Editor’s Note: This is the fourth installment in “The Way Back Machine,” a series of interviews with key theorists and practitioners of alcohol and drugs research, treatment, and recovery among women and communities of color during the 1970s, ‘80s, and ‘90s. Through these interviews, Points co-founder and Managing Editor Emerita Trysh Travis works out some of the theoretical issues she articulated almost ten years ago in “Feminist Anti-Addiction Discourse: Towards A Research Agenda.”
This is the Part II of Trysh Travis’s interview with Jim Baumhol. Be sure to read Part I of their wide-ranging conversation!
Most historians of alcohol and drugs know Jim Baumohl for two classic articles that examine alcohol institutions and policy history: “Inebriety, Doctors, and the State” (1987, with Robin Room) and “Building Systems to Manage Inebriates: The Divergent Paths of California and Massachusetts, 1891–1920” (1994, with Sarah Tracy). Few, however, are familiar with his rich body of work on poverty and homelessness—a polymorphous collection of research articles, white papers, and agency reports that basically map the US government’s failure to adequately imagine (much less implement) solutions to those issues in the post-Great Society era.
Like many of the folks featured in The Way Back Machine series, Jim Baumohl’s life during the 1970s and ‘80s featured a mix of political, intellectual, and research work. The rapidly shifting policy landscape created a set of conditions that invited creative, big-picture thinking as well as a strange mix of unabashed idealism and self-preserving sarcasm. All of these were on brilliant display when Points Managing Editor Emeritus Trysh Travis sat down with Jim for a two-part interview. Read Part I of their conversation.
Trysh Travis: Now all the pieces come together: unhoused youth and alcohol/drugs become “a thing” in the mid-1970s.
Jim Baumhol: Yes, but attention to that thing was operationalized in different ways. Some programs, like Manhattan’s The Door, were run by smart, experienced, and inventive professionals who understood young people and their dismal economic prospects in those years. The Door, which I first visited in 1977, I think, was the best funded, broadest, and most culturally diverse and sophisticated alternative service I ever saw. Perhaps most impressive, they took a variety of funding streams intended to support narrow purposes and provided a wide ranging, seamless, and individualized experience for their clients. As any program administrator will attest, that’s quite an achievement.
Other unusual but impressive programs came out of dissident traditions within established religions. I don’t recall a Hospitality House applying, but in 1977 I went to visit a runaway center in the South Bronx, meeting up with a 40ish nun on the Grand Concourse. She was “bred, red, and dead” in the Bronx, she told me, but she wasn’t sure how to manage the site visit. The program’s office, located in an apartment building that was mostly abandoned, had burned down overnight. We walked around the desolated South Bronx, where it seemed she knew everyone, and she told me about what they did and why, and how their emphasis on justice, dignity, and social group work to promote mutual aid was related to advocacy with the various institutions of New York City and New York state. She didn’t get Freud to lie down with Marx, but she did a pretty good job of marrying elements of 12-Step mutual aid to the traditions of American socialism.
It sounds like once you start using youth as an organizing principle, the divide between alcohol and drug abuse dissolves completely.
I’m not current on the epidemiology of polypharmacy, but I suspect that’s right. There are still specialists, of course, but I think multiple substance misuse has become more common in recent generations, especially among young people. As late as the 1970s, certainly, drunks and dope fiends never much liked each other. This had to do with generational conflict about respectability and the stigmatizing myths that flow from, among other things, pharmacological determinism [the term is defined in Box 1 of the linked article—ed.].
Some of NIAAA’s categorical programs mixed what the Institute called “special populations” in complicated and novel ways. For example, a project in the infamous Kensington section of Philly applied for a youth grant to complement their work with adults. They were forthrightly addressing the problem of polypharmacy, which was the norm among users in Kensington. They were mixing adult male heroin addicts and alcoholics with good results, they thought, because drug of choice didn’t define a critical difference any longer. Instead, the main fault line was race. Amending the therapeutic community approach with a dram of Synanon, they invented an in-your-face racial “desensitization” game, the name of which can’t be reprinted in a reputable outlet, whose merciless aggression would have made Fritz Perls blush.
You’re confirming my sense that the late ‘70s were a moment of eclecticism and experiment—perhaps to the point of “randomness.” Can you identify particularly successful—and influential—approaches that precipitated out of that moment?
My site visits from Boston to Anchorage over five years taught me that NIAAA supported a variety of unnamed, eclectic approaches even if that wasn’t apparent on paper. Grantees may have used the same terms, but they often weren’t consulting the same dictionary. I don’t think this was “random,” however. One version or another of disease theory characterized how the problem was defined and put boundaries on intervention. “Treatment” happened in individual, family, and small group work, not in organizing the resources of a community. (The Bronx nun and The Door were outliers in this respect.) A public health perspective would see the latter as a potentially powerful form of secondary prevention, of course, but NIAAA didn’t consider this treatment and left such approaches to the Institute’s prevention branch.
Even though I was the liaison between the treatment and prevention committees for a year or two, I don’t remember much about what that branch did, and I don’t think it had a very large budget. Robin Room and Joseph Gusfield were members of its grant review committee, and they had great interest in alcohol control measures: the saturation of some communities with advertising; the concentration of liquor stores; the effects of a low drinking age—you could drink at 18 in many states in those days—and lax enforcement of it; the effects of per se and server liability laws; and even the use of automobile technology to prevent impaired driving. These and other issues were and remain important matters at the point where public health and sociology cross paths.
But in the treatment world, disease theory was hegemonic. The National Council on Alcoholism melted down over the Rand report (1976), and they had many friends in Congress, notably Senator Harrison Williams, a Democrat from New Jersey who entered recovery at Seabrook House, a bastion of 12-Step principles. It behooved NIAAA to keep its distance from behavioral therapies not based on the disease ergo abstinence model. I don’t remember if any programs of this sort were funded, but I doubt it. I don’t think Mark and Linda Sobell had federal support for their controlled-drinking experiments.
Also, I don’t recall that much attention was paid to women except as the victims of male abuse. I know that women’s treatment programs existed locally, some of them based on feminist principles. There was only one application from such a program that I recall, and it was not approved because of the organization’s collective management and what many committee members took to be overly vague lines of authority and financial control. I believe that vote followed a clarifying presentation by a senior staff person about administrative requirements for new grantees. Guardrails, you know. Like other federal agencies, NIAAA’s grantmaking rules tended to reproduce bureaucracy.
The lack of useful evidence about results made it impossible to make judgements about programs based on much more than how many people were served and whether the program on the ground seemed to adhere to a coherent logic of plausibly useful intervention. These judgements betrayed powerful biases that committee members debated openly in meetings amongst themselves but were certainly not for public consumption. The majority of committee members weren’t much interested in the nuances of disease theory, but they believed in abstinence and solidarity.
Like the Bronx nun, they understood AA as a mutual aid society, not a self-help program. In this spirit, they favored small, scrappy nonprofits run by recovering people in communities of great need, and they were less enthusiastic about programs run by professionals in hospitals and community mental health centers. They favored the renewal of grants to such programs even if they were out of technical compliance with rules about program administration, or, as a few committee members emphasized, were too small to be cost-effective. This last issue was a very difficult matter. One member who worked for a large insurance company insisted that all efforts like little sober houses on the prairie should be defunded because they were inefficient. He had a few memorable exchanges with committee members, including me, I admit.
Anyway, grant review was a fascinating process through which many highly trained, intellectually honest professionals expressed serious skepticism about the therapeutic efficacy of large-scale professional interventions while others championed professional authority, bureaucratic norms, and sound public investment based on criteria they took to be both objective and self-evidently useful. The community practitioners among the members were all skeptics to some degree; the administrators of large programs tended to be defenders of scale, rigorous evaluation, and replicability. My sense is that over the last 40 years, administrators and program evaluators have largely won this battle, but practitioners, for better or worse, still find ways to do things their way on the ground.
This first era of NIAAA came to an end in 1981, when the Omnibus Budget Reconciliation Act took most service grants administered directly by federal agencies and folded them into block grants to the states. I don’t think anyone in any agency kept track of which projects survived and which were killed by the various states and counties, though it would be very interesting to know if there were discernible patterns of survival. Further, I don’t know of any empirical work on the administration of local alcohol and drug treatment systems that isn’t limited by reliance on dubious management information systems and superficial understandings of how programs work, individually and in concert. Maybe I’ve missed some important research of this sort, but it seems to me that this generation needs studies like Jacqueline Wiseman’s Stations of the Lost and Perrow and Guillen’s The AIDS Disaster.
That sounds profoundly depressing.
Only if you think that federal grantmaking inspired and supported helpful innovations that would have been quashed or allowed to languish by local authorities. I think federal withdrawal from leadership in the mental health field did contribute to the neglect of chronically treated patients who would have been hospitalized in earlier years. In the alcohol and drug field, however, it has often been the other way around.
Certainly, with respect to drug policy and treatment innovation, the feds typically have been an obstacle since implementation of the Harrison Act. Other than belated federal support for the therapeutic use of methadone and “medically assisted treatment” more generally, the feds have been a drag on experimentation and change, administration after administration blunting all challenges. The states are a mixed bag, to be sure, but federal grants for the treatment of substance misuse never changed that. Now, the wealthy, progressive states make up for the lesser funds in block grants and use the flexibility of block grants to innovate. In our geo-political structure, that’s probably the best we can expect. Oklahoma will never be Massachusetts.
I don’t think skepticism about what today we call “best practices” is depressing or unwarranted, especially when the concept is used to create stifling orthodoxy. It is certainly wise to do some things rather than others, and research helps prevent bad mistakes; but clinical success relies on timely material support for clients and consistently caring, individualized relationships far more than modes of program administration; replicable, narrow procedures; or economies of scale. I think most NIAAA treatment committee members were deeply committed to this view, notably the practitioners, and especially the committee’s chair, psychologist Herman Diesenhaus, who was at the time running a community mental health center near Denver. Research wasn’t useless, administration wasn’t unimportant, and efficiency and consistency were admirable, they felt, but only when they served relationships with clients.
Herman, by the way, was one of the finest and smartest people I’ve known. He taught me a lot about the interior politics of institutions and the relations between government agencies and their grantees. He pointed me toward the right questions, and I can see this influence in my historical work and quite explicitly in a paper I wrote with Jennifer Frank that’s in the September 2021 issue of Social Service Review.
I’ve got my Therapeutic Community hat on today, and you may not leave the hot seat until we derive a usable past from this history.
Ah, well. I have many thoughts about the “through lines” of this history. I’m interested in continuities and recurrences, but I hate the reified, mechanistic pendulum metaphor. I find it useful to consider something a bit like David Matza’s notion of “subterranean traditions.” I think established ideas and practices may fall into disuse and obscurity, but they rarely disappear altogether and thus remain available for rediscovery.
I would add to this the idea that cultural logics constrain imaginable definitions of and responses to phenomena. I think this explains why certain ideas and practices are rediscovered by people similarly situated but unaware of each other or the precedents. For example, the founders of Alcoholics Anonymous had no knowledge of the mid-19th-century Washingtonians, but they took on a similar problem within the cultural logic of a Christian middle class concerned with self-control.
You asked me earlier about important and influential precipitates of the treatment turmoil of the 1970s, and I went running off elsewhere. Others are more knowledgeable about recent events than I am, but I think most current ideas and practices would seem familiar, though not identical, to someone who’d been in a 50-year coma.
Certainly, the legitimation of methadone after 50-plus years of conflict about maintenance is extremely consequential, but the cultural bias against maintenance remains strong. In some quarters it remains “the Nazi drug,” and back in the aughts, certainly, if you asked methadone patients if they were in treatment, a notable number answered “no.”
I have the impression that with the first medically-induced opioid epidemic we’ve seen in over a century this antipathy is softening somewhat. I agree completely with David Courtwright that the class and race of addicts—or perhaps more accurately, common understandings about these identities—determines how we think about and address the problem. What seems to be the association of “deaths of despair” with working-class white men has reinforced the legitimacy of buprenorphine and “medically assisted treatment” more generally. That African American men have succumbed to deaths of despair for centuries didn’t seem to do the trick.
Still, the old antagonisms will be available for rediscovery and deployment. The acceptance of addiction as a qualifying impairment for federal disability benefits, pioneered in New York in the ‘70s, succeeded despite ardent objections to “rewarding bad behavior”—only to be repealed by Congress in 1994, when new House and Senate members repeated the same objections voiced by their counterparts in the ‘70s about self-inflicted conditions, addict sociopathy, and the assertion that “treatment doesn’t work.”
The boom of the non-profit and proprietary private treatment sectors has been a durable phenomenon. And this growth has occurred within our familiar and longstanding two-track system of care and represents no revolution in equitable access, so far as I can tell. The industry of upscale treatment has remained remarkably similar over the last 150 years, and poor addicts still detox in jails, where medically assisted treatment seems virtually unknown. The systematic exploitation of impoverished addicts by unscrupulous proprietors of sober houses does seem like a new twist on the addict as commodity—made possible by the intersection of the welfare state and homelessness and the fecklessness of public oversight. Taken together, I think these examples illuminate at least in part why the history of treatment is one of divergence, disorder, and recurrence, reined in but never fully tamed by institutional authority.