I learn about the referral process, assessment, Pretreatment, Primary Treatment, Aftercare, DOMINO (Development in Motivation In New Outlooks) and community support from a number of the practitioners at West Glamorgan Council on Alcohol and Drug Abuse (WGCADA) in Swansea. In entering this new world, I learn about a number of key factors that facilitate recovery at this treatment service. (4,367 words)
The late Lawrence Mylan, who ran the Pre-Treatment programme at WGCADA.
In the previous chapter, I described how I started visiting a local treatment agency in Swansea, West Glamorgan Council on Alcohol and Drug Addiction (WGCADA), in order to learn more about addiction, treatment and recovery. After working as a neuroscientist for 20 years, I had closed down my research laboratory because I no longer believed that neuroscience was helping people overcome addiction to drugs and alcohol. I continue to describe what I learnt at WGCADA.
1. WGCADA Referral and Assessment
People with a substance use problem enter into treatment in a variety of ways. They may refer themselves, realising they have a problem for which they need help, or they may be convinced or ‘pressurised’ into visiting a treatment agency by family and friends. They may be referred by their GP or by other health services, or by social services or a housing organisation. They may be referred by some component of the criminal justice system; in some cases, this may be a ‘forced-choice’ (coercion), with imprisonment being the alternative to attending treatment.
It is essential that treatment agencies establish good relationships with potential referral sources, and also look at every opportunity for bringing people into the service. The latter is particularly important for drawing in the so-called ‘hard to reach’, those people who have a substance use problem but who do not have easy access to (e.g. living out in the country), or who are not in contact with, mainstream services in the community.
When clients first attend a treatment agency, they are assessed to determine the nature and extent of their problem in order to help the practitioner plan treatment goals and strategies with the client. The late Griffith Edwards, British psychiatrist and leading addiction treatment expert, argued in his seminal book The Treatment of Drinking Problems [1] that a variety of different forms of information should be collected, only some of which are related to past drug use or drinking, since the client’s problem must be addressed holistically. The information collected should include:
- Current and past use of different drugs (including form of intake, e.g., injecting) and drinking levels; symptoms of dependence; withdrawal symptoms. Monitoring the latter is particularly important with alcohol and benzodiazepine dependence, since seizures that can occur during withdrawal from these substances can be life-threatening.
- Periods of abstinence; past treatment, nature of services and what happened.
- Lifestyle and social stability (e.g., accommodation; vocational and financial background; interests and hobbies); past psychological, physical, or sexual abuse.
- Family background and social support (e.g., where living, family history of substance use problems, drinking and drug use of significant others, dependent children, marital distress, domestic violence).
- Physical health problems, which may require details from a medical check-up (e.g., liver function, blood pressure, nutritional status, viral infections such as hepatitis and HIV, damaged veins).
- Mental health problems (e.g., depression, anxiety, panic disorder, psychosis), with decision to be made as to whether the problems may be the result of the substance use problem or were present earlier.
The assessment process helps the client and practitioner come to a common understanding of the key issues. Some of these issues may not have arisen because of the substance use problem per se, but have been instrumental in the development of the problem.
For example, a person who started drinking excessively to deal with long-term workplace stress might eventually become dependent on alcohol. The impact of the stress would then likely be greater when the person abstained from drinking, increasing the likelihood of a relapse. In these circumstances, a practitioner would likely encourage the person to learn more appropriate coping methods to deal with the workplace stress.
The assessment process helps the development of a shared language for further conversation. It provides an opportunity for the client to step back and review his or her past and present, and hopefully make sense of what may have been a chaotic array of happenings. It also provides an opportunity for the evaluation of risk, not just risks for the client, but also for their family members (particularly dependent children), the practitioner and other professionals, and the wider public.
During the assessment process, decisions must be made on the most appropriate help to offer, in what order, and who should be responsible for providing it. These decisions will depend on negotiations with the client and other agencies. The assessment process should lead to a detailed written record of the information collected, and the agreements between practitioner and client that are reached. Ongoing assessment allows the client and practitioner to monitor progress towards treatment goals.
Fred Tuohy, a senior counsellor at WGCADA at the time, emphasised to me that this assessment isn’t just about gaining information about the nature of the person’s problems and, along with the client, determining their needs and wants, and deciding which of WGCADA’s (or a collaborator’s) services would best help them address those needs and wants.
The assessment is the first part of the therapeutic process. It is about developing a rapport with the client, helping him or her gain trust and faith in the practitioner and agency, and feel that the practitioner knows what he or she is talking about. It is about enhancing the client’s motivation, building up his or her self-esteem and confidence, and instilling a belief that recovery is attainable, and that the recovery process will be enjoyable.
It is important to emphasise that many clients access treatment whilst experiencing considerable shame and guilt about their addictive behaviour, and its impact on their family, friends and other people. They may well be defensive about their past drinking or drug use. Many have experienced considerable stigma and prejudice; heroin users, in particular, are looked down upon by members of society.
New clients are often very concerned how the treatment practitioner will react to them. Some have become isolated because of their addiction and find the social interaction in an assessment to be difficult. Some are ambivalent, sometimes wanting to stop drinking or using drugs, and other times wanting to continue. They may be in denial about the severity of their drug and/or alcohol problem. They are likely wary about what life in abstinence will mean. Will they lose the only friends they currently have? What does a life empty of drink and drugs promise?
All of these factors, and more, make the assessment a challenging proposition for the person looking for help, and for the practitioner conducting the assessment. An empathic, compassionate and courteous approach by the practitioner is essential for creating a strong trusting connection with the person seeking help. The development of a strong therapeutic alliance, a strong relationship between practitioner and client, is essential even at this early stage of treatment.
Fred Tuohy emphasised to me that the first thing he talks about to clients is confidentiality. Doing so up-front helps clients feel more at ease in talking about their drug use and/or drinking.
Fred also tries to instil in the client right from the start of the assessment a belief that recovery is possible. Many clients have lost faith in their ability to achieve goals. He tells them that staff at WGCADA are used to helping people recover from drug and alcohol problems. He and others are in recovery themselves. He also tells clients that recovery can be an enjoyable process; it’s not about ‘white-knuckling it’.
Fred stressed that clients must be offered choices and that they shouldn’t be coerced into treatment. If the client wants to continue using drugs or drinking, the staff suggest different routes for them, such as reducing their intake and using WGCADA’s harm reduction services. However, they point out to the client that addiction is a progressive condition; the more they use drugs or drink alcohol excessively, the more harm they are likely to cause themselves, and the more difficult it may be to stop using and/or drinking.
Among the options discussed are attendance at AA or NA meetings, or WGCADA’s DOMINO programme (please see below). Clients are encouraged to attend as many AA/NA meetings as possible, in part because they provide a support network that can be used throughout recovery.
If the practitioner and client reach the conclusion that the latter needs help from WGCADA, the normal course of events is that they access Pre-treatment, with the possibility of moving into Primary Treatment. Assessments continue for the whole time that the person is involved in treatment, to enable both practitioner and client monitor progress and continue to determine what the client needs and wants.
2. WGCADA Pre-Treatment
Lawrence Mylan, who had been through the WGCADA programme and now ran the Pre-Treatment programme, also emphasised the importance of the ‘therapeutic’ factors described above.
Phase 1 of Pre-treatment, which took place for two hours once weekly for 11 weeks, was basically an education programme. It covered a range of topics focused on addiction and recovery, what different treatment elements were available at WGCADA, the impact of substance misuse on other members of one’s family, and Step one of the 12-Step model: ‘We admit we are powerless over our addiction—that our lives have become unmanageable.’
Like Fred, Lawrence emphasised the importance of the client having hope, choice, and opportunity. Phase 1 of Pre-Treatment gave them the knowledge to make an informed choice about whether they accessed the abstinence-based Primary Treatment, or WGCADA’s harm reduction services (i.e. needle exchange services, substitute prescribing) if they were not ready for the former.
If they choose the latter, they would still have the opportunity of doing Primary later. Lawrence emphasised that whilst many people know they must stop drinking and/or using and want to do so, they are scared of the process. He gently tells clients that the recovery process will likely not be as scary as they fear.
Lawrence gave a series of ‘lectures’ to clients, some of which contained interactive elements. For example, clients wrote down their ‘blocks to recovery’ (factors that impact negatively on the recovery journey) and these were discussed. Lawrence pointed out to me how important it was for clients to participate in these interactive activities. If they were not engaged, their chances of behavioural change were reduced.
Clients could still be using or drinking during this first phase of Pre-treatment. However, they had to be abstinent for the eight-week Phase 2 of Pre-Treatment, which prepared clients for Primary Treatment. Clients looked at AA’s Step one in much more detail, got used to discussing personal problems and other matters in a group environment, had weekly one-on-one counselling sessions, and completed written exercises which they had to read out to the group.
Topics covered in Phase 2 included powerlessness, acceptance and moving forward, and social and personal manageability. Lawrence considered it essential that clients realised that their substance use problem was their responsibility—they often did not admit to this. He tried to stop them running away from themselves, and understand that they themselves must bring about the necessary change.
Lawrence also worked on the clients’ self-esteem. His therapeutic approach was eclectic, in that he used a variety of psychological techniques, as and when needed. He told the clients everyone has a gift, and he helped them tap into their gift and nurture it.
‘They are special people—they are special the moment they walk through that door. I see a person full of desperation, disillusioned… I say, “But you’ve got courage, and if you’ve got courage we can work on that. We can work on your self-worth. I can help you help yourself. I cannot do it for you, but I certainly can help you help yourself.”’ Lawrence Mylan
Lawrence pointed out to me one major difficulty for clients and the agency itself. Pre-treatment had to be limited to a maximum of 18 people at any one time because of space and staff limits. Given the demand for treatment and the success WGCADA had in attracting clients to their service, waiting lists to access Pre-treatment were long. At the time of the profile of WGCADA that I wrote in 2005, the waiting time was on average ten weeks. Accessing AA, NA and/or DOMINO was very beneficial during this waiting time.
3. WGCADA Primary Treatment and Aftercare
The Primary Treatment programme at WGCADA used key principles of AA/NA and the 12-Step Minnesota model. It was based on the disease concept and on the belief that the illness of addiction is physical, mental and spiritual. A holistic approach was used to help the person recover from addiction, and clients underwent considerable self-examination during the treatment process. Clients could not be drinking or using illegal drugs when they entered the Primary Treatment programme.
‘The Minnesota Model is the most rigorous form of self-examination in the world, and this plays a major role in its success in addiction treatment’ Fred Tuohy
Primary Treatment took the clients through the first five steps of AA by means of a structured programme with group therapy sessions (a morning and afternoon session, one day a week), one-to-one counselling (one session per week), education classes, and written assignments on topics such as denial, powerlessness, the damage to others caused by their drinking/drug use, and a person’s ability to handle feelings.
Clients wrote a detailed life story which they read out to their peers. This was followed by an in-depth Life Story analysis. Later assignments focused on topics such emotional immaturity, self-esteem, communication, anger management, and controlling behaviour.
While the programme was structured, each client had his or her own treatment plan, and the model of treatment was flexible and orientated towards the individual. However, clients were expected to attend at least three AA or NA meetings each week. Primary Treatment generally took between six and twelve months, on average seven or eight months. It involved groups of eight clients at most, who were expected to support each other.
Clients then accessed the Aftercare programme, which comprised monthly group sessions and one-on-one counselling sessions. They worked through Steps 6 – 12 of AA and any recovery-related issues that may have arisen. They were strongly encouraged to continue using peer support groups when they finished the Aftercare programme.
The counsellors at WGCADA told me that group therapy was where the real changes take place.
‘I believe that group is the biggest creator of change in the whole recovery process. It works because they [the clients] are not looking at the world through their own pair of glasses, but are being asked to put on someone else’s pair of glasses and look through these. Group therapy is a vehicle of change. It produces the most dynamic changes. It’s no good just stopping drinking/using. There has to be a massive psychic upheaval.’ Fred Tuohy
The WGCADA counsellors used an eclectic approach to therapy, employing therapeutic techniques such as Reality Therapy (a form of cognitive behavioural therapy) and Motivational Interviewing. They also talked about their own personal experiences in recovering from addiction. They believed that this helped clients, in that the latter thought, ‘If he can do it, so can I.’ The WGCADA counsellors I met pointed out that what was key to a client’s process of change was their honesty, open-mindedness and willingness.
4. DOMINO
DOMINO, run by Keith Morgan, a recovering alcoholic, involved a variety of workshops and activities (e.g. cookery classes, gardening, Information Technology (IT) classes, music lessons, basic skills training, walks, camping, etc.).
The project allowed WGCADA clients—whether they were trying to remain abstinent, use harm reduction services, or had just been assessed—to become part of a friendly, caring group, irrespective of their personal circumstances. The clients could begin to feel valued members of a community, despite the negative effects that substance use problems may have been, or still be, having on their lives. Keith believed that DOMINO played a major role in the treatment process for clients.
‘Once the addiction begins to take over, it’s a natural progression for the drug to take over and become your only friend… and the thought of getting back into society is absolutely terrifying… if I can get anyone to mix with anyone at all then, you know, it’s a start.’ Keith Morgan
DOMINO allowed clients to have fun without drugs or alcohol. It helped them overcome boredom and loneliness. They could meet clients further along in their recovery journey, or clients who were accessing a harm reduction service they were unsure about accessing themselves.
DOMINO provided clients with a safe environment where they could ‘find themselves’, build self-esteem, and experience positive feelings of self-worth. It provided hope, a sense of belonging, and helped enhance motivation. Clients could also acquire skills or knowledge that could help their recovery and enhance their general life.
For Swansea DOMINO, twice-weekly gardening sessions took place in Mumbles, on the outskirts of Swansea. The initial reservations of the local allotment owners were soon replaced by a healthy respect, admiration and pride of what WGCADA clients and staff had achieved on their allotments. I soon realised through my visits that the WGCADA allotment was something very special.
Keith also taught clients to play musical instruments and eventually formed a band, the WGCADA Warblers, which performed at the WGCADA Christmas Party. I will never forget one of the clients, a former heroin user, giving a guitar solo like Eric Clapton. His face showed he was in heaven! The WGCADA Warblers also produced a CD of their music.
Keith Morgan running a guitar class at WGCADA as part of the DOMINO programme.
An annual camping trip to Port Eynon on the Gower Peninsula attracted 20-25 campers, and around 150 people turned up to the trip barbecue. Regular nature walks occurred and Swansea DOMINO produced a fantastic booklet on some of the most popular walks. One client was asked by the National Trust to help them develop their booklet.
The 30-week cookery class not only taught clients how to prepare and cook food, but taught them about nutrition and how to how to budget so that they and their family ate nutritious meals. It also ensured one wholesome, nutritious meal a week!
A DOMINO ‘Arts and Crafts’ course, run by two volunteer, ex-students of Swansea University, led to clients creating many interesting pieces of work and completing a mosaic for WGCADA’s newly developed garden.
In the computer course at Neath Port Talbot DOMINO, clients were provided with various parts and taught how to build a computer. They used the computer to write their own CVs and practiced interviews, the goal being to motivate them into a possible future in IT. The clients were given the computers at the end of the course. Clients at both DOMINO programmes were taught how to use a variety of software packages.
A Multi-gym and Fitness course on the Neath Port Talbot DOMINO incorporated many different modules, including circuit training, nutritional advice, and mathematics. Again, there was a focus on writing a personal CV and interview techniques, hoping to motivate clients into a possible future in the leisure industry. As an added incentive, clients were given £250 worth of sports clothing for free.
For a number of the DOMINO activities, clients obtained an accreditation certificate on completing the course. These certificates were a powerful empowerment tool and helped clients progress into further adult learning or employment.
‘I love the DOMINO projects… Clients in all stages of recovery can meet, talk and have a laugh—usually at my expense! This plays a huge part in motivating them to enter treatment, particularly when they are at the stage of, “I know I’m looking for something but what I am looking for?” They meet others in similar positions, make friends and encourage each other—recovery is infectious, and a huge part of that is belonging. That’s one of the most important parts of my job, just being here to talk to.’ Dave Watkins, Drink and Drugs News (p. 12)
5. Dave Watkins, WGCADA Community Support Worker
Dave Watkins, WGCADA Community Support Worker.
Dave Watkins was originally an engineer, but changed career after a member of his family suffered a substance use problem. In simple terms, Dave helped clients with every aspect of their lives that could interfere with progress on their recovery journey. This included helping put a roof over their heads, getting their social security benefits, dealing with legal problems, helping clients with issues relating to their children… and sometimes involved painting walls, or cleaning up vomit! Dave immersed himself in his clients’ lives. He worked with some of the most chaotic substance users you would ever meet.
‘First port of call when I meet a client… make sure they’re warm, fed and have a place to go. Clients are usually very chaotic, so we need to put some structure into their lives and make sure they receive the benefits [social security] they are entitled to before getting them into treatment. It’s like a game of chess and the longer you do it, the better you get. Next form-filling, the bane of my existence: DSS [Department of Social Security], DLA [Disability Living Allowance]. Another phone call: the gas board. Poor Julie, £2K gas bill landed on her doormat. Enough to give anyone a panic especially as she was on a meter. All sorted!’ Dave Watkins, Drink and Drugs News (p. 12)
Dave worked closely with the courts, police, probation, social services, solicitors, the Community Drug Team, hospitals, rehab centres, housing services, GPs and more. He had an extensive contact list.
He persevered through thick and thin with his clients, sometimes over a period of years. Dave believed that everyone deserved a chance and if they were willing to try to improve their lives by accessing WGCADA, then everything possible should be done for them. He also believed that if he could help some of the most chaotic users and drinkers find recovery, then others of the same ilk in the area would step forward and ask for help.
‘Then there’s Sian: sheepishly trying to get my attention, unsure of my reaction to see her back again, numerous detoxes and rehab attempts later. I mockingly shake my finger at her, sighing inside as I wonder what there is left to try with her. I know this much though—never give up, always go the extra mile, or the extra 100 miles as it sometimes turns out. People do get better. We have a quick chat and she tells me her woes of the last few weeks. She’s only been using a little bit, just to get through this difficult time … she’s going to give treatment a real go this time… she means it.
Let’s wait and see I think, almost chuckling at this latest tale of excuses (she can be inventive, I’ll give her that!). But it’s not funny, people die and we have to remember that. It’s so important to be understanding, the illness is so devious and complicated she really believes she can’t live without that hit—or drink, tab, rock, whatever, it’s got her in its grips.’ Dave Watkins, Drink and Drugs News (p. 12)
‘It’s like being a fisherman. I cast my net with tasty bait and see what I can haul in. Some of my catch is ready to move on, some are not and I have to let them go. But they might be ready next time round.’ Dave Watkins
Cheryl Hancock, mother of Becky Hancock—a former psychology undergraduate who worked with me on the Welsh DATF evaluation—asked if she could do some voluntary work for Wired In. I suggested that she follow Dave Watkins for a week—hoping she could keep up(!)—and then write a report. It was a most stimulating piece of writing! Two years later, my daughter wrote an article entitled A Day with Dave, which appeared in the magazine Drink and Drugs News (p. 10).
Both Cheryle and Annalie mentioned that whilst they were ‘tracking’ Dave, people would come rushing up and thank him for helping them in the past. Years later, when I was over from Australia, I was sitting in the King Arthur pub garden in Reynoldston with my children and Esther, Keith, and Dave of WGCADA. I was telling a friend what I have described above about Dave Watkins, but he looked at me sceptically.
As we stood up to leave, someone came rushing up to Dave and thanked him for all the help he had given him some years before. He excitedly told us that he was still sober and had such a good life! We all congratulated him.
6. The Warm Welcome: Esther and Angie
As they worked in reception, Esther and Angie played a critical role in the initial connection of clients to WGCADA. Knowing how much courage it had taken for some clients to approach the agency, Esther and Angie knew the importance of giving clients a warm welcome, and ensuring they felt wanted and cared for from day one. They had to instil hope, and reassurance to the client that they had made the right decision in coming to WGCADA. I cannot emphasise enough the importance of a ‘warm welcome’.
Angie and Esther spent a lot of time with clients (in-house and on the phone), giving them the chance to offload and share before, during and after treatment. They were very much part of the therapeutic process operating in WGCADA.
Angie and Esther also had to deal with the frustrations of clients who were on the waiting list to join one of WGCADA’s services. One of the downsides of running a successful service, with good positive outcomes, was that more and more people wanted to access WGCADA, numbers that the organisation could not cope with due to insufficient funding and staff.
One thing I found particularly galling was that some of the staff, people like Dave Watkins, were not in a permanent job. The agency had to apply for funding for their position each year.
> My Journey: 4. Learning About Addiction Treatment – WGCADA Stories
