In the early 2000s, I saw how different addiction treatment services operated in Wales. Here, I outline the approach adopted by the government-led addiction treatment system, which was heavily influenced by the 1998 UK Drug Strategy, and describe some of its shortcomings. I discuss what I saw at West Glamorgan Council on Alcohol and Drug Abuse (WGCADA) in Swansea in relation to ideas related to self-healing and the therapeutic process. (2,962 words)
In the last six parts of My Journey I have described various community activities in which I was engaged, both at a local and national level, in the few years after I left the neuroscience field in the year 2000. In this chapter, I reflect on various aspects of these activities and on the environment in which I now worked.
1. Early Reflections on Addiction Treatment
‘Step by step that change is happening and Britain is becoming a better place to live in. But it could be so much better if we could break once and for all the vicious cycle of drugs and crime which wrecks lives and threatens communities.’ Prime Minister Tony Blair, 1998
What was happening in the addiction treatment field was heavily influenced by the UK government’s 1998 drugs strategy, Tackling Drugs to Build a Better Britain, which classed the drug problem as a criminal justice issue, rather than a health/social issue. The UK Government’s priority for drug treatment was to provide methadone, a long-lasting heroin substitute, to people who were addicted to heroin, believing that this would reduce the crime that they perceived was caused by heroin addicts.
In fact, the reality of the situation was that only a small proportion of heroin users carried out large amounts of acquisitive crime to finance their addiction. And heroin was only one form of drug problem. The largest problem was in fact caused by a legal drug, alcohol, which was not covered in this strategy document.
It was sad that the UK government’s focus was on reducing crime, rather than on the well-being of people affected by problematic substance use. It was ironic that I had moved away from a medical field, only to find myself working in a field where a good deal of addiction treatment was medically-based. Most heroin addicts who accessed the treatment system were maintained on methadone, which alleviated heroin-induced withdrawal symptoms without producing a heroin-induced ‘high’, and therefore were still addicted to an opioid. Some people called this a state-sponsored addiction.
The Audit Commission’s report Changing Habits: The commissioning and management of community drug treatment services for adults, published in 2002, stressed that many people with a substance use problem struggled to get the help they needed. The study of adult treatment services that was conducted in ten areas of England and one in South Wales in 2001 found a common set of problems that reduced the scope and quality of care for individual clients.
These problems included: long waiting lists and limited treatment options which drove potential clients away; care management often failing to address client’s wider social problems, and some treatment being delivered inconsistently or not in line with good practice.
Joint working between treatment services and other agencies was patchy. Two-thirds of GPs did not have easy access to specialist support and one-half were reluctant to prescribe substitute drugs. Poor links between mental health services, housing services and prison meant that some drug users with complex problems did not get the help that they needed.
My own research early in the millenium, carried out in collaboration with Sue Morgan (former Director of the Welsh Drug and Alcohol Unit) and retired GP Pat Bradley, revealed that the majority of GPs in the Swansea area with whom we interacted did not feel that there was a sufficient commitment of support from the National Assembly for Wales and the local Health Authority for a joined-up approach in the community to tackling substance use problems. They highlighted a number of problems with the current system.
In 2001, the Labour government created the National Treatment Agency for Substance Misuse (NTA) to help deliver ‘timely, effective treatment’. Although part of the National Health Service, the NTA was jointly accountable to the Department of Health and Home Office Ministers, ‘reflecting the Home Office lead for drug policy within government and the highly significant contribution drug treatment can make to crime reduction’.
Local partnerships—Drug Action Teams (DATs), or Crime and Disorder-Reduction Partnerships (CDRPs)—were charged with delivering drug treatment in the 149 local authority areas in England. They were to ‘understand the needs of their population and create a treatment system able to match that need.’ In Wales, these partnerships were known as Drug and Alcohol Action Teams (DAATs), since there was no separation between the drug and alcohol strategy.
Embedding drug treatment within the criminal justice system was based on the dubious assumption of a causal connection between drugs and crime that assumed once people were ‘cured’ from their addiction criminal activity would cease. However, the relationship between drugs and crime is far more complex than perceived by government. Despite this, government started to roll out criminal justice-related treatment programmes nationally, such as the Drug Interventions Programme (DIP), Arrest Referral Scheme and Drug Treatment Testing Orders (DTTOs) programme, without completion of evaluations of pilot projects.
Much of government-financed addiction treatment was now driven by a criminal justice agenda and a prescription-based service. Counting the number of people being given methadone, rather than trying to determine how many people were overcoming their drug problem, became the priority for the UK government (and the National Assembly for Wales).
I started to hear more and more disturbing stories from people on methadone programmes. The young man who was put on methadone as part of his Drug Treatment and Testing Order (DTTO), who when funding for the position terminated, was left high and dry with no methadone.
The young couple who came to see me in my university office, saying that when they asked to be put on a methadone programme to help them get off heroin, they were told by the treatment service (not WGCADA) only he could receive the drug. He had a criminal conviction and she did not! The service could not offer her any help. (People used to ‘joke’ that if you wanted help for your heroin problem, go and break a window or burgle a house.)
A number of people on methadone programmes complained that they got no support (other than their prescription), or at best a 20-minute interview with a drug worker every two weeks, to address their substance use and other problems in their life. Research by David Best, someone I hold in very high regard, and colleagues revealed that clients receiving methadone in Birmingham typically were seen twice a month for 45 minutes each session:
‘… activities that were typically undertaken were case management activities around prescription management, drug testing and results, compliance and sign-posting. There was very little time available for, and commitment to, delivering evidence-based psychosocial interventions. In other words, what is called treatment, for the majority of clients on substitute prescribing, is in fact ‘a script and a chat.’ [1]
I am not criticising the use of methadone per se. Methadone can play an important role in some people’s lives. However, much of the treatment system had a paucity of ambition for the people who were turning towards it for help. And many practitioners appeared to have little idea of how to help people find recovery. Moreover, a number of people trying to overcome heroin addiction complained to me that practitioners they visited just ‘knew stuff from text-books, not real-life stuff.’
One thing that struck me in those early years was the pessimistic nature of much of addiction treatment—with notable exceptions of course—and the lack of goals of positive expectations. As David Best pointed out in the chapter above, two mantras predominated in much of the system: ‘addiction is a chronic, relapsing condition’ and the aim of harm reduction maintenance is to ‘keep people alive and out of jail.’
At the same time, the NTA had the mantra that ‘Treatment Works’, as if there was one type of treatment delivered and that all people got better. And if they did not get better, it must be their fault. This mantra was earlier used in the US treatment system—with disastrous effects. The general public saw that few people were recovering from addiction in a treatment system dominated by short-termism.
People with a serious drug problem need hope, choice and opportunity. What many of them got was a long wait to access treatment, a pessimistic treatment environment, little or no choice and minimal opportunity. They were already being judged by society for their drug use and this judgement would continue in treatment. ‘Once a junkie, always a junkie’ were words I heard from some practitioners.
The negativism in the UK treatment system contrasted with what I read in the excellent book by James McIntosh and Neil McKeganey, Beating the Dragon: The Recovery From Dependent Drug Use. The authors described their research with 70 people in Scotland who had been able to recover from drug addiction. The great majority of this sample had been dependent on opiates, but were described as poly-drug users since they used a variety of drugs at the height of the addiction.
Interestingly, American researchers have shown that people can recover from heroin addiction without treatment. For example, Patrick Biernarki conducted research in 1986 with a sample of 100 people who overcame their heroin addiction without treatment. In the 1970s, Lee Robbins and colleagues reported that a significant population of American servicemen became addicted to opiates (heroin or opium) during their time in Vietnam. However, in the first year after returning to the United States only 1% became re-addicted to heroin, although 10% tried the drug after their return. You can read a copy of the original research by Lee Robbins and colleagues here.
Sadly, very few people I met working in the addiction treatment field had ever heard of the research described above.
Biernacki emphasised the absence of recovery models for the people participating in his study. ‘There is little, if any, subcultural folklore to give them insight into how they might go about ending their addiction. In fact, they may feel they are treading a path on their own.’
If a treatment agency is seeing few, if any, people recover from addiction, in part due to negativity in their treatment environment, and is not promoting the idea that people do recover from addiction, then they are going to continue to see few or no people recover. How many people who later recover from heroin addiction would go back to an environment that they found ‘unhelpful’ at an earlier time?
The positivity and ‘examples’ of recovery I saw at WGCADA, and later Burton Addiction Centre (now BAC O’Connor Centre), meant that service clients could gain hope that they could recover. Their presence or ‘aura’ was still in the treatment environment.
2. Reflecting on My Early Experiences at WGCADA
I learnt a lot about what people need to help them overcome addiction in those early years, in particular from a number of practitioners of a local treatment agency in Swansea, West Glamorgan on Alcohol and Drug Abuse (WGCADA), as described in Part 2 and Part 3 of My Journey series.
What I learnt from the latter group wasn’t just because they were practitioners working in what appeared to be a successful treatment agency. The were actually in recovery from addiction themselves, or had a family member who was in recovery. They talked about addiction and recovery from their own personal experience and from what they had seen work (or not work) for other recovering addicts with whom they had interacted closely. In those early days, I also interacted with people who had come to WGCADA seeking help with their problem(s).
I ask you to picture the situation that was occurring at WGCADA at that time. Here was a professor from the local university in his mid-40s, someone who had lived a reasonably privileged life and had a nice house on the Gower Peninsula, interacting with people who had serious problems with heroin and other drugs, and/or alcohol, as well as a wide variety of other problems. These problems included having no roof over their head, no money and no loving relationships, even with family members. These were people who were looked down upon by society; some had been abused as youngsters, some had tried to kill themselves. It was such a very different world to what I was used to.
I have to confess that I was a little nervous when I first started visiting this very different world. I also felt humbled by the fact that I was being allowed into such a place and into the lives of people who had experienced so much adversity. And who were trying to overcome what I soon learnt were very serious problems.
I was very grateful for the way that I was initially received by staff and clients, and by the ease with which some of the clients opened up to me. It was an exciting new world and I was energised by what I was soon learning. The atmosphere was so different—refreshing would be a good way of describing it—to what I generally experienced in my university department, an environment with a good deal of arrogance and pettiness expressed by some of my colleagues.
I was later told that my enthusiasm and passion, desire to learn, and caring nature impacted on the clients. I tried to treat the people I met as equals. When I think back now, the adversity that I had faced in some very difficult situations in the university—I was a witness in serious malpractice cases by a senior colleague—and the negative impact that this had on my own emotional wellbeing, probably helped me to identify to some extent with the adversities that clients had gone through and were still going through. I loved going down to WGCADA and hanging out.
Later, my oldest son Ben attended a school a few buildings away from WGCADA and I would often take him and his younger brother Sam down to see their friends at WGCADA after school finished. They loved meeting Angie, Esther, Dave and Keith, and were treated like they were part of the family.
My early experiences at WGCADA resonated loudly with me when some years later I read How Clients Make Therapy Work: The Process of Active Self-Healing, a seminal book written by Arthur C. Bohart and Karen Tallman and published by the American Psychological Association [2]. The following quotes are particularly pertinent.
‘The client is a creative, active being, capable of generating his or her own solutions to personal problems if given the proper learning climate… therapy is the process of trying to create a better problem-solving climate rather than one of trying to fix a person.’ p. xi
‘The most important thing that therapists can do to be helpful is to find ways of supporting, stimulating, and energizing client’s investment and involvement. The second most important thing is to stimulate and support powerful client learning and meaning-making processes.’ (p. xiii)
‘The role of the therapist is (a) to provide a safe place; (b) to provide an opportunity for creative, exploratory dialogue; (c) to provide materials and resources that help clients fashion solutions; and to train specific skills when needed.’ (p. 20)
The staff I knew at WGCADA had certainly created a ‘problem-solving climate’ for their clients, through their empathy, understanding and the education they provided (via staff and peers). They connected clients to a variety of sources of support, helped them deal with distractions in life that impact negatively on the recovery process, and facilitated improvements in their psychological wellbeing (e.g. self-esteem, self-belief). They provided a safe environment where the person could look honestly and openly at ‘who they are’ in the context and content of their lives, and do the necessary deep work required to create personal change.
The connection between the people I mentioned earlier— Esther Mead, Keith Morgan, Lawrence Mylan (R.I.P.), Norman Preddy, Fred Tuohy (R.I.P.), Dave Watkins and Angie Welch–and clients at WGCADA was very special. Clearly, this was an empathic group of people who could see the world through the eyes of the people they were trying help. Those staff who were in recovery freely spoke about their personal experiences on their journey when they knew it might help clients. I believe these conversations were of great help to the latter group.
By visiting a treatment agency in their own community, rather going away to a residential rehab centre in another part of the country, clients were able to integrate what they learnt at WCADA into their daily lives in the environment where they were residing and would likely continue to live. They could gain access to other support services and community activities that could facilitate their ongoing recovery.
It must be emphasised that most of a WGCADA client’s healing would have occurred in the community, as they spent only a limited time each week in the treatment agency. This is the case for the majority of outpatient addiction treatment services. As pointed out by Arthur C. Bohart and Karen Tallman in their book:
‘The ultimate healing takes place at home and not in the therapy office, for the most part, as clients integrate their therapy experiences into their lives.’ (p. 20)
Endnotes:
[1] David Best, Mapping Routes to Recovery: The Role of Recovery Groups and Communities. In: Rowdy Yates and Margaret S. Malloch, Tackling Addiction: Pathways to Recovery, Jessica Kingsley Publishers, 2010.
[2] Arthur C. Bohart and Karen Tallman, How Clients Make Therapy Work: The Process of Active Self-Healing, American Psychological Association, 1998.
