a generally secluded existence so that the first impact of her hospitalization was shocking indeed. In discussing the hospital Mrs. O. first stated that doctors had been "very good" to her in withdrawing her; though she added immediately that she had almost suffered a nervous breakdown. She was "abashed" by her experiences with other patients, was concerned about some homosexual activity she observed, and remained extremely fearful of the other patients throughout her hospital stay: "Their lingo stymied her and their bold advances frightened her." She disliked the attitudes of hospital personnel at times. Followng this, she lashed out at her local doctor again, stating that she never wished to see him "or any other doctor, for that matter." If she were ever ill in a hospital, she wouldn't "want a nurse with a hypo to come within 50 feet of me." In discussion, Mrs. O. revealed that her negative attitude toward medical personnel had been further conditioned by her having lost four children through miscarriage "from nervousness.". It should be helpful now to examine more closely how our 12 patients reacted to hospitalization. Though the recorded information is rather sparse, we do find sufficient clues to their varying behavior, in keeping with the general profiles as outlined: Mr. A. had been committed for selling and using heroin. The history describes a "marginal hospital adjustment and fair work record." Though three adverse behavior reports are listed, the nature of his infractions is not detailed. In general, Mr. A. resented hospitalization as “a kind of jail" and complained about the food and lack of recreational facilities, though admitting that he had been helped in being withdrawn from drugs. He was able to relate somewhat to the hospital social worker, who described him as stating in interviews “that he had never done anything right, that he is incapable of doing anything well, is probably not very bright, and that he is incapable of being loved while having an insatiable need for affection." No fuller discussion of his problems was possible in view of extreme disturbance and his involvement with self. Mr. B. entered the hospital relieved to have been let off so easily after seeing 1 friend killed and 2 others jailed. During hospitalization he participated in the juvenile research project and was seen in individual and group therapy for a short time. He insisted that he had "always wanted to get off drugs," was glad he had come to the hospital, and was sure he could now remain off. He discussed plans to complete his education and training which savored of fantasy; and evidenced mixed feelings about enlisting his mother's and grandmother's help in support of his plans. His work adjustment was listed as "fair"; one adverse behavior report is recorded, nature unspecified. Mr. C. was rebellious and hostile during his first stay at the hospital, but seemed to be responding much more positively the second time. He participated in both individual and group therapy sessions and professed to have a better intellectual understanding of the emotional problems in his addiction; he expressed a desire to stop hurting his mother since "you can be a bastard just so long," and showed some awareness that this treatment was only a "beginning" and should be continued on the outside. Mr. D. saw in hospitalization an opportunity to satisfy his dependency needs and used his woes as a means of soliciting attention. His stay was beset with disturbances. He became emotionally upset during withdrawal, suspected the doctors and felt they were ridiculing and persecuting him. He feared the hospital bars, wondering "what he had done wrong" to be here. He was unable to shoulder even limited responsibility, claimed too much was expected of him, said he was being rejected, cried, and resorted to threats in order to win the attention he needed, which, when granted, was never commensurate with his expectations. Mr. E. was happy in this one-sex environment, in which he saw a chance to satisfy his homosexual strivings, and stated this was the first time he had participated in group activities and felt part of the group. He was sent to another part of the hospital when discovered to be engaging in homosexual activity. He enjoyed his work as a male nurse, but evidenced some anxiety regarding his postdischarge adjustment since he was on leave of absence from a city hospital and was apprehensive that he would not be rehired. Mr. F. felt demeaned by his close association with addict patients and felt he had "gone down" in the hospital. He was apparently unable to tolerate any closer associations and experienced a period of excitement described as "homosexual panic" after several interviews with a female social worker. He had been committed for violation of probation because of his use of drugs and was not fearful of another breakdown if he attempted to avoid using drugs. He was suspicious of the doctors and expressed paranoid and delusional ideas about them.. Mr. G. This was the fifth admission for Mr. G. He had been frightened by his. workhouse sentence and was now caught up in mixed feelings, on the one hand determining to break himself of his habit to avoid further involvements with the police, while simultaneously doubting that he could stop now after a lifetime of use. He made a good hospital adjustment, participating in research and expressing resentment toward other patients who deprecated the hospital's work. Mr. H. was helped with his physical ailments and was happy to be brought back to par. His stomach pains disappeared, and he claimed he was now free of his "main" reason for using drugs. During his last hospitalization he had come to think increasingly of the hospital as a kind of sanctuary from the problems of life and the difficulties occasioned by a habit. Mr. I. maintained a bland, suave manner and managed to be "in the know" about any matters which might pertain to him. Though cooperative, he managed to keep his real feelings to himself and preserved a "correct attitude" toward the hospital administration. Mr. I. indirectly showed that he had no intention of remaining off drugs and evidenced little anxiety in regard to the postdischarge period, though he was scheduled to be picked up on old charges after leaving the hospital. Miss K. had managed to pick up a good deal of the psychiatric jargon as a result of her participation in group therapy and had some awareness that drugs constituted an emotional problem, though she showed no ability to use this knowledge to change. She admitted that she had come to the hospital because she was frightened by the "lumps" impure drugs had raised, but planned to avoid such difficulties in the future by obtaining her supplies from a doctor. Mrs. L. This was the first admission, voluntary, for Mrs. L. The history records a "satisfactory" institutional adjustment, "good" work adjustment, and one adverse behavior report, unspecified. Though she expressed her gratitude for the hospital's having withdrawn her from drugs, Mrs. L nevertheless wrote to her mother, congratulating herself on her success in evading treatment. She assumed an extremely dependent attitude in relation to her mother, expecting her to make full arrangements for employment, etc., in her absence. Mrs. M was hospitalized voluntarily for the first time. The history lists a "satisfactory" institutional adjustment and one adverse behavior report, unspecified. It was Mrs. M's feeling that hospitalization was not "so bad"; but she admitted she saw the institution "as a kind of jail" and wished to break herself of her habit since she did not want to spend the rest of her life in places "like this." She continued to show some ambivalence about drugs, however, stating that they did relieve her tensions, and she was tempted to continue though resentful of her dependency on them. 2. Treatment opportunities during hospitalization Patients, for the most part, seem to have little understanding of their emotional conflicts, and are hesitant about confronting them in any case. One of the advantages of hospitalization lies in the unique opportunity it affords for reaching individuals never approached before, away from the pressures of their regular environment. Patients may then gain at least a beginning awareness of their personal difficulties through individual and group therapy, and through various group activities, and their isolation, and learn to identify with others on the basis of common problems and strivings. The means may be provided for building a great tolerance for the ordinary frustrations of living and for channelizing energies along more constructive lines. Since treatment is ordinarily an extended process, it cannot be hoped that very ambitious goals can be realized in the 135 days customarily spent at the hospital. It should be possible for patients to obtain a beginning understanding of their interpersonal difficulties, however, and to pave the way for continued treatment following discharge. This discussion points up the need for research into possible modifications in existing treatment techniques-possibly along the brief psychotherapy lines suggested by the Chicago Psychoanalytic Institute-so that we may learn how best to approach this group. It is a fact that a large section of the hospital population has steadfastly refused to permit itself to be involved in any of the available treatment resources. A corollary of any effective planning is the conception of the hospital fundamentally as a treatment center, with due provision: for the careful screening out of those chronic patients who have no desire to change and wish to use the hospital only as a convenient stopping-off place in times of stress. 3. Social rehabilitation As in the case of psychological help, hospitalization offers a rare opportunity for advancing the social reorientation of patients. While addicts may have initial difficulties in relating to other individuals, their antisocial attitudes are reinforced by periodic removal from the community by imprisonment and hospitalization, so that they become even less fitted than before to cope with people and the ordinary problems of living. In such settings, patients sometimes identify treating persons with the authoritarian environment, which may block treatment unless the doctors somehow show that they are identified with, and related to, the problems of the patients. Youthful offenders frequently resent the bars and guards of the hospital, the lack of adequate segregation, and their treatment as second-rate citizens by hospital personnel who sometimes fail to distinguish between different categories of patients. Any hopefulness the firsttimer may have can be shattered by the fatalism of the hardened addicts; he may, contrariwise, be encouraged to emulate the glamorous adventures of the older patients. Our recent literature has stressed the positive influence all hospital personnel, from doctors to attendants, can exert in countering such attitudes and in creating the permissive environment so necessary for progress. How best to achieve this, in face of the need for effective precautionary measures to prevent smuggling of drugs, remains a ticklish question. Apart from therapy itself and the opportunities afforded for constructive socialization, hospitalization provides additional possibilities for recreational activities involving teamwork and cooperation, arts and crafts, to stimulate further interests and ego-building achievements, schooling to advance the educational level of patients, and vocational training to develop new skills— a point especially important in the case of younger patients who have spotty work records and little or no training. In this reorientation process, the hospital cannot isolate itself from the community but must gear its planning toward the eventual return of the patient to his old environment. It is apparent that the best work of the hospital may be negated by failure to anticipate the postdischarge problems of the patient and to offer facilities for continued help with them. Contact with the patient by doctor and social worker might very well start at the very beginning of hospitalization with some interpretation of the purposes of hospitalization and efforts to establish a working relationship as a means of eliciting his confidence and helping him with his problems. By discussion with the patient and, if necessary, by communication with families and agencies in a position to be of assistance, social workers can do a great deal to instill feelings of direction and hopefulness and to ease the difficulties of adjustment during the crucial first weeks following discharge. A logical sequence of this discussion is the necessity for careful followup activities on the part of an agency related to the hospital-the indispensable "step 4" of any effective hospital program. Such a followup agency familiar with the special problems of addicts and in close communication with the hospital social-service staff would be in a strategic position to pick up on predischarge planning and offer the patient complete support in effecting a satisfactory adjustment in his community. It is disturbing to think how few facilities exist for helping addicts as a group. Most agencies have been reluctant to become involved because they think of addicts as an unrewarding group to treat and because they are fearful of being placed in a position where it may be said they are supporting addiction. Some agencies that tried in all good faith retreated after negative experiences. The work of numerous followup agencies, nevertheless, confirms how basic these services are in helping patients adjust adequately. Albert Deutsch has described the lack of followup resources as a major reason for the high relapse rate of discharged addicts." POSTDISCHARGE PROBLEMS OF ADDICTS Every dischargee has some problem confronting him after he leaves the hospital. Even if there were no financial, vocational, medical, marital, or familial problems, there would still be personal difficulties and probems of transition to the old environment after an absence of months. Added to this, each dischargee 15 Albert Deutsch, What Can We Do About the Drug Menace? (Public Affairs Pamphlet No. 186). must face the question of whether he can avoid a relapse-if he has not already decided to return to drugs. Mr. A returned to find a bleak home, abandoned by the mother and occupied only by a depressed and unemployed father. A brother was serving time in the workhouse for addiction. Mr. A had been disappointed in his hope of being reconciled with his wife, and was under considerable pressure by his probation officer to find immediate employment. This proved difficult in the face of his feelings of depression and apathy. Mr. A did not see how he could function without using drugs, yet he was fearful of violating probation and again becoming involved with the police. Though he was in need of help, his usual difficulties in relating to people made it hard to accept any approaches on the part of interested agencies. Mr. B came home to face almost total rejection by his mother and grandmother, who were leery of again becoming entangled in his addiction. Though he had been referred to a social agency by the hospital social service, he was ambivalent about accepting help and approached the social workers with a good deal of suspiciousness. Mr. B found himself unable to remain on the job he had found and could not follow through in his planning with the agency. He thought of desperate maneuvers to remove himself from the community, especially as he found himself taking more and more shots to find release from tension. Mr. C was soon involved in friction with his parents, and became discouraged when appointments with social agencies, arranged by the hospital social service, were not immediately forthcoming. He became too apathetic to carry out his hospital resolutions and readily fell into his earlier pattern of punishing his parents by relapsing to drugs. The parents despaired and required a good deal of support and interpretation as to how to proceed in relation to their son. Mr. D. assumed an attitude of complete helplessness and requested help of anyone available. He was under a good deal of pressure during the first 2 weeks; for the department of welfare was slow in granting assistance and his sister-inlaw refused to have him in her home, especially since she suspected that he had again begun to use drugs. Mr. D. was deeply hurt by his sister-in-law's rejection of his demands for attention and expressed suicidal thoughts. Mr. E. was confused as to his employment plans and not at all certain that the city hospital would rehire him after his absence of months. He had naively assumed that his aunt and uncle would support him until he could find employment but was disappointed in this expectation and responded with strong words. Further difficulties ensued when his relatives became aware of his homosexual activities and began to resent his cavalier attitude toward repaying his old debts. Mr. F. was confused, disoriented, and depressed following his discharge and was unable to return to his old employment because of paranoid ideas to the effect that hospital doctors had been in communication with his boss. Since he was responsible for the support of his mother, he had to borrow money from relatives to maintain the home and to pay for the treatment he resumed. He was suspicious of all offers of help and felt he must stand on his own feet, even though clearly unable to do so. Mr. F.'s mother did not understand his condition and agitated him further by pressing him to return to work. Mr. G. was depressed by the sudden death of his father and seemed to be having difficuties with his invalided wife. Though his old job was waiting, he feared remaining in the same environment and was anxious to find work in another neighborhood. The remembrance of his earlier imprisonment was still vivid, yet he could not see how he could manage without drugs after a lifetime of use. Mr. H. found that his last remaining friend had died in his absence. Though without funds, he had a very difficult time being accepted for relief by the department of welfare, which attempted to refer him to the municipal lodging house. Though finally set up in a furnished room, Mr. H. continued to be troubled by his chest condition, stomach, and pancreas pains. After relapsing into his addiction, he feared the effects of drugs, especially as he had to resort to any mixture he could find; and worried about breaking down or ending up on Skid Row. He felt quite lonely and thought of the hospital as a kind of sanctuary. Mr. I apparently developed a swelling of the limbs on his way home and was hospitalized. Little information is available about him. Miss K was unemployed and needed funds to maintain her habit. She was early picked up on charges of prostitution and given a suspended sentence and warning. Miss K worried about jail as before and feared the "impure" drugs on the street. She managed by relying on her mother and her separated spouse. Mrs. L permitted her mother to arrange an extended stay with relatives in Canada for her. As in the hospital, she saw no need for psychiatric treatment, though this had been suggested. No further thought was devoted to her husband, who had become an incident of the past. Mrs. M relapsed to drugs after being at home only 1 month. Though she found employment, she was discharged after 1 week and saw no means of supporting a habit she deplored. There was a great deal of friction with her mother, who resented caring for Mrs. M and ordered her out of the home if she could not pay her rent. She was depressed and despairing and looked forward to returning to the hospital as a means of escaping from her predicament. Along with the numerous immediate problems described here, dischargees are frequently under strong pressure from various sources to prove themselves. In the face of universal suspicion as to their intentions and ability to remain off drugs, their own uncertainty is augmented considerably. Where they are determined to remain "clean," they find themselves in no man's land since they can no longer mingle freely with their user-friends and may be rejected by their original companions. They are thus subjected to a combination of pressures which test their frustration tolerance unbearably in the first weeks following their discharge and foster the temptation to fall back on familiar patterns of resolving tension. As we saw in these cases, they are frequently suspicious of outside agencies and fearful of revealing any information about themselves. Many are closely supervised by probation officers and even more so by their families, who do not understand what was involved in their addiction and hospitalization and are now fearful of a repetition of earlier events, including the pawning of family possessions, stealing, etc. Most discharges are unfamiliar with the resources of the city in relation to obtaining help with specific problems even if they should desire it. Agencies may cut off their tenuous approaches and reinforce whatever feelings of discouragement and hopelessness they have by adopting a standoffish attitude. The Riverside Hospital in New York and the Chicago clinics mentioned previously seem to represent the first local concerted attempts to meet their problems effectively. VARIOUS GROUPS HAVE SPECIAL PROBLEMS 1. Adult discharges without family or financial resources As we saw in the case of Mr. J., the problems of this group may be more acute than those of other dischargees since they are frequently isolated from "normal" individuals and can expect little emotional or financial support. A number of men in the older age level have additional medical problems and increasing difficulty in tolerating the effects of the drugs they use and in keeping up with their sources of supply. Where their main hope for subsistence resides with the department of welfare, they are often subjected to severe pressure until they can complete the application process and weather the delay involved in establishing eligibility and need. Their difficulties have been exacerbated by the department's hesitancy in granting assistance. In view of public pressure in the past, welfare centers appear reluctant to place themselves in a position where it may be said they are supporting the habits of addicts. They may try to take the easiest way out by referring the older, single dischargees to the municipal lodging house or suggesting some work program where the expenditure of department funds can be justified. An interested followup agency could contribute a great deal by helping dischargees establish their eligibility and need without undue delay, by verifying the facts of hospitalization, interpreting their problems, and obviating their being shunted about from office to office until they can find the proper point of application. In general, such an agency could attempt to meet |