Forty-three homeless, chronic alcoholics and drug addicts stand in the stuffy basement room of an old government building, now the Federal City Shelter, at Second and E streets NW in the District. The men and women have just been admitted as Group 41 to Clean & Sober Streets, a long-term drug and alcohol rehabilitation program that charges nothing for stays that may last a year or more. Sweat, body heat and lived-in clothing make the air humid. It smells.
Even though each person has been through a week of Twelve Step meetings from Alcoholics Anonymous--a requirement of the program--most still wander on the far side of recovery. It's there in the eyes, in the jittery hands.
Six weeks later, 37 of the original group sit in two rows of almond-colored plastic chairs in a second-floor cafeteria. They face an audience of family, friends and previous graduates at their "step-up," or graduation, ceremony. Having completed the first phase of treatment, they are a changed group. Some invisible hand has wiped each face, smoothing away frowns of misery and lines of anger. Eyes once dull and bloodshot are focused and clear.
A social worker or physician might say these people are sober thanks to a period of stabilization, housing, counseling, group therapy, regular meals and sleep. But as they received their certificates, each one explained the improvements in blunt spiritual terms.
"God rescued us body and soul from alcoholism so we could love one another unconditionally the way He loves us," declared one woman. Residents spoke on a first-name basis since all are members of Alcoholics Anonymous or Narcotics Anonymous and follow AA's tradition of anonymity. Other graduates thanked a "higher power," in keeping with the nondenominational spirituality embraced by most Clean & Sober residents and which is embodied in the AA philosophy.
With four full-time staffers and a $300,000 budget based on contributions but no government money, Clean & Sober Streets Inc., a nonprofit agency, admits more than 100 people a year. There are no fees or residency requirements. Clothes and equipment are donated. The bulk of its funds come from three Washington philanthropies--the Morris and Gwendolyn Cafritz Foundation, the Arcana Foundation and the Public Welfare Foundation.
At any given time, there are 80 residents in the program. Since 1988, Clean & Sober has treated 1,500 people. Most are from Washington, although some have come from as far away as New Jersey and Florida.
In a dozen informal surveys conducted by Marsh Ward, the program's clinical director, between 50 and 75 percent are still drug-free or sober as long as two years after graduation.
Anne Allen, executive director of the Cafritz foundation, which has provided grants since 1991, praised the group's "enormous success rate." "We've funded a number of other programs and their success tends to be 50-50," she said.
Clean & Sober's results are being evaluated by the federal Substance Abuse and Mental Health Services Administration as part of a national initiative to improve addictions treatment. Initial results "are very good," said Joann Bennett, an evaluator for Westat Inc., a Rockville firm under contract to the federal agency. Bennett is checking on a group of 30 graduates every six months for three years. According to her first round of visits, she said, "most are staying clean and sober."
Although her research is incomplete, Bennett ranked Clean & Sober among the leaders of 15 treatment programs she has evaluated in the Maryland-Washington area.
Clean & Sober differs from mainstream treatment in several ways. The absence of fees and the small operating budget are among the most noticeable. "They do a great deal with very little," said Joan Kennan, executive director of the Arcana Foundation. Personnel costs typically are the largest single expense at mental health or treatment agencies. At Clean & Sober, Kennan said, staff members "get paid very little."
Marsh Ward noted that Clean & Sober saves by not having the resident psychiatrists and psychologists, counselors, nurses and other employees who staff mainstream, 28-day programs that can cost as much as $300 per client per day. Medical care and psychiatric assistance are provided by Unity Health Care, a medical agency for homeless people.
Since it is not a federally certified treatment center, Clean & Sober does not have to meet such requirements as one nurse per 12 residents. In addition, the program receives its space, heat and electricity as a donation from the District government, said Henry Pierce, Clean & Sober's development director. And for several years, the local branch of AmeriCorps, the national service program, has sent over volunteers to help with clerical, computer and other tasks.
Another difference is the simple admission procedure: Show up on time on the day of interviews; attend a week of AA or NA meetings; come back on time for the admission. "If you come to us and say you're ready to change, we'll take you," said Ward. Most private programs require insurance and extensive interviews. Public programs for the poor usually expect "a person to have a police clearance, be on welfare or Medicaid, have had their tuberculosis tests," said Pierce. A former heroin addict who came to Clean & Sober to quit methadone, he stayed on as one of the four staffers. "At our interview, you don't have to have all that done. We'll do tests later and get them medically fit once they're here."
Clean & Sober eschews the use of antidepressants and other psychiatric medications. The program also lacks the niceties of other residential programs, such as staff chaplains or nurses, private rooms or vans for transportation to outside AA and NA meetings. At Clean & Sober, they walk.
One homeless man, 38, entered the program last May as part of Group 41 with a broken knee and yet another arrest for drug possession. Previously, he had gone through treatment programs run by the Salvation Army and American Rescue Workers, but relapsed after each.
"I'm trying to figure out why I keep going out," he said, using a popular phrase for relapse. "I always wanted to stop but I couldn't." He knew friends from the streets who had successfully emerged from Clean & Sober. "You come in here and see what you're missing," he said.
How change happens remains "the million-dollar question," said Julia Lightfoot, the executive director. "What people get here is the transformation, after having endured a lifetime of criminality, abuse, neglect."
Ward, the clinical director, cited several factors that help people change at Clean & Sober. "The people sitting in the alley are absolutely desperate, and that's the first ingredient," he said. "The second ingredient is to take all the chemicals out of their system. In about three weeks you have the return of some of the basic human qualities that go into making them spiritual creatures." These include caring for others, a sense of family in the group and a desire to be honest regarding their pasts and personalities. "They find out they want this closeness with others, and the price they have to pay is to be honest," Ward said.
Key in the process are the spiritual elements of Clean & Sober. As the 38-year old resident put it, "There's got to be something outside myself, something that got me here. I can't do this on my own."
Six weeks later, the man's smile appears permanent. "I see a spirit, a spirit of doing right," he said. He also cited graduates who shared their experiences.
"The alumni coming back and talking about what life is like now, sober, that's the essence of the program," Ward said.
Clean & Sober was founded in 1987 by Julia Lightfoot and Marsh Ward, both recovered alcoholics. "They know I know what I'm talking about," said Ward, who is also a psychotherapist. He served for seven years as director of the Minnesota Security Hospital, a state psychiatric institution in St. Peter, Minn.
The program has four phases. Phase I lasts six weeks and aims to stabilize residents mentally, physically and spiritually. During Phase II, which lasts 90 days, residents develop independence and vocational goals. During the six-month Phase III, residents find outside jobs and start working while also helping newer residents. Phase IV lasts three to six months, during which residents move out.
Rules are strict: one drink, one romance with another resident, one missed curfew or meeting and they're out. The idea is to concentrate residents' attention on personal rehabilitation by avoiding distracting entanglements. Experience showed that people who break the rules tend to keep misbehaving and hurting or distracting other residents.
Ward and Lightfoot also noticed that residents who did well were going to nine or 10 outside meetings of Alcoholics Anonymous or Narcotics Anonymous a week, so now all are required to attend that number. Successful residents were not taking overnight passes, so the staff eliminated passes.
In residence, people cook, clean and help run the program. Veterans guide the newer residents and staff administrative committees.
Four times a year, alcoholics and drug addicts line up at dawn outside the building to be interviewed for admission. Ninety showed up for Group 41. The first 63 were interviewed and the rest turned away either because they had missed the 6 a.m. deadline or were not willing to fulfill other requirements. According to Pierce, three questions are asked of each applicant: "Do you have a problem? What is the nature of that problem? What are you willing to do about it?"
Those accepted from the 6 a.m. lineup are told to come back a week later, and to attend three Alcoholics Anonymous and/or Narcotics Anonymous meetings a day in the interim.
"It's another test of willingness," said Pierce. In the end, 43 of the 90 were admitted and 37 made it to the step-up ceremony. By comparison, a 1989 National Institute on Drug Abuse survey of 11,000 drug abusers who went through treatment reported "a relatively high dropout rate in the first weeks of treatment."
Limiting admission to those who agree to fulfill certain requirements raises the chances of success. "The devastation in their lives makes for some real motivation," Pierce explained.
Each day begins with a period for meditation, followed by a community meeting for announcements and the airing of any residents' grievances. During Phase I, the group has virtually no contact with outsiders for six weeks. They gain an average of 20 pounds each thanks to meals prepared on site.
They also exercise, attend lectures on anger, addiction and HIV/AIDS prevention. Ward provides residents with group and individual counseling and family therapy. Residents receive training in money management and how to apply for disability and other welfare benefits from Unity Health Care and Unity Health Care Social Services.
Phase II adds art and vocational classes and a program to help residents earn high-school equivalency degrees. The final two phases vary in length for each individual as they begin working, finding homes and moving out.
"Most of them are very motivated and most really want to go to work," said Marsha Dubose of the District's Rehabilitation Services Administration, who helps prepare residents for work.
On average, men stay a year at Clean & Sober and women 18 months, "usually because they've just gone down a lot further," Lightfoot said. Low-income female alcoholics and addicts tend to postpone seeking treatment because of their children and may feel more shame than men. Alcohol and drugs also have different physiological effects on women.
Throughout the program, the staff offers a nonreligious, spiritual solution for addiction. "You talk to alcoholics and addicts and they tell you there's this hole there," Lightfoot said. She asks residents: "What makes you feel good? You! Your higher power as expressed in your relations with other people."
For one woman, a nurse's aide who said she once smoked $400 worth of crack cocaine a week, Clean & Sober offered a spiritual experience different from what she had known in her churchgoing youth. After crying "for three weeks straight," she recalled, "I was at an AA meeting and something went through me. I was changed, and I could finally hear people talking to me."
"You have to get honest, you have to work on your character; it's the old-fashioned idea that if you don't have character you can't get spiritual, and without that, the day will come when you relapse," said Ward. "For this group, the sine qua non is spirituality."
Christopher D. Ringwald, a visiting scholar at The Sage Colleges in Albany, N.Y., is writing a book on spirituality in addictions treatment. He researched this article while on a Kaiser Family Foundation Media Fellowship.
CAPTION: Marsh Ward, right, and Julia Lightfoot, left, co-founders of Clean & Sober Streets, lead a discussion.