PROMIS: What we do and why we do it

PROMIS is the embodiment of an idea: that patients should be centrally involved in their own care. Treatment should involve their active participation, rather than be something that they receive passively.

Professor Lawrence Weed, Professor of Medicine and Community Medicine at the University of Vermont, created the idea of a Problem Oriented Medical Information System (PROMIS) in which medical records are used as a central resource for patient care and education. The format of the records provides a basic data base, that determines the foundation of subsequent clinical conclusions, and a précis of the subjective statements of the patient, the objective findings of the clinician, his or her assessment of particular problems, and the plans made for further investigation and treatment, including education of the patient about the clinical conditions and what he or she can best do as the central person involved in future management. Subsequently Professor Weed developed Problem/Knowledge Couplers which use the memory and cross-referencing powers of the computer to assist the judgement powers of clinicians.

The PROMIS Unit, my medical practice in South Kensington, uses this system of ideas and, with permission from Professor Weed, we also incorporated the name and the principles into our work at the in-patient PROMIS Recovery Centre and out-patient PROMIS Counselling Centre where we look after patients suffering from depression and any form of addictive or compulsive behaviour. Thus, the basic PROMIS ideas are applicable to any field of clinical practice. (For example, there could be a PROMIS Cardiac Surgery Hospital.) Our work in depressive illness and addictive or compulsive behaviour is only one of many offshoots from Professor Weed’s pioneering work.

Our ideas on the management of depression and addiction are our own, although we incorporate ideas from many sources, most notably Minnesota Method principles based upon the Twelve Step Programme first formulated by Alcoholics Anonymous and also various therapeutic methods such as Gestalt Therapy, Transactional Analysis, Choice Theory, Cognitive Behavioural Therapy and Psychodrama. We believe that depression and addiction are the same thing: addicts have found ways of "treating" the inner emptiness with which we believe they were born as a result of defects in the neuro-transmission systems in the mood centres of the brain. Our starting position is therefore the belief that addicts are responsible for their behaviour as it affects other people but not responsible for having an addictive nature. As with other patients, they therefore deserve to be treated with respect and dignity, given appreciation for their intelligence and determination, helped to understand the nature of the clinical condition from which they suffer, and shown what they can do to help themselves to live abstinent, happy and constructive lives for the future.

PROMIS is proud to take its place very firmly in the private sector, focusing our attention upon innovation and with our ideas being judged in the clinical and financial crucible of whether they actually work in practice. A principal commitment of PROMIS is that clinical practice should be based upon research evidence. However worthy or "obviously true" a political or clinical idea might be, it should be discarded, and the "unthinkable" alternatives thought, if it doesn’t work in practice.

For one small organisation such as PROMIS to fund major research projects on therapeutic approaches is clearly impossible. The budget for Project MATCH, being conducted over eight years in one hundred treatment settings in the USA in order to compare the effectiveness of Minnesota Method approaches with Cognitive Behavioural Therapy and Motivational Enhancement is $28 million. Nonetheless PROMIS has a significant research department, headed by Professor Geoffrey Stephenson, emeritus professor of Psychology in the University of Kent at Canterbury, and with two full time PhD graduates, one PhD student and further part-time input from two university senior lecturers. Our research department studies both the process and the outcome of our work and publishes articles in national and international journals each year. Our contribution to the wider community (those who can not afford the fees for treatment) is the ideas that we publish in these articles or in books, on audiotapes, videotapes, or on the internet, although the local NHS Trust have recently approached us to consider purchasing our services.

The prime purpose of PROMIS is therefore to generate ideas and research their effectiveness. Currently, we treat one hundred and eighty inpatients and three hundred and fifty outpatients each year, an almost insignificant number relative to the potential demand, but our ideas have the potential to reach a much wider community throughout the world. A study of our patients shows that they have a higher general psychiatric morbidity (they are more mentally ill) than average inpatients in a psychiatric hospital. We do not use drugs except for acute psychoses and for a short (five to ten day) period of detoxification.

Yet two thirds of our patients are shown to have significant benefits one year after treatment (other than in anorexia where the figure is one third, although our anorexic patients are older and have had more previous treatments than those seen in standard hospital units) and this compares exceedingly favourably with other approaches.

For example, fifty percent of people being prescribed regular Methadone as a "treatment" for heroin addicts (so that they can be less at risk from AIDS, Hepatitis B and C and other medical complications, to be out of the clutches of crime, and to be able to have some stability in their lives and even seek some form of gainful employment) have been shown to be obtaining daily heroin (the other fifty percent less regularly) from illegal sources, with all their risks, and more people now die on Methadone than ever died on heroin.

By contrast, PROMIS believes that the most effective "harm-minimalisation" is abstinence from all mood-altering substances and processes that affect the suffering individual (as seen on the answers to the Shorter PROMIS Questionnaire that assesses sixteen potential addictive outlets), coupled with a balanced and creative life obtained through working the Twelve Step programme of the anonymous fellowships, such as Alcoholics Anonymous, on a continuing basis for life. This true recovery enables sufferers from a chronic medical condition to become fully functional in body, mind and spirit as well as in their chosen employment and domestic situations. It is extraordinary that such treatment is so far the exception rather than the rule in the UK.

Our central idea is that patients have the capacity to learn from experience and to make choices that help them to be happier, healthier and more productive in ways that they themselves would wish. Professor Weed argues that patients are the most valued members of his staff. He says that they are motivated, there is one for every patient, and that they actually pay him while they are doing their work! The advent of the internet gives patients direct access to specialist information, although specialist experience and judgement will always be a vital input. Nevertheless it is no bad thing that increasing knowledge gives increasing power of personal choice to patients.

At PROMIS (which from here on implies The PROMIS Recovery Centre and The PROMIS Counselling Centre) patients have access to their own records (we didn’t need the Freedom of Information Act to require that) and they even contribute to them in writing significant feelings sheets each evening. One research project, conducted by Professor Stephenson using narrative analysis techniques, showed that patients benefited from subsequent feedback illustrating how their perceptions had changed during the course of treatment. In other words, patients benefit from being treated as intelligent adults rather than as supplicant imbeciles who should be grateful that great men and women give them time and attention. Patients sent to us and paid for by the Probation or Social Services have shown the most dramatic changes when given the dignity of personal respect while at the same time, along with any fee-paying patients, being left under no illusions that we would tolerate inconsiderate behaviour towards staff or other patients. As a result, episodes of violence or disruption of any kind are exceedingly rare occurrences at PROMIS (two physical fights in fourteen years in a patient population that has often used the threat of violence, or its actualisation, as a natural mode of expression) whereas the Royal College of Psychiatrists reports that physical and verbal violence is the most common concern of general psychiatric institutions. Patients behave well when treated well. Dr William Glasser, the consultant psychiatrist author of "Choice Theory" and "Reality Therapy" and another major contributor to the ideas and clinical practice of PROMIS, found exactly the same results when he gave pupils in a girl’s reform school in Los Angeles greater choice in how they managed their own lives in their restrictive community.

The fact that we use pharmaceutical drugs so rarely is, I am sure, a major factor contributing to the emotional and behavioural stability of PROMIS patients. Psychotropic drugs do not only what the pharmaceutical companies say that they do (along with their side effects). They also suppress feelings so that patients become emotionally inaccessible.

Patients on psychotropic medication may be able to understand things but, in our experience, that does not help them to change their behaviour. In particular antidepressants as well as tranquillisers and sleeping tablets (and even Zyban, that is used to suppress cravings for nicotine and which might also come to be used in cocaine addiction, Naltrexone, used as an anti-euphoriant for people addicted to opiates, and Antabuse, used as a deterrent in alcoholism because it makes people feel ill if they drink alcohol while taking it), are all contraindicated for patients with depression/addiction. The reason for this is that the positive feeling that they provide is false. They prevent the achievement of a naturally contented and tranquil state. They distort the body’s own homeostatic, self-regulating mechanisms. The temporary respite that they provide is at

the expense of emotional and/or physical dependency. They do nothing to encourage patients towards finding out how to change their own feelings and behaviour: they actually get in the way of that vital process.

At PROMIS patients are encouraged to learn that their feelings act as a barometer that indicates whether their actions are in accordance with their true values. Bad feelings help them to recognise destructive behaviour and good feelings indicate self-enhancing behaviour. This simple mechanism is disrupted by mood-altering substances or behaviours of any kind, the prescribed or legal as much as the illegal. When patients treat their inner spiritual emptiness that, as stated previously, we believe comes from their genetically impaired neuro-transmission systems in the mood centres of the brain, with mood-altering substances or behaviours they run the risk of dependency. That is the precise nature of addiction: the inability to function effectively long-term without the support of mood-altering substances or processes. In time the damaging effects of the physical and/or psychological dependency cause other problems so that patients can not live with their mood-altering substances or processes but also cannot live without them. Exactly this psychological double-bind occurs with mood-altering prescription medications as with any other mood-altering substance or process.

A major part of the work of PROMIS is therefore educational, not only for the patients themselves (telling them primarily about the principles of addictive disease and recovery rather than merely about safe sex and the dangers of particular substances and behaviours) but also for their families, through our residential and non-residential family programmes, and for health professionals, employers and the wider community through seminars, lectures, books and other methods of communication, and now the internet. We provide a major educational resource on our web site and thereby provide free access to our ideas and experience.

The specific work done on a day-to-day basis at PROMIS, and the details of our understanding of working a Twelve Step programme of recovery, are outlined in my book "Kick the Habit" (Carlton Books £8.95).

Our work is mostly in group therapy. One-to-one sessions run the risk of creating a mutual dependency and the further risk that patients will see themselves and their problems as being special and different, rather than being generally the same as for other people who have the same condition. Blame and self-pity, the cardinal features of depression/addiction, can at times be fostered rather than countered by one-to-one sessions whereas in a group therapy session the patients are able to counter their denial (the psychological feature of their clinical condition that tells them that they haven’t got it) by seeing themselves reflected in the behavioural mirror of the other patients. This mirror is effective both when they are doing badly and when they take their first steps towards recovery. The true opportunity to be special and different comes only when patients are fully free from depression/addiction.

Within the group therapy sessions we use a variety of therapeutic approaches as follows:

Gestalt Therapy

Initially developed by Fritz Perls, observes that specific blocks can occur in the emotional evolution associated with any experience. Patients may become blocked repeatedly in the same way, for example finding it difficult to move from

contemplation to action. Gestalt Therapy looks at helping people to remove these blocks, at modifying the shifting patterns in focus of attention between foreground and background issues, at resolving the dilemmas involved in choice, and at ways in which people can modify their inter-relation with their individual human and wider social environment.

Transactional Analysis

Whose originator was Eric Berne, looks at people’s psychologically internalised parents, adults and children, formally reflecting their concepts of authority, maturity and fun, and at how people inter-relate with others within this psychological structure. Particular note is made of crossed transactions, where a relationship may be viewed and used differently from either side, and ulterior transactions in which the words used may belie the emotional content. Eric Berne’s profoundly stimulating and humorous book "Games People Play" (Penguin £6.99) illustrates common patterns of ulterior transaction in the hope of encouraging people to drop all these games and make adult, mutually honest and supportive, relationships.

Choice Theory

Developed by Dr William Glasser from his earlier work on Reality Therapy and Control Theory, begins with the claim that among the most damaging of all statements is "I know what’s good for you". As with Professor Weed, he puts patients at the centre of management of their own lives. He demonstrates that people choose not only their own thoughts and actions but also their feelings (in accordance with their values) and their reactions. He argues, absolutely correctly in my view, that nobody can make anyone feel or do anything. His various books on the application of choice theory show how we can choose a different set of total behaviour (thoughts, feelings, actions and even physiology: they come as a package) if we wish to do so and are prepared to give up long-held assumptions and habits of inter-personal relationship.

Psychodrama

The origin of all group therapy, was created by Jacob Levy Moreno, a man of stupendous influence who is today rarely acknowledged. In psychodrama the patient’s inner world is externalised with the aid of "auxiliary egos", other people taking real or inanimate roles as the story unfolds under the care of a director. The focus of the psychodrama can look backwards or forwards in time, can be on one relationship or many, one issue or many: the scope is immense. So is the potential for healing or harm. Looking at thoughts, feelings and behaviour all at the same time, psychodrama can illuminate patterns of interaction in which the patient has become stuck and from which he or she can be helped to move forward. Nobody can watch a psychodrama without in some way being influenced by it. Directors therefore require care and skill, they cannot simply hide behind intellect or professional persona. Hence the lack of general acceptance and even fearful disregard of psychodrama in the general psychotherapeutic world – but, when done well, it works wonders.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy acts on the belief that people will change their behaviour if they come to understand that their current behaviour is damaging. The extent of the failure of government health warnings on cigarette smoking shows the limitations of this approach when treating addicts. People with depression/addiction may have perfectly good minds but their behaviour is governed primarily by their feelings. Ultimately, if the alternative is suicide (forty percent of all suicides are in alcoholics, let alone those in people suffering from other specific addictive behaviours) then anything else is preferable. Nonetheless PROMIS includes Cognitive Behavioural Therapy approaches to help some aspects of patients’ lives at the time when they are already abstinent and working a Twelve Step programme.

Motivational Enhancement

Motivational Enhancement sensibly recognises that one cannot impose behavioural change upon patients. However, enthusiasm, understanding and will-power cannot by themselves combat a compulsion. Habits can be changed, addictions cannot: they have to be acknowledged and countered as a simple routine on a day-to-day basis for life. The techniques of Motivational Enhancement can be usefully employed by any clinician and are used at PROMIS in support of a Twelve Step programme.

Rational Emotive Behaviour Therapy

The brainchild of Dr Albert Ellis, in essence, says to the patient "This is what you have been doing wrong; no wonder you are such a mess and you feel so awful. Practice an alternative approach and you’ll be fine." The Twelve Step programme in the alternative that PROMIS suggests.

Cognitive Analytical Therapy

Cognitive Analytical Therapy is an attempt by Dr Anthony Ryle to marry cognitive approaches, that impart wisdom, to analytical ideas, that say that childhood influences may be considerable. The C.A.T. diagrams of therapeutic pathways are intellectually stimulating and help to focus the counsellor’s mind on making clinical progress.

Psychoanalysis

Concepts of transference and counter-transference illustrate how childhood relationships come to influence, and even contaminate, adult relationships.

Pharmacology

Pharmacology is appropriate for psychoses, diseases of thought process, but it is now often used also primarily for neuroses, disorders of feeling. Our knowledge of brain biochemistry is still in its absolute infancy yet anti-depressants, tranquillisers or sleeping tablets are prescribed on a regular basis to one third of the adult population. By taking patients off all psychotropic medication other than those that are necessary to correct thought disorders, PROMIS sets itself the most difficult but also most rewarding task. Patients find that raw feelings have to be dealt with in new ways; painful experiences can no longer be pushed down and glossed over. The past, present and future all have to be faced. Recognition has to be given to the fact that one is primarily the cause of one’s own problems. Previously drugs, prescribed or illegal, provided a swift blanket to cover all these painful insights and responsibilities. Without drugs, patients have to face up to reality and start to develop resources that will help them towards self-acceptance and healthy, mutually regarding, relationships in the future. They learn to be mature and even demanding of self rather than for ever running away.

The common problem with many therapeutic approaches is that people who are skilled in only one of them may come to believe that that is the one true faith and that other methods are either inferior or misguided. There certainly are misguided therapies but it is a commonplace to note that a skilled therapist mostly uses himself or herself regardless of the techniques employed. Unfortunately, this can lead to guru worship when, like some opera singers, therapists and their acolytes come to believe the front rather than the substance, the publicity material rather than the actual process.

At PROMIS we are exceedingly careful in the selection and training of our counselling staff. Mostly we choose our own former patients (with a minimum of three years in recovery) because their starting position as patients at The PROMIS Recovery Centre was so broad: they had to look at all their addictive tendencies, including nicotine addiction

and compulsive helping (using oneself as a drug for other people) right from the day they were first in treatment. When they start work as counsellors we begin by requiring that they say nothing during a group therapy session but afterwards recount to us what they saw and heard. This trains them to become aware of the entire group process rather than do a series of one-to-one sessions in a group setting. They need to be aware of body language, and of what is not said as well as what is said, but, more importantly, to develop a gut instinct for what is important and what is not, when someone is stuck and how he or she can be helped, when to be firm or relaxed on various practical matters and, most importantly of all, how to have natural authority while not being carried away with one’s own importance. The three year MSc degree course in addiction psychology is the least of their challenges.

Perhaps the most important attribute for a counsellor (which is what I prefer to call myself) or therapist of any kind is to be as much at ease in the world of the arts as in the sciences. One needs both the heart and the head, the instinct and the evidence.

In our work at PROMIS the essence of group work is that patients learn to help themselves through the process of helping each other. This prepares them for a lifetime of maintenance of their recovery in the anonymous fellowships. By taking their minds off themselves and their own pre-occupations and reaching out to help others anonymously and by working the Twelve Step programme on a continuing basis, they experience a mood-altering process that is a direct substitute for their previous depression/addiction but with no downside. This experience of a constructive philosophy is freely available throughout the world in the anonymous fellowships, the addresses and times of their meetings being published in their pamphlets called "Where to find".

PROMIS is primarily a clinical educational institution as well as a treatment centre and we help a significantly larger number of people to get better in the anonymous fellowships than would otherwise do so. These patients have a broad understanding of depression/addiction and recovery and they are less likely to relapse than those who have not had the privilege of Minnesota method treatment.

What do we do at PROMIS? We help people suffering from depression/addiction to find a happier life. We aim to enable them to achieve peace of mind in spite of unsolved problems, mutually fulfilling relationships, and the attributes of spontaneity, creativity and enthusiasm.

Why do we do it? To change the world. Why else?

© Dr Robert Lefever January 2001

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