Out with Orthodoxy

Don’t tell the 40-person staff at the addiction treatment, outreach, and advocacy organization Exponents that terms such as “incentives” and “harm reduction” represent newfangled or unproven ideas in the treatment community. The New York City-based center, with roots dating to a late 1980s grant program targeting parolees with an injection drug use history, was engaged in these kinds of creative strategies for reaching clients long before most of the ideas even had a label.

At a time when many addiction treatment organizations are shoring up a foundation of 12-Step treatment with a variety of supportive services and individualized approaches to improve client engagement, Exponents can serve as a model for being willing to meet the client where he/she is situated—whatever the implications may be.

“We see our role as that of a conduit; we work with people in a noninvasive manner,” says Exponents’ charismatic co-founder and executive director, Howard Josepher, LCSW. “We tell people that we’re not here to modify their behavior and break them down. We can help people to change their behavior and develop new and enduring values.”

From humble beginnings teaching a class of post-release offenders in the basement of a Lower East Side church nearly 20 years ago, Josepher has seen his program of support grow into an organization serving 13,000 in a typical year and encompassing a smorgasbord of treatment, outreach, life assistance, and advocacy services.

From the time he and his cofounders didn’t take a salary for 18 months to their present status as an influential force in New York's drug treatment and policy community, Josepher and his team have consistently infused the organization with outside-the-box thinking. Perhaps that makes sense when one contemplates Josepher's own uncommon path, as a man with several advantages who in the 1960s found himself injecting heroin dozens of times a day and later being one of the first beneficiaries of New York's fledgling therapeutic community movement.

Exponents staff and former clients talk about the sense of belonging that for participants characterizes its programs, many of which are run by those who went through Exponents programs themselves.

“If the newcomer can see someone very much like them who's now making it, that can create the hope and spirit that is necessary,” Josepher says.

Program's roots

Exponents traces its roots to Josepher's being asked by a team of researchers to join a National Institute on Drug Abuse-funded project targeting criminal offenders reentering society. This late 1980s project marked the first time NIDA was focusing on a population of injecting drug users with or at risk of HIV infection, says Josepher, and he recalls the intense stigma that prevailed over how to address this group.

“This was a very dark time; people who were infected were being refused admission to treatment programs because of the fears that existed,” Josepher says. “There were reports that prison guards were wearing scuba gear when they transported inmates.”

At the time, Josepher had been consulting for drug treatment programs in the community and in the New York prison system. Under the NIDA-funded research project, he was asked to help develop the program's curriculum and lead its clinical component, consisting of educational sessions for reentering offenders. Seven men showed up for the first session taught by Josepher in the church basement; the program was known as Project ARRIVE (AIDS Risk Reduction for IV Drug Users on Parole), and retains that name today.

“People coming out of prison did not want a residential [treatment] situation, or an arduous commitment,” Josepher says. “The program we developed was similar to a three-credit college course. “They would come to three two-hour classes a week for eight weeks.”

This was also a time when few offenders who did not know their HIV status wanted to be tested, for fear that another form of prison sentence would be imposed on them if they received bad news. Grant administrators wanted testing to be a mandatory part of the program, but resistance from participants proved so strong that the research team made it optional.

Yet that did not stop Josepher from engaging in efforts to persuade participants to get tested. He even got tested himself, in an attempt to demystify the process for the others.

Soon women began to enroll in the ARRIVE classes as well. Topics covered in the curriculum ranged from HIV education to general health and wellness information to relapse prevention to tools for accessing health and social services in the community. Josepher and his team also had another item at their disposal to encourage participation in the early days: They paid participants $10 a class for their attendance, at a time when offering incentives in this fashion was practically unheard of. The team knew it was better to have people in the learning sessions, receiving the needed information about healthy lifestyle behaviors, than somewhere on the streets.

By the end of the two-year grant period, 167 people had graduated from the educational program, and the classes were supposed to cease. But based on positive feedback from participants and a small waiting list to enroll, Josepher and his team decided to keep the classes going, even without identified funding.

One day, Josepher was telling a friend how each class had gotten larger and had graduated more individuals than the previous one, and the friend remarked that such growth was “exponential.” The reference stuck, and the organization Exponents was born as a nonprofit corporation in 1990.

Broadening the mission

While it is still true today that many of Exponents’ clients are at risk for HIV or hepatitis C, the organization's programs have broadened to embrace a range of individuals trying to reclaim their lives from addiction. In late 1991, the company's reputation in the HIV/AIDS arena helped it win its first public funding as a nonprofit: a $160,000 state grant under an HIV prevention initiative. “It was not our proposal writing that got us the grant; we were complete novices,” Josepher says.

Today, about 80% of Exponents’ funding comes from the federal, state and local governments, with foundations and private donations covering the rest of its expenditures. All services under Exponents are free of charge to the client, with the exception of outpatient treatment that is structured as a fee-for-service program under Medicaid.

“These are mainly inner-city individuals living at or below the poverty level,” Josepher says of the client population. “Many come from the shelter system,” which is also why housing assistance and meals constitute a major focus in Exponents’ programs. More than half of the clients have had some criminal justice involvement.

From the days before Josepher and his cofounders established Exponents, the group decided that total abstinence from substances would not be considered a prerequisite for program entry or retention. It was one of the first questions the leaders asked as they designed the original curriculum, and they knew they couldn’t reasonably shut out from the program the people whose ongoing substance-using behaviors were placing them and others at the highest risk of HIV infection.

“We decided that as long as the individuals were not disruptive, we would take everyone, whether they were actively using or working a recovery-based program,” says Josepher. “We didn’t have a term like ‘harm reduction’ for it—we knew it just was the intelligent way to do things.”

Many members of Exponents’ current full-time staff are program graduates, and nearly half of graduates overall stay with the organization in at least a volunteer capacity. Denise Drayton graduated from ARRIVE in 1991 and began working at Exponents in 1995; she is presently director of education and prevention.

“This was another supportive network that was a perfect supplement to my outpatient treatment program,” Drayton recalls of her experience as a client. Later, “I and another graduate were allowed to establish a class of our own. They put a lot of confidence in you here.”

Drayton sees Exponents as offering the kind of stable environment for which many addicts are longing in their lives. “It's an atmosphere where people feel safe to share,” she says. “In the first week, individuals will talk to someone else for the first time about being HIV-positive. After being here eight weeks, they don’t want to leave.”

Beyond the center's walls

Once it expanded from the original ARRIVE program into an array of treatment and support services, Exponents began to help clients see that they could contribute to a greater good beyond their own recovery as well.

At first, program directors had begun to work with advocates in the gay community to bring public attention to issues related to HIV/AIDS, and began to be seen regularly at rallies and other events in the city. Later, Exponents staff also started to look for ways to involve clients directly in advocacy activity, such as enlisting them to visit policy leaders’ offices to help educate those with access to dollars on the need for more services.

“This helped our people to see that they can have an impact on the system, that they can change the system from within,” Josepher says.

He believes the efforts of many former Exponents clients have been instrumental in achieving significant policy initiatives in New York, such as a state law requiring that syringes be made available for over-the-counter purchase.

Today, many Exponents program graduates sit on various planning councils and are having a direct role in policy-making and resource allocation, Josepher says. The program's leaders say Exponents always has been about seeing limitless possibilities in people whom the rest of society shuns.

“We didn’t just want to hand out clean needles; we wanted our people to grow and change,” Josepher says. “We required people to stretch themselves.”