1. The history of substance abuse and substance abuse treatment is a difficult one to follow in large part because the stories of alcohol abuse and drug abuse have followed different paths, even though they are intertwined. As a consequence, people who write about these subjects often fail to make clear when they are discussing alcohol versus illegal drugs. In an attempt to forestall that confusion, this article will refer to the abuse of both alcohol and illegal drugs as “substance abuse.” “Drug abuse” will refer only to illegal drugs.

2. In addition to affecting the health of the approximately “5.5 million Americans [who] have a drug problem serious enough to need treatment,” substance abuse causes many problems to society. These problems include harm to drug-exposed infants (estimates of annual births of drug-exposed babies range from 14,000 to 739,200), automobile and workplace accidents, and reduced production in business and industry. Furthermore, there are many links between substance abuse and crime, including robbery, burglary, and theft.

Costs to society are staggering. A recent California study (CALDATA) estimated that “in the year before treacment, participants treated in California's treatment system engaged in crime, health, and productivity-related behaviors that cost taxpaying citizens $3.1 billion and cost society $4.4 billion.” Janny Scott, “Mathea Falco: Finding the Right Road to a Drug-Free America,” Los Angeles Times, 14 February 1993, M3; U.S. Bureau of Justice, Drugs, Crime, and the Justice System: A National Report from the Bureau of Justice Statistics, December 1992, 2–14; Gerstein, Dean R. et al. , Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment (CALDATA), California Department of Alcohol and Drug Programs, 1994, 64.Google Scholar

3. Anglin, M. Douglas and Hser, Yih-Ing, “Treatment of Drug Abuse,” in Tonry, Michael and Wilson, James Q., eds., Drugs and Crime (Chicago, 1990)Google Scholar; Gerstein, Dean R. and Harwood, Henrick J., Treating Drug Problems, vol. 1 (Washington, D.C., 1990)Google Scholar; Hubbard, Robert L. et al. , Drug Abuse Treatment: A National Study of Effectiveness (Chapel Hill, 1989)Google Scholar; Institute of Medicine, Prevention and Treatment of Alcohol Problems: Research Opportunities (Washington, D.C., 1989).Google Scholar

4. A 1989 study by the Institute of Medicine emphasized the need for “detailed historical analyses, contrasting case studies, and large-scale statistical studies … to provide a knowledge base to guide health planning and treatment policy.” (Institute of Medicine, Prevention and Treatment, 146). Although the Institute of Medicine scrutinized only alcohol abuse, the lack of historical studies in drug treatment is also apparent. Most reports about drug treatment programs are clinical evaluations of effectiveness, such as Holland, Sherry, “Evaluating Community-Based Treatment Programmes: A Model for Strengthening Inferences About Effectiveness,” Intemafional Journal of Therapeutic Communities 4 (1983):285–306Google Scholar. Other inquiries give a more detailed but still incomplete picture of individual drug treatment programs, such as Judianne Densen-Gerber and Drassner, David, “Odyssey House: A Structural Model for the Successful Employment and Re-entry of the ex-Drug Abuser,” Journal of Drug Issues 4 (Fall 1974): 414–27.Google Scholar

5. Warm Springs, located in the Angeles National Forest, is midway between Castaic and Lake Hughes. Acton is 1 1/2 miles south of the small community of Acton, about 14 miles south of Palmdale.

6. Although the centers are not technically hospitals with a full complement of medical practitioners, they are supervised by Los Angeles County's Bureau of Hospitals and offer a daily medical staff. Acton has a total of 292 beds and Warm Springs has 183 beds. “Desktop Resource: Top 25 Alcohol/Chemical Dependency Hospitals,” Health Week, 11 April 1988, 17.

7. United States Department of Commerce, Statistical Abstract of the United States: 1992 (Washington, D.C., 1992), 22Google Scholar; State of California, California Statistical Abstract: 1992 (Sacramento, November 1992), 13.Google Scholar

8. Courtwright, David T., “A Century of American Narcotic Policy,” in Gerstein, Dean R. and Harwood, Henrick J., eds., Treating Drug Problems, vol. 2 (Washington, D.C., 1992)Google Scholar; Morgan, H. Wayne, Drugs in America: A Social History, 1800–1980 (New York, 1981)Google Scholar; Musto, David F., The American Disease: Origins of Narcotic Control, expanded edition (New York, 1987)Google Scholar; Musto, David F., “Opium, Cocaine, and Marijuana in American History,” Scientific American, July 1991, 40–47Google Scholar; and Wilbert, Martin I., “Efforts to Curb the Misuse of Narcotic Drugs: A Comparative Analysis of the Federal and State Laws Designed to Restrict or Regulate the Distribution and Use of Opium, Coca, and Other Narcotic or Habit-Forming Drugs,” Public Health Reports 30 (1915): 893–923.CrossRefGoogle Scholar

Other sources for understanding the changing attitude of Americans toward drug and alcohol use and treatment include Courtwright, David T., Dark Paradise: Opiate Addiction America Before 1940 (Cambridge, Mass., 1982)Google Scholar; and Levine, Harry Gene, “The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America,” Journal of Studies on Alcohol 39 (1978): 143–74.CrossRefGoogle ScholarPubMed

9. Musto, The American Disease; idem “Opium.”

10. Gerstein and Harwood, Treating, 47.

11. Baumohl, J., “Inebriate Institutions in North America, 1840–1920,” British Journal of Addiction 85 (September 1990): 1187–1204CrossRefGoogle ScholarPubMed; and Corwin, E.H.L. and Cunningham, Elizabeth V., “Institutional Facilities for the Treatment of Alcoholism,” Quarterly Journal of Studies on Alcohol 5 (1944): 9–85.Google Scholar

12. Morgan, Drugs, 71–73.

13. The same Supreme Court ruling—Webb et al. vs. U.S. —that gave the Treasury Department its impetus to close clinics banned maintenance therapy, a practice that lasted until the mid–1960s. Courtwright, Dark Paradise, 11–12; Musto, American Disease, 132, 151–82; idem, “Opium,” 44.

14. Although those “farms” accepted some volunteers, the original concept was to take the overflow of addicts from penitentiaries. According to Courtwright, Lexington “remain[ed] the single most important treatment and research facility in the country well into the 1960s.” Courtwright, “Century,” 15; and idem, Dark Paradise, 114–15.

15. Courtwright, “Century,” 16.

16. Ibid., 14–16; Deitch, David A., “Treatment of Drug Abuse in the Therapeutic Community: Historical Influences, Current Considerations, and Future Outlook,” National Commission on Marihuana and Drug Base, IV (Washington, D.C., 1972), 159.Google Scholar

17. Harry E. Raitano, Lease and Contract Officer of the California State Relief Administration, to Wayne Allen, Chief Administrative Officer, Los Angeles County, 10 April 1941, Los Angeles County Board of Supervisors, Executive Office Archives, Los Angeles County (BOSEO), 40.00, 637; “Special Use Permit, Warm Springs CCC Camp, F-137,” 8 January 1940, BOSEO, 40.00, 637.

18. From 1 July 1941, to 16 October 1946, Acton accepted tubercular patients from the nearby Olive View Sanitarium. Anonymous, “Acton History”; Marie Milburn, interview by author, 16 December 1992.

19. Schlesinger, Arthur M. Jr., The Coming of the New Deal (Boston, 1959), 20, 337, 339Google Scholar. For further information on the Civilian Conservation Corps, see Salmond, John A., The Civilian Conservation Corps, 1933–1942: A New Deal Case Study (Durham, N.C., 1967).Google Scholar

20. Los Angeles County, Department of Charities, Department of Charities Report, January 1938, BOSEO, 40.5, 772.

21. Los Angeles County, Department of Charities, Department of Charities Report, April 1938, BOSEO, 40.5, 772.9.

22. Los Angeles County, Annual Report 1949–50, Report of Inspectors of County Institutions, November 8, 1954 to February 21, 1955, Inclusive. BOSEO, 310/?; Gillis, Bill, “Acton Camp Is Good for Inmates and Is a Boon to the Taxpayers,” Antelope Valley Ledger Gazette, 6 August 1958, 16.Google Scholar

23. Los Angeles County, Annual Report 1949–50, Report of Inspectors of County Institutions, November 8, 1954, to February 21, 1955, Inclusive, BOSEO, 310/?.

24. In addition to the 70 percent alcoholic population in 1958, about 25 percent of the residents had once had tuberculosis, and about 2 percent were considered mentally retarded. Gillis, “Acton Camp.”

25. Ibid. At that time, the cost of housing residents at Acton was $2.01 per day (which included prescriptive medication), while Luglan estimated that it would cost $7 to $20 a day to support residents at other county institutions.

26. Los Angeles County, Public Welfare Commission, Annual Reports, 1950–1951, 1951–1952.

27. Los Angeles County, Department of Charities, Annual Report Digest, Warm Springs Camp, Fiscal Year 1951–52, BOSEO, 40.00/637.22; Earl E. Studley, Warm Springs Camp Manager, to William A. Barr, Superintendent of Charities, 23 September 1953, BOSEO, 40.00, 637.25.

28. Marie Milburn, telephone interview by author, 17 May 1993.

29. Los Angeles County, Public Welfare Commission, Annual Reports, 1950–1951, 1951–1952.

30. Marie Milburn, telephone interview by author, 17 May 1993.

31. Los Angeles County, Department of Charities, Annual Report of the Warm Springs Camp Projects and Expenditures for the Fiscal Year 1952–1953, 23 September 1953, 40.00 637.25.

32. Kurt M. Freeman, former executive director of the AVRCs, written comments on previous draft, n.d.

33. For a history of Alcoholics Anonymous and an explanation of its Twelve Steps as well as the Twelve Traditions, which emerged in a series of articles published in 1947 and 1948 in the Fellowship's monthly magazine, “A.A. Grapevine,” see Anonymous, Alcoholics, Twelve Steps and Twelve Traditions (New York, 1952)Google Scholar; Kurtz, Emest, Not God: A History of Alcoholics Anonymous (Center City, Minn., 1979)Google Scholar; and Thomsen, Robert, Bill W (New York, 1975).Google Scholar

34. McCarthy, Raymond G. et al. , Alcoholism m Los Angeles County: Problems and Recommendations (New Haven, 1950), 1–11Google Scholar. The Yale Center began and continues to publish a prominent journal, originally entitled Quarterly Journal of Studies on Alcohol and now entitled Journal of Studies on Alcohol. It also established public clinics for the treatment of alcohol and a program for dealing with alcohol in industry. Additionally, the Yale Center helped establish the first volunteer health organization on alcoholism. Keller, Mark, “A Historical Overview of Alcohol and Alcoholism,” Cancer Research 39 (July 1979):2826–27.Google ScholarPubMed

35. Musto, American Disease, 254.

36. Anglin and Hser, “Treatment,” 398; Karst J. Besteman, “Federal Leadership in Building the National Drug Treatment System,” in Gerstein and Harwood, Treating Drug Problems, 2:71; Morgan, Drugs, 153.

37. Methadone maintenance, which arose out of studies in a New York hospital in the mid-1960s by Marie Nyswander and Vincent Dole, aimed at reducing the need for heroin by “maintaining” the addict on a synthetic drug. Although, according to Gerstein and Harwood, this modality “has yielded the most positive results” for those who seek it, methadone maintenance is also the most controversial modality. Some critics claim it legitimizes drug use and creates new addicts. Others contend that addicts merely replace one drug with another. Gerstein and Harwood, Treating Drug Problems, 2:13, 133, 136–54; Courtwright, “Century,” 27–28; Hubbard et al., Drug Abuse Treatment, x; Morgan, Drugs, 150.

38. This treatment modality consists of a variety of approaches, ranging from one-time “rap” sessions to programs offering daily counseling or psychotherapy that continue for a year or longer. Although outpatient nonmethadone therapy has its roots in the psychoanalytical treatment of “toxicomania” in the 1930s, the programs have been shaped by the 1960s innovations—such as the community health movement, free clinics, crisis counseling, and drop-in centers. Gerstein and Harwood, Treating Drug Problems, 1:167–70.

39. Chemical-dependency programs, the primary therapeutic approach of privately financed patients, emerged from programs oriented toward alcoholics. Over the years, these programs have admitted increasing numbers of illicit drug abusers. Abstinence, self-help, and a broadened twelve-step program continue to be the basis for treatment in these highly structured three- to six-week programs. Congress, Senate, Committee on Governmental Affairs, Causes and Consequences of Alcohol Abuse: Hearings Before the Committee on Governmental Affairs, Part 2, Alcoholism Treatment, 100th Cong., 2d sess., 16 June 1988, 6–7; Secretary of Health and Human Services, Seventh Special Report to the U.S. Congress on Alcohol and Health, Preprint Copy (Rockville, Md., 1990), 409Google Scholar; Gerstein and Harwood, Treating Drug Problems, 1:170–74.

40. Therapeutic Communities, which emphasize a shared patient-staff responsibility in addiction treatment and in the management of residential facilities, offer residential programs of at least fifteen months that emphasize drug abstinence, housekeeping responsibilities, and a change in behavior as well as lifestyle. DeLeon, George, “The Therapeutic Community: Status and Evolution,” International Journal of the Addictions, 20 (1985): 824Google Scholar; DeLong, James V., “Treatment and Rehabilitation,” in Drug Abuse Survey Project, Dealing with Drug Abuse (New York, 1972), 174–78Google Scholar; Hubbard et al., Drug Abuse Treatment, ix. Mark Schlesinger and Dorwart, Robert A., “Falling Between the Cracks: Failing National Strategies for the Treatment of Substance Abuse,” Daedalus 121(3) (Summer 1992): 201Google Scholar; Gerstein and Harwood, Treating Drug Abuse, 1:172.

41. Cameron, James M., “A National Community Mental Health Program: Policy Initiation and Progress,” in Rochefort, David A., ed., Handbook on Mental Health Policy in the United States (New York, 1989), 132.Google Scholar

42. Freeman, Kurt M. and Koegler, Ronald R., M.D., From Skid Row to the Olympics (Castaic, Calif., 1978), 1–9Google Scholar; Christy Park, “Building New Lives at Warm Springs,” The Newhall Signal, 12 April 1974; Anonymous, “Physical Recreation Primes Patients for Therapy by Building Self-image,” Alcohol and Health Notes, September 1973, 2.

43. Baker and Picken, Licensing.

44. Kurt M. Freeman, interview by author, Acton, California, 29 July 1992.

45. Coffler, David B. and Hadley, Robert G., “The Residential Rehabilitation Center as an Alternative to Jail for Chronic Drunkenness Offenders,” Quarterly Journal of Studies in Alcohol 34 (1973): 1180–86.Google ScholarPubMed

46. M. Douglas Anglin and Yih-Ing Hser, “Legal Coercion and Drug Abuse Treatment: Research Findings and Social Policy Implications,” in James A. Inciardi, ed., Handbook of Drug Control in the United States, 162. For more on civil commitment programs, see also Besteman, “Federal Role,” and Mary Dana Phillips, “Courts, Jails, and Drug Treatment in a California County,” in Gerstein and Harwood, Treating Drug Problems, vol. 2.

47. Becker, Maki, “Celebrating Success in Sport and in Sobriety,” Los Angeles Times, 14 May 1995.Google Scholar

48. “Vocational Rehabilitation Project: 18 Month Report,” n.d., 1–2, AVRCs files.

49. Kurt M. Freeman, interview by author, Acton, California, 14 September 1992; Gary Alexander, interview by author, Acton, California, 18 September 1992.

50. Language Improvement Program (LIP) Annual Performance Report, January 3, 1989, to June 30, 1989, AVRCs files.

51. Richard Rioux, telephone interview by author, 2 July 1993.

52. Los Angeles County was not the only region that neglected treatment for women. Although studies estimate that women comprise from 25 percent to 50 percent of the alcoholic population in the United States, they have been a consistently underserved group. Women suffer a greater stigma for their addiction than men and as a consequence the American culture often denies the reality of the alcoholic woman. This denial continues to be borne out by the lack of services for women addicts.

In 1974, the problem of women addicts was finally recognized when the National Institute of Drug Abuse established its program for Women's Concerns. It took two more years for the government to conduct a national conference on women's issues and enact a law (Public Law 94–371) that granted priority consideration for the funding of women's treatment and preventional programs. Sandmaier, Marian, The Invisible Alcoholics: Women and Alcohol Abuse in America (New York, 1980), 73–74Google Scholar; Congress, Causes and Consequences, 206–10.

53. Los Angeles County Department of Mental Health, Statement of Problems: Phase I of the 1972 Mental Health Plan for the AVRCs, 1972, 1; Robert W. Baker, Short-Doyle Plan 1973–74 and 1973–78: Phase II for AVRCs, 3 April 1972, 8; Bruce Picken, M.D., Antelope Valley Rehabilitation Centers Planning, April 1973, p-2; idem, Need for Added AVRC Beds, 1 July 1974, AVRCs files.

54. Women Alcoholic Services: Pilot Program, 26 March 1975, AVRCs files.

55. Motion by Supervisor Baxter Ward, Minutes of the Board of Supervisors, 29 April 1975, BOSEO 40.il.

56. “Pilot Program for Women—Acton,” California Alcoholism Review, July-August 1975.

57. Women Alcoholic Services, “Pilot Program for Women—Acton,” n.d.; Bruce R. Krudis et al., Program Description and Evaluation of the Antelope Valley Rehabilitation Centers: A Three Year Study, 1976, AVRCs files.

58. Kurt M. Freeman, interview by author, Acton, California, 18 September 1992.

59. Ibid., Women Alcoholic Services, n.d.

60. Lynne Dahl, interview by author, Acton, California, 14 September 1992; Kurt M. Freeman, interview by author, Acton, California, 18 September 1992.

61. Anonymous, Acton History.

62. Marie Milbum, interview by author, Acton, California, 17 September 1992.

63. Additional statistics showed that 88 percent of the men were Caucasian, 7 percent “of Mexican-American descent,” 4 percent were “negro,” and 1 percent were “oriental.” While the youngest man was 33 and the oldest 86, the majority of the men were between 50 and 70. Gillis, “Acton Camp,” 16.

64. Due to sketchy record-keeping, it is impossible to correlate age groups exactly.

65. Krudis et al., Program Description, 16–23; Department of Health Services, Public Health Programs and Services, Alcohol and Drug Program Administration, County of Los Angeles, Report of a Board Ordered Study of the Antelope Valley Rehabilitation Centers, 1988; “Monthly Resident Census Report, Antelope Valley Rehabilitation Centers,” November 1994, December 1994, January 1995, AVRCs files.

66. According to AVRCs's administrators, a future Pulitzer Prize winner checked into the program during the 1950s. Kurt Freeman and Dave Potter, interview by author, Ventura, California, 28 September 1992.

67. Lynne Dahl, telephone interview by author, 18 February 1995; Richard Rioux, current executive director, written comments on previous draft, n.d.

68. Acton's role in the Sober Transitional Housing and Employment Project (STHEP) was to provide a twenty-bed treatment program that built upon existing AVRCs's services by adding a series of employment workshops geared for the homeless participants of the program. Those workshops inventoried the participant's skills, helped them prepare résumés, and instructed them in interviewing skills. Department of Health Services Comprehensive Plan for Homeless Health Services, DHS Task Force on Health Services for the Homeless, April 1988, AVRCs files; NIAAA, Synopses of Community Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals (Rockville, Md., October 1988)Google Scholar.

69. Institute of Medicine, Prevention and Treatment, 142; Schlesinger and Dorwart, “Falling,” 195–96.

70. Lynne Dahl, telephone interview by author, 22 June 1995.

71. “Monthly Resident Census Report, Antelope Valley Rehabilitation Centers,” June 1994, July 1994, October 1994, November 1994, and December 1994.

72. Anglin and Hser, “Legal Coercion,” 162–63.

73. Lynne Dahl, interview by author, Acton, California, 14 September 1992; Gary Alexander, interview by author, Acton, California, 18 September 1992; Richard Rioux, interview by author, Stevenson Ranch, California, 30 October 1992; Richard Rioux, telephone interview by author, 23 May 1995.

74. In the early 1960s, there were approximately 75–80 employees with no formal rehabilitation staff. By the late 1960s, the AVRCs began to add treatment staff and employed 110–120 people. Hiring freezes in the 1970s were partially responsible for a dip in the number of employees and since then the staff has hovered at about 102—107. The resident population has remained steady at approximately 450 (the occupancy rate is about 95 percent) during the past few decades. Lynne Dahl, letter to author, 22 February 1995; “Monthly Resident Census Report, Antelope Valley Rehabilitation Centers,” January 1995.

75. Thirteen out of 25 rehabilitation staff members have remained at the AVRCs more than ten years.

76. Brad Allen, interview by author, Acton, California, 15 December 1992.

77. Lynne Dahl, interview by author, Acton, California, 21 October 1992.

78. Congress later passed legislation authorizing the permanent formation of SAODAP. Gerstein and Harwood, Treating Drug Problems, 1:54; Courtwright, “Century,” 30–31.

79. Besteman, “Federal Role,” 73.

80. Cameron, “National Program,” 134–40.

81. The National Institute of Drug Abuse was formed in 1972. Its original functions included the management of national treatment, training, and prevention programs as well as drug-abuse research. After the block grant began, research became NIDA's primary responsibility. Smith, Jean Paul, “Research, Public Policy, and Drug Abuse: Current Approaches and New Directions,” International Journal of the Addictions 25 (1990–91): 188.CrossRefGoogle ScholarPubMed

82. Besteman, “Federal Role,” 80.

83. Although there was much excitement at the state level when these changes first occurred, the vacuum caused by federal withdrawal soon became noticeable. This vacuum has not been filled, but the country has been moving toward a greater federal role once again. In 1984, strong state advocacy resulted in NIAAA and NIDA (National Institute of Drug Abuse) contracts and grants to provide the National Association of State Alcohol and Drug Abuse directors with some of the services lost by the 1981 block grant. Additionally, the 1988 Anti-Drug Abuse Act indicated a reconsideration of federal responsibility. Because of limited resources, however, the authorization to establish a national data system on drug treatment has been slow in implementation. Gerstein, Treating, 55; Besteman, “Federal Role,” 80–82.

84. Besteman, “Federal Role,” 79–80.

85. Bruce Picken, interview by author, Sylmar, California, 17 December 1992.

86. Baker and Picken, Licensing.

87. Boyle, Dan, “Acton Rehabilitation Center Called ‘Utopia,’ but County May Close It,” Los Angeles Times, 28 June 1987Google Scholar; Aidem, Patricia Farrell, “Treatment Facilities May Close,” Santa Clarita Daily News, 23 May 1989.Google Scholar

88. In 1987, immediate savings would have amounted to $367,000 per month. Richard B. Collins, Chief, Contracts and Grants Division, to “Alcohol Program Provider,” 16 December 1987, RRF: Contracting Out; AVRCs files.

89. Melvin J. Fleming, Deputy Director of Hospitals, to Kurt M. Freeman, Director, 1 September 1981, Cost Benefit Report File, AVRCs files.

90. Cost Effective Study: Antelope Valley Rehabilitation Centers' Programs, 30 September 1981; Antelope Valley Rehabilitation Centers Justification for Continuance of Services, n.d.

91. Department of Health Services, Board Ordered Study, ix; Hamilton, Walter, “A.V. Rehabilitation Center Runs Efficiently, Study Finds,” Santa Clarita Daily News, 16 July 1989Google Scholar; Lee, Linda, “AV Rehabilitation Centers Move to Broaden Services, Seek Case,” Antelope Valley Press, 6 October 1989.Google Scholar

92. The Department of Health Services administers both the Department of Hospitals and the Public Health Program. The Office of Alcohol and Drugs Program works under the Public Health Program. Richard Rioux to AVRC staff, “Transition to Hospitals,” 17 March 1993, AVRCs files.

93. Krudis et al., Program Description, 4.

94. Lynne Dahl, telephone interview by author, 11 December 1993.

95. Lynne Dahl, interview by author, Acton, California, 14 September 1992.

96. Antelope Valley Rehabilitation Centers, “Proposal for Community Development Commission Block Grant,” n.d., AVRCs files.

97. AH patients are required to participate twenty hours per week in Mandatory Work Assignment Programs, except those with pending legal industrial accident cases or medical restrictions that prevent them from working in the food service or housekeeping departments. Residents are required to work a minimum of two weeks in the Food Services Department before becoming eligible for work in another department. “Mandatory Work Program,” Effective Date: 1 August 1990, AVRC Policy and Procedure Manual, Policy/ Procedure No. I-A-166; AVRCs files.

98. At Acton, recreational therapy includes the options of golf, tennis, baseball, weight-lifting, exercise class, paddle tennis, and billiards. At Warm Springs, activities include weight-lifting, hiking, and paddle tennis.

99. Although the AVRCs's staff is not involved in Twelve-Step programs, the centers offer several Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous meetings each week. Narcotics Anonymous and Cocaine Anonymous are based on the Twelve-Step program developed by AA.

100. Occupational therapy consists of structured and semistructured group and individual activities that are designed to increase coordination and develop muscles. In 1975, for example, approximately 100 patients were referred and treated for various disabilities, mostly related to alcoholism or alcohol-related accidents. Krudis et al., Program Description, 39–40.

101. Suzanne Kassinger and Lynne Dahl, interview by author, Acton, California, 17 September 1992; Bruce Krudis, interview by author, Acton, California, 18 September 1992.

102. Social-skills training aids substance abusers in reducing their alcoholic consumption, while assertiveness training helps alcoholics improve their self-esteem and gain emotional freedom. Secretary of Health and Human Services, Seventh Special Report; Hirsch, Steven M. et al. , “Effectiveness of Assertiveness Training with Alcoholics,” Journal of Studies on Alcohol 39 (1978): 89CrossRefGoogle ScholarPubMed; David Potter, interview by author, Warm Springs, California, 15 September 1992.

103. Linda Bulman, interview by author, Acton, California, 7 July 1992.

104. Some ex-residents strenuously attest to the success of the program. A self-professed “dope fiend” and former drug dealer claims that the program “adds character” and will help him get a job. The most written-about success of the program, Oliver Young, could not write and could read only at second-grade level when he entered the AVRCs program, but three years later he was tutoring other students and had written a children's book about the dangers of substance abuse. “Jake,” interview by author, Acton, California, 16 September 1992; “Literacy Proves to Be Important Key to Overcoming Substance Abuse, Program Finds,” Community Foundation Forum, Fall 1992.

105. A summary based on the 4,180 residents who left the Acton Center between January 1989 and October 9, 1992, stated that those involved in the literacy program “had a completion rate of 70 percent, while those residents who were not involved with the [literacy program] had only a 46 percent rate of completion.” The problem with this information is that not only was there no control group or comparison to previous completion rates, but there is no consideration of the possibility that those residents motivated to join the literacy program may have been more motivated to complete the program even without the literacy component. Additionally, it is difficult to believe the AVRCs's claims in light of the only statistics made available—from November 1994 through January 1995—which show an overall completion rate of 47 percent. “L.I.P. Residents vs. Non-L.l.P. Residents Completion Rates,” January 1993; AVRCs files; “Monthly Resident Census Report, Antelope Valley Rehabilitation Centers,” November 1994, December 1994, and January 1995, AVRCs files.

106. Anglin and Hser, “Treatment,” 393, 432; Falco, Mathea, The Making of a Drug-Free America: Programs That Work (New York, 1992), 110Google Scholar; Edward Gottheil, Introduction, in Lettieri, Dan J. et al. , NIAAA Treatment Handbook Series 1: Summaries of Alcoholism Treatment Assessment Research (NIAAA: 1985): 1Google Scholar; Hubbard, Drug Abuse Treatment, 5.

107. Despite the assertions of numerous scholars claiming that treatment does work, the Institute of Medicine study concludes that little evidence is available for chemical dependency programs which—similar to the AVRCs's purported mission —use Twelve-Step groups. Additionally, since chemical dependency programs primarily treat alcoholism—again, similar to the AVRCs—they have not been evaluated carefully for the treatment of drug problems. Gerstein and Harwood, Treating Drug Abuse, 1:12, 16, 173; Hubbard, Drug Abuse, 5; Moos, Rudolf H. and Finney, John W., “The Expanding Scope of Alcoholism Treatment Evaluation,” American Psychologist (October 1983): 1036Google Scholar; Secretary of Health and Human Services, Sixth Special Report to the U.S. Congress on Alcohol and Health (Rockville, Md., January 1987)Google Scholar, DHHS Publication No. (ADM) 87–1519: 129; Gottheil, Introduction, 1; Anglin and Hser, “Treatment,” 396, 432.

108. According to Moos and Finney, many studies use the “black box paradigm,” which evaluates addicts before treatment and on followup(s) but ignores the process of treatment or other components that may influence the addict. These studies fail to examine the effect of specific treatment aspects or to consider external influences, thereby giving few clues about how to improve treatment. Moos and Finney, “Expanding Scope,” 7–8; Anglin, “Treatment,” 393–460; Kleber, Herbert D., “Treatment of Drug Dependence: What Works,” International Review of Psychiatry 1(1989): 81–100CrossRefGoogle Scholar; Mendelson, Jack H., “Inpatient Programs,” in Treatments of Psychiatric Disorders: A Task Force Report of the American Psychiatric Association, vol. 2 (Washington, D.C., 1989), 1140.Google Scholar

109. According to the Institute of Medicine study, some key questions that have yet to be answered are: What client and program factors influence addicts to seek treatment? What components incline them to remain in treatment? What influences treatment efficacy? What inclines clients to relapse? Furthermore, how can these factors be managed better? Gerstein and Harwood, Treating Drug Abuse, 1:19, 194; Anglin, “Treatment,” 430, 433.

110. This literature includes evaluations of major programs and modalities that were “conducted both as individual program assessments and as parts of large-scale multimodality studies. The latter include nationally oriented data bases such as the Drug Abuse Reporting Program (DARP) and the Treatment Outcome Prospective Study (TOPS).” DARP, conducted from 1969 to 1973, included information on 44,000 clients, while TOPS studied 11,750 clients from 1979 to 1981. Anglin and Hser, Treatment, 416.

111. Ibid., 432.

112. Secretary of Health and Human Services, Sixth Special Report; Mendelson, “Inpatient Programs,” 1140; Moos and Finney, “Expanding Scope,” 1036; Gottheil, Introduction, 1.

113. These providers offered a variety of “recovery service approaches.”

114. The investigation did not explain much about this type of residential treatment or reveal how it differs from other residential treatments facilities. Apparently this type of facility is smaller and has fewer staff members than the AVRCs and other residential centers. Additionally, these houses have no medical staff.

115. CALDATA looked at two subtypes of methadone programs: methadone outpatient and detoxification (which lasted a maximum of twenty-one days). Gerstein et al., Evaluating Recovery Services, 24–31.

116. CALDATA measured effectiveness by the prevalence of substance usage (whether a substance was used five or more times during the period assessed), peak density (the number of days in the month of greatest use), and percentage of months during which a substance was used during the evaluation period. If “reduced density of heroin use” is the goal, then this study claims that methadone maintenance is even more effective than residential treatment programs. This conclusion accords with other studies. See note 37. Gerstein et al., Evaluating Recovery Services, 1–3, 23–26.

117. Secretary of Health and Human Services, Seventh Report, 427.

118. De Leon, George, Editorial, “Alcohol: The Hidden Drug Among Substance Abusers,” British Journal of Addiction 84 (1989): 839.Google ScholarPubMed

119. Kleber, “Treatment of Drug Dependence,” 82.

120. The CALDATA, for example, claims that there are significant monetary benefits from substance abuse treatment. “In all, treatment providers in the State of California and within the scope of [the CALDATA] study saved taxpaying citizens $1,493 million during and following treatment, at a cost of $209 million.” Anglin and Hser, “Treatment,” 393; Falco, The Making, 110; Gottheil, Introduction, 1; Hubbard, Drug Abuse Treatment, 5; Moos and Finney, “Expanding Scope,” 1036; Secretary of Health and Human Services, Sixth Special, 129; Gerstein et al., Evaluating Recovery Services, 82.

121. Falco, The Making, 108.

122. Anglin and Hser, “Treatment,” 444.

123. Congress, House, Select Committee on Narcotics Abuse and Control, Drug Abuse Treatment Research: Hearings Before the Select Committee on Narcotics Abuse and Control, 101st Cong., 2dsess., 10 October 1990, 14, 31.

124. Success, as defined by Kurt Freeman, AVRCs's executive director from 1974 to January 1993, is when a resident remains sober and in the program for the entire ninety days. Freeman justifies this definition by comparing a substance abuser to a patient recovering from a heart attack. Once heart patients are treated and released from the hospital, they may be susceptible to further attacks, but the hospital already discharged its duty and is not considered liable for such a “relapse.” Kurt M. Freeman, interview by author, Acton, California, 14 September 1992.

125. The staff at the AVRCs understand that there is no magic cure and residents may need to attend several rehabilitation programs before they effectively eliminate substance abuse from their lives. Because of a large waiting list, residents cannot come back after two or three stays, even though staff members have seen substance abusers finally “get it” after twenty recovery programs. Lynne Dahl, interview by author, Acton, California, 15 September 1992.

126. Falco, The Making, 111.

127. Deitch, “Treatment of Drug Abuse,” 175.

128. Krudis et al., Program Description, 73–74; Anglin and Hser, “Treatment,” 416.

129. Gerstein and Harwood, Treating Drug Problems, 1:130–31.

130. Ibid., 8. CALDATA falls into the last category, measuring effectiveness in terms of the reduction of drug use, decreased health costs, and diminished criminal activities. Gerstein et al., Evaluating Recovery Services.

131. Congress, Causes and Consequences, 161; Secretary of Health and Human Services, Sixth Report, 133.

132. Krudis et al., Program Description, 73–74; Moos et al., Alcoholism Treatment, 226.

133. Krudis et al., Program Description, 53.

134. Warrick, Pamela and Spiegel, Claire, “Paying the Price to Stay Sober,” Los Angeles Times, 21 October 1992, Section I, A1Google Scholar; Spiegel, Claire and Warrick, Pamela, “Troubled Sanctuary,” Los Angeles Times, 22 October 1992Google Scholar, Section V, El; idem, “County Downplays Rehab Home Problem,” Los Angeles Times, 12 February 1993.

135. Statistical data relating to the resident's “drugs of choice” are unavailable. Rehabilitation staff members, however, report that residents in the 1970s used multiple drugs—including alcohol, LSD, and PCP. In the 1980s and 1990s, polydrug abuse has expanded to include cocaine, crack cocaine, and heroin.

136. Al-Impics International, Amending State Alcohol/Drug Rehabilitation Program Laws and Regulations to Provide Better Access to Service for Polydrug/Alcohol Abuser, 30 March 1993; AVRCs files.

137. The CALDATA study is an exception. It examined every “main drug”—crack, cocaine powder, heroin, amphetamines, and alcohol—and concluded that treatment helped reduce the use of each of these substances. Unanswered, though, are the questions of whether treatment should vary for different substances and which treatment is best for which substance or combination of substances abused. Anglin, “Treatment,” 402; Hubbard, Drug Abuse, 175; Gerstein et al., Evaluating Recovery Services, 23–31.

138. Smith, “Research, Public Policy and Drug Abuse,” 183, 184.

139. The AVRCs, for example, do not even subscribe to Alcohol Health World and News, the NIAAA's magazine targeted to substance abuse treatment centers, or to Prevention Pipeline, a bimonthly Center for Substance Abuse Prevention publication intended as a comprehensive informational guide to preventing alcohol and other drug problems. This lack of connection to the outside world is not the plight of the AVRCs alone. Moos and Finney report that program planners pay little attention to evaluations and that “journals reporting treatment research are little more than decorations.” Moos and Finney, Alcoholism Treatment, 4; Richard Rioux, telephone interview by author, 30 March 1993.

140. Congress, Drug Abuse Treatment, 11; Anglin and Hser, “Treatment,” 433; Gottheil, Introduction, 3; Schlesinger and Dorwart, “Falling Between the Cracks,” 200.

141. During the past two decades the AVRCs have been masters at garnering publicity. The Al-Impics receives enormous press coverage every year from local newspapers and occasionally from international papers, including publications in Mexico, France, and Scandinavia. The Hollywood-produced twenty-eight-minute film Breakthrough, based on an alcoholic's recovery and filmed at Warm Springs—which included staff members in the movie and behind the scenes—premiered at the Motion Picture Academy of Arts and Sciences. Small local newspapers constantly feature articles about the recovery centers. In addition to covering situations such as the financial woes of the AVRCs, local publications have included feature articles on everything from Thanksgiving dinners at Warm Springs to an Argentinian drug official's visit to Acton.

142. During a three-month period (November 1994 to January 1995), there were at least 312 “successes”—residents who finished the program. “Monthly Resident Census Report, Antelope Valley Rehabilitation Centers,” November 1994, December 1994, and January 1995, AVRCs files.