(3) Our clinical staff makes a primary alliance with the criminal justice referral agency as well as with the clients. This process of dual alliance with the client and the disciplinary agency is the basis for successful work in Employee Assistance Programs. The process is not at all contradictory as long as the primary focus is on sobriety and increasing the client's integrity which is the common goal of all parties. Unfortunately many treatment agencies see themselves as adversaries to the courts and end up by disguising the results of sobriety testing and making excuses for continued abuse. This pattern is called "enabling" in our field. The Lincoln clients are very accepting of this "dual alliance" strategy. There is a lack of contradictory messages, a lack of excuses, and an abundance of interest in their daily struggle to be drug-free.

(4) The counseling process at Lincoln emphasizes a non-judgmental, non-invasive supportive approach. The firm challenge of sobriety is established, but the treatment relationship is quite flexible and open-ended. On some days patients may want to "ventilate their feelings each day; at other times they may want to just say, "hello" and take the acupuncture treatment. Patients often experience fear and resentment toward intrusive questions and advice. This phenomenon is particularly true with court-mandated clients. These fears often prevent frequent attendance at otherwise helpful programs. The therapy program cannot "hold a grudge" and put increasing pressure on the patient for previous failures to respond to treatment. Pressure and concern must be appropriate to the quality of today's struggle and not reflect the residue of the past. The use of acupuncture makes this non-judgmental process much easier.

(5) Frequent urine testing provides an objective non-personalized measure of success that can be accepted equally by all parties. In this system, the counselor is the "good cop" and the urine machine is the "bad cop." The counseling process can be totally separated from the process of judgment and evaluation. According to this approach, clients will not feel a need to be friendly to their counselor in order to gain a positive evaluation. The computer print-out showing a series of drug-free urines is the only documentation they will need to gain a favorable report for the court.

(6) Clinical supervisors at Lincoln have developed an approach that encourages self-sufficiency in their colleagues. A counselor who perceives that his or her autonomy is respected will be much more able to develop autonomy in individual clients. The treatment field frequently neglects the principle that autonomy is a major component of health and sobriety. So much effort is focused on referrals to 24-hour facilities that this basic and practical reality often fades out of view. No matter how effective 24-hour rehabilitation is, the patient will spend 99% of the time in an independent state. The pressing reality of criminal justice is comparable. To help people, we need to help them function well independently of our agencies.

(7) The fear and shame associated with impending incarceration or removal of a child is certainly beneficial for a prospective patient to face a fearful concrete reality. The myth of the well-motivated walk-in patient is just that: a myth. Similarly, court-related referrals should always be made with definite requirements. Referrals of the type "why don't you see if this treatment can help you" lead to an unusually low rate of success. According to recent trends of budget deficit and court congestion, the threat of incarceration is often more symbolic than real. The response of probation and SSC clients indicate that a temporary, more-or-less symbolic threat may often be quite effective in persuading a client to begin treatment and these clients continue in treatment long after the circumstances suggesting the threat of punishment abated. This type of situation is actually quite typical of interventions and contracting in chemical dependency treatment.

(8) "There is no such thing as a hopeless case" is another basic principle. The Lincoln program does not screen out prospective patients as "poorly motivated" or "unsuitable" as is frequently done in regard to criminal justice referrals. All referrals are accepted: a fact that makes these statistics all the more promising.


SUGGESTIONS FOR THE FUTURE

In cooperation with the primary referral sources, Lincoln is developing a selection of treatment contracts that can be mandated for criminal justice clients. For example, a parole client might be required

(1) to attend acupuncture 5 days a week for a minimum of three weeks,

(2) provide drug-free urines on at least 10 of the first 20 days of treatment,

(3) drug-free urine once a week for a subsequent 6 months,

(4) attendance at Narcotics Anonymous or equivalent programs for 6 months. Note that these requirements allow some leeway in the early period of treatment and continue to require sobriety during the early recovery period. Another client might be mandated to give 6 weeks of daily urines and up to a 2-year follow-up period. Such contracts could easily become the basis of revenue saving court diversion and early release program. Unsuccessful clients would face incarceration, but a sizable number would be spared by their commitment to a drug-free life.

At a recent NYC Bar Association retreat, I suggested that drug abusers who are identified by the police sometimes be given summons instead of being arrested. The summons might require that the abuser provide a number of negative urine toxicologies during a specified period of time in order to avoid actual arrest. The availability of effective and inexpensive acupuncture treatment for crack abuse makes this type of non-institutional management a legitimate possibility to cope with the huge dimensions of our drug abuse epidemic.


MILLIONS OF DOLLARS HAVE BEEN SAVED EACH YEAR BY TREATMENT OF CRACK MOTHERS

One of the bittersweet realities of public service is the opportunity to confront major problems of the day as they develop, much as an explorer discovers new territory and learns to cope with new dangers. Often we are overwhelmed or simply lack methods to handle a given situation. One of the worst symptoms of the crack epidemic has been the massive increase in maternal substance abuse and consequent retention of cocaine-positive infants in hospitals as boarder babies. Many of these infants are deprived of love and nurturing until their mothers are able to receive successful drug abuse treatment. As virtually the only available outpatient program for crack abuse in the city, Lincoln Hospital has received more than three thousand referrals of drug-abusing mothers in the past 30 months. We are pleased to report that the Lincoln Hospital Acupuncture Program appears to have saved the city more than three million dollars in 1987 by reducing costs of boarder babies and subsequent foster care for infants born of crack-abusing mothers. The hospital and Special Services for Children (SSC) refer nearly all maternal patients to the acupuncture program. Their attendance and urine results are satisfactory enough so that the agency and the courts release custody of the infants in most cases. Most city hospitals are severely overcrowded and drained of resources due to the boarder baby crisis. Millions of dollars are lost unnecessarily; hospital nurseries are prevented from helping infants with medical needs; and numerous children remain separated from potentially caring parents. The Lincoln acupuncture program is a reliable alternative to much of the suffering and deprivation of maternal substance abuse.

We sent Dr. Wendy Chavkin, then Director of Maternal Health for the City Health Department, the following reports describing 290 post-partum women whose babies were held in the hospital because of a positive cocaine toxicology. Seventy percent of all post-partum referrals interviewed by our staff have attended acupuncture treatment and counseling on a regular basis for at least two (2) consecutive weeks. Fifty percent of all referrals have provided an average of 10 or more clean urines on a regular basis. In one series, post-partum clients provided twice as many clean urines after regaining custody of their child as compared to the pre-custody testing period. These women completed an average of three months of attendance in our program. Fifty percent of them attend NA meetings. The use of acupuncture detoxification has produced substantially beneficial results in this large scale clinical trial.


SPECIAL CHALLENGES FOR WOMEN IN TREATMENT

Lincoln Hospital is the only drug abuse program that I know of which has a large number of child-rearing female clients. Usually female clients in drug programs are rather street-oriented and accommodate to the dominant male clients in that manner. Child-rearing for these women is generally a secondary activity. Lincoln works with many of these street-oriented women. However, a large part of our maternal substance abuse caseload consists of women who identify primarily as homemakers and parents. These women sometimes have outside employment but they almost always have a "job" at home raising children and coping with domestic pressures.

Drug abuse activities invade their home life, but once drug-free status is regained, these women have a respectful "job" they can return to. Consequently, these women have needs that are quite different than the needs of an unemployed person.

Female drug users are often trapped in very destructive and exploitative relationships. Many drug-related relationships involve violence and abandonment. When we ask a mother with small children to stop using drugs, we are usually asking her to leave her home and her relationship as well as the identified addiction. These women are often forced to live in a shelter or welfare hotel if they leave the apartment where their crack-using companion remains in physical control. In a previous session of this subcommittee, we heard that shelters and welfare hotels are hardly safe harbors in the drug abuse war. A woman with small children is uniquely vulnerable to the intimidating and intrusive nature of the crack sub-culture.

Immediate pressures of child care may also hinder a woman's response to treatment. We instruct acupuncture patients to sit quietly in the chair while the needles are in place. This request takes on an entirely different meaning when the maternal patient has a newborn and a 2-year old with her. Attendance in Narcotics Anonymous is also more difficult when children tag along. Every day in our clinic 45-50 women bring small children with them during treatment. We appreciate their commitment to parenthood, but also recognize the increased challenge of their regular attendance. Many of our new mothers visit the hospital each day to feed their infant. Others have to make difficult arrangements for child care.

All too often women are said to have greater resistance to treatment than men. Reality-based fear of physical violence may be falsely interpreted as only part of their fear of confronting addiction. Dependence on living in an apartment and a relationship where crack happens to be used will compound the apparent degree of dependence on the drugs.

At Lincoln we have been able to design a program with a relatively high rate of success for women with small children. Acupuncture provides convenient relaxation and reduction of fear on a daily basis. Scheduled appointments are not necessary. Frequent supportive sessions are used rather than early stage confrontations that are often typical of drug-free programs.

Let me conclude this discussion by mentioning one principle that is vital to the success of any maternal substance abuse program. The program must work in terms of the women's autonomy and ask her to become drug-free for herself, not "for the sake of her baby." Guilt is not a good medicine. A person who appreciates her own value will be a better parent and also be able to say "no" to drugs and drug-filled relationships.


ENHANCEMENTS OF THE MATERNAL SUBSTANCE ABUSE PROGRAM