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The International Journal of the Addictions, 14(1), 77-82, 1979

Attitudinal Issues in Methadone Maintenance Programs* Elliott M. Heiman, M.D. Department of Psychiatry and Department of Family and Community Medicine University of Arizona Health Sciences Center Tucson, Arizona 85724

Abstract

When the addict fails to meet treatment goals, staff may split into “help” vs “shape up or be expelled” groups. To diminish this conflict, team meetings aid the staff to better understand the addict and their own intrapsychic and interpersonal attitudes, set reasonable treatment goals, and provide concrete help. General staff meetings clarify policy and increase awareness of various role stresses. Nondegree counselor subgroups help to define stresses in this unique role. The wish to protect and care for the addict vs the insistence that the addict accept responsibility for himself and change his behavior divides methadone maintenance program staffs. The consequences of this attitu*This paper is based on the experiences of the author while he was Medical Director of the Hope Center Drug Program (a part of Tucson Southern Counties Mental Health Services, Inc.) from October 1970 to December 1972. 77 Copyright @ 1979 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.

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dinal conflict between “care for” vs “responsibility” is most clearly manifested when an addict is unwilling or unable to accept such program “rules” as daily attendance for the purpose of supervising the ingestion of methadone, discontinuing the use of heroin, or changing his life-style by attending groups, going to school, or finding a job. In response to these failures the staff must decide whether or not an addict should be dropped from the program. The “hearings” at which these decisions are made are often compared by both staff and patients to a “courtroom.” The addicts are “judged” and if found guilty, they are expelled from the program. In order to diminish potential conflict in the “courtroom,” clinical staff should organize into patient care teams that meet frequently. It may be that team members spend more time talking to each other about the patients than talking to the patients, but this may be necessary and profitable. These team meetings, together with sessions with experienced supervisors, must increase staff awareness of the following. 1. Addict attitudes. Heroin addicts are in desperate straits with a long history of severe emotional and situational problems. They have feelings such as distrust of institutions, need for a magical cure, fear of failure because of lack of skills in a nonheroin addicted world, and resentment about becoming dependent on the program’s methadone for the rest of their lives. The addicts assume the helpless posture that they have suffered unjustly due to outside forces, and that their fate is in the hands of the staff. They usually do not perceive that their behavior has led to inevitable consequences nor that they have the power to change their behavior. Addicts enjoy their addiction; they do not suffer from it (Bejerot, 1972). At the time of “judgment” the addicts are masters of finding grey areas where there is no simple solution such as inconsistencies in the rules, instances when the rules may be clearly harmful, and former times when rules were bent or broken for other patients. 2. Staff “intrapsychic” attitudes. Each staff person joins the program as an “apostle” of a particular approach to the treatment of the heroin addict. This preexisting “moral” position is quite important. Clinicians in the program may develop a need to rescue the addict from his life-style. When this attempt fails, they wish the patient out of the program but are unclear concerning their motives. They ask themselves if they are angry with the patient because of his failure or if they are acting rationally in the best interest of both the patient and the program (Chappel, 1973).

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Methadone maintenance staffs attribute more positive characteristics to the drug-free state than to being on methadone (Brown et al., 1974, 1975). Because of the addictive power of methadone, the staff justifies its use with the belief, not necessarily conscious, that methadone will rescue the addict from his heroin-dependent life-style. Addicts do all they can to further this tendency. When this magic fails, the staff feels guilty about addicting the patient to methadone. As we see, the staff is very ambivalent about methadone. Repeated treatment failures make the staff feel quite helpless. This helplessness, together with anger, guilt, and ambivalence, intensifies either the need to help the addict or the demand that the addict change his behavior and face the consequences. This intensification then increases the staff conflict (Main, 1957). Expressing these feelings within the team will decrease the sense of isolation and anxiety and hence the potential for conflict. Although there is a tendency for each staff person to favor a “judgmental” attitude, in all likelihood this attitude will swing like a pendulum from “helping” to “shape up” and then back again. As a matter of fact, program policies tend to swing in the same pendular fashion. This attitude movement is inherent to the nature of the situation and is to be expected. 3. Staff interpersonal attitudes. In this courtroom atmosphere the “defendant” group accuses the “prosecutors” of being rigidly tied to arbitrary and infantilizing rules and even of being sadistic (Roberts, 1975). Because they feel angry, powerless, and disillusioned with the decisionmaking process, they passive-aggressively sabotage the program’s policies. The “prosecutors” become increasingly defensive and angry in what they may perceive as unjust attacks by both patients and staff. As a result, they rigidly defend the rules of the program against what they see as manipulating patients and soft-headed staff who overidentify with the addict. The prosecutors assert that the rules are necessary to insure constructive change and guarantee that the program will not just dispense another addicting drug and become a “federally funded dealer.” In order to prevent or ameliorate this conflict, the team members should have both the responsibility for treating the patient and the power to make patient care decisions. Certainly, some team members will have more power than others; the crucial factor is that all members have input. Open communication within this “team” is important but will not resolve all the differences. At times of basic disagreements the team must be ready to negotiate in a spirit of openness and respect.

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4. Goal setting. The staff must recognize that the “all or none” goal for the heroin addict is unrealistic just as it is with the alcoholic (Goldstein, 1976). The alcoholism counselor is always prepared for his client to “fall off the wagon.” Much of the health care system deals with chronic, relapsing conditions such as alcoholism, heart disease, back pain, and schizophrenia. The persons treating patients with these conditions must become comfortable with their powerlessness to provide a definitive cure. The rehabilitation approach is often used in which the individual’s strengths are maximized, and limited goals such as increasing function and quality of life are recognized as legitimate. 5. Provide help to the therapists. Because an addict is in continual turmoil and has so many frustrating situational and emotional problems, his treatment will often be overwhelming for one therapist. The team members provide concrete assistance to the therapists by not only providing encouragement and ideas but also by actively sharing clinical responsibility as co-therapists.

Regular staff meetings which include both administrative and clinical personnel have the following goals. 1. To clarify the origin of program policies. Some program policies and the rules derived therefrom have grown out of program needs and can be modified by the staff when appropriate. Other policies have been imposed on the program by the government. By openly discussing the origin and rationale for policy, the staff will understand the limits of power of the program “authorities.” Policy that can be modified should be openly debated with all staff participating. 2. Maintenance vs maintenance and abstinence. The ambivalence within each individual concerning the use of methadone is reflected in program policy. Staff may argue whether the policy should unequivocally acknowledge “endless” methadone maintenance as being as desirable as abstinence. Policies will undoubtedly change on this sensitive issue. If a program “officially” supports “long-term” maintenance, staff must be sensitive to the subtle clues that indicate the unspoken wish for abstinence. 3. To develop awareness of the pressures on each role within the program. The administrator is under pressure to justify his program to funding agencies and to run a clean program in the eyes of law enforcement agencies and the community. The clinician who is providing direct service to the addict identifies with the addict and feels intense pressure to be helpful. The nondegree drug counselor is probably the extreme of this latter position.

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The nondegree drug counselor who is in a uniquely difficult position (Committee on Therapeutic Care, 1974) might benefit from a subgroup to better define his role. He was hired as someone who speaks the addict’s language, lives in the addict’s community, and frequently has a history of drug abuse. This counselor may initially verbally accept the program’s expectations but he often finds himself increasingly in the middle between the rules and the patient. The danger lies in either feelings of frustration and helplessness in overidentifying with the patient and, thereby, losing his objectivity and credibility to the institution, or increasing professionalism and identification with the administration and institution and, thereby, losing his credibility and identification with the addict patient. “Degreed” staff have more clear allegiance to the institution and frequently do not experience as severe a conflict. Therefore, the strength of the drug counselor, which helps him understand the needs of the addict, also makes him more vulnerable to divided loyalties when perceived program and patient needs conflict. Studies of the attitudes of methadone maintenance staff toward methadone itself are accurate but do not go far enough. Further research could clarify the intense ambivalence about methadone which we have been discussing; that is, methadone is both a savior from a heroindependent life and also a dangerous and perhaps life-long addiction. Other topics for research could be (1) the influence of preexisting moral values on the attitude toward program policy and (2) the attitude change in staff after experience in drug programs and after moving from a clinical to an administrative position. In conclusion, team meetings, individual supervision, large staff groups, and role subgroups should become a regular structure within the program in order to provide help in dealing with potential attitudinal conflicts. These sessions offer an opportunity to clarify administrative, intrapsychic, or interpersonal problems, and to provide concrete help. At its best the resulting milieu can provide an espirit de corps in battling an extremely difficult and frustrating condition. A methadone maintenance program’s potential for divisiveness is great, but in no other type of program do staff members need this group support more.

REFERENCES BEJEROT, N . A theory of addiction as an artificially induced drive. Am. J. Psychiatry 128: 842-846, 1972.

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BROWN, B.S., JANSEN, D.R., and BASS, U.F. Staff attitudes and conflict regarding the use of methadone in the treatment of heroin addiction. Am. J. Psychiatry 131: 215-219, 1974. BROWN, B.S., JANSEN, D.R., and BENN, G.J. Changes in attitude toward methadone. Arch Gen. Psychiatry 32: 214-218, 1975. CHAPPEL, J.N. Attitudinal barriers to physician involvement with drug abusers. J . Am. Med. Assoc. 224: 1011-1013, 1973. COMMITTEE ON THERAPEUTIC CARE. The community worker: A response to human needs. GAP lO(91): November 1974. GOLDSTEIN, A. Heroin addiction. Arch. Gen. Psychiatry 33: 353-358, 1976. MAIN, T.F. The ailment. Br. J . Med. Psychol. 30: 129-245, 1957. ROBERTS, D.P. Areas of conflict between methadone regulations and treatment of patientaddicts. Hosp. Community Psychiatry 26: 832-833, 1975.

Attitudinal issues in methadone maintenance programs.

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