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Citation: Baumohl, J. and White, W. (2003). Treatment Institutions. In Blocker, J. and Tyrell, I., Eds., Alcohol and Temperance in Modern History. Santa Barbara, CA: ABC-CLIO, pp. 619-624. Posted at www.williamwhitepapers.com

Treatment Institutions

Jim Baumohl and William L. White

This article reviews the history of shortly before and after the Civil War. institutions established to “redeem,” Although the temperance movement would “reform,” “rehabilitate” or “treat” individuals become increasingly associated with the who experience problems in their goal of alcohol prohibition, groups like the relationship with alcohol and/or other drugs. Women’s Christian Temperance Union, Historically, the combined use of alcohol and founded in 1874, typically supported efforts other drugs has been very common, and to sober and rehabilitate obsessive drinkers. institutions established to treat obsessive Most temperance leaders believed that while drinkers rapidly found themselves dealing prohibition would prevent the creation of with habitués of opium, morphine, heroin, drunkards and make treatment measures cocaine, and in later years, a variety of more unnecessary at some point, in the meantime, exotic substances. treatment was an important element in the battle against Demon Rum. Therapeutic Temperance The temperance movement’s most important contribution to the history of Pleas from physicians and social treatment was a fellowship-based approach, reformers for the creation of specialized drawn from Protestant religious practices institutions for the care and control of (most notably early Methodism). Put simply, habitual drunkards came on the heels of a “therapeutic temperance” as practiced by the tripling of annual per capita alcohol Washingtonians, fraternal temperance consumption in the decades following societies and reform clubs, relied on American independence. It was in this collective measures to exhort drunkards to context of widespread heavy drinking and pledge their abstinence and keep their related problems that medical leaders like pledges. Sobriety was to be achieved within Dr. Benjamin Rush and Dr. Samuel a network of likeminded others who provided Woodward conceptualized chronic support and maintained surveillance. drunkenness as a disease and called for its Usually, this process was undertaken treatment. without the use of any segregation in a The first such institutions were formal treatment facility. The affected established by temperance organizations individuals, typically men, attended williamwhitepapers.com 1 temperance meetings and other “elevating” Nineteenth-Century Inebriate Asylums activities held in local temperance halls and tried to limit their social partners to others In some part, the conflict between the pledged to abstinence. Visiting committees supporters and critics of inebriate homes looked in on recovering people and their was about understandings of human nature. families. However, some temperance While many supporters of inebriate homes groups established formal residences for were physicians, and while most used the recovering people. Often, these were called language of disease to characterize habitual “homes” to convey their simultaneously drunkenness, they emphatically denied that supportive and controlling character. inebriety could be reduced to an involuntary The first “inebriate homes” based on state created by changes in the brain or these principles were established in Boston nervous system. Their logic was religious: (1857), San Francisco (1859), and Chicago Human beings had immortal souls that (1863), with many others following their lead. represented the spirit of God; thus, habitual These homes shared several important drunkards had a residual self-control that characteristics: Their residents were present could never be entirely extinguished. While on a legally voluntary basis rather than treating the physiological symptoms of treated by force of law; they were private inebriety, the homes’ methods spoke to organizations (although some received matters of human purpose and community in public funds); they employed recovering ways that were often frankly spiritual. people as staff; they were relatively small, Their critics tended to be younger, housing fewer than fifty residents at a time; trained more rigorously in scientific and they were located in cities so that family, medicine, and enormously influenced by the friends, and the members of temperance neurological research emerging from fellowships would be available to each Europe. They took a decidedly material resident. Finally, they relied on a very short approach to inebriety: It was a disease of the term of residence, usually just long enough brain and nervous system, often incurable, for residents to get through withdrawal and always requiring lengthy treatment in symptoms and be restored to reasonable settings distinctly segregated from health. The real work of achieving sobriety insalubrious influences, including those of was to be accomplished in fellowship outside friends and family. Asylum enthusiasts had of the institution. little regard for the methods of therapeutic It is impossible to know how temperance, and to achieve treatment of the effectively such institutions and their related sort they admired, they turned to the model fellowships restored alcoholics to sobriety. of the insane asylum. For every testimonial to their success there Important reasons quite apart from is a condemnation of their methods. The therapeutic ideology inclined these men to homes’ critics focused mainly on the admire the asylum. In the late 19th century, voluntary nature of the treatment and its public insane asylums – or mental hospitals short duration. They developed an alternate as they would begin to be called early in the view of treatment derived from institutions for 20th century – represented the single largest the treatment of people with mental illness. annual expenditure of American states. They In time, the asylum model prevailed, but were grand, castellated affairs and their inebriate homes never disappeared entirely. superintendents were men of great Though transformed in significant ways, the professional and political power. The philosophy of therapeutic temperance Association of Medical Superintendents of remains influential, as we discuss further on American Institutions for the Insane in this entry. (AMSAII), the forerunner of the American Psychiatric Association, was the model for any professional group seeking power and influence. The promoters of inebriate williamwhitepapers.com 2 asylums were attempting to create a new its therapeutic approach. While the methods medical specialty and the AMSAII’s success of therapeutic temperance were derided as was not lost on them. A specialty needed an sentimental and unscientific in an era institutional base. The American Association increasingly enamored of hard-headedness, for the Cure of Inebriates (AACI) was formed therapeutic temperance at least had in 1870 to do for medical specialists in methods appropriate to its philosophy. The inebriety what AMSAII had done for asylum approach, on the other hand, had no “alienists,” physicians now known as therapeutic methods consistent with its psychiatrists. claims about the nature of inebriety. Simple In addition to the prestige and power custody, healthy diet, exercise, the routine of associated with the control of public institutional work – these were not medical institutions, the inebriety doctors sought interventions. Moreover, such methods were financial stability. The cyclical depressions the stock in trade of a variety of institutions that followed the Civil War caused many that managed inebriates at far less cost. In inebriate homes to fold, especially those that the end, the inebriate asylum was perceived depended on payments from patients. Early in most jurisdictions as a costly and in its career, the AACI took up the cause of redundant enterprise. In Toronto, Ontario, creating public inebriate asylums on the only North American jurisdiction in which substantially the same political and financial public support for an inebriate asylum was footing as asylums for the insane. put to a vote (in 1889), it failed in every ward, The asylum model offered another usually by a wide margin. advantage that was both therapeutic and Other responses to the treatment of political: The force of legal commitment inebriety in the nineteenth century included could be brought to bear most easily on the private, for profit addiction cure institutes, patients of public institutions designed to bottled home cures offered by the same provide some measure of secure custody. patent medicine industry that was Legal commitment would permit the lengthy distributing alcohol-, morphine- and cocaine- detention of patients, thus allowing the AACI laced patent medicines, and religiously- to portray the inebriate asylum as a potential oriented urban rescue missions and rural solution to the endemic homelessness of the inebriate colonies. The most culturally visible late 19th and early 20th centuries. Just as the and controversial of the nineteenth-century insane asylum had to some extent allowed treatments promised brief, low-cost local poorhouses to transfer the care of the treatment usually involving some medicinal insane to state institutions, inebriate asylum specific that was promised to destroy all promoters envisioned a similar transfer of craving for one’s pet poison. Most of these tramps and habitual drunkards who turned cures bore the names of their founding up in local police courts over and over again. entrepreneurs: Keeley, Neal, Gatlin, Key, Indeed, as the inebriate asylum idea was and Oppenheimer, among the most elaborated over time, it became two prominent. institutions in one: A treatment facility for “recent and hopeful cases,” as the asylum The Influence of the Mental Hygiene rhetoric often put it, and a custodial facility Movement for the castoffs of poorhouses and jails. The strategy failed. Very few public In 1875 the AMSAII grudgingly inebriate asylums were ever opened, and approved the creation of public inebriate even the best run and most long-lived asylums. The superintendents were example, in Foxborough, Massachusetts, reluctant to create political competitors, but closed with the advent of Prohibition after this was outweighed by their intense desire only twenty-seven years (1893-1920). to rid their institutions of patients whom they Ironically, the seed of the public inebriate bluntly characterized as “nuisances.” asylum movement’s failure was contained in Indeed, by the 1870s many well-established williamwhitepapers.com 3 private mental hospitals had banned the Early and Mid-Twentieth Century admission of inebriates. Others hoped for Treatment the day when their finances would permit them to do the same. But as the years went The number of inebriate homes, by and few inebriate asylums materialized, inebriate asylums and private addiction cure state hospitals remained the principal sites institutes diminished dramatically during the of public treatment. In large states with first two decades of the twentieth century as several hospitals, it was common for one to America sought to resolve problems related be designated mainly for inebriates. From to alcohol and other drug use mainly by the superintendents’ point of view, this prohibiting or aggressively controlling the concentrated the evil in one location. manufacture and distribution of these drugs. In the decade before World War I, Four different types of institutions however, what we now call filled the continuing need for treatment: 1) “deinstitutionalization” began to take hold in outpatient clinics that utilized recovered several states under the influence of what is alcoholics as lay psychotherapists, 2) private customarily called the mental hygiene sanatoria and hospitals, such as the Towns movement. Mental hospitals were Hospital in New York City that provided scandalously crowded and their therapeutic discrete detoxification for the affluent, 3) intent had been, in most places, reduced to public hospitals that treated narcotic professional pieties. Involuntary addiction (Riverside Hospital in New York commitment resulted in many infamous City), and 4) outpatient narcotic abuses of civil liberties. At the same time, maintenance clinics, most of which operated office practice had become a more common only briefly between 1919 and 1924. The method among psychiatrists and brunt of care for the impoverished inebriate neurologists, who devoted themselves fell upon the large public hospitals, the increasingly to the treatment of mental “drunk tanks” of city jails, county work farms distress that fell short of psychosis. In this – many of which functioned as inebriate context, the treatment of what was by now colonies -- and state psychiatric hospitals. frequently called “alcoholism” was recast, Beyond private hospitals and particularly if the patient was employed or sanatoria, there was very little specialized had a family to support. In Massachusetts, institutional treatment for alcohol and drug the Foxborough State Hospital was addiction during the 1920s and early 1930s. reorganized in 1908 to emphasize brief, Only California funded a specialized facility voluntary inpatient treatment combined with (the State Narcotic Hospital at Spadra, 1929- systematic aftercare in local outpatient 1941) for the treatment of narcotic addiction, clinics. Here, the older methods of and few state-funded alcoholism treatment therapeutic temperance were reworked in units existed. This began to change in 1935, the service of building a coherent system for with the opening of the first of two U.S. Public the treatment of inebriates that linked Health Hospitals for the treatment of narcotic hospitals and community care. Although the addiction and the founding of Alcoholics “deinstitutionalization” of inebriates would Anonymous (A.A.). not occur until the 1960s and 1970s, the Through much of the 1930s and methods employed by Foxborough during its 1940s, the only addiction treatment facilities last decade were a striking anticipation of were these federal hospitals in Lexington, treatment as it developed after World War II Kentucky and Forth Worth, Texas. During as the result of community psychiatry and this period a growing number of hospitals did the rapid growth of Alcoholics Anonymous. begin to collaborate with A.A. The first were Rockland State Hospital, a psychiatric facility in Orangeburg, New York, and Blythewood Sanitarium in Greenwich, Connecticut. To detoxify and stabilize the large number of williamwhitepapers.com 4 “late-stage” alcoholics entering the A.A. progressive, primary disease (not as merely fellowship, members pioneered a model of symptomatic of other disorder); the use of a brief detoxification and treatment at St. multidisciplinary treatment team that Thomas Hospital in Akron, Ohio, St. incorporated recovered alcoholics as Vincent’s Hospital in Cleveland, Ohio, and at primary counselors (a practice that recalled Knickerbocker Hospital in New York City. the era of therapeutic temperance); the So-called “A.A. wards” spread across the infusion of A.A. philosophy and A.A. “step United States in tandem with A.A.’s growth. work;” the focus on abstinence from all mood A.A. “retreats,” “farms” and “rest homes” altering drugs; and reliance on continued were also started by A.A. members to meet support from A.A. following treatment. This the post-hospitalization needs of alcoholics. approach became closely aligned with a Many of these small institutions, such as “halfway house” movement in the 1950s that Alina Lodge (Kenvil, NJ), High Watch Farm provided a structured transition from (Kent, CT) , and Beech Hill Farm (Dublin, institutional treatment to a sustained NH), later evolved into formal alcoholism recovery lifestyle in the community. treatment programs. In 1939, having worked While there were other residential with alcoholics along the lines of therapeutic models of alcoholism treatment during this temperance since the 1880s, the Salvation period (Bridge House in New York City, Army opened its first alcoholism treatment Portal House in Chicago, Brighton Hospital facility. The Army subsequently became one for Alcoholism in Brighton, Michigan), the of the largest providers of alcoholism Minnesota model evolved into the dominant treatment services in the United States. approach in the second half of the twentieth During the 1940s, several new century. A rise in juvenile narcotic addiction models of alcoholism treatment gained led to the re-opening of New York City’s prominence. First, an inpatient psychiatric Riverside Hospital as a juvenile treatment model of addiction treatment was promoted facility and the creation of addiction wards in by private psychiatric hospitals like the such hospitals as the Detroit Receiving Menninger Clinic in Topeka, Kansas. This Hospital, Chicago’s Bridewell Hospital, and approach provided medical detoxification Bellevue, Kings County, Manhattan General, and treatment of the primary psychiatric and Metropolitan hospitals in New York City. illnesses of which alcoholism was thought to Local religious organizations also sponsored be a symptom. new counseling agencies aimed at juvenile The second approach was an addiction. Some of the more notable were outpatient clinic model pioneered at the St. Mark’s Clinic in Chicago, the Addict’s Georgian Clinic and Rehabilitation Center for Rehabilitation Center in Manhattan, and Alcoholics (Atlanta, GA), the Yale Plan Exodus House in East Harlem. During this Clinics (New Haven and Hartford, CT), the period, many states organized alcoholism Institute of the Pennsylvania Hospital treatment units within their state psychiatric (Philadelphia, PA), and Johns Hopkins hospitals, and a few states organized Hospital (Baltimore, MD). These clinics hospitals that specialized in alcoholism viewed alcoholism psychodynamically as an treatment (Blue Hills Hospital in Connecticut escape from life’s travails and, like the and Avon Park in Florida). Menninger Clinic, sought to resolve underlying problems. Treatment Comes of Age The third approach was a residential model of alcoholism treatment developed . The National Council on Alcoholism within three Minnesota institutions: Pioneer and a joint committee of the American House, Willmar State Hospital and Medical Association and the American Bar Hazelden. The major components of the Association were at the forefront of “Minnesota model” were the advocacy for the expansion of treatment for conceptualization of alcoholism as a alcoholism and “drug abuse” during the williamwhitepapers.com 5 1950s and 1960s. To be successful, this community-based treatment agencies. movement needed models of addiction Together, these partners planned, built, treatment that could be widely replicated. staffed, operated, and evaluated treatment Added to the outpatient clinic, detoxification, programs across the United States. The and residential treatment and halfway house remote federal narcotic hospitals and models were three new approaches to alcoholism wards in state psychiatric narcotic addiction and “polydrug abuse.” hospitals gave way to community-based Ex-addict-directed therapeutic treatment agencies. communities (TCs), representing a long- The emerging field of addiction term, residential model for the treatment of treatment was marked by expansion (from drug addiction, began with the opening of less than 200 programs in the 1960s to more Synanon in 1958. TCs viewed drug than 500 in 1973, 2,400 by 1977, and 6,800 addiction as a problem of immaturity and by 1987), increased regulation poor socialization that required a (development of accreditation and program reconstruction of personality and character. licensure standards), and By 1975, there were more than 500 TCs in professionalization (preparatory training and the U.S. modeled after Synanon. In 1964, worker certification/licensure). The field also Drs. Vincent Dole and Marie Nyswander reorganized itself from what had essentially conceptualized heroin addiction as a been two separate fields (one treating metabolic disease and introduced the daily alcohol problems, the other treating “drug” oral administration of methadone as a problems) to a single field that addressed all means of stabilizing the addict’s disordered alcohol- and other drug-related problems metabolism so that social rehabilitation could within an integrated framework. This very begin. By 1973, more than 80,000 heroin contentious integration process was nearly addicts were maintained on methadone in complete at the state and local levels by the licensed treatment programs in the United mid-1980s, leaving in its wake new language States. Growing concerns about youthful such as “chemical dependency” and alcohol and polydrug use during this same “substance abuse.” period generated an outpatient clinic model The 1980s witnessed significant that provided individual, group and family growth in for-profit and hospital-based counseling for young people experiencing addiction treatment programs and an problems with drugs other than narcotics. expansion of programs for special Outpatient drug-free treatment quickly populations of clients: adolescents, women, became the most frequently utilized ethnic and cultural minorities, and those with treatment modality in the United States. co-occurring psychiatric illness. The service Federal support for community-based missions of many treatment institutions also treatment of alcoholism and other drug expanded to include early intervention with addiction increased through the 1960s and alcohol and other drug-impaired employees, culminated in the passage of landmark students, and drivers. legislation in the early 1970s. The The growth of residential treatment Comprehensive Alcoholism Prevention and programs was reversed in the 1990s when Treatment Act (Hughes Act) of 1970 and the ethical concerns about the field’s business Drug Abuse Treatment Act of 1972 created and clinical practices led to an aggressive a federal, state, and local partnership to treat scheme of managed behavioral health care alcoholism, drug addiction and drug abuse. that significantly reduced inpatient treatment The major elements of this partnership were admissions and lengths of stays. This led to two federal institutes (The National Institute the closure of many for-profit and hospital- on Alcohol Abuse and Alcoholism and the based treatment programs and in all National Institute on Drug Abuse), programs, a greater emphasis on outpatient, designated treatment planning authorities brief therapies.. within each U.S. state and territory, and williamwhitepapers.com 6 The Current Status of Addiction standards of the Joint Commission for the Treatment Institutions Accreditation of Healthcare Organizations or the Council on Accreditation of Some 15,239 institutions participated Rehabilitation Facilities and/or state in the latest (1999-2000) national survey of program licensure standards. The programs alcoholism/addiction treatment facilities in are staffed by interdisciplinary teams of the United States, 45 percent of which were physicians, nurses, social workers, concentrated in eight states. This national counselors, counselor assistants, and network of facilities is made up of private outreach workers. non-profit agencies (60 percent), private for- Individuals with alcohol and other profit organizations (26 percent), and drug problems get to these programs by self- state/local government-operated facilities referral or referrals from physicians, (11 percent). In sixty-five percent of these community service agencies, the courts, facilities, treating addiction was the primary employee assistance programs, schools, organizational mission. Ninety-six percent of alumni and members of recovery support the facilities treat both alcohol and other groups like A.A. and Narcotics Anonymous. drug-related problems. Types of care Most treatment consists of a combination of provided by these agencies include one or more of the following: outpatient rehabilitation services (82 percent outreach/engagement services, of facilities), residential rehabilitation detoxification; individual, group, and family services (25 percent), partial hospitalization counseling; pharmacotherapy (e.g., (19 percent), outpatient counseling (13 methadone, LAAM, antabuse, naltrexone); percent) and residential detoxification (5 relapse prevention training; linkage to percent). community mutual aid groups; and a Seventy percent of all clients structured program of follow-up counseling. admitted to American treatment institutions Nearly all addiction treatment programs in are men. The racial/ethnic composition of the United States provide treatment that is these clients is 60 percent non-Hispanic based on the goal of complete abstinence white, 25 percent non-Hispanic black, 10 and the majority provided treatment based percent Hispanic, and five percent other. on A.A.’s Twelve Steps. The primary drug choices of clients being The United States spends more than admitted to these facilities are alcohol only $3.1 billion federal dollars per year on (26 percent), alcohol with a secondary drug addiction treatment and treatment-related (20 percent), opiates (16 percent), cocaine research, and more than one and one half (14 percent), marijuana (14 percent) and million people each year are admitted to the other stimulants (5 percent). More than nation’s treatment institutions. Today’s field 1,200 facilities (8 percent of all facilities) of addiction treatment has achieved partial dispense methadone or LAAM (levo-alpha- ownership of the nation’s alcohol and other acetylmethadol) for the treatment of narcotic drug problems. The field has attained a high addiction. Two -thirds of the facilities level of professional organization. It is provided both treatment and prevention supported by multiple federal and state, services. addiction-focused agencies. Its interests are Addiction treatment programs in the promoted by public advocacy organizations United States are today funded by a (National Council on Alcoholism and Drug combination of federal, state, and local Dependence) and numerous trade grants and contracts; public (Medicare and organizations (American Society of Medicaid) and private health insurance; and Addiction Medicine, National Association of by client self-payment. Costs of treatment Addiction Treatment Providers, the National vary widely by modality and by type of Association Addiction Treatment provider organization (public versus private). Professionals). And the field’s development Most programs meet the accreditation is being supported by major philanthropic williamwhitepapers.com 7 foundations (the Smithers Foundation, the Contemporary Drug Problems, 27, 17-75. Robert Wood Johnson Foundation).

References SAMHSA (2001) Uniform Facility Data Set (UFDS): 1999 (Data on Substance Abuse Baumohl, J. and Room, R. (1987). Inebriety, Treatment Facilities. Rockville, MD: Doctors, and the State: Alcoholism SAMHSA, Office of Applied Treatment Institutions Before 1940. In: Studies\Treatment Episode Data Sets Galanter, M. Ed. Recent Developments in (TEDS). 1994-1999. National Admission to Alcoholism: Volume Five, pp 135-174. NY: Substance Abuse Treatment. SAMHSA, Plenum Publishing. Office of Applied Studies.

Baumohl, J. (2000). Maintaining White, W. (1998) Slaying the Dragon: The Orthodoxy: The Depression-Era Struggle History of Addiction Treatment and over Morphine Maintenance in California. Recovery in America. Bloomington, IL: Chestnut Health Systems .

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