Heroin Harm Reduction: Naloxone based reflections

Posted on 3 CommentsPosted in Harm Reduction, History, Treatment, Uncategorised

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In 1987 the south of England was hit by one of the worst storms in history when hurricane force winds ripped up trees and tore off roofs. In Manchester we were creating our own little storm by producing harm reduction comics with, and for, people with opioid use disorders. I spent much of late 1986 and early 1987 ‘in the field’ with people who were injecting and smoking heroin on a daily basis (people with Opioid Use Disorders – OUD). The method I used is called participant observation. The idea was to get alongside people who were using brown powder heroin and, with them, produce harm reduction information in a format that would be read, shared and discussed.

The characters in the first edition of Smack In The Eye (SITE) were based on real people and the jokes were reflections on real life. In the same year we (Lifeline) opened our first Needle and Syringe Programmes (NSPs). By 1988 we had a team of Outreach Workers working across the North West of England. Our friends and colleagues in Merseyside were engaged in similar activities and had, let the record show, blazed the trail for us at least a year earlier. Looking back at this time our harm reduction work did not have direct, formal links with treatment services. Many of us worked in treatment services but our harm reduction work was truly independent of treatment. For example, the first editions of SITE were distributed by people selling heroin. Some early NSPs were supported by people selling heroin. Those who were selling from houses and flats gave out our comics and our injecting equipment and provided sharps boxes for the return of used equipment.

Fast forward to today and harm reduction in the UK is either nonexistent or provided by professionals inside treatment services. Pharmacies operate most NSPs and those NSPs located within or alongside treatment services are compromised. Opioid Substitution Treatment (OST) is the primary service provided to people with OUD by treatment services. The primary purpose of OST is to reduce ‘use on top’ of the prescribed opioid. The use of other drugs (street heroin, crack cocaine, pregabalin, benzodiazepines and alcohol) ‘on top’ of the prescribed opioid is endemic in the UK and several reviews are underway to try and reduce ‘use on top’.

naloxone

Naloxone is a life saving medication that can reverse life threatening opioid overdoses. The idea is that Naloxone (“Narcan” in the US) is distributed as widely as possible to users and their families and all first line response professionals (ambulance staff, police, fire service etc, etc). It seems obvious to me that Naloxone should be like rats in London – never more than six feet away from everyone. So, I was taken aback to hear a seasoned OUD treatment expert say that ‘naloxone is a response to failing OST systems’. This was a throw away comment made in the margins of a conference some time ago but it has been haunting me ever since.

 

If we had Naloxone in 1987 it would have been distributed by everyone we knew in the heroin distribution retail scene. The point is that back then; harm reduction was linked to treatment but was not part of treatment. In the mid 1990s, health authority officials in Manchester initiated a plan to get thousands of people into OST. They were successful and Manchester (like Wirral and Liverpool) soon had a high treatment penetration rate. Most people with OUD in Manchester were enrolled in OST. This same scenario was played out across the whole of England. Today, we are rightly proud to say that the English OUD treatment system has one of the highest treatment penetration rates in the world. Yet, we have worryingly high rates of Drug Related Deaths (DRDs) among people with OUD and ‘use on top’ remains the norm.

In this context, the distribution of Naloxone is a critical harm reduction intervention. However, is the need for Naloxone an indicator of a failing OST system in England and the UK? Personally, I do not agree that it is. However, the failure to distribute Naloxone throughout our system does say something important. I suspect that the failure to get Naloxone out is linked to the decline in discrete and bespoke harm reduction services. I know that some treatment providers are making great efforts to distribute Naloxone and provide NSPs to their service users. It is a real challenge to provide harm reduction services from today’s treatment services.

In recent years these services have been driven by notions of abstinence based recovery and measured by the number of people with OUD who exit treatment via a successful completion and do not return (“represent”) in the next reporting period (six months). People in abstinence based recovery have been recruited to these treatment services as volunteers and workers and are influencing treatment practice and ethos. Whilst this is a positive development in terms of equity and social inclusion it can have a negative side effect in terms of harm reduction.

Back in 1987 our community connections were with people using illicit opioids on a daily basis. Our outreach workers either had personal experience of opioid use, were well trained in harm reduction or both. Many could give direct advice on the intricacies of safer injecting and safer drug use per se. Until the mid-90s push there was no pressure to get these people into OST in Manchester. Harm Reduction was provided to them on their terms with the sole aim of making their own drug use safer. The situation today is that harm reduction, if it is offered, is often provided by people who know little about safer, continued drug use. There is an inbuilt reluctance to engage in harm reduction services provided by these treatment providers if you are also on OST with them. After all, the primary purpose of OST is to reduce ‘use on top’. Attending a NSP means, by definition, that you are ‘using on top’ of your OST prescription. Your key worker may be a staunch advocate of abstinence based recovery and take the attitude of “I did it (abstinence based recovery) so can you”. In recent years progress has been made in treating HCV amongst people with OUD in treatment. If these people continue to ‘use on top’ and do not access NSPs provided by treatment providers there is a risk of re-infection amongst those who have successfully cleared HCV.

So, in summary, is the need for Naloxone an indication of failing OST systems in England and the UK? In my opinion no, it isn’t but the failure to get Naloxone within six feet of everyone who might need it is a critique of the state of harm reduction in the UK. Budgets are falling and treatment contracts are being let and awarded with every decreasing financial settlement. Harm reduction, independent of treatment, is a casualty of public service cuts and a performance management system unable to recognise the importance of keeping people alive. Perhaps the ultimate irony is that people who leave treatment and die can be chalked up as a success in a system measured by the numbers of people leaving treatment and not returning. Grandpa Smackhead Jones will be turning in his grave.

Founding Fathers of Contemporary UK Recovery Movement

Posted on Leave a commentPosted in ABCD, Harm Reduction, History, Recovery, Treatment

This article was published in Druglink, September/October 2011

As the organising principle for drug treatment, harm reduction was not rocket science. Provide needles and syringes to make contact with injection drug users and reduce the transmission of blood borne viruses. Provide maintenance medication to maintain that contact and cut crime. We did this and it worked. However by 2005 there was growing concern that this was not enough, articulated in the NTA‟s Treatment Effectiveness Strategy. Questions began to be asked about whether recovery should be the organising principle for treatment.

In that year, a group of almost twenty commissioners, providers and ex-users met in Manchester to face this challenge from a local perspective. The North West was where the UK heroin epidemic started and we had a disproportionately high drug-misusing population. We discussed the role of abstinence- based treatment and how to move from a focus on quantity to an emphasis on quality. This group gave birth to the North West Recovery Forum, which has been exploring the ways that treatment can be organised to support recovery ever since.
Recovery is now the organising principle of everything we do in the commissioning and provision of substance use disorder treatment. Building recovery in communities is one of the triple pillars of the coalition government‟s Drug Strategy, with its commitment to create a recovery system that focuses not just on getting people into treatment but getting them into full recovery and off drugs and alcohol for good. We have our own UK recovery champions but who inspired and inspires them?

When harm reduction was the organising principle we often looked to Europe and Holland in particular, for inspiration and ideas. With recovery as the organising principle we look to the US and draw inspiration and ideas from four of their most influential recovery thinkers and writers. These are Dwayne Simpson, George De Leon, William L. White and John McKnight. Together they also represent a range of interventions that move from the individual to the collective. The treatment of addiction and „addiction science‟ has focused primarily on the individual. „Recovery‟ on the other hand is focused on fellowship, mutual aid, community and the collective.

Dwayne Simpson (1) first came to the NTA‟s attention in 2005 as a result of the NTA partnership with the Institute of Behavioural Research (IBR) at Texas Christian University (TCU). At that time the NTA were very keen to look at ways of reducing the numbers of individuals who dropped out of treatment very early. Dwayne Simpson is internationally recognised for his work on maximising treatment engagement and retention. But, it was Dwayne‟s emphasis on treatment as a journey that grabbed the attention of the North West Recovery Forum. People on journeys need maps and the International Treatment Effectiveness Project (ITEP) is perhaps most associated with mapping. This was revolutionary to our client group. At a meeting of the North West service user group in 2005 the idea of treatment as a journey was met with a mixture of quizzical and concerned responses. “What do you mean treatment journey? I didn’t know I was going anywhere? I thought I had arrived. I am settled on methadone maintenance. I thought this was it!”
This was met with: “You’re on a train that has MMT (Methadone Maintenance Treatment) on the side and unless you get off then the evidence based destination is the grave”.

Also in 2005 one of Dwayne‟s colleagues was visiting the UK and visited a classic Tier 3 community prescribing centre. They came back to the NTA and said how impressed they were with the “dosing clinic” and looked forward to seeing treatment. They were a little shocked when they were told “that is the treatment”. So, Dwayne Simpson gave us the whole notion of recovery being about movement, journeys and maps. He also prompted us to question whether medication dosing alone should be classed as „treatment‟.

George De Leon is perhaps best known for his work on Therapeutic Communities (2) and the stages of recovery (3). But it was in the work of George De Leon that we first came across the notion of Recovery Oriented Integrated Systems (ROIS). We set ourselves the challenge of trying to articulate or better still, establish a ROIS in a geographically defined community. De Leon‟s work on community as method was crucial in our thinking. De Leon‟s proposition is that by coming together as part of a therapeutic community people can learn how to live right. “Right living” is another of De Leon‟s contributions to the UK recovery
movement. In the past, places like Liverpool had sent significant numbers of people to residential rehabilitation centres far away. Northern regional accents could be heard in residential rehabilitation centres all over the South of England. If they did well they stayed away from their home towns and cities. If they didn‟t do so well, they relapsed and came home. So, North West commissioners of residential rehabilitation were exporting „success‟ and importing „failure‟. Inspired by the work of George De Leon we wanted to see if we could establish a ROIS in Liverpool. Can people get well where they got sick? Can people learn how to live right in the same communities where they had been living wrong? When George De Leon came to Liverpool in March 2011 this question had been answered with a resounding yes.

Liverpool now has a very large and growing network of Narcotics Anonymous (NA). Cocaine Anonymous (CA) and Alcoholics Anonymous (AA) have seen similar growth.
Inspired by the work of George De Leon we have embraced the mutual aid mantras of “I can’t but we can” and “You alone can do it but you can’t do it alone”. Most people start using substances as a communal thing. There was a time when substance use was a fun thing to do with friends and peers. In the grips of active addiction social isolation takes hold, self will runs riot and the addict‟s identity as a victim takes hold: “Poor me, poor me, pour me a drink”. Long term sustainable recovery for George De Leon requires a complete identity change. With this identity change people become pro-social, conventional adult citizens. If their recovery is visible and attractive it becomes contagious. They become role models for recovery. They show that recovery is a reality. They model recovery in their communities and living in those communities becomes a method of recovery.

This is where the work of William L White became crucial (4). William L White is one of the most important thinkers and writers on recovery and recovery communities. At a seminar in London in March 2009, William White employed the metaphor of a dying tree. You can take a tree that is dying and dig it up and replant it in rich soil. If you nurture the tree it can flourish. But, if you dig it up again and replant it in the old soil it will start to die again. The question then becomes, can we enrich the soil so that the tree can survive and thrive without having to be dug up and replanted elsewhere. In recovery terms; can you get well where you got sick? The answer from Liverpool is yes you can or more precisely yes we can. The recovery community becomes a method of recovery. William Whites latest contribution is Medication Assisted Recovery and Recovery Oriented Methadone Maintenance. This work reminds us that there are many paths to recovery; all are a cause for celebration and that includes people on methadone and Buprenorphine. The best treatment will prepare you for ongoing support in a community. Commissioned treatment systems can support but not provide long term recovery. Long term recovery is sustained and maintained in fellowship and mutual aid in recovery communities.

By 2009, it was becoming clear that there was a piece of our recovery jigsaw missing. What happens to people in long term recovery? Do they just stay in 12 Step and SMART Recovery meetings? Where else do they go and what do they do? We had come to believe that people in long term recovery were “better than well”. This is where the work of John McKnight and his colleagues fits into the UK recovery picture. Asset-Based Community Development (ABCD) has emerged as a way of responding to the challenges posed by general health and social inequalities (5). The most difficult and complex cases of addiction, presenting to public services for treatment, tend to be emerge from, and are located in, the most impoverished communities. Treatment alone cannot provide a long term answer to addiction that has its roots in intergenerational health inequalities.

As the treatment system prepares for the transition to a new public health system, under the auspices of a new body to be called Public Health England, the NTA is already encouraging local areas to adopt asset based interventions. Its action plan for 2011-12 makes clear this approach will enable partnerships to assess the recovery networks of their own communities as part of the local strategic planning process. Treatment that is recovery-oriented and recovery that is asset- based can ensure that our sector plays a major role in our new public health system. People recovering from addiction in the same post codes that they were sick are real community assets. They show that new and healthier identities can be forged by coming together and creating communities that foster recovery in the widest sense of the word.

References
(1) http://www.ibr.tcu.edu/persons/simpson.html
(2) De Leon, G. (2000). The therapeutic community: Theory, model and method. New York: Springer Publishers, Inc.
(3) De Leon, G. (2005) Stages of Recovery Univ. of California at San Diego (UCSD) Center for Criminality and Addiction Research Training and Application (CCARTA)
(4) www.williamwhitepapers.com
(5) http://www.abcdinstitute.org/profile/?ProfileID=47&/JohnMcKnight/

Yin and Yang: Successful Completions and Recovery Communities

Posted on Leave a commentPosted in Recovery, Treatment

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Successive UK governments have been talking about ‘recovery’ from ‘addiction’ since the build up to the 2010 general election. This resulted in a target for recovery – a ‘recovery rate’ – that is defined as the number of people successfully completing treatment and not returning to treatment in the next 6 months.

The ‘successful completions’ target followed on from the two previous targets of access to treatment (measured by reductions in waiting times) and retention in treatment (measured by how many stayed in treatment for a minimum of 90 days). The first two targets could claim an evidence base. Being in treatment is a good thing as it has a protective effect and the longer you stay in treatment the better. The ‘successful completions’ target doesn’t have an evidence base and was the result of political pressure to get people out of treatment and into ‘recovery’. This pressure was particularly focused on services providing Opioid Substitution Treatment (OST) to people who came into treatment dependent (‘addicted’) to heroin. There are problems with using successful completions of treatment as a proxy measure of recovery. We are asked to accept that leaving treatment means entering recovery and that not returning to treatment in six months means that the person has stayed in recovery. But, how would we know what has happened to people leaving treatment?

This is where the need for a peer led recovery community in every local authority becomes crucial. People with a Substance Use Disorder (SUD) – the preferred term for ‘addiction’, ‘alcoholism’, ‘substance misuse’ or ‘dependence’ – experience this in isolation. One of the key features of living with a SUD is being alone. Conversely, one of the key features of successful recovery from a SUD is community and active engagement with positive social networks. If we could ensure that everyone leaving treatment is connected to a recovery community then we could claim that the ‘successful completions’ target is linked to an evidence base.

There are some good examples of places where this is working well (eg Lancashire, Birmingham, Manchester, Calderdale, Cumbria) and the commissioners recognise the importance of establishing and supporting a recovery community in their local authority area. This is even more important as budgets shrink and contracts are let with as much as 50% less financial resource.

One of the ways of ensuring this is for commissioners to write the requirement into specifications when tendering services and issuing invitations to tender. Bidding organisations could then be asked to evidence how they have achieved this in other areas where they are already operating. Or, they could be asked to detail exactly how they would operate to ensure that they build a recovery community in the area over the time of the contract being let. One of the key markers for this would be the number of new independent and peer led mutual aid groups that are established over the time of the contract.

There are many service provider organisations that talk about recovery and recovery communities but on inspection these tend to be groups of their own service users and not independent peer led organisations such as Lancashire User Forum and Red Rose Recovery, The Well in Cumbria and The Basement Recovery Projects in Calderdale and Kirklees. There are also some ‘patients’ in treatment that only want a medical and clinical OST service on a maintenance basis. Offering access to the recovery community and exposing these patients to peers who were once like them is as much as might be possible until they feel motivated to change. There is no point in trying to push people out of treatment if they are settled on OST especially when they are in employment, have a home and family and friends. There are more than enough people in treatment who do want to leave and join a recovery community.

The key to this lies in some kind of ‘patient segmentation’. In any population of people in treatment, there will be a group who are not interested in recovery because they are settled on OST. There will be another group who are definitely ready for recovery and a group who are not sure. The quickest wins will come from concentrating on the group who are keen and ready to move. They can be directed onto a discrete community detoxification pathway that utilises specific detoxification medications such as the Lofexedine and Buprenorphine combination as described in Detox In A  Box (https://drinkanddrugsnews.com/wp-content/uploads/2016/07/DDN-0716-web.pdf page 22). Where services are combined drugs and alcohol then the other place to start is with people whose primary problem relates to alcohol. They, almost by definition, will be looking to pursue abstinence based recovery for simple health reasons. One place to bring these two groups (the opioid detoxification people and the alcohol abstainers) together would be in ACT Peer Recovery mutual aid meetings. ACT Peer Recovery is a form of mutual aid that focuses purely on behaviour change and offers an easy way into mutual aid and recovery communities. Once people have experienced positive behaviour change they tend to want more and see the importance of changing other behaviours that have been stalling their progress in recovery. ACT Peer Recovery works perfectly alongside the 12 step mutual aid fellowships of AA, NA and CA.

Once we have established a thriving local recovery community we should be able to monitor the progress of those who have successfully completed treatment. Experience in those areas where this is happening illustrates the importance of the early identification of relapse. If someone relapses and stops attending their mutual aid meetings or disconnects from the recovery community we will know and be able to reach out and assertively support the person back into treatment and recovery. Commissioned treatment providers working in complete partnership with thriving local recovery communities are the yin and yang of a complete treatment and recovery system. This is the way to deal with reductions in funding and to provide the necessary evidence that is required to legitimate successful completions of treatment as a recovery rate.

Why psychiatry?

Posted on 1 CommentPosted in History, Treatment

lucy

This piece was primarily stimulated by conference presentation by Dr Colin Drummond that you can find on Lifeline’s FEAD website.

If Colin thought that psychiatrists were demonized by commissioners and the NTA, he really needs to look and see what the recovery lobby have got to say about them. Anyway, somebody raised the question of why psychiatry should be responsible for drug treatment in the first place.

To answer that question, you have to look back at the demise of the old British System. Prior to the 1960’s, heroin addicts in the UK were invariably drawn from one of two groups. They were either ‘therapeutic addicts’, people who had gotten dependent on opioids as a result of having been prescribed them for pain relief. Or they were medics — people who had access through their jobs. These people were largely indistinguishable from the rest of the community and so the old British System — prescribing them sufficient heroin to meet their needs — worked well.

This began to change at the start of the 1960’s when the media and the Home Office both began to notice an upswing in a ‘new’ type of heroin user. Unlike the previous groups, these tended to be young, criminally deviant with attitudes that challenged the system. Rather than keeping to themselves and just using their scripts, these people seemed to be socializing with and ‘infecting’ other young people. Consequently, the prevalence of heroin use (and addiction) was growing exponentially.

So in 1961, the government convened a committee of the Great and the Good to look at the issue and decide whether anything needed to change. But doctors guarded their independence with great vigour, and argued that the current system was working well.

Rather than settling down though, the problem just kept on growing. The papers were starting to report some of the excesses associated with the old British system. You had the likes of Dr Petro, setting up his clinic in the cafe at Piccadilly Underground, selling heroin scripts at £3 a time to get the cash to go gambling. Or Dr. Frankau, who seemed to keep a staff of servants drawn from her patients.

When the Brain Committee was reconvened in 1964, they decided that the dramatic growth in overprescribing was really a function of this small handful of overprescribing doctors. It’s certainly true that that’s where the drugs were coming from in London. The demand for amphetamines on the mod scene was fuelling pharmacy break-ins in other parts of the UK, but there certainly wasn’t any significant quantity of imported illicit heroin until we started seeing small quantities of imported Chinese heroin on Gerard Street in the early 70’s.

The Brain Committee then, decided to put an end to the old free-for-all, in which any GP could prescribe any drug they liked, in any quantity, to any heroin addict that was their patient. It recommended the establishment of a number of specialist treatment centres — which came to be called Drug Dependency Units or DDU’s — that would be responsible for the treatment of heroin addiction. If a doctor wanted to prescribe to addicts, they had to have a Home Office special licence that would allow them to prescribe heroin and cocaine. (In the mid-70’s, Diconal was also added to this list — a measure that saved a lot of limbs, as well as a lot of lives.)

And who was to staff these Drug Dependency Units? Well, addiction was viewed primarily as a psychological problem, so didn’t it make sense to staff the units with psychiatrists? And thus begun the long term relationship between psychiatry and treatment for drug dependency that lasted for for nearly 50 years in the UK, but that Colin Drummond feels today is under attack.

And Professor Drummond isn’t wrong. When I entered drug treatment in 1975, I’d see a Consultant Psychiatrist twice a week. Some were awful, but the majority of them were humane, intelligent people who did their best for their patients.

Although the guidelines say a patient should be seen at least quarterly, in many services it’s not unusual to be seen every six months — perhaps even every year. And you might be seen by an unskilled, unqualified ‘Recovery Coach’ who’s volunteering after being six months drug free.

We used to pretend drug treatment was a ‘Cinderella service’, but for most of the last fifteen years, it’s actually been a ‘Sleeping Beauty’ service, and as the princess lay sleeping on her bed, the world was passing her by.

Today, we’re in a new world, and as Professor Drummond astutely points out, it’s unlikely that the pendulum will ever swing back to where it used to be.

Peter McDermott

Stations of the Lost and Found

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Stations of the Lost: The Treatment of Skid Row Alcoholics by Jacqueline P. Wiseman was first published in 1970 and won the C. Wright Mills award for best book in the area of social problems. It gave us the view of the alcoholics who passed though all the places those skid row alcoholics pass through and the view of those working in these places. I have been thinking about this book a lot recently because it always made me think of a pin ball machine. You get shot out of the chute at birth and you bounce around the bumpers doing well and getting the prize – a free game – or you get a couple of bad bumps, get a miserable score and slide back down the chute – game over. Once I had exhausted the pin ball metaphor I tended to think of it like a form of Jacob’s ladder that went both ways – up towards heaven and down towards hell. Several years ago I was stood talking to a friend who was then a drinking alcoholic in Piccadilly Gardens in Manchester. As we were talking another guy came up who “looked like he’d fell off a flitting” (as my Mother would have put it). “Excuse me lads, how do I get to Val’s Hotel?” (Which at the time had a reputation as occupying one of the lower rungs on the descent of Jacob’s ladder?). Quick as a flash my mate replied “Carry on drinking and don’t pay your rent!” We are now working out how recovery housing works in Greater Manchester, Cheshire, Lancashire and Cumbria. As part of this process we might do well to start by thinking how the down ward escalator works. Each of our 152 local authority areas in England will have its own Stations of the Lost. These are the places that people pass through on their way down into the hell of active addiction, social isolation and premature death. Besides the police stations, prisons, hospitals and treatment centres there are hostels and bed and breakfast hotels. Once we have mapped out the rungs of the ladder on the way down we can begin to map the way out and upwards. We can offer Stations of the Found. These are the places where you find people in recovery climbing away from addiction, social isolation and premature death and towards the sunlight of the spirit of recovery. The lower rungs might be a sofa or a spare room in the house of someone else in recovery. The higher rungs are total freedom in your own home with a job, friends and family. So, what do the stations of the lost look like in your town and are they matched by stations of the found?

Peter Sheath on “Why it is the way it is…”

Posted on 2 CommentsPosted in Administration, Treatment
Why?
Why?

Why it is that we’ve got the way we deal with human mental health so wrong

In discussing human mental health, I’m talking about a pretty broad church. I’m talking about all aspects of human mental health which I’m becoming increasingly convinced are intrinsically linked but we seem to be intent on making them separate. Starting in childhood, we allow the medical profession to diagnose our children with ADHD, ADD and, with increasing alacrity, things like bipolar and psychoses. Not stopping there they seem almost obsessionally committed to medicalising almost every aspect of the human condition including things like development, coping mechanisms and learning and we let them. Out of necessity they create more and more specialisms, associated experts and the pills and potions they are going to need to give people, in the main, just to prove the diagnosis put on them. A la, “He must be schizophrenic because he has responded to resperidone!” It’s pretty much the same across the whole thing, sometimes admittedly it may involve talking therapies but they are all too often delivered in a prescribed and manualised way as something done to people. Whole systems have evolved, all working in this way by treating people as if they are sick, disabled or have some kind disease. The problem being that when we are treated in this way, unless very careful measures are put in place to prevent it, we learn to become helpless and the system is a very good teacher.

Question: What Is Learned Helplessness?

Answer:

Learned helplessness occurs when an animal is repeatedly subjected to an aversive stimulus that it cannot escape. Eventually, the animal will stop trying to avoid the stimulus and behave as if it is utterly helpless to change the situation. Even when opportunities to escape are presented, this learned helplessness will prevent any action.

While the concept is strongly tied to animal psychology and behaviour, it can also apply to many situations involving human beings.

When people feel that they have no control over their situation, they may also begin to behave in a helpless manner. This inaction can lead people to overlook opportunities for relief or change.

The Discovery of Learned Helplessness: The concept of learned helplessness was discovered accidentally by psychologists Martin Seigleman and Steven F. Maier. They had initially observed helpless behaviour in dogs that were classically conditioned to expect an electrical shock after hearing a tone. Later, the dogs were placed in a shuttlebox that contained two chambers separated by a low barrier. The floor was electrified on one side, and not on the other. The dogs previously subjected to the classical conditioning made no attempts to escape, even though avoiding the shock simply involved jumping over a low barrier.

In order to investigate this phenomenon, the researchers then devised another experiment. In group one, the dogs were strapped into harnesses for a period of time and then released. The dogs in the second group were placed in the same harnesses, but were subjected to electrical shocks that could be avoided by pressing a panel with their noses.

The third group received the same shocks as those in group two, except that those in this group were not able to control the duration of the shock. For those dogs in the third group, the shocks seemed to be completely random and outside of their control.

Later, the dogs were placed in a shuttlebox. Dogs from the first and second group quickly learned that jumping the barrier eliminated the shock. Those from the third group, however, made no attempts to get away from the shocks. Due to their previous experience, they had developed a cognitive expectation that nothing they did would prevent or eliminate the shocks. (Seligman & Maier, 1967).

Learned Helpless in People: The impact of learned helplessness has been demonstrated in a number of different animal species, but its effects can also be seen in people. Consider one often-used example: A child who performs poorly on math tests and assignments will quickly begin to feel that nothing he does will have any effect on his math performance. When later faced with any type of math-related task, he may experience a sense of helplessness.

Learned helplessness has also been associated with several different psychological disorders. Depression, anxiety, phobias, shyness and loneliness can all be exacerbated by learned helplessness. For example, a woman who feels shy in social situations may eventually begin to feel that there is nothing she can do to overcome her symptoms. This sense that her symptoms are out of her direct control may lead her to stop trying to engage herself in social situations, thus making her shyness even more pronounced.

As I’ve mentioned before, things like shyness, loneliness, depression, anxiety, phobias and addictions are becoming increasingly looked at as biomedical conditions. A quick look in the DSM VI (the Diagnostic and Statistical Manual of Mental disorders) and you will find all of these, nicely psych speak labelled as things like social phobia, substance induced anxiety disorder, etc. no one seems to bat an eye lid because, hey, it’s the doctor’s call and doc knows best. And after all we’ve got a robust evidence base to support our decision making and inform the treatment package we decide to prescribe. If and when it doesn’t work, yes we’ve even got a label for that, it’s “atypical, non-responsive, sub symptomatic or, the best one of all, borderline.” Then when they ultimately reach the point of not having a clue they’ve got the whole rich spectrum of personality disorders to milk.

This whole thing serves to disable, disempower, disenfranchise and cannot help but give a sense that the person’s so called “symptoms” are out of their direct control and will almost inevitably stop them trying to engage with the social situations that are probably going to help them recover. It actually brain washes people into the belief that they are sick and, in many ways helpless or even cannot possibly be trusted to manage their own life. As they engage with the system, it takes more and more away from them. Assessments are very medically oriented, designed to find out what’s wrong so that the system can then tell you what they need to do to you to put it right. Congratulations and welcome to victimship, and boy have we got some drama triangles for you to involve yourself with! For a start we’ll make sure you’re paired up with someone with a pathological need to rescue you, then we’ll punish any indication of self efficacy or responsibility taking.

The underlying problem here is that we have developed a serious intolerance of the uncertainty of mental health. We desperately want certainty and the best way of deluding ourselves that we are achieving this is to medicalise it. If we bung it into a conceptual box, slap a label on it, the uncertain moves towards a position of certitude then all we need do is design something to wrap round it to keep it so. It gives us the illusion that we are in control, so what if by doing so we are actually teaching people to be helpless passive receivers of what we do to them? When something goes wrong, which it does with remarkable frequency, we create yet another set of drama triangles blaming “the patient” for not taking the treatment or the latest overworked rescuer for not having a risk assessment in place. No one ever looks at the system, the culture it creates, the lives being ruined and the further away it takes us from where we should be. It has to be right, doesn’t it?

Peter Sheath will be presenting these ideas alongside Peter McDermott and Mark Gilman on Tuesday 1st Sep 9.30-5.15 The 7th UKRF Community Gathering, Manchester http://www.ukrf.org.uk/index.php/community-gatherings/2015

Recovery in Post Industrial Society: New Formations of Politics, Culture and Identity

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The grandiose title that came out of a snarky comment on a Facebook post by Alistair Sinclair, chair of the UK Recovery Federation. We’d just seen the recent election results, and while Alistair was being his usual positive and upbeat self – continually reinforcing Gramsci’s wonderful phrase, “Pessimism of the intellect, optimism of the will”, for me, it felt like yet another major defeat.

After five years of defeat. Which really comes on top of a lifetime of political defeats.

A child of the sixties, I often tell people that my own addiction was a response to the failure of the whole new left project of the 1960’s. In 1968, it looked as though a whole new world was not only possible, but was inevitable. The world was filled with new ideas – civil rights, gay rights, a transformation of the old left to something more joyous, more playful. As Emma Goldman said after visiting Russia, “I don’t want to be a part of any revolution where you can’t dance.”

But by the start of the seventies, the creative parts of our culture had been co-opted and was being sold back to us. Labour Home Secretary James Callaghan had completely rejected the Wooton Report, and was implementing the Misuse of Drugs Act – laws aimed at increasing penalties for possession and use. The period that had finally seen an end to post-War austerity, as characterised by Harold Macmillan’s ‘You’ve never had it so good’ was coming to an end, and as I left school, Britain had a million people on the dole for the first time ever. Council rents had just doubled as a result of the Housing Finances Act The politics of neo-liberalism and austerity had begone. In the absence of any positive political project that I could engage with, my own response was a retreat into nihilism and heavy drug use.

For the last forty years, that process has continued unabated. We’ve seen the demolition of the old working class communities – through slum clearance, through mass immigration, through gentrification. And the demolition of the old working class industries – shipbuilding, steel, mining, manufacturing – one thing after another went in search of cheap labour and ended up mostly in Asia.

And we’ve seen the end of the left wing political project. The fall of the Berlin wall brought it home to all of us just how bankrupt the socialist enterprise was when it came to delivering on people’s aspirations. Nobody was migrating into socialist countries. The flow was all towards capitalism – the very thing that ultimately, would come to destroy us? Or at the very least, would tear large rents in our communities and divide us into the rich and the poor, the ‘workshy scrounger’ and the hard working striver.

And there, in the middle of all this, was British drug policy. (Which invariably means British treatment policy.)

The end of the 60s saw the end of the prescribing free-for-all, in which any GP could prescribe heroin and cocaine for their patient for the treatment of addiction. 1968 saw the opening of the first Drug Dependency Clinics, and it wasn’t long before they began to realize that the whole business of prescribing heroin and cocaine wasn’t actually working that well. They began to look to the USA, and in particular, to Dole and Nyswander’s work on Methadone maintenance. That looked promising? Perhaps we should try that?

Nevertheless, throughout the 70’s and much of the 80’s, people were very uncomfortable with methadone. You heard all the same arguments you still hear today – it’s replacing one drug with another. Treatment should be about abstinence. It gets in your bones and turns you green, etc. etc. Patients were regularly underdosed, and all too often the treatment had little impact because of this.

All this was to change though, in the second half of the 1980’s when HIV/AIDS appeared on the scene and it became clear that drug injecting was a major vector for transmission.

Harm Reduction transformed drug treatment – and not just in the UK, but internationally, as well. Today, it’s mainstream drug treatment in most of the world, but there’s been a groundswell of popular opposition to Harm Reduction of late.

Some of this opposition is politically based. If the political agenda from the 80’s onwards favoured disease control and crime control, the political agenda for today is all about austerity and self reliance. As drug consumption patterns change, and the ‘new heroin users’ of the 1980’s have become the ‘old heroin users’ of today, harm reduction has successfully quarantined this group. They were successfully encouraged to remove themselves from a shrinking labour market, and now, twenty, thirty, forty years on, we’re demanding that they re-insert themselves into a market that even the ‘respectable’ working class are struggling to find a meaningful role in.

This discussion was prompted by the outcome of the last general election, when it struck me that, generally speaking, the rhetoric of recovery was very much in line with the rhetoric of the Conservatives. The rhetoric was very much about personal responsibility, standing on your own two feet, voluntarism, rather than relying on the state, and building community to take care of each other, rather than expecting the state to do those things.

Until recently, I was running a volunteer programme for mentors in the drug treatment system, and I was struck by the extent to which most of my volunteers genuinely saw themselves as sick, and felt the state had an obligation to take care of them – not at the jobseekers rate of benefit, but at the much higher rate associated with Disability Living Allowance. It was almost as if Opiate Substitution Therapy had convinced these people that they had some genuinely debilitating psychological illness. Yet if I’d offered any one of them a job that interested them with a reasonable salary, every single one of them would have miraculously found themselves fit for work again. If the rhetoric of recovery was a profoundly Conservative one, then the people I knew in OST were indelibly wedded to the idea of a welfare state that takes care of everyone, from Cradle to Grave, regardless of the contribution they make to our society.

And I’m not criticising these people. In their shoes, I’d probably do the same thing myself.

I had some volunteers who had, in a burst of recovery-based enthusiasm – given up these sickness benefits, only to find themselves desperately trying to re-enrol some time after, because managing on jobseekers was such a struggle. And in practice, large sections of the local ‘recovery community’ continue to live on disability benefits and spend their days watching Jeremy Kyle, browsing the internet on their mobile phones, and going to one of the many daily 12 step meetings that can be found in the area. They might not be using drugs any more, but their friends are primarily addicts of ex-addicts, they still live on benefits, there is little in the way of measurable improvement in their lives that I can detect.

And that’s exactly what you’d expect. The greatest predictor of whether someone will get work in recovery, is whether they’d had work prior to developing a drug problem. And by and large, our drug treatment population is made up of people who have little or no experience of the world of work. High levels of unemployment have characterised most of the large impoverished areas of Liverpool since the late 1970’s. Drugs offered people an economically productive role in a thriving black economy that was otherwise denied to them by mainstream society.

So we’re now telling people, ‘You’ve been on a script for far too long. You’ve got to get out of treatment and into recovery’, well, first we have to be able to offer people a vision of a better life – and one that’s actually accessible to them. For the last ten years, that better life tended to involve the prospect of a career in the drug treatment field – but as the field starts contracting, and levels of accountability and professionalism increase, that’s an area that will be open to ever smaller numbers.

And it was never something that would benefit the bulk of people in treatment anyway. So the key question becomes, where do those people find meaning in a society where work has become scarce? Where do they find community when the old geographically-based communities have been decimated by successive waves of slum clearance and gentrification, rendering feral sink estates one of the few affordable housing choices for the poor?

And to what extent is recovery genuinely even possible without these vital supports of some sort of meaningful activity and a sense of belonging?

And where does the drug treatment system fit into all this? While they’ve demonstrated that they can provide an effective legal opioid rationing system, have they yet demonstrated that they can deliver that thing called ‘recovery’ If so, how do we define it and what does it look like?

For me, the biggest problem with the British treatment system is in this conflation of the legal opioid rationing system with drug treatment. If the only way that somebody could legally get a drink was to enter alcohol treatment, I expect you’d have similar skews there as well.

I believe that we need to separate the two functions. If all somebody wants is a clean, legal supply of opiates, let them have access to that, through a low threshold system.

And there’ll always be a need for people wanting a medically supervised detox, where it’s just too risky or too hard for someone to attempt without support and supervision.

But the real work involved in recovery — those processes of reintegration, reeducation, rehabilitation – those things invariably take place outside and away from treatment, back in the community with family and friends.

So to what extent do these local communities exist? And what do we need to do to facilitate their growth? Is a new community spirit focused around recovery possible? Or can it only work if the notion of recovery is limited to an abstinence-focused idea of recovery?

There are encouraging signs out there though, and much of that hope comes from the USA.

Take the city of Detroit. I don’t think there’s anywhere in the UK that is as socially and economically bankrupt as Detroit was, just a few short years ago. But that city has embarked upon a renaiisance that has grown directly out of the local community, and it’s music and dance/drug subculture.

Similarly, you could point to Faces and Voices of Recovery,   or the National Alliance for Medication Assisted Recovery — national advocacy organisations that don’t discriminate against people in opiate substitution therapy, but rather fight against the stigma against this valuable and long proven medication.

Who would have thought that the USA, for so long a regressive backwater when it came to drug policy, would actually end up teaching the UK what a progressive drug treatment should look like?

Over the last few years, the UK Recovery Federation has worked phenomenally hard in an attempt to build exactly this kind of community of recovering people and nobody can take anything away from their success in this respect. But they’ve really just laid the groundwork. The real work must take place in local communities and online, with people who aren’t full time organisers or paid workers, but who are committed to creating the kind of community that’s essential if we’re to stand any sort of chance of surviving.

Ultimately, what the future of treatment, of recovery, of recovering communities — what that looks like — ultimately, that future is up to you.

Peter McDermott