Mr. PITTMAN. There is no reason they should not if they have the desire, motivation, and willingness to do it.

Mr. ROGERS. What do you estimate the population of the alcoholics in the area served by this center to be?

Mr. PITTMAN. In the city, we carry an estimate of approximately 50,000 alcoholics, of which approximately 5,000 to 6,000 would fall into this area. Most alcoholics are not police cases.

Mr. ROGERS. Can someone come in for voluntary treatment?

Mr. PITTMAN. Not to this facility, but we have the community mental health center unit, and they are referred to them.

Mr. ROGERS. Are the 30 beds sufficient to serve the population? Mr. PITTMAN. No, sir. We have had great financial problems in the sense of slowly but surely increasing from 24 to 30 beds, and we feel that approximately 36 to 40 beds will cover it.

Mr. ROGERS. That would be about correct for this service for this 5,000 or 6,000 patients that you feel are chronic?

Mr. PITTMAN. Yes.

Mr. ROGERS. What would that ultimate cost be?

Mr. PITTMAN. Approximately $400,000 is the estimate.

Mr. ROGERS. What is the overall population of St. Louis?

Mr. PITTMAN. 700,000 in St. Louis City.

Mr. ROGERS. If you would let us have a complete breakdown, it would be helpful to the committee.

Mr. PITTMAN. I will be glad to do that.

(The following document was received by the committee:)

PRELIMINARY EVALUATION REPORT OF "THE ST. LOUIS DETOXIFICATION DIAGNOSTIC AND EVALUATION CENTER"

INTRODUCTION

The St. Louis Detoxification Center has been in operation since November 18, 1966 under funds provided by Grant No. 93 from the Office of Law Enforcement Assistance Act. the following is a preliminary evaluation of some of the results achieved in the initial period of this operation. The underlying philosophy of the Center is a humanitarian theme which acknowledges that the alcoholic offender is a sick individual who involuntarily displays the symptoms of his disease. It has long been recognized that the "revolving door" process of arrest, incarceration, release, and rearrest has no rehabilitative effect upon the individual. Rather than achieving rehabilitation, this process caused further harm and suffering to those individuals whom we might term the chronic police case inebriate.

The Detoxification Center is a major forward-looking step in eliminating the "revolving door" process. It effectively removes these individuals from the criminal process and places them in the context of a medical, social and psychological treatment milieu. The results reported below, although preliminary, demonstrate explicitly that the Center has been successful in both goals. In addition to these long range goals, there exists a knowledge that criminally processing these individuals is a time consuming procedure which creates a heavy burden not only on law enforcement, but upon the courts and correctional systems as well.

In terms of both the grant stipulations and the continued impact of the sociolegal reform movement in this area, a comprehensive evaluation of the Center is being carried out. The evaluation can be dichotomized into the following categories. The macro-social category deals with the impact of the Center's operation on those agencies and institutions traditionally endowed with the responsibility for dealing with this social problem. This section will consist of a simple cost accounting procedure to weigh the costs of the treatment program against the costs of the continuance of the old criminal process system. Tangible gains would be in the form of patrol time saved, reduced clerical operations, adminis

trative efficiency and the reduction of supplies and other resources consumed in support of the criminal processing of these individuals. These savings on the part of the affected agencies and institutions, rather than reflecting budgetary excesses are in fact merely "paper economies" which show what proportion of their present resources may be reallocated to the other pressing problems in our society.

This report leaves aside the first category of the evaluation and focuses on the infra-social level of analysis. The clinical evaluation of the patient population for both before and after treatment gives the positive side of what can and has been accomplished by treating the revolving door chronic inebriate. As a demonstration project, the Center has been a pioneering effort, particularly in terms of its sponsorship under the St. Louis Metropolitan Police Department. It is not, however, a demonstration in the sense that it is an untried or untested idea. This would be tantamount to saying that we need proof that treatment measures are better than current punitive procedures under the criminal justice system. There can be no argument that rehabilitation is better than simply punitive incarceration. It is rather the job of this evaluation to show how much better and in what ways our resources can be better utilized in dealing with the chronic police case inebriate.

THE CENTER IN OPERATION

The first question which must be answered is simply, "Who are these people whom we are treating?" Since the Center opened, until July 1, 1967 there has been a total of 548 admissions. A profile of this group demonstrates that we are indeed treating the chronic police case inebriate. Some of the indices which clearly point this out are the demographic characteristics of race, sex, age, marital status, educational level, income, etc. By comparison, the similarity between the patient population and the drunkenness offender for the year of 1966 shows high congruence. If we limit ourselves to those individuals who were arrested three or more times during the year 1966, the parallels are obvious.

A breakdown of the marital status of the treatment group lends further support to the idea that we are reaching the target population for whom the Center was designed.

A further analysis of the treatment group yields the statistic that per admission these individuals had an average of 1.6 arrests during the year 1966. Many individuals have extensive police records, some of whom had in excess of 100 arrests for public intoxication previous to treatment.

These personal characteristics are highly consistent with the findings of other studies of the skid row alcoholic or the chronic police case inebriate. The patients averaged less than an eighth grade education. Approximately 47 percent of those admitted had an eighth grade education, or less. Only 29 percent entered but did not finish high school, while only 24 percent have an education of high school or beyond. Less than 1 percent completed college. The average weekly income of the patients at the time of admission was $48.75. Fully 34 percent were not gainfully employed at the time of admission. Some of these, however, are receiving income through old age pensions, disability payments, and very few are on relief rolls.

Not only can it be demonstrated that the Detoxification Center is dealing with the revolving door inebriate, but is also effectively eliminating the revolving door process in St. Louis. The Center is drawing from three out of a total of nine police districts. It serves those districts which accounted for 82 percent

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of all public drunkenness charges registered in 1966. Below is a table which shows the arrests for the time the Center has been in operation and the comparable period of the previous year.

These figures represent the total drunkenness offenses for the entire City. The foregoing data leave no doubt that the Center is indeed treating the chronic police case inebriate, for whom it was intended.

EVALUATION OF TREATMENT PROGRAM

Before proceeding with the patient analysis, an over-view of the referral network and after-care program is presented. Of the 548 patients admitted as of July 1 of this year, approximately 7 percent are leaving before the end of the seven-day treatment. This is a very low percentage considering that the treatment program is administered on a purely voluntary basis. Another 8 percent of the patients were transferred to various state and city institutions to continue their physical and mental rehabilitaion. Many in this latter group without the treatment and diagnostic services of the Center would have suffered serious consequences, possibly even death due to other complicating diseases.

The following dispositions can be reported for those who went directly back into the community after treatment. Approximately 43 percent were found not to need assistance in employment. Seventeen percent were offered and accepted referrals for employment. This then is 60 percent of the patient population who upon their return to the community had a productive self-supporting role to fulfill. Fully one-third or 33 percent were offered employment assistance but refused our help in this area. Many of these people stated they preferred to "make it on their own." Another 7 percent were not offered employment assistance. For the most part, this latter group was composed of retired and/or disabled persons who received some form of support or were adjudged to be unemployable.

In the area of housing it was found that 43 percent had a relatively stable residential setting to return to, another 23 percent were offered and accepted referrals for living accommodations. This means that approximately 66 percent of those returning to the community had adequate housing awaiting them. As in the case with employment, 33 percent refused referrals for housing. These were, in the main, individuals who preferred to return to the more familiar, though inadequate, accommodations they had in the skid row environment. Less than 1 percent left the Center without the benefit of the offer of adequate housing arrangements.

It was anticipated that since we admittedly are dealing with a chronic disease, a certain percentage of the patients would return for treatment more than once. In the more than eight months of operation since the Center has opened, the readmission rate is presently 28 percent. Seventy-six percent of the treatment group have been admitted only once. Another 14 percent have two admissions, while only 10 percent have been admitted more than twice since the Center opened. Although no complete statistics have been compiled to date, there do seem to be significantly fewer police contacts with the treatment group after treatment as compared to the arrest rate prior to the opening of the Center. Once one accepts the chronicity of this disease and is aware of the fact that on the average our treatment group has been unsuccessfully coping with their alcoholic problem in excess of 14 years, this readmission rate seems low, particularly in comparison with the revolving door process prevalent in some other major cities. The above results indicate the opportunities provided by the Center's treatment program and referral network.

For the most part these individuals are the chronic police case inebriates who have become "institutionalized." Their life cycle exhibits not only a dependency on alcohol but also dependency on the various agencies and institutions of our society which contribute to the maintenance of their bare existence.

PRELIMINARY CLINICAL EVALUATION

Among those subjects being treated at the Center, a detailed clinical evaluation is being conducted on a sample to determine the rehabilitative gains from this therapeutic setting. The evaluation consists of a series of before-treatment characteristics on which each individual studied is rated. Follow-up interviews are conducted after a minimum period of 90 days from the patients' first discharge. Three areas are rated by the use of scales which have been developed specifically for this treatment population. The scaled items are residential accommodations, employment and drinking patterns. The scales used are not presented in full in this report; however, a complete description of all instruments will be given in the final evaluation.

At present the evaluation is past the mid point. One hundred patients have been located and follow-up interviews conducted. As the study is not yet complete, the findings in this preliminary report are tentative; however, these trends seem to be a good approximation of the final results.

The data used for the before treatment measure are drawn from the patients' admission forms, medical records, social histories (conducted by a social worker at the Center), and the records of the St. Louis Police Department. The simple before and after design was deemed most appropriate in that each patient would set his own standard in assessing any change. This retrospective-prospective model to a great extent avoids the necessity of establishing success standards. This rationale rests on two assumptions, first, that alcoholism is a progressive disease. Deterioration in the individual is markedly uniform in the alcoholic's life, this is particularly true for the chronic police case inebriate). Second, without some therapeutic intervention into the disease progression, the prognosis is hopeless. Success then in this study rests on the ability of the measures to demonstrate either the arresting of the disease progress or improvement where found. The decision was made to focus on the qualitative changes after treatment. It was feasible to set up categories within some of these scales so that a continuum appeared imparting the qualities or ordinal ranking between classi fications. This is made possible due to the above assumptions that in the advanced stages of alcoholism, there is a pronounced downward movement in the socioeconomic ranking and, the clustering of certain variables (which are actually indices of socio-economic standing) is uniform enough to allow the generalizations implicit in the classification scheme.

In dealing with the scale items, the lower the ranking the lower the socioeconomic standing of the individual. For one to move into higher categories on any of these scales would represent a significant positive change in his life style since receiving treatment.

RESIDENTIAL ACCOMMODATIONS

The high mobility of this problem group has been characterized in a number of ways by the experts in the field of alcoholism. The homeless man stereotype illustrates the migratory patterns and social isolation of this group. This would seem to be of a piece with other personality and social characteristics of the indigent alcoholic all of which points to his inability to assume responsibility and/or function in a stable capacity. This scale deals with two correlated variables: first, the frequency with which the subject finds shelter and, secondly, the type of shelter or lodging to which the individual typically has access.

Of the first 100 patients evaluated, approximately 14 percent evidenced some significant improvement in their living arrangements. Eighty-three percent remained at about the same level of housing after treatment, while only 3 percent showed a decline in the frequency of shelter or the quality of their living arrangements.

Below is a table which gives a breakdown number of individuals assigned to each category before and after treatment. On this scale a rating of four or lower would place the individual in an undesirable and/or unstable residential setting.

In the before rating of these individuals, 39 percent had what would have to be considered inadequate housing arrangements. In the after treatment rating, 32 percent were still in the categories which would have to be considered inadequate. The average rating before treatment is 4.8 while on the after measure the average is 5.0. This is not an impressive change. A rating of four could be characterized as an individual who is a regular inhabitant of the missions, shelters and transient lodgings in or surrounding the skid area. This individual will average six days a week in some type of shelter and finds himself sleeping in streets and alleys of the city less than once a week. Category five is characterized as a structured environment such as a half-way house, accommodations with friends, relatives or some form of semi-permanent address with some food arrangements within the housing situation. The after treatment ratings (categories five through seven) indicate that 68 percent were at the time of the follow-up interview, living in a more or less stable structured or home-like environment. By far, then, the majority of patients after treatment had adequate residential accommodations.

EMPLOYMENT

Even with the progression of alcoholism, many of these individuals are still capable for some varying lengths of time to maintain their present job skills, if any, and to continue at a steady job. Progressively, as the individuals move lower and lower on the scale into the skid row environment, many other factors such as declining health, emotional instability, as well as such subtle factors as one's personal appearance, all enter to negate the possibility of steady employment. The employment scale takes into consideration both the type and frequency of employment.

At the time of intake, 34 percent were totally unemployed; that is to say for a period of three months prior to admission these individuals had not been gainfully employed. A rating of four or below would have to be considered underemployment. Categories five through seven may, depending on the individual's needs, i.e., dependents, housing, etc., be adequate for some of these individuals. The average rating for the first 100 cases evaluated was 3.8. This rating in terms of our scales must be considered inadequate by any criteria. The after-treatment ratings average 4.4. Although this is a statistically significant change, it would still have to be considered inadequate employment. Twenty-five percent of those followed-up had shown some significant improvement in their work patterns. This means that they were either working with more frequency or had achieved some stability in an occupational role. Sixty-six percent evidenced no significant change either positively or negatively. The interpretation of this figure must be tempered by the fact that some of these individuals already had adequate employment. We were unable to rate four of the individuals (or 4 percent) studied due to their being institutionalized for the majority of the time since their release. Only 5 percent according to our scales showed a decline in their employment.

1 Excluded are 10 retired patients and 6 individuals receiving disability compensation. 2 4 patients at followup were institutionalized.

This table shows 38 percent of the study group having "regular" employment as evidenced by a rating of five or higher at the time of admission. Forty-three percent had achieved this level by the time of the follow-up interview. This latter figure of 43 percent is not indicative of the complete employment picture. Ten percent of the study group were retired and 6 percent received disability benefits, hence, a total of approximately 59 percent could be reported as selfsufficient to an appreciable degree three months after receiving treatment.

INCOME

Since the modal occupation of the treatment population is casual day labor, income was best estimated on a per weekly basis. The gross average weekly income of the study group was $48.75 at the time of admission. This figure