communities are declining rapidly (Fischer, 1982). 5. Despite continuing racial segregation, residential communities are becoming more ethnically diverse and economically homogeneous (Clark, 1993; Lynn and McGeary, 1990). 6. People's inability to define and shape their local living space, and their dependency on outside institutions, largely account for mounting alien-
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ation in American life (Bellah et al., 1985; Harrell and Peterson, 1992; Stouffer et al., 1949). Based upon these trends, there is an emerging view that residential community is increasingly problematic and in decline in the United States. There is a sense that most Americans have fewer, weaker, and more conditional social affiliations today than at the turn of the century (Stein, 1960). Evidence from drug treatment research shows the importance of social support while in treatment as well as supportive social relationships to sustain recovery. If these trends in community are accurate, they must heavily impact drug abuse and the prospects for successful treatment. An alternative view of the very same evidence is that community is not in decline, but is only in transition (Fischer, 1982; Wellman and Wortley, 1990). In this alternate interpretation, there are many people trying to maintain the older and now outmoded form of folk community, a point missed in the research on black poverty (Williams, 1992), drug abuse, and crime in the United States (Harrell and Peterson, 1992). Where residents are able to maintain control over their public space, violent crime is lower (Simpson et al., 1997). Community based upon kinship, neighbors who hopefully will not move, a clear residential area social identity, local autonomy and decision making, and same ethnicity and race may be waning. There is a declining economic and cultural basis for such community (Anner, 1996). A young urban professional can live in the very same area in decline for traditional residents. This new resident may experience a community in emergence, because his social relationships are based upon friends and work associates, and are diffused rather than local. This new social identity is not defined by physical neighborhood and community (Fischer, 1982). In the alternative view of community, we can hypothesize that community-based drug treatment serves drug abuse clients from traditional racial, ethnic, and social class communities in transition. Communities in transition have compromised employment bases, are heavily dependent upon social services, are centers of drug dealing and trafficking, and are heavily policed (Lynn and McGeary, 1990). In these communities, drug abuse is conditioned by poverty, and successful recovery from drug abuse is conditioned by efforts to achieve freedom from poverty. Alternatively, recovery from drug abuse among people with the appropriate education, skills, and employment is now more likely to take place in HMO-, union-, professional, and private hospital-based drug treatment programs. For clients from new communities, drug use is likely to be initiated from experimentation and curiosity, and sustained by background trauma, and personal and professional stress rather than poverty.
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DISCUSSION With the sorting out of community-based drug treatment, the first open question is: Who will respond to the growing need in traditional communities for drug treatment? It is questionable whether institutionally based programs in universities and hospitals, and the few community-based programs that make the transition to the new community, can meet the need. The continuing need for drug treatment will not go away because there is less government funding and fewer treatment programs. The consequence for neglect of drug and alcohol abuse through prevention and treatment costs the nation an estimated $77.6 billion per year in federal entitlements (CASA, 1996). This does not include the costs to the nation of drug-related crimes and criminal justice costs for using jail and prisons for drug treatment. The second open question is whether there is the capacity in communities in decline or transition to continue to produce new drug treatment programs. General social movements have uncanny abilities to continue generating organizations to address community needs and to rise anew when they are least expected (McCarthy and Zalder, 1973) and even attempt to affect expressed needs through invention (Abbott, 1987). When the current generation of drug treatment programs declines far enough, we may very well witness the emergence of another generation of drug treatment initiatives which may not be so ready to compromise their missions for government funding (Frye, 1991). Despite the problems and open questions, bidirectionality between community-based treatment practitioners and drug treatment researchers is possible. But it will require researchers to see the community-based research movement and mission as a source of new theory, as people with potentially useful insights about drug abuse and treatment, and as a well of experience waiting to be tested that can benefit both clients, practitioners, and science. Community-based practitioners can also benefit from alliances with researchers sensitive to community-based issues. Practitioners want to know the outcomes of their best efforts and improve outcomes for clients. Many want their ideas tested and improved upon. They want to know why some clients recover and others do not. They also want to be able to learn from research, and to show specifically where their work has value. For these reasons collaborative research is crucial. Community-based drug treatment is not simply an attempt to treat individual addicts in their community. Whether one takes the view that community is in decline or in transition, community-based drug treatment is part of a larger effort to struggle with neighborhood decline or transition. It is an effort to maintain residential community as a vital human institution for the majority of people who do not have a place in the postmodern world.
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