First steps toward a solution: innovative approaches by indigenous institutions

Young people have many problems, whether or not they use drugs. They get sick and need medical care. They get toothaches and need a dentist. They get in trouble and need a lawyer. They get lonesome and need friends, plus a place to meet with their friends. They need food and a place to sleep. They get confused and need wise counseling. In addition, if they use drugs imprudently, their problems may become more complex.

The first waves of youthful migrants to Haight-Ashbury in San Francisco, to the East Village of New York City, and to the other youth drug scenes during the 1960s brought with them their full share of such problems, and acquired new ones in the drug scene. To help them with these problems, indigenous institutions arose–– centers that were themselves a part of the drug scene, and that were established to meet the needs of drug-scene participants rather than the needs of the "square" society outside. Some of the institutions were staffed by ex-drug users (some of whom might still smoke marijuana on occasion); others were founded by sensitive adults who recognized hippies as human beings with many human needs.

The indigenous service agencies set up to help drug users are so numerous and so varied as almost to defy description. We shall here describe, accordingly, only a few significant prototypes. We shall consider them at some length and with great seriousness, however; for out of these youth oriented service centers there are currently emerging both the first reliable insights into the nature of the deviant youth drug subculture and the most hopeful approaches toward solving the manifold problems of illicit drug use. In contrast to high-sounding policy formulations at the national level, the drug scene's indigenous institutions are evolving policies out of their day-by-day confrontation with the practical problems of today's young people, including but not limited to their problems with drugs. When effective approaches to this country's "drug crisis" are ultimately adopted, they will almost certainly include solutions currently being pioneered by these informal, loosely organized, and apparently haphazard local institutions within the drug scene itself.

"Switchboards" and "hot lines." During San Francisco's 1967 "Summer of Love," when adolescent "flower people" descended upon the city from all over the United States, a young resident of the Haight-Ashbury named Al Rinker realized that there was an urgent need for a primitive communication system–– a place where young migrants could get answers to pressing questions:

"I'm sick; how do I get to a doctor?"

"I'm broke. Where can I get a pad for tonight? A hot meal? A bath?" "I'm pregnant; now what do I do?"

"My girl friend has just slashed her wrists. Help!"

Parents, too, needed a communications center:

"Where can I find my daughter? She's fifteen, has red hair, and wears lavender-tinted glasses."

"Can you find my son and tell him his mother died last night?"

In an effort to meet such needs, young Rinker publicized his personal telephone number in the underground press and elsewhere; calls promptly came pouring in. Volunteers, some of them drug users, helped him man the phone around the clock. Friends contributed small sums of money. Additional phone lines were installed. The service moved to larger quarters in the Haight-Ashbury. Thus arose one of the first and most urgently needed of the indigenous drug-scene institutions, the San Francisco Switchboard. Similar "hot lines" were soon in operation in other drug centers. Today there are several hundred hot lines, at a rough estimate, operating in towns as small as 20,000 as well as in most large cities. The best of them are concerned not only with drug problems but with the countless other problems young people today confront.

"Rap centers" and "crash pads." Alcohol drinkers have countless places to meet, talk, and drink–– saloons, taverns, cocktail lounges, roadhouses, and night clubs, to mention only a few. The first migrants to the youth drug scenes had only their overcrowded pads and the streets. Help soon came, however, from a limited number of broad-minded churches, neighborhood centers, libraries, and other helping agencies, which set up "rap centers" where young people could meet, talk, rest, listen to music, escape from the streets. Some rap centers took the form of coffeehouses, others adopted other patterns. Many, not all, have rules against using illicit drugs on the premises; * all or nearly all have rules against dealing in illicit drugs on the premises.

* A number of cities in the United States and other countries have also tolerated places–– sometimes called "coffeehouses"–– where young drug users can congregate and smoke marijuana; but these are not subsidized public agencies. "Turning on" has been similarly tolerated at some rock-music festivals and other large-scale youth gatherings. The city of Amsterdam in the Netherlands has gone considerably further; it has made available public buildings and subsidies from tax funds for "rap centers" and music centers (such as the widely publicized Paradiso) where marijuana and hashish are publicly smoked. Many visitors to Amsterdam are amazed by this tolerance. One explanation is that city officials want to keep young people off the streets; another possible motive may be a desire to strengthen the marijuana-hashish culture at the expense of the opiate culture, the amphetamine culture, perhaps even the alcohol culture. Perhaps, too, Amsterdam's city fathers genuinely want to help meet the needs of young people as they try to meet the needs of other segments of the population. The fact that Amsterdam's young people have their own political party and elect their own representatives to the city council is probably also relevant. it is possible that the recent lowering of the voting age to eighteen here in the United States may have similar results.

"Crash pads"–– that is, rooms with cots or at least mattresses where young migrants can spend a night or two–– have similarly sprung up within the drug scene, in association with hot lines and rap centers or independently, sponsored by churches and other helping institutions or founded by drug users themselves. The rap centers and crash pads may be staffed by concerned volunteers, or they may boast a paid (minimally paid) staff of "indigenous nonprofessionals."

The useful functions of these centers are numerous. For one thing, they serve as news centers where young people can find out what is going on. (The scene is rarely the same from one season to another; new drugs, new ways of using and misusing them, and new nondrug problems are constantly turning up.) The centers also disseminate important information such as warnings against a fresh shipment of worthless drugs, or of especially damaging drugs. Again, these centers are the places where peer standards are generated and peer pressures applied. The pot smoker who stays stoned all day, for example, or the "head" who drops acid too often, or the "speed freak" who shoots too much amphetamine over too long a period, or who engages in other forms of self-defeating, group-endangering behavior, can here be called to account by his fellow drug users.

Such peer pressures within the drug scene are far more effective than official or educational warnings. They do not, it is true, work miracles. They do not convert a compulsive drug user into a total abstainer. But neither does the conventional warning: "If you take LSD, you'll end up in a mental hospital." The goal of the rap centers, crash pads, and other indigenous drug-scene institutions is to minimize the damage done to young people by drugs and by other adverse influences. This goal, however modest, has at least the merit of being achievable.

The need for meeting places for young people was set forth in a speech by Canada's Minister of Health John Munro before the British Columbia Medical Association on October 5, 1970:

Most of all, drop-in centers–– drug-free, harassment-free spots where young people can come around to mix and talk with people whom they consider their brothers and sisters–– are an absolute must. Many people feel that their development should go hand in hand with the erection of the proposed national hostelling network. ¹

This Munro speech, quoted further below, is particularly important because it demonstrates how a wholly new approach to the problem of illicit drugs, replacing traditional methods of repression, can be made politically palatable to voters. The Canadian Medical Association Journal, which called it "one of the most forceful and understanding speeches of [Munro's] political career," reprinted it at length in its November 7, 1970, issue.

"Crisis intervention centers." Young drug users, like other human beings, young and old, face crises from time to time. A crisis may be drug-related–– an LSD "bad trip," for example, or a "crash" following a prolonged "speed run." Or a crisis may be simple exhaustion due to sleeplessness and malnutrition rather than drugs. Again, the presenting symptom may be mental depression, drug-associated or not; such depressions can reach suicidal intensity among young people as well as older people, among abstainers as well as drug users.

Such crises outside the drug scene are ordinarily handled by the emergency rooms of local hospitals; and before the rise of the indigenous drugscene institutions we are describing, participants in the youth drug scene also tried the hospital emergency rooms. They also sought help at first from established clinics, welfare agencies, social work organizations, and other helping institutions. With some notable exceptions, however, these agencies proved poorly adapted to the needs of youth-drug-scene participants.

Many established agencies tended to view the crisis as essentially a drug problem, and sought to solve it by persuading the young patient or client to abstain from drugs altogether. Young drug users responded by walking out and staying away.

Many established agencies at first disapproved of the hippies' hair style, costume, sex mores, and style of life generally–– and did not hesitate to make their disapproval known. Young long-hairs responded by staying away.

Many hospital emergency rooms and other established agencies asked questions and adhered to rules and regulations. Many refused to serve minors, for example, without written parental consent. Proof of local residence was also often required. Many participants in the youth drug scene were both minors and migrants; they responded to the questions and regulations by simply staying away.

Many established agencies felt called upon (as required by some state laws) to report drug users to the police. Once such police reports were made, the grapevine spread the news–– and young drug users stayed away.

The youthful drug user who went to an indigenous "crisis intervention center" instead of to a hospital emergency room met with very different treatment. This was his place, set up to serve his interests. No questions were asked. The staffs of the indigenous centers, moreover, gradually learned from day-to-day experience improved methods of handling crises. In hospitals, for example, LSD "bad trips" or "freakouts" and other LSD emergencies were generally treated in the early days by administering tranquilizers and other medication. The staffs of the crisis intervention centers learned instead to "talk a man down," using reassurance, friendliness, diversion of attention, and other simple psychological methods to calm the panic. Only the most serious cases required a physician, or hospitalization. Unlike the hospitals, the crisis intervention centers did not simply turn patients loose after the crisis was over, or call the police. Postcrisis counseling was available–– at the moment when it was most likely to be effective.

"Free clinics." Just as Al Rinker founded the original San Francisco Switchboard on his own initiative, so Dr. Joel Fort founded the first "free clinic" in San Francisco in 1966; and Dr. David E. Smith and a few physician associates, acting as volunteers, founded the Haight-Ashbury Medical Clinic during San Francisco's 1967 "Summer of Love," to meet the medical needs of the youth drug scene migrants. Currently an estimated 50 to 80 other "free clinics," modeled more or less closely on the Fort and Haight-Ashbury patterns, are functioning in major drug centers from coast to coast. Some are subsidized by voluntary contributions, others also receive funds from local health departments. These clinics are "free" in the sense that no charge, or only a nominal charge, is made for services. The term "free" also indicates, however, a clinic free of the traditional rules, regulations, and attitudes.

The following 1970 prospectus for a Montreal "youth clinic" illustrates the principles common to most free clinics:

As you may be aware, there exists today a large population of youth who are not seeking the advice and help of established medical facilities for their problems. These problems include . . . normal difficulties found in that population, as well as specific disorders related to the non-medical use of drugs and to sexual activity, e.g. drug-induced mental disturbances, unwanted pregnancies, venereal diseases, etc.

One approach to the problems mentioned above has been the establishment of "Youth Clinics," organized and directed by the youth population, and located in a community centre setting, which patients do not regard as foreign or hostile. 4424 Youth Clinic is such an establishment and is now in operation. It is permanently staffed by a physician and a psychiatric social worker. Clinics are held in general medicine, gynecology and psychiatry. Additional staff work on a voluntary basis and include residents from the Queen Elizabeth and Montreal Children's Hospital as well as volunteers from the youth centre. A full range of medical services is provided; referrals to specialists in the outpatients' departments are made when necessary. There is no fee for service and medications are provided free of charge if the patient is unable to pay.

One of the major factors in the success of this type of clinic is that complete confidence between patient and doctor is maintained: parents are not informed without the knowledge of the patient.

The aim of the clinic is threefold:

1. Treatment

2. Prevention

3. Crisis Intervention

Typical illnesses treated include mouth and chest infections, skin diseases, allergies, venereal infections, etc. as well as psychiatric problems of adolescence and disturbances related to drug use.

Prevention Includes the Following:

1. Information on drug hazards given in a factual and non-dogmatic manner, i.e. the most recent scientific data concerning drug hazards.

a) dangerous drugs currently being sold in the street.

b) procedure in case of bad drug reaction.

2. Information on venereal disease and birth control.

3. Drug information to parents and the community at large, thus narrowing the "generation gap" aspect which motivates many youths to risk taking dangerous drugs to defy their "straight" parents.

Crisis Intervention will include a 24 hour telephone service where a doctor can be reached to treat a bad drug reaction, as treatment in hospital emergency wards are not only often inadequate but may even be detrimental. ²

By common consent, anyone coming to a free clinic for help is deemed to be eighteen years of age–– or whatever age is locally required for treatment without parental consent. There are no local residency requirements. No unnecessary questions are asked. The police are not informed. If requested, only the patient's nickname is recorded. Even the shabby psychedelic decor of the clinic is designed to make participants in the youth drug scene feel welcome and at home. The physicians staffing the free clinics are mostly young volunteers who give their spare time or else are minimally paid; few have short haircuts or other stigmata of respectability.

Canada's Health Minister John Munro vividly described these free clinics, known in Canada as street clinics, in his 1970 address:

Perhaps the best answer is one which blends in emergency drug care with the rest of the spectrum of medical practice. I refer to the street clinic. After all, many illnesses crop up among drug users which are only indirectly related to the drugs they take. They come more from the dropout life-style of the heavy user, which is itinerant and mendicant. They include malnutrition from a diet rendered insufficient either by personal poverty or by the type of drug used. They also include the full gamut of respiratory ailments, from coughs and flu to chronic bronchitis and pneumonia, stemming from over-exposure to inclement weather in inadequate clothing, and compounded by nutritional deficiencies. They also include VD. They include hepatitis and other varieties of vascular infection resulting from dirty needles.

To deal with this constant demand for basic health care, the street clinic locates itself in the neighborhood of its primary clientele. As a matter of fact, its staff members may more closely resemble the clientele than they do regular health personnel. As in one case we ran into recently, the central doctor may have shoulder-length hair, and wear a headband and serape. So located and staffed, the clinic takes care of medical problems of all varieties, not just crises. And it doesn't require documentary proof of Medicare coverage * before extending treatment. Thus it is more than a clinic; it is a refuge for those who are not welcome at numerous regular sources of care, or mistrust them, or want at all costs to avoid the identification procedures which are followed there.

* Medicare in Canada covers all ages.

Thus, these centres are vital, and I hope that they will spread. I also hope that their development is plotted hand-in-hand with municipal and regional health planning agencies, so that the clinics have the necessary back-up for major cases, which may lie beyond the scope of their own capacity. ³

The quality of the medical care delivered by these free clinics is not always high; but it gets delivered. In the process, it subtly affects the attitudes and behavior of youth drug scene participants. A warning against a new drug shipment which has just hit town, for example, achieves an altogether different credibility rating if it comes from a free clinic rather than from a traditional agency–– for several reasons: First, the free clinic does not destroy its own credibility by issuing unrealistic warnings. Second, the free clinic has earned respect as a truly helping agency; its warnings are therefore perceived as designed to serve the best interests of drug users themselves rather than repressive goals. Third, the free clinic's advice is based on its own experience. It can therefore be readily confirmed by a drug user's personal observations within the scene. Much the same is true of warnings circulated by other institutions indigenous to the drug scene; but because of its medical orientation, the free clinic is the most authentic source of reliable drug information, and is perceived as such by its patients.

Most medical problems handled by the free clinics are not drug-related at all. Indeed, when asked what service drug users need most urgently, clinic physicians often cite dental care.

As the free clinics and other indigenous institutions have established their usefulness and earned respect from both the "square" and the "hip" communities, they have been increasingly successful in bridging the chasm between drug users and established institutions. The clinics have accomplished this in part by interpreting the drug users to the established hospitals, clinics, welfare and other agencies, and in part by interpreting the established institutions to the drug users. As a result, patients and clients requiring medical or other services beyond the scope of the free clinics are now being referred to established institutions with much less of a "hassle," and with greater likelihood of a favorable outcome. Where drug users feel they are being treated unfairly, the free clinic can sometimes intervene effectively in their behalf.

Comprehensive drug scene centers. The newest, rarest, and most hopeful development among the drug scene's indigenous institutions is the appearance of a few comprehensive centers combining all of the functions described above, from hot line and rap center to free clinic–– and offering in addition a wide range of other services including education and prevention. In particular, these comprehensive centers are concerned with two as yet unanswered questions:

How can emergence from the youth drug scene be encouraged and facilitated?

How can the recruitment of additional participants be discouraged?

Some comprehensive center approaches to these questions will be described in the following chapters.

Are these indigenous institutions, from hot lines to comprehensive youth centers, worthy of public support–– even though their primary goal is to help drug users rather than to repress drug use? Canada's Minister of Health John Munro eloquently stated the case for generous support in his 1970 speech:

After all, it is our children we are talking about. And some of the drug users of today will be the leaders of tomorrow. Will they come to power with a fierce dedication to destroy everything we now represent–– the good along with the bad–– because of the way we now treat the drug problem? Or is there still time to show them that the "system" is flexible enough to understand them, help them, and accommodate their valid opinions about the necessity of social change? ⁴

Footnotes
Chapter 65

1. John Munro, in Canadian Medical Association Journal, 103 (November 7, 1970): 1100.

2. Interim Report for 4424, Inc., Youth Centre Clinic, Montreal (1970); unpublished.

3. John Munro, in Canadian Medical Association Journal, 103: 1097.

4. Ibid., p. 1102.