Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Adam Langer (DP134)

Essential Points

1.What drug services actually treat is being misrepresented and needs to be theoretically clarified by independent qualified experts.

2.The information database of many of the incumbent service providers does not bear up to informed scrutiny, yet is being presented to those with political power as factually accurate.

3.Many of the employees of current service providers do not believe in the working practices they are forced to adopt, yet this voice is not being heard.

4.The inputs that lead to long term recovery from drug dependence are theoretically definable in terms clear enough for politicians to fully understand.

5.The managers and employees of both DAATs and service providers often lack the training and experience for what they do. Many are assuming they can forgo the specialist trainings that relate to working with addicts on the basis that backgrounds in social work, probation and mental health are adequate.

6.Replacement prescribing culture has become distorted, seemingly to plug the hole created by shortfalls of recovery capital within incumbent service providers.

7.The criminal justice system is in need of fundamental reform in terms of the way it addresses dependency within the prison/probation population.

8.NICE guidelines need to be followed.

Brief Introduction of Adam Langer

Background

Born 1964, London. Recreational and then dependent crack and heroin drug user. Experienced both community and residential drug treatment. Abstinent since 1999.

Relevant Training

Advanced Diploma in Integrated Humanistic Counselling (BACP accredited) 2005.

Relevant experience

Administrator for Outside Edge Theatre Company in London. Run by people in recovery from drug/alcohol dependence. Has produced professionally written and performed participatory theatre within treatment centres, community projects, and prisons for the past 10 years.

Counsellor at “Off the Record”. Charitable youth counselling service in London.

Counsellor at Lampton Court Residential Drug Treatment Centre in Devon.

Senior Key Worker for Bethany Project, Barnstaple. Supported Housing service for homeless people with drug and alcohol dependency issues.

Spent the last two years advocating for better drug and alcohol services for Devon.

Professional supervisor: Ursula Carter (UKCP).

Experienced a total of 18 months addiction focused participatory group therapy.

Attended a variety of mutual aid organisations for 14 years (more than 5,000 hours of witnessing the testimony of other addicts), including representing Devon, Cornwall, and the Channel Islands for the largest addiction focused mutual aid organisation at their National committee level.

Factual Information for Improvements to Drug/Alcohol Treatment Services

A brief look at terminology

1. There appear to be a variety of highly subjective representations of what services are actually treating. Though an uncomfortable place to start, a glance at terminology and meaning seems important.

2. “Dependency” and “Addiction” both imply an impaired faculty for choice. Dependency seems to be a statement of circumstance rather than a diagnosis. It begs the question “dependent on drugs/alcohol to do what”?

3. “Addiction” seems to hold two interesting dynamics. The first is its etymological root. Past meanings include “yielding to”, “sacrifice”, “sell out”, “betray”, and “devotion”. Its literal composition, holds, “ad”—to, “diction”—language.

Putting these together; Clients of drug and alcohol services appear to have yielded to, sacrificed themselves to, devoted themselves to a relationship with artificial chemicals rather than their bodies own natural chemistry which they have betrayed (I don’t particularly like these words, but they are the etymological roots listed and seem useful here). They have also stopped expressing themselves in the direction of, “to”, their needs, choosing the direction of artificial chemicals instead. They have become “flat affect”, only expressing emotion in extreme passive-aggressive outbursts. By drowning out the body chemistry that is their emotional content, they have ceased to be motivated to express themselves in accordance with this natural self care system. They do not feel the chemistry of guilt or love even if it exists powerfully within them, so act in ways that hurt the people that matter most, leading to rejection, social exclusion and often homelessness. Thus the distinction between “an addict” and a “non addict” is the compulsive patterning to avoid experiencing the body’s own wisdom.

4. My own experience of clients has led to the belief that dependency is on self medicating overwhelmingly difficult/painful internal phenomena. Behaviour, though apparently choiceful to begin with, has become compulsive to the point that even when primary relationships, and personal health and liberty are being destroyed, the client does not stop. The pain being medicated can be physical, emotional, or psychological, and only at the point when the fear of phenomena such as death become so dominant within awareness that artificial chemicals won’t drown them out, does the willingness to seek help and engage in a process of change becomes possible. This is the stage of “action” within the cycle of awareness, and the state that most clients present.

5. Many service providers respond to this healthy anxiety and readiness for change with fear. They choose overcautious replacement prescribing regimes as a means of short term harm reduction without appearing to understand the consequences of this in terms of medium/long term harm, or the damage to a recovery process.

6. Many years ago I attended a lecture about the nature of emotion. It described emotions as “E”—the energy of, “MOTION”—action. The lecturer described how thoughts on their own do not lead to actions. It is the emotional relationship with phenomena that motivates actions. When a client’s emotional experience is dominated with mood altering chemicals (including replacement therapies), they do not experience the necessary anxiety needed to motivate self care.

7. Causes: Some people believe that there is an addictive gene, others that addiction is related to trauma, and some hold spiritual beliefs that explain addiction as something of that domain. Using an informal disease model (not a conventional medical disease), avoids the problem of trying to define something that is experienced so subjectively. Current treatment options are not reliant on a particular causal root.

8. As a trained counsellor I was taught to trust the “Self Actualising Process” of the client. This concept, born of the Person Centred model of psychotherapy holds that all people are meeting their needs as well as they can within their frame of reference. When given the chance to express and explore their frame of reference more fully their self awareness grows and they make more self enhancing choices based on their better grasp of their circumstances. Whilst there are many models of psychotherapy, most support this dynamic as the fundamental foundation of the therapeutic process.

9. What is strikingly consistent with the clients of community drug and alcohol services is the client’s unwillingness to experience their frame of reference, “their world” in an authentic way. Whilst everyone has parts of themselves that they fear to acknowledge (existential givens), those people who have become locked into self destructive patterns of drug and alcohol use experience a sort of extreme panic at the thought of experiencing their lives in an authentic way. This panic is, to my mind, still part of their Self Actualising Process. I guess we have all witnessed, in films if not in our own lives, people who in a state of panic, run in front of cars, over cliffs, say the worst thing at exactly the wrong time etc. These people’s internal realities are experiencing a fear similar to that of impending death even when their external world clearly doesn’t fit this. It appears to be the central challenge of drug and alcohol service provision to find affordable ways of helping clients to bridge the gap between their internal and external worlds. This “is” the recovery process. Clients need to re-establish relationships of trust with the outside world so that when difficult internal experiences arise for them, they meet their needs, reaching out for help rather than just trying to drown out their body’s messages.

10. Current providers have accumulated a huge and ever increasing number of clients who are dependent on replacement prescriptions. Devon DAAT has stated “The Methadone trail in Devon is huge”. Clients begin trainings and work whilst still on replacement prescriptions. This traps them in a position of either maintaining their replacement prescription or facing the psychotherapeutically unsupported and traumatic movement into authentic experiencing whilst trying to maintain work or education commitments. Unsurprisingly, overwhelm, relapse, and a new replacement prescription is the most common outcome.

11. There are two processes that seem to achieve the needed bridge of trust between internal and external worlds mentioned above. Both are specific types of relationship.

1.A psychotherapeutic relationship.

2.A peer mentor relationship.

12. In a psychotherapeutic relationship the therapist has developed the skills to provide a relationship that holds heightened awareness of the client’s world so here-and-now phenomenon are explored or avoided according to a fine sensitivity to what the client can handle being with. The therapist has the personal development to avoid polluting the relationship with personal stuff that would be unhelpful, differing to the client’s experience. Pacing the highlighting of incongruencies within client disclosures also requires deep insight and sensitivity. Many tools employed by psychotherapists are also used in MI (Motivational interviewing), however, MI trainings are very short, just a few days. A psychotherapist will have undertaken at least two years training that included work on their own issues. Psychotherapy is a fine art with the self as the tool of the work.

13. There seems to be an unfortunate pattern with drug workers endeavouring to key work using MI. Even with psychotherapeutic training, it is extremely difficult to develop a therapeutic alliance with a client who is using mood altering chemicals. For someone who only has a brief MI training, it is not possible to create a therapeutically viable relationship. As clients fail to make progress, the worker has to find a way of maintaining a sense of validity to their endeavours. This requires a sort of cynicism about the client and their recovery, and a disengagement from the underlying vulnerability of the client to avoid acknowledging the skill shortfall within the professional. Once this has happened a co-dependent relationship emerges, with the member of staff seeing the client as failing in their recovery process rather than recognising the shortcomings within their abilities and treatment system being employed. The professional and client move into exchanging positions of “Victim, Rescuer, and Persecutor”, the classic co-dependent triangle. Once co-dependency is in place the therapeutic process is blocked. When a project has a treatment philosophy based on MI, it seems the whole organisation becomes entrenched in co-dependency. Management act as unqualified pseudo-therapeutic supervisors of front line staff. They support and justify what their staff do to defend a reality too unpalatable for everyone to acknowledge as near valueless and often doing harm.

14. Design of this kind of flawed system of treatment seems to be the result of not respecting the need for specialist training and experience. In Devon, neither the DAAT nor management of commissioned services have any specialists qualified in the treatment of addiction within service design teams. Backgrounds in probation, mental health and social work are assumed to be sufficient, as if the specialist trainings that exist are an unnecessary luxury. Over-reliance on guidance from incumbent commissioned service staff by DAAT management holds a conflict of interest that has no safe guards, and leads to skewed representations of data that support maintenance of the status quo.

15. Within a peer mentor relationship, it is empathic identification that creates the trust to bridge the gap between internal and external reality. Clients experience someone who has used drugs and alcohol in a similar way to them but who has managed to stop. This represents a believable and safe bridge for them to also cross. Where the peer shares that they can accept awareness of, move through and then beyond uncomfortable internal experience, clients realises they can too. Shared historical experience also helps facilitate trust and empathy.

16. It is these relational aspects of client experience that are not being adequately met. Clients do not engage with services because they feel too scared of what experiencing their worlds authentically will feel like. They sabotage their own treatment plans.

Five Key Areas for Improvement/Savings

1.Cutting back the CBT workshops offered before clients detox (excluding harm reduction).

2.Redesign of replacement prescribing culture.

3.Underuse of the mutual aid organisations.

4.Redesign of criminal justice system’s sentencing and treatment regimes.

5.Better use of Tier 4 budget.

17. The rationale for this is described above.

18. Current prescribing policy is incoherent and ineffective. Replacement Therapies are accumulating clients suspended in chemical limbo. With only nine residential rehab places for drug users and only 17 for Alcohol each year for the whole of Devon (£200,000 total budget), most of the thousands of registered clients remain in community treatment for years, making little or no progress. The supported housing projects have to manage extremely chaotic people. Virtually no one breaks free from dependency, and community spirit has been sapped.

19. The first change to prescribing policy is distinction between “harm reduction” and “recovery” prescribing.

20. A client’s human rights might include “choice to remain on a replacement prescription”. If not upheld, client overdose could be argued as resulting from clinical negligence. Until proven both ethical and viable, long term prescribing should remain an option.

21. Clients who choose long term prescribing should be key worked from a harm reduction and health monitoring perspective.

22. Clients choosing recovery should be stabilised and ready to begin their detox within the “12 week effective drug treatment” window. If clients have dual diagnosis issues these should be addressed through appropriate prescribing within this time. If a client is too chaotic or has such antisocial behaviour that this proves unachievable, they should be presented (accompanied) by key workers to mental health services and a short term solution agreed. If not possible, a mental health section order should be recommended. Leaving unstable clients within communities costs a fortune to police, hospitals, social services and others. It deepens client feelings of despair and alienation, and damages communities.

23. In most circumstance, clients will be clean and have completed treatment including any aftercare, within 26 weeks of first presenting, providing huge savings.

24. NICE guidelines state that “All treatment professionals should routinely provide information on self help groups; these will normally be 12 Step, for example Narcotics Anonymous, Cocaine Anonymous”. It also recommends that key workers accompany interested clients to their first meeting. This is not being followed. With services utilising the mutual aid groups, many of their clients will establish lives in recovery without needing expensive long term community or residential treatment.

25. The criminal justice system seems to be a place of huge wastage. What is needed is not currently achievable as many elements require legislative changes by central government. I’ve including them as the only way to arrive at a coherent system is stake holders grasping how their actions affect partner agencies.

26. In principle, someone found guilty of drug/alcohol related crime, should be required to address their dependency issues. Clients who consent to undertaking a detox and attending an intensive therapeutic program within the prison system (eg Rapt) should then by made eligible for unusually early release (25% of sentence?) on probation orders requiring regular testing, attendance of mutual aid groups (12 Step groups run a chit system for verification) and abstinence. This will create huge savings and see many prisoners achieving socially harmonious patterns of life rather than the huge rates of repeat offending that currently exist.

27. Clients who have just committed drug related crime but refuse drug treatment should be denied probation as they are choosing to stay in patterns that will in all likelihood lead to reoffending on release.

28. Drug rehabilitation requirements should include attendance of mutual aid groups for the reasons described earlier in this document regarding life style changes and a movement away from old using peers to new recovery peers.

29. The clients I see going through the prison system have all been maintained on replacement prescriptions. They immediately relapse into the same patterns they were in before their last arrest. Money spent on policing, judiciary and prison services has all achieved nothing for the community or for the client, other than a holiday in the company of people also entrenched unhealthy patterns of behaviour.

30. Sentences cannot currently specify which prison someone is to go to. This needs to be changed. Someone sentenced for a drug related crime should be sentenced to attend a prison with a therapeutic drug treatment regime.

31. Quasi residential services using the Supported Housing sector for accommodation can offer the same standards of intensive psychotherapeutic treatment journey for about a third of the cost of most residential Tier 4 services. They also create excellent recovery capital for Tier 3 services. Action on Addiction’s SHARP projects exemplify good practice.

32. These might be fundable solely through savings from Tier 3 budgets, which would be an ideal. If this proved possible, the Tier 4 budget could be used to focus on meeting the needs of dual diagnosis clients who are not stable enough to be treated within the community.

January 2011

Prepared 8th December 2012