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?
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?
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
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.
The English system of providing treatment to people with substance misuse problems is going through a period of challenge and change. The current system was built on the basis of fear. In the mid 1980s significant numbers of working class young men began to smoke heroin.
Those who developed a taste for this new ‘brown’ heroin quickly graduated from smoking to injecting the drug. Most of them were unemployed and some resorted to acquisitive crimes, including domestic burglary, to finance their new habits. These new heroin users created fear and this fear attracted public funding.
The Conservative government of the day began to invest in services and interventions that would reduce the harm that the behaviour of these new heroin users caused to society. The New Heroin Users were provided with Needle and Syringe Programmes (NSPs) so that they wouldn’t spread HIV and AIDs to the wider population. They were enrolled into Opioid Substitution Treatments (OST) such as Methadone Maintenance to reduce heroin driven acquisitive crime. Methadone and other opiates were prescribed in doses high enough to produce a blockade against use on top and overdose.
This was successful.
NSP and OST reduced crime, reduced HIV transmission and prevented overdose deaths. The success of this system saw investment reach a high of £1 billion and then the bubble burst and disinvestment began. The bubble burst when, in an age of economic austerity and public service reform, critics of this medical model began to point out its obvious flaws.
There is nothing in the pharmacology of methadone that means you can’t get out of bed and go to work. The person on MMT should be as economically active as his or her neighbour on insulin or blood pressure medications. But in the UK they aren’t.
In the USA a majority of people on OST and MMT are in employment. In France and Italy it is thought at least half of the people on OST and MMT are in employment. In the UK it looks like only a small percentage of people on OST and MMT are in employment. This is probably because of the culture within which OST and MMT emerged in the UK. The culture of OST and MMT in the UK is one of welfare dependency, social exclusion and marginalisation. The US had ‘Methadone, Wine and Welfare’, we have ‘Methadone, booze, benzos, benefits and daytime TV‘
The performance of the current system is measured against three processes; access to treatment, retention in treatment and completion of treatment. There is no measure of real world, common sense outcomes such as new Jobs, new Friends, new Homes and better lives. Local authorities now hold the treatment purse strings and they are interested in economically active citizens and public service reforms that address inter-generational complex dependencies. Asset Based approaches and Asset Based Community Development point the way to real world, common sense outcomes and away from deficit based systems of procedure and process.
Let me tell you a story about Successful Sid. He was born in 1972 and on his 30th birthday he entered treatment for heroin dependency. Within 3 days of asking for help he was on a methadone maintenance treatment programme. Sid stayed on MMT for the next 12 years. In January 2015, Sid was successfully discharged from treatment as his treatment was complete. Sid hasn’t returned to treatment so the six months are up and he is a successful completion and we can be sure he will not represent because he is dead.
Sid went to his grave at the age of 43 as a direct result of his addictions – white cider saw him off in the end. Sid did have a job once – as a paper boy, but he never worked as an adult and relied on welfare payments to support him and his partner and their 3 children. Sid is survived by his partner (still on MMT) and his 3 children who are now young adults and are themselves reliant on welfare benefits to raise Sid’s grandchildren. The current treatment system see’s Sid as a success – he got into treatment quickly (access ), he stayed 12 years (retention ) he successfully completed treatment and did not return within 6 months (successful completion ).
If Sid is a success, what does failure look like? Those who defend the current system and the status quo might say that failure looks like death from overdose.
Fair point, but Sid didn’t die from a heroin overdose.
They might also say that failure looks like increased acquisitive crime committed by people who can’t get onto OST and MMT or who leave the same prematurely.
Fair point, but Sid didn’t commit much crime before he died because you can easily drink yourself to death on benefit payments alone – as long as you don’t eat much and can stomach white cider and supermarket own brand vodka.
They might also say that we in England have a majority of our treatment population in treatment and we should be proud of this when compared to somewhere like the USA where only a minority of their treatment population are in treatment.
Fair point, but Sid died from a problem (alcohol dependency) that he developed whilst he was in treatment. He came in with a heroin problem and left with an alcohol problem that killed him.
But, Sid is a success story:
“You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.” – Thomas Sowell
There’s a short piece by Mark Gilman and Ray Jenkins in the current Drink and Drug News on how and why the North West of England became the epicentre of the UK’s new Recovery movement.
His work on projects like Smack in the Eye and his early writings identified Mark Gilman as one of the early pioneers of Harm Reduction, so his embrace of Recovery and the 12 step fellowships was seen as something of a betrayal of those early principles by some. For Mark, it has always been about getting the best possible outcomes for the communities he serves.
You can read the article here in Drink and Drug News
For many years now, it’s been an accepted truism in the drug treatment industry that the treatment programmes aimed at medics have success rates that are enormously above the average — with claimed rates of over 90% being substance free after completing treatment.
There’s been a huge range of speculation as to why this should be so. Is it because of the intensive supervision and aftercare that doctors get on completing treatment? Is it because the 12 step based intensive three month in-patient programmes have a higher success rate than out-patient CBT based treatment? Could it have something to do with the enormous amounts of social capital that medics have — along with the very real threat of losing a salary in excess of £100k a year?
But just how accurate are these outcome statistics anyway? Most are provided by the programmes themselves, rather than by independent evaluators. And what happens when the programme is a bad match for the patient?
These are some of the questions posed in an interesting article posted on KevinMD.com
I’d be interested to hear your thoughts on this issue.
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