Residential Rehabilitation – A Confession

Posted on Posted in History, Recovery, Treatment

I have never liked the idea of Residential Rehabilitation. I never understood the ideas behind the different models of Residential Therapeutic Communities. I had never heard about residential rehabilitation until 1984 when I was interviewing young heroin users in the North of England. I knew a lot about drugs and had been using them myself since my first encounter with benzodiazepines in 1969 at the age of 12. One of my closest friends from primary school died from a barbiturate overdose in his early twenties. Until 1995, I had known many people who had died from drugs (barbiturates and opioids) but I had never seen anyone ‘recover’ from ‘addiction’ (Substance Use Disorder).

In September 1985 I was employed as the manager of one of the first Community Drugs Teams in Trafford, Greater Manchester. Lifeline was started in 1971 by Rowdy Yates and a small group of ‘addicts’ and a supportive doctor called Eugenie Cheesman. Rowdy was, and is, an inspiration to me. He is one of my, very few, drug sector heroes and he remains a good friend (I hope). However, I never understood the fixation on sending people away from the North West of England to residential rehabilitation. Some of the rationale included getting the ‘client’ away from ‘triggers’ in the places where their problems had originated. I never understood this because by then I had started to develop my own alcohol problem. As I sat watching TV during one of my countless DIY detoxes from alcohol I had to sit through alcohol adverts. I had to walk past pubs shivering and knowing that I had the money to go in order a large brandy and port and a pint of stout (my favorite morning tipple).

I could never understand why ‘addicts’ had to be sent away, out of area, to residential rehabilitation whilst ‘alcoholics’ like me (I never admitted this till 1995) were sent to the local psychiatric hospital (the notorious ‘Ward 15’ in Bury) for a detox and then sent home. What happened in those residential therapeutic communities seemed to me like some bizarre therapeutic cabaret. Chairs and benches seemed to be essential props. There were benches to sit on if you had been naughty and chairs to talk to if you wanted to vent at a loved one who had died or done you harm. You could impersonate fruit and walk round with a placard saying ‘I am a liar’ and ‘I am a thief’.

I never understood what all this had to do with recovering from a heroin habit you had picked up on a council estate in Bury. It wasn’t just me either. In 1985 a friend from Bury (who I had used drugs with) was in court for a string of offences committed to get the money to buy heroin. He passed through Lifeline’s Induction Programme and went to residential rehabilitation centre as an alternative to prison. From memory he was there about 9 months. When he came out went for a pint and he told me all about it. He said it was a laugh and, once he realized he couldn’t head butt the counselors ‘in group’ he did OK. After a couple of pints he said “right great to see you, I’m off to score some ugly dust (heroin)”.

Variations on this scenario played out over the years and I came to regard residential rehabilitation as a bit of a joke. There is the possibility that my perspective has always been tainted by the fact that I have always lived in Bury (apart from a brief exile in Bradford) and mix with people I grew up with on an almost daily basis. When I first sought help for my own alcohol problem it never even occurred to me to go anywhere other than 12 step mutual aid. Unlike my negative experience of people from Bury going away to these residential rehabilitation centres, I knew some real alcoholics (who I had drank with) who had stopped drinking by going to Alcoholics Anonymous (AA). Residential rehabilitation if discussed was dismissed as a joke but AA was treated with a degree of respect because people had seen the change in people like ‘Terry from Bury’.

Fast forward to 7th September 2018 and I am sat in the audience at the recovery conference and I hear David Best talking about building recovery communities by connecting people to hope. He seems to say, or I choose to hear him say, that sending people out of area to residential treatment is harmful because it doesn’t add to the local therapeutic landscape. I get excited and start to tweet. In the haste to tell the world that one of our leading, bone fide academics on recovery is presenting evidence that says ‘keep it local’ I fear I may have over egged the pudding. If I have, I want to publicly apologize to David Best for misquoting him. However, I do want to state, for the record, that I certainly think that if people do need residential detoxification and residential rehabilitation they should stay as near to home as they can.

We do recover and we can get well where we got sick. When we are ‘recovered’ or ‘in recovery’ and walk through our local shopping centres, people who know us, who drank and used with us but are stuck in the madness see us and they can connect to hope. They can’t do this if they are recovering 250 miles away on the recovery Riviera. Finally, I want to dedicate this rant to ‘Terry from Bury’ who planted a seed of hope in me that grew roots and 23 years later sprouted and gave me a life beyond my wildest dreams. The photo is of the author in 1981.







Giman Bradford 1981

5 thoughts on “Residential Rehabilitation – A Confession

  1. I subscribe to this completely. I took it upon myself to go away, not to a rehab facility but out of my local area, to get sober. I did so successfully, but then came home, and it was 2 days later I picked up. I am very early on in my recovery now (2 months), but this is the longest I have been without a drink since starting as a teenager. I have managed to get this far through mutual aid groups, and finding support for my daily life issues by accessing services in my local area. If you go away from it all, one day you will likely have to return, and the issues will still be there waiting for you until you deal with them in the flesh, in my opinion.

  2. Nice to find out abit about you Mark. Totally agree with your piece in the main. Myself, I cleaned up locally not through choice but the only show in town regarding funding was 15 miles from home. It made transition into the community tough as everyone else in my cohort (2009) was able to re-enter society without being confronted by previous using peers & other triggers. On the upside I drew strength from my unique situation & the positive interactions I had with my old using buddies (I wasn’t in prison, hospital or dead,I was recovering) ….so I know it can be done yet I know of no one in my old using cohort that has recovered due the their local interactions with myself but some have moved away and cleaned up. In regards to visible recovery I think we misrepresent this; recovery walks, barista jobs and allotment projects are great but nowhere near as powerful as educational attainment, professional qualifications and disclosing to other professionals, work colleagues and friends at a persons choosing that they are recovering/recovered from addiction. As a way of challenging stigma & ensuring visible recovery as well as changing the publics mindset I think its possible.

    I allways thought ppl shpuld recover at home but local drug services have poor outcomes so a flexible approach is still needed.


  3. Agree Mark that local is the first choice, but as I said before, I believe that some people do need ‘the far away house on the hill’ and it would be wrong not to have that option available. I also think that there is a need for some head space for people to do the work on themselves that needs to happen in order for them to recover and what we dont want is a cheap option where there is a DIY approach to getting your head right with no structure or informed support. However, after your comment about wearing I’m a thief’ placard…maybe not an ‘expert’

  4. Mark

    Some thoughts/corrections on your rant about “residential rehabilitation”.

    1. Clarity – I think you need to be clear that therapeutic communities are a very particular type of rehabilitative intervention and shouldn’t be (wilfully?) lumped together with other types of residential provision which tend to range from pastoral retreats to 12-step sober houses with a lot in between. And frankly, “they don’t work cos I knew a bloke who used again after” is just shite thinking (could do better).
    2. Keep Up! Please – If you’re going to criticise TCs the least you could do is to make sure you’re up to date. To the best of my knowledge, psychodrama has not been used in any European TC since the mid-80s. Even then it was only fashionable for a brief time. Similarly, label wearing disappeared at least 30 years ago!
    3. Send them away – Sending people away from the North West of England at that time was the only option. Until Phoenix Futures opened in the Wirral, there were no TCs in the NW and the other residential rehabs were unimpressive in terms of both treatment input and outcomes.
    4. Why do we need it – Dosage my friend. The 12-step fellowship is OK but even at one meeting every day, some folk will need more. And bear in mind that because we have this completely unfounded idea that residential TC treatment is more expensive than other state subsidised interventions (research shows that in long-term and even intermediate outcomes it’s cheaper) then only those who show they can fuck up a number of other interventions actually get there.
    5. They’re just more Fucked Up – Again, research shows that people entering a TC in Europe are generally older, with longer drug-using careers, higher levels of suicidal ideation, more extensive histories of abuse and consequently poorer prognosis. See my point above about dosage.
    6. Let’s Give them a Half-course of Treatment – The marginalisation and chronic underfunding of residential services since the cynical introduction of Thatcher’s Community Care Act (see my article for Dianova Portugal:…/2018/09/Dianova_EXIT_n31_2018.pdf) has resulted in the closure of a lot of services and the foreshortening of programmes to the extent that they are now far shorter than what research suggests is optimal. It’s like giving someone a half-course of antibiotics but still expecting the same outcome.
    7. Local Recovery Champions – I certainly agree that there is great value in local recovery champions (although I do worry that there is now a lot of pressure on folks to flaunt their sobriety – some people would rather just leave their past well buried behind them). The problem is that with the perception that these services are costly, we only have a handful scattered throughout the UK. So naturally, folk need to leave their area to access one. And equally naturally, a lot of them don’t want to go back once they’ve completed their programme.
    8. Role Modelling – Since we’re on role-modelling as an important element of recovery, it’s worth noting that the structure in a TC is deliberately designed so that older residents role-model good behaviour to newer residents. In Phoenix Futures TCs and in De Kiem (Belgium) and Proyecto Hombre (Spain), senior residents are also expected to volunteer at local drug treatment services as part of this process too.
    9. AA, the Best Gig in Town – TCs grew out of AA but made some significant changes from what was then very much a middle-class, white, male club for former drinkers. Firstly, TCs recognised that “cross talking” was not necessarily destructive. Sometimes folks need to be reminded they’re talking shite. Secondly, the younger (often female) addicts coming to AA at that time (late 50s, early 60s) lacked any real structure to their lives and often had never had it. Thirdly, TCs walked away from the AA notion of continuous recovery (in AA terms, I’ve now been in recovery for nearly 50 years – a ridiculous and quite insulting notion).
    10. The Incurable Disease – And that brings me to one of my concerns about the 12-step fellowship. Basically AA/NA are giving out the same message as the methadone maintenance services. Remember, stigma is rooted in the notion of an incurable disease. I don’t want to employ you (live next to you; have you teach my kids) because sooner or later you’ll fuck up and start using again. How do I know this? I saw a doctor say, “It’s an incurable disease. The best we can do is control it with this drug for the rest of his/her life”. So you tell me how that differs from: “It’s an incurable disease. The best we can do is control it with regular meeting attendance for the rest of his/her life”.
    11. It’s All about Outcomes Stupid – Finally, just going back to your starting point. We now have around 50 years worth of outcome data on TCs varying from 12 months post-treatment to 12 years post treatment (see George’s summary of the American evidence: There’s a pretty telling correlation. In almost all of these studies (including with those who leave without completion) people do better than before they entered. Engagement with treatment is more telling than time in treatment (but time in treatment predicts better engagement) and a high percentage go into full time employment or education.

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