North Charles Center for the Addictions
People at the Cambridge Health Alliance (CHA), where I did my second internship for the Simmons College MSW program, told me that the North Charles methadone clinic, just three blocks away from the CHA Outpatient Mental Health clinic, was affiliated with Harvard University and offered clinicians a Harvard affiliated supervisor as well as access to both internal and external training. It sounded like a place where I would be able to continue my education and gain more clinical experience. I interviewed, was accepted, and started work in June of 2004.
There were about a dozen clinicians, some administrators, a couple of nurses, and someone at the front desk who acted as a receptionist and helped with scheduling, filing, and other tasks. Each clinician had an office with a door to provide privacy for client meetings. There were three larger rooms for conducting group sessions. The clinicians were divided into teams, each with a supervisor – team leader. Mine was “Barbara”, who reported to the Clinical Director, “Margo”, who reported to the Agency Director, “June”.
My clientele were adults of all ages who defined themselves as opiate addicted. They were mainly from the cities around Boston and Cambridge, mostly on Medicaid insurance, and they had chosen to participate in the NCIA Methadone Maintenance Treatment (MMT) program. Daily dosing of Methadone took place at the nearby hospital under the supervision of the nursing staff who reported to the Director of Nursing. Participation in both individual and group therapy was mandatory.
I arrived full of energy and enthusiasm, fresh from school and from my internship at CHA. I was attracted to NCIA because of its progressive reputation, Harvard affiliation, and the chance to do long term therapy as well as substance abuse counseling. I was willing to help the program in any way I could. For example, I offered to help drag an old mattress that had been dumped in our parking lot to the curb, and I solicited a previous corporate employer in an effort to get computers donated to NCIA.
I dove into my work as a counselor, picking up clients, engaging in treatment, being diligent with paperwork, trying to learn the job quickly, soaking up information and gaining understanding by asking many questions. I made friends with the office staff, a couple of the nurses, and with two other counselors. One of the counselors was the only other male therapist and the other, a young woman, seemed to me to be the most mature and thoughtful of the counselors.
I admired the organization of the program, clearly the result of well considered theory and experience. The staff was knowledgeable and willing to share their knowledge with me, the new clinician. The groups for clients covered a wide range of topics starting with mandatory introductory groups for new clients beginning MMT. Not only was careful attention paid to clients’ education but it was also paid to that of the clinicians’ who were given a binder covering many relevant topics. At the beginning of my tenure there, the agency seemed to run like a well oiled machine. Only later did I encounter problems.
Some clients, particularly those recently arrived at the clinic, utilized Methadone as “just another drug” while they continued illicit use. The program would accept clients who were still using illicitly, with the understanding that those clients would make a commitment to wean themselves off the illicit drugs as they were given an increasing substitute dose of Methadone.
Many clients had chronic health problems, including HIV and hepatitis, often the result of years of drug abuse and physical neglect. Some of those who were mostly compliant with the program lived in circumstances and relationships that were detrimental to their health.
My job was to see clients individually and in group to help them acclimatize to and eventually adhere to the program rules and goals, to get help for their other health problems, and to provide counseling for their program participation and for their challenges of daily living. Some clients viewed me as a partner to help them achieve their current life goals, while others saw me as just another authority figure.
The MMT program started new clients with daily dosing and regular urine toxicology testing or “tox screens” to determine not just illicit use but, for new clients, what the effective dose might be at which the client’s cravings for illicit opiates would stop. The tox screens could distinguish methadone, heroin, and other opiate use as well as marijuana, amphetamines, cocaine, and benzodiazepines (“benzos” or “BZs”). For clients still looking for a high, use of benzodiazepines, including drugs like Lorazepan and Klonopin, was common because benzos enhance the opiate euphoria. They also increase the risk of overdose.
A program goal was for clients to eventually be able to give clean, illicit substance free urine and then to be able to maintain clean urine while receiving the therapeutic dose of methadone. There was an institutional belief that “addiction is a disease of relapses” and some allowance was made for relapses.
One way to imagine the process of a new, heroin addicted client lessening her heroin use while getting an increased methadone dose is to use the metaphor of a “glide path” of a plane seeking to land. While there can be great variation among flights and landings, beyond some parameters the plane must abort the landing or crash. The dramatic changes of life style, relationships, and habits required of a new client are significant and include trusting the methadone, diminishing the heroin, losing the heroin-using friends, submitting to drug testing, accepting the rules and authority of clinic staff, getting to the clinic whatever the weather and whatever your health, attending classes, group and individual therapy, and more. Many clients were in chronic pain due to various maladies and had to coordinate clinic and medical staff to get their needs met.
The total treatment regime was rigorous and a large percent of clients dropped out or were kicked out in the first six months. Some of the old timers had seen dozens of new clients arrive and depart. Young clients in particular might have to try several clinics before they could stick with one of them. Some hated the rules and requirements so much that they would decide to take the chance of another detoxification, another clinic, or the street.
The Clinical Director, Margo, stated that most addicts “lacked boundaries” because they did not have parents who established firm boundaries for them when they were growing up. This was part of her explanation for why addicts became addicts. According to her, one of the functions of the clinic was to establish strict boundaries, which were expressed through rules. Rules were to be enforced rigorously and usually without exception so that clients would learn skills of respect and obedience, skills that the director considered necessary to recovery.
Clients who wanted to both get methadone and continue to use might try to find ways around the system. For example, some clients told of other clients who sold and bought drugs while waiting in line for their methadone and some had techniques to buy and transport “clean urine” so that they could substitute it for their own when asked for a urine sample. There were stories of clients “cheeking” the methadone, holding it in their mouths until they could spit it into a container to sell it, and of clients selling take homes by reducing the amount they themselves took. There was an element of cat and mouse played by some clients circumventing rules and clinic staff trying to catch them. “Cat and mouse” can also express an unequal distribution of power. Mice find ways.
Some illicit use showing up in tox screens was tolerated as long as the client owned up to it and the client’s direction was towards a greater ability to become and to remain “clean”. As at CAB, there were privileges that could be attained that were dependent upon giving clean urine for a certain period of time and then continuing to do so after the privilege was won. Foremost among these privileges was the chance to get “take home”, doses of methadone that could be taken home in a locked box so that clients would not have to come into the clinic on the days for which they already had methadone. During my time there, NCIA implemented a policy allowing up to thirteen days of take homes for the most compliant and successful clients. Clients with take home privileges worked hard to achieve them, valued them greatly, and tried to avoid doing anything that would cause them to lose those privileges.
I participated in staff meetings and wondered why other clinicians did not join the conversation. I wasn’t aware that the reticence of others was due to their having experienced that their opinions were not really wanted. I learned that it was easy for a clinician to say the “wrong thing”. This realization was confirmed for me by my friend and fellow clinician Marcus.
In a meeting, Margo had told us that most of our clients had not been raised in families that had set appropriate “boundaries” for them, and that it was the job of the clinic to maintain strict boundaries as part of clients’ rehabilitation. This was her reason for running the clinic in a way that prioritized the clear, rapid, and inflexible enforcement of rules. She called it a “container model”, a strictly behavioral model. Clients and clinicians may learn how to behave, but a strictly behavioral approach, based upon hierarchy and power, can breed resentment. Isn’t it also important for clients to learn how to have relationships of mutuality, caring and trust?
My first trouble occurred in the September. I was occupying an office in the rear part of the building. There was a terrible odor of mold in the room, which I and my clients found offensive, and which had caused the former occupant to move out. A decision was made by the building manager to clean the rug. The rug was to be cleaned on Tuesday. If the cleaning worked, I would have been happy to stay in my then current office (let’s call it A). There was another office available (B) which I was in line to take if the cleaning did not work.
Margo told me that my indecision was preventing another employee from moving into either office. Margo said that I needed to decide if I wanted to move and if I did, I had to be out of my current office by Friday, before the Tuesday of the cleaning. When I pointed out that it made no sense for me to move before the cleaning, I was again given the order, Friday was the deadline.
I moved on Friday, unwilling to risk staying in a moldy office if the cleaning was unsuccessful. On the next Tuesday, the cleaning was successful and the odor was eliminated. I was already in B. The other employee told me that she had no interest in moving into the now odorless office A, which then sat empty for months.
Margo never acknowledged that she prevented two clinicians from each getting the office of our choice. If we had waited until Tuesday, I would have been happy staying in A, and the other clinician would have gotten B. This incident struck me as a demonstration of Margo’s power to make arbitrary and ignorant decisions.
Nevertheless, I was enjoying the work at NCIA, appreciating and feeling appreciated by my clients and my fellow clinicians. I saw a young woman who was on Social Security Disability Insurance (SSDI) due to extreme anxiety. She seemed grateful to be able to describe her experience to me without my judging or offering unsolicited advice, and she told me so. “Most therapists I have seen simply cut me off and give me advice that I don’t want or need” she told me.
A young man, traumatized by his war experience, struggled to understand what happened to him and “why I am so messed up that I can’t stop using”. He wanted me to know that he was happy to be “in the program”, liked meeting with me, and still could not stop doing “crazy things”, even while working full time. He disappeared several times, not showing up for dosing or therapy, but each time reappeared hoping to learn from and not repeat his prior relapse. He was learning how to live and I was learning from him how to be helpful to him.
A mother was pleased to start in the clinic so that “I don’t have to worry each day about getting drugs and putting food on the table” for her child. After a few months she was able to achieve some stability in the program and hold a steady job. She had been off and on clinics over the years and still hoped to eventually detox from the methadone and live a drug free life. She focused our conversations on topics she thought would be helpful to her and I respected her focus.
Your grandmother doesn’t count
Marcus and I often had lunch together. When his grandmother died, Marcus informed his manager that he would be going to the funeral, which took him three days as he had to travel to California and back to Massachusetts. The company docked his pay because the relative was not on the “approved list” of family members.
Marcus had already believed that management was unfair to him. A new client whom he had seen only once, committed suicide, and Marcus felt like he had gotten blamed even though he had acted as instructed by a senior clinical manager. Marcus also felt that he was blamed for another client’s illicit drug use. Marcus observed that there were punitive aspects of the NCIA system affecting both clients and clinicians. “First, assign blame” seemed to be a management practice, he said.
Once, when the doctor was being observed by Margot, the doctor, feeling “put on the spot”, complained that one of Marcus’ referral forms lacked sufficient information. Marcus got “written up” as a disciplinary action, even though the referral form was actually complete and Marcus was available if the doctor had questions. When Marcus appealed the write up, he felt like he never got a fair hearing or closure on the issue. I was surprised to hear about this kind of punitive practice.
Marcus started looking for another job and when he departed, managers, who knew the true source of his dissatisfaction, claimed to the rest of the staff that he had left NCIA to do work in which he was more interested. Marcus told me that he was sad to leave, that he liked his clients and felt like the clinic helped many people, but that he could not continue to allow himself to be abused as an employee.
I saw in what had happened to Marcus the emergence of NCIA patterns that I would experience myself and see repeated with others. There was management inflexibility, blaming rather than supporting the clients and clinicians, one-sided closure of issues, and obfuscation about the true causes of employee attrition. These issues were remarkably similar to client complaints about the clinic. In retrospect, I believe that those patterns stemmed from a hierarchically structured management philosophy and exercise of power that was antithetical to equality, collaboration, respect, and real team work.
I was given two groups to lead including a group based upon 12-step principles and a group for clients new to the clinic. There was a significant curriculum of well thought out psycho-educational and health material. My favorite was the 12-step group. It was comprised of some of the clinic’s most experienced clients, committed to helping each other maintain sobriety. They welcomed me as the group clinician, and really, it was they who led me, introducing me to their philosophy and practices, asking me to participate as one of them.
They were a group of people who were older than the average NCIA client, with more life, drug, and recovery experience; I came to rely on their wisdom and experience. They had perspective about how clients experienced the clinic. Unlike CAB (internal link), NCIA did not have a client council or any way for clients to be heard as a group. When I asked managers about starting a council, I got vague assurances about future intentions. The lack of a client council was consistent with a non-responsive hierarchy.
There were also caring clinic practices. I had a client who was using benzos in addition to methadone. He became so incoherent in my office that he had to be taken to the hospital by ambulance. He was allowed to stay on the clinic after agreeing to go from the hospital into a detox to end his benzodiazepine use.
I also got as a client a young man who seemed to have no intention of stopping illicit use and who was given warnings when toxicology screens showed growing illicit opiate use even as his methadone dosage was increasing. He was in danger of overdosing on the combination of illicit opiates and methadone and finally he was told that he would have to detox from the methadone and leave the clinic. Even under those circumstances, he was provided with a referral to another clinic in the hope that he could succeed there.
The combination of caring and authoritarianism is familiar in social services administration. It is an elitist construct that says, “I know what is best for you”. While much good can result when real client needs are met, like MMT and education, the met needs do not include the needs of clients for respect and the development of clients’ own ability to be heard, contribute to decision making, and to have power in this most important aspect of their own lives.
I saw a man who claimed that his need for methadone was to dull the pain of his injured knees so that he could to climb the ladders necessary to do his job as a house carpenter. He said that orthopedic doctors who had been of no help. Despite some research, I could not find any studies that explained the relationship between opiate addiction, methadone use, and pain management. Stories of pain, addictions resulting from prescription medications, and methadone for pain seemed commonplace but relationships between them did not seem to be well understood.
My mistake, October 2004
One evening, I was asked to fill in for another counselor group leader. Groups sometimes became a forum where clients discussed what they considered to be experiences of disrespect and unfairness at the hands of clinic staff. If discussion went in this direction, I would discourage gossip about staff not in the room and encourage the group members to bring their complaints to staff and to those able to do something about them.
As the group session was ending, “Mark”, said, “I’m surprised that nobody has brought a gun in here because of how we are treated”. I did not react, unsure if what he said constituted a threat. I did not feel threatened, but I knew that managers believed that tight boundaries needed to be maintained around the clients. I asked the therapist who had that particular individual as her individual client if she considered the statement to be a threat. She answered that she did and said that she would inform her manager. I offered to speak to her manager but the counselor declined my offer saying “it’s my client”.
When I met with Barbara, I was told that Mark’s words were to be construed as a threat and that NCIA considers safety to be extremely important. In the future, I should deal with similar situations at once by informing the client that what he said constituted a threat for which there would be consequences. I was also to inform a manager at once. I understood the policy as she explained it, and said that I would comply with it. My intention was to comply with NCIA policy, even though I hoped that clients could feel safe expressing their thoughts and feelings in therapy. In my view, appropriate and productive expression of anger is a learned skill. Do “immediate consequences” help clients learn that skill? Maybe.
At the next Team meeting, there was a discussion about what was to be done about Mark’s infraction. It was decided that his own counselor would discuss the incident with him. I said that I thought that it would be better if I spoke to him first because I was the clinician leading the group meeting. I was concerned that, by my not speaking directly to him, and then reporting what he had said, he would mistrust me in the future. I was informed that this was not necessary, that others would deal with him. I was surprised that the managers in the room either did not understand how this path would affect my relationship with Mark, or they did not think it mattered.
Shortly thereafter, Margo told me that she wished to speak with me. She began the meeting by informing me that what I had suggested, my talking to Mark first, showed disagreement with clinic policy and constituted insubordination. She told me that I needed to recognize and not be taken in by “counter-transference”, which led me to give clients too much credibility. She told me that I acted like I knew too much and should not be so quick to offer my opinion.
Barbara, who was not present at this meeting, had gone to Margo with the charge that I had voiced disagreement with clinic policy. Barbara had not discussed the issue directly with me first and now became someone that I felt that I could no longer trust, an interesting parallel to what was happening with Mark and other clients and clinicians.
I was stunned by Margo’s charge since insubordination is a serious charge and sometimes precedes discharge. I pointed out that I had been told that disagreement was acceptable as long as it was not done in front of clients. Margo, considering this, agreed with me and withdrew the charge of insubordination. But the damage to me was done; it was dangerous to disagree with anything at NCIA ! My opinions were a sign of arrogance; I did not know how ignorant I was, and needed to shut my mouth. Now I understood why no other clinicians ever spoke at “Team” meetings.
An outcome of the other counselor talking with Mark was that Mark announced that he wanted nothing more to do with me because he could not trust me to talk directly to him first if I had a problem with him. He chose to be absent from group the next two times that I filled in. I eventually spoke to Mark and I apologized for not speaking with him when he said what he said. He expressed appreciation for the apology and subsequently greeted me when we met. Barbara never apologized to me. Just as clients were to be treated in a generalized, authoritarian manner, so were the clinicians. Authority and obedience were valued; relationships were not, even though research shows that relationship is the most important factor in therapy success.
“Hopefully it’s the urine that’s positive …”
There were reports that some NCIA clients were substituting other people’s urine as a way to cheat on toxicology tests. Oral fluid (OF) testing was implemented as another way to check on clients with take-home privileges. Some clients with significant take-home privileges came up positive in the OF testing, indicating that, according to the OF test, they had used a benzodiazepine illicitly.
Many of those testing positive complained that the test was flawed, they had not used illicitly. I thought that input from clients should at least be considered, and therefore I asked in a staff meeting about the accuracy of the OF tests. I felt like I was taking a risk, just asking the question. I was told that the question “should not even be asked” because we had no choice but to stand by the accuracy of the tests. If the test indicated illicit use, then the client used illicitly and must suffer the consequences, another arbitrary and authoritarian response.
While some of those proclaiming innocence may not have been innocent, I also knew that all tests have some degree of error including OF tests, and I was troubled by the implication that some who might be truly innocent would be wrongfully charged and convicted at great personal cost. One of my group clients, finally getting sufficient take-homes, had bought airline tickets to visit his son and his son’s family in another state. He had not been able to visit them for many years. In light of his adamant denial, I worried that the test was flawed and he would unjustly suffer.
Prior to the team meeting on 10/20/04, I had already heard the client’s side of the story, including adamant denial of illicit use. I knew that a second test, a urine test, had been requested by the client right after the OF test because he did not trust the OF test. In the industry, a urine test was considered to be more accurate than an OF test. I also knew that, while the OF test was positive, the more accurate urine screen was negative. Because I had already been charged with insubordination, it was clear to me that it was dangerous to advocate too forcefully for a client. At the same time, I cared about him and wanted him to be treated fairly. Here is the conversation that occurred in the team meeting. () indicate my comments here, not in the meeting. Bold is my emphasis:
Client’s individual counselor (not me): My client tested positive for BZs.
Barbara: Well, that’s two positives, which certainly shows that he is using. He loses his takeouts immediately. You should call him and tell him so we don’t have a scene in the clinic in the morning.
(Loss of takeouts meant that he would not be able to visit his son and might lose money he already spent.)
Me: (I already knew both test results because I had asked for them. Others in the meeting had not.) There were actually two tests that day with different results. I think that, when he was tested for oral fluids, he also demanded a urine because he does not trust the OF test. (“demanded” was a really poor choice of words on my part)
Director of Nursing: He had no right to demand anything and they should not have given him the urine test.
His counselor: What do we do about the fact that the results differed?
Director of Nursing: It makes things even worse for him because the fact that the results of the two tests are different results shows tampering, which could result in immediate discharge and detoxification (forced withdrawal from methadone, major disruption of his life, possibly significant health impact).
Barbara: Hopefully, it’s the urine that’s positive for BZs. (my emphasis – She does not know which test had which result and she is rooting against the client).
Me: No, it was the OF.
Barbara: Too bad. Still, it doesn’t matter. He got a positive for BZs and loses his takeouts. Can we charge him with tampering and discharge him? (Where is caring and compassion? We are talking about one of the most compliant clients in the clinic!)
Director of Nursing: Unfortunately, we can’t charge him with tampering because we don’t have any other evidence. (“Unfortunately”? I am stunned by their hostility towards this otherwise model client)
Counselor: What if the urine was supervised (I am relieved that at least his counselor is trying to be on his side)?
Director of Nursing: If it was a supervised urine, that wouldn’t even matter because clients have ways to circumvent that with tubes and stuff. He probably walked in there with a bag of urine in his pocket.
I was shocked by this conversation. The data indicated a strong possibility that he was innocent, but the data had been ruled out of order. I had been told by Margo that I shouldn’t act like I know so much, and yet I watched the highly experienced head-of-nursing and Barbara whip each other into a frenzy of suspicion and accusation against the client. Barbara even stated her hope that the data would show the man to be guilty. And the director of nursing was outraged that the client demanded something, a client having his life torn apart by the clinic whose mission says that he will be treated as “a partner in a respectful and supportive environment.”
I could not detect any respect by the other senior clinicians for this client. I knew this man. In group, he had talked about being worried about the OF test and requesting the urine test. He denied illicit use, and questioned the accuracy of the OF test. But according to the NCIA belief system, he was probably lying, possibly tampering, and my believing him was indicative of my weakness of “counter transference” (an interesting concept whereby caring about the welfare of a client becomes a problem).
This client appealed the Team ruling; he brought other resources to bear in his own defense, generating calls to Margo from other care providers. There was now some outside scrutiny of the agency. Margo was the most powerful person in the building hierarchy and the only person who could counteract the effects of that which she herself had created. Only she could hear appeals and change outcomes. She did some research and discovered that, combined with certain other medications, the OF test can indeed produce a false positive. This was information that I and others, including clients, already knew. She reversed the decision of those below her in the hierarchy, and restored his take-home privileges.
The client, relieved and vindicated, credited Margo with being “the only person in the clinic who cared about me”. Thus he was split from his counselor and her supervisor whom he characterized as “useless” and he said he could no longer trust the rest of the team. He credited Margo, the very person responsible for the policies and practices that had threatened his well being, as “the only person who cared”.
Looking back, my conflict was not with the policies and rules but with the arbitrary, top down, micromanaged ways in which they were enforced. Clients and clinicians behavior was managed top down. The “skill” being developed, compliance, to obey the rules, is necessary to live in a society. But without dialogue, it can be stifling and is not a sufficient skill to be a participating member of society.
The top-down approach, with an intolerance of questions and dissent, forced conflicting information and disagreement underground, into private conversations. Asking questions was construed as “insubordination”, with no place for dialogue or respectful discussion. More than one client observed to me that he had to act “as if I was in prison”. He had to be vigilant, assume that anything he said could and would be used against him.
Behavioral Management
As my career progressed, “behavior management” became a theme around both psychological theories and management practices. I wondered, is the purpose of psychology social control, social freedom, or both? The tension between them seems to form a key tension in all aspects of the field. Behavior management focuses on the needs of some to control the behavior of others. Bureaucracy and rigidity produces alienation, humiliation, and degradation (Hasenfeld, 1983; Shotter, 2003).
NICA clients needed to follow rules both for their own safety and for the smooth operation of the clinic. Did those rules need to be enforced in a way that did not allow for consideration of the clients’ and clinicians’ perspective and needs? Why wasn’t there a client counsel when having one was standard industry practice? In a non-collaborative system, clinicians and clients were treated similarly. I decided that I did not want to work at NCIA under those conditions, and I started to look for another job, unaware that similar relationships also occur elsewhere in the industry.
I resigned from NCIA in February, 2005 after getting hired at another agency. No one in management seemed surprised or displeased. Agency managers must have also concluded that I did not fit. The two therapists I was closest to had already left for similar reasons.
My clients were sad to see me go, but not surprised. One client declared, “All the good ones leave, I knew you wouldn’t stay too long”. He had told me what did and did not work at the agency from his point of view. I considered it part of therapy to help clients understand the systems and relationships of power in their lives, to help them get their own needs met and when and how to respond to problems. Such conversations were never discussed in my supervision sessions with Barbara. She seemed to assume that she should get unquestioning compliance by me in ensuring full and unquestioning compliance by my clients.
Margo and June were highly regarded Harvard affiliated experts, often featured in conferences about Methadone Maintenance Treatment. Margo told me that she was “sure that I would act appropriately” when I left. What did that mean? I took it as a veiled threat considering that I would have to list NCIA on my resume as I looked for my next job.
It has taken me almost ten years to write this up and much may have changed. Clients now have more treatment choices outside of clinics. I am publishing this because I have found authoritarian management to be present in many institutions. Its examination at an experiential level is crucial to understanding both its effects and how to change it. My time at NCIA was productive though my relationships with peers and clients, but I found many management practices to be oppressive and counterproductive to employees and clients.
My experience at CAB showed me that, despite Margo’s assertion, an authoritarian approach is not essential to MMT. As in all institutions, rules and boundaries are needed, but, as proven by CAB, rules can be applied in a collaborative and mutually respectful manner. “Team” can be a meeting of equals rather than a vehicle for command and control. In my time at NCIA, I did not know how to have any impact on NCIA policies and practices. Like many before me, I “voted with my feet”.