J. DRUG ED., Vol.

4(1), Spring, 1974

TREATING THE METHADONE ADDICT:

A CONFRONTING COUNSELING
AND REALITY THERAPY MODEL*

RICHARD R. RAUBOLT, M.A.

Program Director
THOMAS EDWARD BRATTER, ED.M.
Director of Treatment
City Island Methadone Clinic
Bronx, N. Y.

ABSTRACT
The City Island Center has used a confrontation counseling and Reality
Therapy model for treating methadone addicts. This approach assists
the addict to accept responsibility for his actions and to adopt more
productive behavior. This method consists of four phases: 1)establish-
ing the relationship, 2) inducing a crisis, 3) restructuring behavior, and
4 ) drawing up behavioral contracts. Methadone is viewed as an interim
treatment modality with the ultimate goal to be drug abstinence.
Results have been promising in providing positive alternatives to drug
abuse and methadone maintenance.

Introduction
Methadone maintenance treatment, since the research of Dole and
Nyswander [l], has been accepted uncritically by the medical
profession, the courts, and most of the concerned public as the
answer t o addiction. The reason is simple. Proponents have
succeeded in creating a false dicotomy which treats physical
dependence separate from anti-social behavior (violence, manipula-
tion, irresponsibility, etc.).
Methadone has been termed “successful” in treating addiction
since i t reduces heroin usage [l, 21. Any concurrent behavioral
difficulties such as excessive drinking, theft, abuse of non-narcotic
drugs or pushing are excused as failures of the rehabilitation
program, not the medication. It is my contention that this treatment
separation plays neatly into the hands of the manipulative,
unmotivated, addiction prone personality.
*Request for reprints should be addressed to T. Bratter, 88 Spier Road,
Scarsdale, N. Y. 10583.
51
0 1974, Baywood Publishing Co.

doi: 10.2190/YG0L-BQVK-8RHB-H744
http://baywood.com
52 I R . R . RAUBOLT A N D T . E . BRATTER

With methadone, addiction is considered a metabolic disorder

requiring medication indefinitely; the symptoms (heroin craving) can
be arrested but not eliminated. The addict becomes a patient, He
suffers from a sickness over which he has no control and must remain
under medical supervision and chemical care. He becomes dependent,
passive, and weak. Expectations of success are limited to employ-
ment and a reduced criminal record. Functioning within the
established social boundaries becomes the goal with growth and
development unmentioned and unexpected. Responsibility, self-
reliance, maturity of feeling and action, and actualization of
potential are foreign terms. The addict is considered to have a drug
problem exclusively. Such feelings as self-respect and self-confidence
are not emphasized in methadone maintenance treatment.
Even more disconcerting is the implicit message in substituting
dependencies (methadone is highly addictive). The addict is told, in
essence, that no more is required of him than his attendance. It is not
surprising then with his psychological and social difficulties
unresolved that the acting out continues. A negative self-fulfilling
prophecy results. Multiple drug use (barbituates, cocaine), urine
substitution (when urines are analyzed for drug content), selling and
numerous program memberships are all excused by the addict. After
all he is on a methadone program and he is sick, so nothing more
should be expected.

The City Island Experience

The City Island Center is a small (N = 65) private methadone
maintenance program located in the northeastern section of the
Bronx, New York. The drug addict seeking treatment there is white,
male, single, unemployed, and undereducated. He most often carries
with him a lifetime of failures: academic (truancy, numerous failed
courses, inability to read, high school dropout), social (few
heterosexual relationships, limited number of “straight” friends),
economic (criminal record, unemployed, unskilled, unmotivated,
welfare recipient ).
A poor concept of self results and drugs are used to erase the
failure and fear. He remains infantile, unmotivated, and hostile. He
follows the hedonistic pattern of instantaneous gratification and
avoidance of responsibility. He is impatient, demanding, and
self-destructive, seeking good feelings a t any cost. As Van Kaam [3]
has written “he increasingly craves some situation which will grant
him an experience of meaning and fulfillment without effort, pain,
or labor; a situation which will redeem him from unbearable
boredom and anxiety, a situation no matter the social, moral or
 THE METHADONE ADDICT I 53

personal consequences [3] .” Having no faith in his abilities or his

environment he continues to remain manipulative and aloof. The
threat of violence i s used to fulfill his desires and to keep possible
friends at a distance. He fears extended social contact and personal
vulnerability. This means expectations and demands which he feels
inadequate t o meet. He is unsatisfied with his lifestyle because
securing drugs is more difficult and the quality is poor and yet, he
feels powerless to change. Methadone comes to represent the painless
way out, for he no longer has to “hustle” for drugs. However, he
feels with proper manipulation he can still obtain his “high.” The
pressures of the police, family, and courts are now reduced, since he
is taking a socially sanctioned chemical.
The addict initially comes to us in this unique position; seeking
limited help (further drugs) on his terms with someone else’s money
(family, welfare).

Treatment
In order t o alter this pattern of anti-social and self-destructive
behavior The City Island Clinic has begun implementing a
confrontation model stressing accountability and responsible be-
havior. This treatment draws from the works of Glasser [4] and
Bratter [5] and consists of four phases:
1. establishing the relationship,
2. inducing a crisis,
3. restructuring beh,avior,
4. drawing up behavioral contracts.

ESTABLISH1 NG THE RE LATlONSHlP

The addict is initially mistrustful of authority, demanding, and
abusive. The therapist, if he is to gain entrance into this world of the
addict, must first gain trust and acceptance. A sense of openness,
honesty, and sincerity must be established to neutralize the hostility
and manipulation. This is best achieved by self disclosure on the part
of the therapist. The therapist, by revealing his beliefs, values, goals
and expectations, sets the direction, and temper of the therapeutic
encounter. Self-disclosure further tends to ease the addict/pro-
fessional barrier. The addict can see that while the therapist never
used drugs he still had t o grapple with many of the same “bad”
feelings (i.e., pain, anxiety, frustration). This serves as a foundation
for therapy providing a common experiential base.
Due to the failure of past relationships the therapist is strongly
54 I R . R. RAUBOLT AND T. E. BRATTER

tested for corruptability and contradictions. The therapist must

consistently demonstrate his responsible concern and investment in
the addict. The therapist must as Glasser [ 4 p. 221 states,
“. . . be a very responsible person-tough, interested, human, and sensitive.
He must be able to fulfill his own needs and must be willing to discuss some
of his own struggles so that the patient can see that acting responsibly is
possible though sometimes difficult. Neither aloof, superior nor sacrosanct,
he must never imply what he does, what he stands for or what he values as
unimportant . . . Willing to admit that, like the patient, he is far from perfect,
the therapist must nevertheless show that a person can act responsibly even if
it takes a great effort.”
It is imperative, at this juncture, that the therapist act as a firm
role model. He is thereby called on to set and enforce limits giving
structure through which the addict can direct himself. At our clinic
we make demands such as bi-weekly group attendance, one
individual counseling session weekly, a limit of two positive urine
specimens per month, and no violence or threat of violence in or near
the clinic. Failure t o comply with such guidelines could result in
immediate dismissal. The message is given that there is no excuse for
irresponsibility and that self-destructive behavior will have no
accomplice. The therapist by these actions further demonstrates
compassion, understanding, and strength. The addict needs the
reassurance that his fears and frustrations are human problems and
only his chemical solutions are self-defeating and must be changed.

INDUCING A CRISIS
Once the therapist perceives the addict’s patterns of behavior he
must set about to disrupt them. These individuals in the past have
avoided any and all of the anxieties of developing maturity by
escaping to chemicals. They often, despite their age, remain childlike
having failed to resolve life’s three major problems: social, sexual
relationships, and occupational relations. By refusing to admit these
failures to themselves or those with whom they associate they create
an image. This image is an impression that the addict wants others to
have of him which represents qualities which he does not possess but
wishes he did. The image most often envoked is fearless, aggressive,
hostile, cunning, and confident. If he can convince others to believe
this impression it becomes true, real. This in turn works to suppress
the addict’s own private feelings of inadequacy, passivity, boredom,
and despair. This “dope fiend’’ image is dangerous and constraining.
Not only does he prevent others from knowing him, he actively
avoids knowing himself. The addict says he did things he did not do,
 THE METHADONE ADDICT I 55

says he feels things he does not feel, and says he believes things he
does not believe. He becomes dependent on the approval of others.
Having no confidence in himself or his abilities he must constantly
seek their reassurance and attention. This serves to increase his
passivity and confusion because his behavior must always be in
response to the dictates of those around him. Soon the image
becomes so estranged from the real self that the consequence is
self-alienation: he no longer knows who he is, what he believes or
where he is going.
As long as this image or representation of self continues
unchallenged the greater the amount of acting out irresponsible
patterns of behavior. The image can be altered by an induced crisis
created by the therapist. The addict is confronted and ridiculed. His
statements are exaggerated. Finally, his behavior is attacked as
immature, stupid, and irresponsible, in order t o emphasize the
self-defeating nature of his actions. Through this process “the
participant is forced to make decisions. Does he wish to become
more responsible or does he want to duplicate his immature,
irresponsible behavior? Does he wish to continue his dependency on
drugs (including methadone) or does he want to be chemically free?
Does he want to justify to others his life? 151 ” The expectation is to
provoke the same ugly feelings that were previously dealt with in a
self-destructive manner. Then, with encouragement and support, to
face these feelings and to find a more mature and self-respecting
solution.
Throughout, the position is taken that each person has the
capacity and freedom necessary to alter his behavior. There are
certain undeniable environmental factors influencing a person’s
actions. A man cannot always control the conditions. He can control,
however, his responses and his actions.
Dwight: Dwight had one such image; the tough guy. He was an only child of
weak and permissive parents, who protected him at all costs. His only job was
in his father’s grocery store, where he named his hours Not surprisingly, he
was hostile, aggressive, and loud. Dwight took fierce pride in his various
arrests, the numerous fights he was involved in, and the size of his habit. He
was demanding and selfish. When denied a request (such as higher dosage) he
would bellow and threaten. He was never without his knife and seldom
without “shades.” As his parents gave in t o his demands and fellow addicts
recounted his tales, he escalated his abuse. Dwight continually placed himself
in the untenable position of having to out talk even the toughest while still
avoiding physical confrontation. Only when he was confronted with the
human cost of his behavior and firm, unyielding limitations did he feel the
necessity of reexamining his direction and his goals. It was a long arduous
task requiring constant encounter and close supervision.
56 I R . R . R A U B O L T A N D T. E . B R A T T E R

R EST R UCT U R I NG BE HAVlO R

In creating the disequilibrium and dissonance necessary in the

previous phase a new set of options emerge for the individual client
t o assess his behavior. It is a difficult and frightening process for
those who have avoided emotional discomfort for so long. The thera-
pist must again intervene, as Glasser [ 6 p. 411 states,
“when confronted with reality by the therapist . . . he [the client] is forced
again and again to decide whether or not he wishes t o take the responsible
path. Reality may be painful, it may be harsh, it may be dangerous. This
process involves assessing with the client his continued growth and
development in all areas: social, sexual, educational, vocational, and
physical.”
Two major therapeutic tasks are involved with this component:
1. The therapist is often called upon t o clarify, teach, demon-
strate or model various available behavioral patterns open t o
the client.
2. The therapist must “encourage, persuade, cajole and occasion-
ally insist that the patient engage in some activity (such as
doing something he is afraid of doing) which itself will serve as
a forceful counter-propaganda agency against the nonsense he
believes [ 71 .”
The addict assumes an active role in his own treatment for the
concern is not with the “why” of his behavior but how and when he
will change. He is continually called t o account for his actions and
alter his self-destructiveness. The emphasis is on the present. What is
he doing t o become a more productive, self-reliant, authentic, and
mature adult? Insight alone is viewed as insufficient, for the addict
must choose and then act in order that treatment be successful.
A person’s past remains, at this stage of treatment, irrelevant.
Neither the addict nor the therapist can alter the past. They can
together, however, strive t o change current conditions and redirect
behavior. The addict only changes when his actions change. The
ex-addicts have a saying for this concept; “Act as if.” A person
obtains good feelings about himself after behavior becomes
responsible and self-respecting.

DRAWING UP BEHAVIORAL CONTRACTS

A t this juncture a sense of powerlessness, on the part of the

addict, usually prevails. Previously there was a sense of security, a
pattern of behavior which prohibited growth but shielded feelings.
 THE METHADONE ADDICT I 57

Now with his behavior pattern disrupted he is open t o experience his

own worthlessness. He may experience an inability to influence
people, guilt over past failures, loneliness, anxiety over his future,
and the meaninglessness of family values. More frightening t o him is
a lack of self-recognition and of personal uniqueness. These human
and potentially constructive feelings must be channeled or they will
erupt in violence or apathy. The addict must begin to formulate a
positive concept of self; a personal meaning for his existence if he is
to grow and develop. This sense of meaning cannot merely be
thought about, it must be asserted through behavior. May [8] has
written, “The cry for recognition becomes the central psychological
cry: I must be able to say I am, to affirm myself in the world into
which, by my capacity t o assert myself, I put meaning, I create
meaning. And I must do this in the face of nature’s magnificent
indifference to my struggles.’’ The therapist and addict begin to
formulate goals and create a plan of action, whereby, the addict
begins t o establish a sense of power and realize his personal potential.
It is imperative that once a commitment is made and plan (of
action) agreed upon that a contract be written. The contract implies
accountability which is unique t o the addict. Previously most
parents, doctors, teachers, and therapists had labeled the addict as
“sick” and helpless. His actions were considered beyond his control
and, therefore, the addict owned no sense of responsibility for them.
The contractual agreement alters this passivity by placing demands,
expectations, and equally important, consequences on behavior as
would be the case with any mature and responsible adult. The
contractual agreement works best when it is written out and based
on sequential, progressive action (behavior). By placing the agree-
ments in writing it guarantees clarity and commitment. Both addict
and therapist are clear on what is expected of each and the
consequences for failure. This written agreement also solidifies the
behavior and gives the client a better perspective and grasp of the
situation and where he is headed.
It is based on sequential action for two major reasons:
1. By constructing small and manageable components the client is
encouraged and challenged about his chances of success.
Self-confidence is not at this point fully established and must,
therefore, be built firmly on a solid foundation.
2. Establishing sequential contract conditions allows for the
therapist to raise continually his demands and expectations
furthering growth and development. The therapist, consistantly
demanding more, conveys a confidence in the addict’s
58 I R. R. RAUBOLT AND T . E. BRATTER

capabilities and potential. This is usually accepted by the

addict as an ultimate expression of caring and involvement as
opposed to the possessive demands of his parents.
Peter: Peter entered into one such behavioral contract to cease using cocaine.
He could, until this time, refrain from cocaine for no longer than a six week
period. His initial contract stipulated: 1) daily attendance at the clinic for
eight months, 2) no association with any known addicts, 3) attendance at all
group therapy sessions (three times weekly). Upon fulfillment of these
conditions the contract was renegotiated to its current status: 1) clinic
attendance three days weekly, 2) secure and maintain full time employment,
3) continued attendance at all group therapy sessions, 4) termination of
friendship with anyone currently using drugs. Since beginning the contract
system, Peter has not used cocaine to our knowledge, is working full time,
and has begun seeing a young woman who has never used drugs He has, in
addition, mentioned a desire to find his own apartment and fiiish high
school, which will be included in his next contract. (Peter was given an
ultimatum either t o conform to the contract or t o join another program.
While his reasons for remaining may be numerous, this suggests he understood
the necessity of such demands)
Throughout this process the therapist continues to offer encour-
agement and support by acting in behalf of the addict. As a
professional he holds influence, personal contacts, and status which
may provide opportunities for his client. Bratter [9] states,
“in his efforts to Secure direct services the therapist becomes his client’s
advocate, his supporter, his champion, his representative. In many respects
this role is similar to the attorney who protects his client’s interests and
attempts t o negotiate the most favorable deal . . . even at the expense of an
adversary. Manipulation of the environment is believed t o justify the means”
Treatment, at this stage, is best described as a therapeutic alliance
with addict and therapist working together for continued growth and
responsibility. As the addict becomes more autonomous and
self-sufficient he is given less direction and structure. The addict by
this time should have a firm understanding of his personal needs, as
well as, his abilities. He must be encouraged to assert his
independence by developing his own life goals and plans to obtain
them. The therapist for his part offers support and acceptance but
limits his intervention to clarification and advocacy. He also remains
available and informed, should the addict again begin to engage in
self-destructive behavior.

Summary and Results

Addiction may be considered from two distinct perspectives: 1)as
a medical problem (metabolic disorder) requiring medication
 THE METHADONE ADDICT I 59

(methadone) on a permanently scheduled basis to assure social

functioning, or 2) as a manifestation of irresponsible, infantile and
self-destructive behavior requiring medication (methadone) on a
short term basis, while behavioral and attitudinal difficulties are
outgrown.
The emphasis and position of the program are obvious. One year
ago we began implementing a confrontation-Reality Therapy model
with significant results: twenty successfully detoxified patients
(remaining drug free, employed, and no arrests t o date), four in final
stages of detoxification (below twenty milligrams), nine referrals t o
therapeutic communities (three subsequently have left, six remain
drug free t o the best of our information and continue t o attend
group meetings at the clinic), approximately forty of the current
forty-eight members on the basis of urine analysis remain free from
drugs other than methadone and possibly marijuana.
Methadone maintenance, as it currently exists in most of this
country, remains a myth, a cruel hoax, and a fraud. If we are t o treat
addiction we must go far beyond merely keeping our addict
population dependent, passive, and helpless. A confrontation-
Reality Therapy approach offers one option. Reality Therapy,
according to Glasser [lo], “is a system of ideas designed t o help
those who identify with failure learn t o gain a successful identity.”
By demanding accountability, responsibility, and self-reliance we can
foster emotional and cognitive growth, in addition t o a drug free
existence. We have a choice. We can either write off a sizable portion
of our population (300,000-500,000)as hopeless or we can begin t o
develop this vast reservoir of potential manpower. The more
appropriate question may be, can we, as a nation, afford not t o meet
such a challenge?

ACKNOWLEDGMENT
We wish t o express our appreciation to Vernon H. Sharp, M.D.,
our psychiatric consultant, for his encouragement, wisdom, and
constructive criticism.

REFERENCES
1. V. Dole and M. Nyswander, A medical treatment for diacetylmorphine
(heroin) addiction: A clinical trial with methadone hydrochloride, Journal of
the American Medical Association, 193: 646-650,1965.
2. V. Dole, Research on methadone maintenance treatment, The International
Journal of the Addictions, 5(4): 359-363,1970.
3. A. Van Kaarn, Addiction and existence, Review of Existential Psychology
and Psychiatry, VIII(1): 60,Winter, 1968.
60 1 R . R . R A U B O L T A N D T. E . BRATTER

4. W. Glasser, Reality Therapy: A New Approach to Psychiatry, p. 2 2 , Harper

and Row Publishers, New York, 1965.
5. T. Bratter, “The Therapist as Advocate: Treating Alienated, Unmotivated,
Drug Abusing Adolescents,” unpublished paper presented at the Society for
Adolescent Psychiatry, Inc., New York, April 19, 1972.
6. Glasser, p. 41.
7. A. Ellis, Reason and Emotion in Psychotherapy, p. 94-95, Lyle Stuart, New
York, 1962.
8. R. May, Power and Innocence, p. 20, Norton, New York, 1972.
9. T. E. Bratter, Group therapy with affluent, alienated, adolescent drug
abusers: A reality therapy and confrontation approach, Psychotherapy:
Theory, Research and Practice, 9: 4, Winter, 1973 (in press).
10. W. Glasser, The Identity Society, p. 103, Harper and Row Publishers, New
York, 1972.