Dealing With Drugs: Family Based Treatment Options

MICHEL MARTIN, host:

I'm Michel Martin, and this is TELL ME MORE from NPR News.

Coming up, an actor whose career has spanned five-plus decades, we're talking about none other than Louis Gossett Junior. We'll talk to him about his body of work and his new memoir, "An Actor and a Gentleman." That conversation in just a few minutes.

But first, Dealing with Drugs. Over the next few days, TELL ME MORE will be taking an in-depth look at the Obama administration's new drug policy and some of the treatment options. The U.S. has been fighting the, quote, "war on drugs" since the Nixon administration.

And while the popular drug of choice has changed from LSD in the 1960s and '70s, to heroin and crack cocaine in the 1980s, crystal meth in the 1990s and prescription drugs in the later years, very few people, if any, believe that the so-called war on drugs is being won. With the 2010 National Drug Control Strategy, the Obama administration is endorsing prevention, treatment and law enforcement, hoping to cut the rate of youth drug use by 15 percent over the next five years.

With us today, we're joined by Imani Walker. She's the director of the Rebecca Project for Human Rights, where she works with treatment centers to help mothers recover from addiction to curb drug use in their communities and hopefully keep families intact. Centers like hers were touted in the administration's drug report for their effectiveness. Welcome, Imani. Thanks so much for joining us.

Ms. IMANI WALKER (Director, Rebecca Project for Human Rights): Thank you.

MARTIN: In a few minutes we'll also be joined by Scott Henggeler. He's a professor at the Medical University of South Carolina. And he studies drug abuse strategies and services for disadvantaged children and their families. We'll hear from him in just a few minutes.

But first, Imani Walker, we want to start with you. You've shared publicly your journey through drug treatment a few years ago. And I wanted to ask, what were some of the treatment options that were presented to you and which of those were successful and which weren't?

Ms. WALKER: Twelve years ago, I was a mom who was suffering from a drug addiction to crack cocaine and I sought treatment based upon the insurance I had at the time, which was Medicaid. So I was a low-income mom needing help. I had been in a marriage for 11 years that was physically abusive and I was self medicating to the underlying issues of violence and trauma. Those underlying issues of violence never were addressed in those programs. They were short term. They were 28 to 90 days in length. I was not able to stay clean.

It wasn't until I was pregnant with my fourth child that I was finally referred to a comprehensive family-based treatment program. It was 18 months to 24 months in length and the services were comprehensive for me and my child.

MARTIN: So you were able to bring your child, at least one child, with you.

Ms. WALKER: Absolutely. I was able to bring my infant child into the treatment program. And he was put into their early intervention program.

MARTIN: What do you think finally made the difference for you? I mean, you'd in part say that being, I would think being able to have your one of your children at least with you, is that really the relevant factor? You think, well, what was the difference between success in one program and lack of success in the other? What would you identify?

Ms. WALKER: I always talk about how in the single adult treatment model, I refer to it as drive-by treatment. It was very short. The length of stay is important. In these family center treatment models, they are usually at least six months long. And the research also bears out that the longer time a parent has in treatment, the better the outcomes. The comprehensive nature of the services, individual counseling, therapeutic services for the children, both the infant and my older school-age children.

MARTIN: Tell me a little bit about some of the other women you've worked with.

Ms. WALKER: Across the country, we have several chapters. I've had the fortune of meeting many moms across the country. And, you know, some of the things that are in common with the moms, of course, is that they're mostly low income. Most of these mothers are single mother-led households. They have several children. And most of them, very similar to me, try to access treatment and found that it was easier to have their children either taken away by the child welfare system or for them to land in jail.

So, most of the moms have, in fact, been in jail for nonviolent drug offenses. Some of them have the good fortune of finally accessing family treatment and being reunified with their children. But it's been a struggle.

MARTIN: Let's bring in Scott Henggeler. He's a professor of psychiatry and behavioral sciences at the Medical University of South Carolina. He's also the director of the university's family services research center and he happens to be in Bangor, Maine today, which is where we caught up with him. Welcome.

Dr. SCOTT HENGGELER (Psychiatry and Behavioral Sciences, Medical University of South Carolina): Well, thank you for the invitation.

MARTIN: Professor Henggeler, what your research has been on substance abuse services for families. What have you learned about this whole question of family treatment centers and their rates of success versus those that focus on treating adults as if they were single individuals?

Dr. HENGGELER: Well, I think Imani raises some very, very interesting and important points. And most of my work has focused on families and adolescents with substance abuse problems and the parents with substance abuse problems. And I think the point that the services need to be comprehensive and need to be family friendly is extremely important.

MARTIN: You've told us, though, I think prior to this conversation, that you have some skepticism in general about success rates that are reported by a number of programs. Do you have more skepticism about family-based treatment centers than others? Or are you just skeptical across the board?

Dr. HENGGELER: Well, I'm a basically a research scientist. My career has been 35 years of doing randomized clinical trials and NIH supported research. And so I'm generally skeptical of anyone claiming, you know, high success rates. But if you look at the research, if you look at the gold standard work, and I think the National Institute on Drug Abuse has a really nice website that kind of lays out what are the evidence-based practices.

And these are the interventions that repeated high-quality scientific studies have shown to reduce substance use in adults and in adolescence. You know, as well as improving other types of functioning in their lives. You know, really kind of understanding what the drives are of the substance abuse and then developing individualized interventions to focus on those drivers and, you know, to reward abstinence and to try to deal effectively with recurrences.

MARTIN: So, like her idea, for example, like, saying that the abuse issues that were a very large part of her using the fact that the initial treatments that she was in, that wasn't even discussed, you agree with that? That that has to be for particularly either gender.

Dr. HENGGELER: For the people that that pertains to, right, either gender. Now, not everybody has that, you know, as a main driver of the substance abuses. There are many different drivers. And so the whole point about having a comprehensive model is one that has the flexibility to attend to the idiosyncratic or the unique drivers of the problem for the individual person and the family context that they're in.

MARTIN: If you're just joining us, this is TELL ME MORE from NPR News. We're speaking with Imani Walker and Professor Scott Henggeler and we're talking about particularly how families deal with substance abuse and what treatment methods might work. One of the things I'm curious about is at the beginning of our conversation, I talked about how long the so-called war on drugs has been fought.

And even though the drug of choice has changed, the fact is that we have very high rates of incarceration in this country, one of the highest in the industrialized world. A very large number of the people are incarcerated on drug crimes and yet we still have drug-related violence and maybe you have a difference of opinion about whether we're making headway or not.

But I don't think very many people would say, you know, we're winning, you know, we're winning. We're ahead of the curve here. We've licked it. We're in sight. That kind of thing. And I'm wondering why you think this is. Imani, if I could ask you to start.

Ms. WALKER: Sure. Absolutely. I like to start out by saying I commend director Kerlikowske for supporting and uplifting the family treatment model as a success. Family treatment has been chronically underfunded. It's easier for a mom to go to jail than it is for her to access appropriate treatment. And 70 percent of the mothers behind bars are nonviolent substance abusers.

So when we are looking at evidence-based programs and we're looking at the success rate of treatment in general. And in 2001, the Center for Substance Abuse Treatment evaluated its pregnant and post-partum women in their infants program and found that 60 percent of the mothers remain alcohol and drug free.

And in 2000, they did additional cross site evaluation of 24 residential family-based treatment programs, and 60 percent of the mothers remained completely clean and sober six months after the discharge. So if we don't look at substance abuse as a public health issue and we look at it more towards the criminal justice end, we will continue to not be successful in the so-called war on drugs.

And, you know, I don't think that language, the war on drugs, is appropriate anyway. And the current administration also does not support that language anymore.

MARTIN: Okay. And Professor Henggeler, if we could get a final thought from you. What's your sense of do you feel that this country's achieving success? Are we not achieving success? And what do you think would make the most difference?

Dr. HENGGELER: I mean, I agree that the legal emphasis and the supply side emphasis just really has not borne much fruit. You know, and I'm clearly and it's a function of my, you know, training, what I've done my whole career, which is focusing on, you know, treatment of youths and families with very serious clinical problems.

I think there are multiple answers and I think the president's strategy has multiple prongs to it. But I think one of the key is really moving evidence-based prevention programs and evidence-based treatment programs out into the communities.

And I'm not a fan of residential treatment at all. But I think community-based programs that are comprehensive in nature, that are family focused, I think those types of models have proven to be effective and can make a real change on a case-by-case basis, and on a larger basis if implemented on a large scale.

MARTIN: Can I ask each of you, do you think that the administration's goal is achievable? Let me remind you of some of the targets set for the year 2015. The plan is to cut the number of chronic drug users by 15 percent, reduce drug-induced deaths by 15 percent, reduce the prevalence of drug driving by 10 percent. Imani, do you think that this is possible, based on what you know from the inside out?

Ms. WALKER: I do believe it's possible. I the research bears out that the family treatment model, in fact, reduces substance abuse. It's upwards to 60 percent successful in its rate of effectively treating parents who are substance abusing. So I do believe that that's possible.

I'd like to just go back to something that was said a minute ago about the drivers for substance abuse. The pathway to addiction for moms is pretty specific, upwards to 97 percent of mothers who are substance abusing have first experienced either physical or sexual violence. So when it comes to moms, there is a pretty particular pathway.

MARTIN: Professor Henggeler, do you want to address that? Do you agree?

Dr. HENGGELER: That path, no I don't agree. But I'd rather address the goals of the...

MARTIN: No, but I think, no, let's focus on that, though. Let's take them both. We have time to take those both on. You just don't agree that physical or sexual abuse is as well isn't a factor.

Dr. HENGGELER: No, I think it can be a relevant and a factor, but to say that is relevant for 97 percent of moms I think is a bit high.

MARTIN: Based on what?

Dr. HENGGELER: Based on my knowledge, although the epidemiological data and on the families that we've worked with. I don't want to discount it, and I think it's important in many cases, but I think it just is too high a number.

MARTIN: Professor Henngeler, one other point that I think I've heard Imani make before is that she feels that the role of physical and emotional abuse in women is often not even recognized. And it's certainly not recognized by law enforcement, which is the way a number of these issues even get addressed to begin with. Do you think that that's a fair statement?

Dr. HENGGELER: Oh, I think that's absolutely a fair statement. And I think in many, many, probably the vast majority of treatment programs, they're not recognized. But I think increasingly over the past couple decades that has changed.

MARTIN: Professor Henngeler, how about the goals that the Obama administration is setting forth? Do you think they're reasonable?

Dr. HENNGELER: I think they are extremely ambitious. And I think if you could say a 5 percent decrease, that would be a phenomenal change. But being ambitious, I think they can be achieved. But I think they can only be achieved through a very, very serious commitment to moving evidence-based prevention programs into communities, into schools, into community organizations and adopting more evidence-based treatments in the substance abuse field.

MARTIN: This whole question of whether people should get treatment in some kind of residential setting or whether they should stay in the community seems to be one that is something to be debated. And I wanted to ask if each of you has an opinion about that. On the one hand, residential treatment is something that has long been available to people of means. And some people might argue that that's something that should be available to more people.

But other people say, well, that doesn't make any sense. The community is where people have to live, so that's where they should get their treatment. I'd like to ask if each of you has an opinion about that. Imani, do you want to start?

Ms. WALKER: Sure. My treatment stay was actually outpatient treatment. I was in one of the few long-term outpatient family treatment programs. Most are residential because when it comes to ensuring child stability and child safety, it's really important from a child welfare point of view to have the children within the context of a family treatment center.

I'm familiar that there are programs that have been developed that actually go and work with the moms inside of their home. But substance abuse is an issue that, you know, is criminalized. That the children are very likely to be taken away from you. So it's important that for the child welfare point of view that you have a family treatment program. That's a safe place for the child and the mom to go.

MARTIN: Now, professor, what do you think about that?

Dr. HENGGELER: Oh, I agree totally. But I think that can be made to be the home versus a residential facility. And it requires intensive services. I tell you what I don't like about aside from the fact that the randomized clinical trials have not supported residential treatment over community-based treatment, they are extremely expensive. And so what they do is I think they take monies away from the effective community-based programs.

And the types of changes they make are often just not linked with the real world, real life circumstances that people are in. And so our clear preference is to make those changes where the problems occur that change the home context and the neighborhood context and the friendship network, where things occur, where the therapist can work intensely with the mom, can help guarantee the safety and safety of the kids.

So I just think for the sustainability of change, if you make the changes where the problems are occurring, you have a much higher likelihood of sustaining the change. You still can have lots of failures, but I think you just increase the probability, it's lower cost, and I think the evidence base is much stronger for community-based work.

MARTIN: Scott Henggeler is a professor of psychiatry and behavioral sciences at the Medical University of South Carolina. He's also the director of the university's family services research center. He joined us from our member station in Bangor, Maine.

Imani Walker is the director of the Rebecca Project for Human Rights. She joined us in our studios in Washington, D.C. Thank you both so much for speaking with us.

Dr. HENGGELER: Thank you very much.

Ms. WALKER: Thank you.

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