Index

2.1. PROMIS

PROMIS Recovery Centre and the PROMIS Counselling Centre were established in the 80’s to treat people suffering from addiction. The organisation treats all forms of addictive disease most frequently alcohol, drug and food problems but also other forms of addiction such gambling, sex and work. The centre in Kent is now an extensive 40 bed in-patient treatment facility, and the centre in London is an assessment centre which also operates on an out-patient basis. PROMIS aims to treat addictive behaviour within the traditions of the Minnesota method. The founder, Dr. Robert Lefever, has described the approach in a number of publications (e.g. Kick the habit, 1999). This approach is based on the "Twelve step" philosophy of the Anonymous fellowships and is now often referred to as Twelve Step facilitation therapy.

Interpretation of Addiction

There are many definitions of addiction and many differing opinions on the nature of addiction. At PROMIS the Twelve Step Minnesota definition is used and incorporated into the programme’s philosophy. This defines addiction as a disease and views all expressions of addiction as having the same basis. As akin to other diseases it is seen as having symptoms, a notable progressive course and outcome. Addiction is also believed to be hereditary in part and that sufferers can experience multiple addictions. This is where an alcoholic may also use drugs or where an anorexic also uses exercise to compulsively mood alter. Though essentially incurable, addiction is taken to be a treatable and controllable illness. Obsession is thought to be the core of the problem and this is characterised by compulsive behaviour. Alcohol, recreational and prescription drugs, nicotine, over and under eating, work, compulsive helping, relationships, gambling, and sex, are some of the behaviours which are seen as being addictive. (A more detailed look at these areas will be taken in the chapter four when the PROMIS questionnaire is examined). Formal diagnostic criteria such as the DSM are not strictly adhered to at the centre, as any use of these addictive behaviours which result in significant negative consequences for the patient is seen to be worthy of treatment.

One feature of addiction that is commonly emphasised in treatment is that of "denial". This is the constant inner urge to persuade themselves that they are not really an addict, and that the cause of the addiction stems from other factors such as current circumstances. By comparison, it is often the case that the cause of addiction is seen as lying with the individual and that it is a lack of intelligence, loss of will power or weakness of character that gives rise to the problem. At PROMIS these popular common knowledge assumptions are discouraged and it is emphasised that the individual is not responsible for the addiction itself, though has responsibility for the actions that the addiction may have invited. Emotional trauma is taken to be a potential precursor and sensitising agent to a pre-existing genetic potential and when experienced in conjunction with exposure to something that affects the mood of the individual, such as alcohol or food, this can begin to trigger the addictive process.

Referrals and Assessment

People come into PROMIS either through self- referral, employers, the patients’ families or through General Practitioners or Psychiatrists. The initial assessment is typically conducted by the treatment director. One task of the assessment is to try to rule out competing explanations for their problem behaviour. Elements such as the severity of their addictive use of a substance or behaviour is investigated in relation to any personal, legal and social consequences that the person is suffering due to that use. Modes of treatment are recommended and the following areas are typically discussed; group and family psychotherapy, detoxification medication and intensity of treatment intervention. When a person has been admitted for treatment a more in depth history is taken by the nursing staff and patients are also seen by the General Practitioner and the Consultant Psychiatrist.

One limitation which often concerns those working in the field is the lack of professional assessment involved in the self help Twelve-step community. This omission is thought to be a problem where people are suffering from further psychiatric disorders and would benefit from further intervention. At PROMIS, this problem is directly addressed. There is a team of professionals who are trained to investigate the intricacies of addictive behaviour, to look for competing explanations for the presenting problems and to ascertain whether there are co-morbid factors which may necessitate a complementary approach such as additional pharmacological interventions.

"Patients"

At PROMIS those who enter are called patients, this is in part because they are viewed as suffering from an illness. PROMIS is also a registered hospital, making the term appropriate, if not necessary. The participants in the subsequent studies in the thesis are accordingly referred to as "patients".

Treatment

PROMIS aims to diagnose and treat all stages of addictive disease and is involved in the longer term commitment to a plan of continued recovery. All expressions of addictive illness are addressed: physical, social, emotional and spiritual. Cross addiction (the phenomenon of switching from one addictive area into another or having concurrent addictions), is addressed in treatment, as is relapse prevention. In addition to this, social, financial, occupational and environmental matters are also considered where appropriate.

Family Involvement

This is a key element in the treatment of the individual as it has been increasingly recognised at PROMIS that the whole family is often integral to the addictive process for the individual. This could be in terms of family members inadvertently "enabling" the addictive process by providing money, ostensibly looking after their family member, or by protecting them from untoward consequences of their using. There is a degree of education and instructional work to be undertaken so that the family has a clear and informed idea of what addictive disease entails and means. On a different level their involvement can aid the process of recovery in learning how to assist in a genuinely supportive and healthy way. In addition to these aspects family members often require counselling themselves and are encouraged to attend anonymous fellowship meetings designed to help relatives of addicts.

Many addicts have not achieved independence from their families and the family can function to maintain the user’s habit. Focusing on the substance abusing member of the family distracts attention away from the real problems within the family (Madanes, Duke & Harbin, 1980). The family may undermine the user’s attempts to abstain as they have a vested interest in keeping the user dependent. Yandoli, Mulleadly and Robbins (1989) have termed these family situations as enmeshed, and in such cases the family needs to be involved in treatment and independence encouraged.

Staff

The staff who have direct therapeutic contact with the patients are the treatment director and other trained counsellors. At the present time all of the treatment staff are in recovery themselves and although many have various forms of formal counselling qualifications the bulk of their training though comes through a probationary learning period at PROMIS. On entry the counsellors are encouraged to take a certificate/diploma in Addiction Counselling which is run by PROMIS in London, and validated by the University of Greenwich. In addition to the counselling team there is a team of registered psychiatric nurses, a Consultant Psychiatrist and a General Practitioner. The employment of recovered addicts in this field is typical, as it is thought that counsellors that have successfully been through the same treatment process offer inspiration and a helpful source of identification to those who are currently being treated.

2.2 Treatment method (Twelve Step Facilitation, linked with Anonymous Fellowships)

The PROMIS treatment follows the main Minnesota model of the treatment of addicts and this has its methods rooted in the Twelve Step Anonymous Fellowship Programme of Alcoholics Anonymous and other variants of this group that have developed, for example Narcotics Anonymous, Overeaters Anonymous and Gamblers Anonymous.

The programme

The programme is highly structured and intensive and the individual’s personal dedication and ultimate responsibility for his/her own recovery is emphasised. The key to the programme is abstinence from the mood altering substances or behaviours and long term commitment to the appropriate Anonymous Fellowship. Emphasis is placed on physical, social, emotional and spiritual aspects of addiction, dealing notably with problems of shame guilt and anxiety. From the initial diagnosis the aim is to detoxify, stabilise and treat, aid in rehabilitation and to encourage an ongoing and lasting recovery.

The programme can be interpreted as uncomplicated in essence as it is proposed that by simply adhering to the Twelve Steps and attending meetings this will lead to a successful outcome. The programme in some way gains strength from this as the patients and their experiences are complex and diverse, and the philosophy with its simple roots is therefore applicable to all. Therefore within treatment common experiences are shared and from this mutual support is encouraged. Emphasis is mainly placed on "working the steps" and although the period of time in treatment may be seen to be an introduction, this prelude is the beginning of what, hopefully, will become a life long endeavour. During treatment this aim is further facilitated by requiring patients to attend outside Twelve step meetings in the local area. Although the focus of the problem is acknowledged whether this be drugs, alcohol etc., the programme offers a total lifestyle solution, in that it addresses the individual’s values, attitudes and relationships. Instead of human functioning being broken down into component parts with addiction being just one element of their functioning a holistic approach is taken.

For each step patients are encouraged to think about its meaning and significance and to try to understand the various challenges that it implies. The patients’ thoughts and feelings regarding each step are discussed with fellow peers and are written about in work-books. When a sufficient amount of work has been completed the step is presented formally to fellow peers and a counsellor, and it is in this arena where peers can help, encourage and challenge points that the presenter is making, thus further aiding their recovery. Post treatment this process is encouraged to be carried on within the fellowship meetings with discussion occurring with their fellowship sponsor or with other members of the Fellowship. Ultimately what is encouraged is for the steps to be actively lived. In the patient’s own time step studies, meditation and reading of AA’s "Big book" are encouraged.

Treatment Format

When a patient enters treatment they are encouraged to participate and be active as quickly as possible. To facilitate this during their first week in treatment outside contact i.e. phone calls and visits are only permitted in exceptionable circumstances, this is to help patients concentrate their efforts on their recovery.

Life Story

After being in treatment for a few days the new patient is asked to write about his/her life story. The following areas are considered: Progression of addiction, general life background, family details, relationships, important and painful events in life. The patient then presents this to all of their peers, giving them the opportunity to find out more about the new member and to ask questions about them. This life history group enables the group to get to know the new patient quickly, and it is also considered to be the first step in looking honestly and in detail at one’s life.

Group Therapy

The dominating medium of treatment is group therapy and this takes differing forms, such as gender groups or peer evaluation groups (these are discussed in the next section). Through a variety of activities and from constant support from staff and peers, new behaviours, coping strategies and cognitions are encouraged and so are used and developed. The patients are strongly encouraged to "trust, risk and share" feelings, thoughts and emotions, both positive and negative, in and out of the group setting and this encourages a constant flow of an ongoing process of therapy. Emphasis on the expression and awareness of feelings is paramount as it is thought that people’s behaviour is predominately governed by their feelings and that actions can be better understood when the feelings associated with them are comprehended.

Most patients enter the centre believing that they are quite unique in that they alone have a certain set of concerns, problems and impulses centring not only around their addiction but also in other areas of life. Through the group interactions, peers share elements of their life and attract identification and guidance from others. The group’s method of operation involve peers taking it in turns to voice a concern or worry and others identifying and offering alternative viewpoints or ways that they themselves have managed a particular problem. It is perhaps through the acknowledgement of a number of people’s similar opinions that the power of the group therapy lies. Many find a powerful sense of relief in this process as common factors between the individuals are quickly found, and this ongoing process of identification often acts as a powerful cathartic tool.

Through the revealing of their deepest concerns and problems that are broad in spectrum such as unresolved childhood experiences, marital problems and of course their struggle with their addiction, there is often an increasing realisation that they are not alone in their experience. With this there comes a greater sense of self awareness and an acceptance of the illness. It is, perhaps, the process of verbalising a concern in front of a group and having that concern identified in others that decreases its significance and increases the likelihood of change. The counsellor in these settings acts predominately as a facilitator, managing the group process and steering the direction of the discussion when and where deemed necessary.

Process Group

There is usually at least one process group a day where all the patients and the majority of the counsellors attend, it is in this arena where any issue can be raised. At the start of the session patients can ask for time if they have something which they would like to discuss. After someone has raised their concern peers are invited to identify with the comment and it is from this that further discussion, illumination and insight can be drawn. This group also provides an opportunity for the counsellors’ concerns about specific individuals or the group in general to be voiced. Process group is closed by the Serenity Prayer, which is a Twelve Step Tradition.

Table 3: The Serenity Prayer

God grant me the serenity
To accept the things I can not change,
the courage to change the things I can
and the wisdom to know the difference.

Gender Group

This occurs on a weekly basis and is when the patients are split into separate gender groups for a session of group therapy. It offers those patients who have issues that they would find awkward discussing in a mixed setting an opportunity to do so with members of their own sex. Unlike other groups, topics raised in gender groups are not discussed outside of that setting, so this allocated time allows for sensitive issues to be raised and discussed in a more private setting.

Peer Evaluation

This is where some of the more senior peers assess how the individual is progressing, highlighting potential "blocks" to recovery; these being areas that are seen to be causing an arrested or retarded progress through treatment and that may cause later relapse. Peers affirm areas where the person is coping well, and it is stated whether they believe the person has accepted the powerlessness and unmanageability of his/her addiction.

Collage

This is where a patient assembles pictures from newspapers and magazines to aid the depiction of a certain aspect of his/her addiction or life that the counsellors see as needing particular attention and focus. The title is chosen by a counsellor, and the collection and arrangement of the picture for the presentation aids the patient in confronting the areas that the counsellors have highlighted in a different format. The collage is presented to the group and involves the individual discussing the chosen pictures’ significance and relevance in relation to the title, an example being, "The cost and the consequences of my relationships". The pictures may aid the patient in revealing the progression of a period of time or, perhaps, in depicting certain characters in the patients’ life. The collage offers a further opportunity to address difficult areas utilising an expressive medium.

Psychodrama

This is a therapeutic model originated by Moreno (1889-1974) which originated from his early experiences in spontaneous theatre and community therapy (Marineau, 1989). It is a therapeutic method where exploration of painful and often traumatic events are re-enacted therapeutically rather than talking about them as occurs in other therapies. It aims to uncover the genuineness of the individual in relation to other people in their lives (op cit).

Lectures and Videos

These are used to impart knowledge about a variety of topics which is valuable in understanding addiction. Both lectures and videos are useful for sparking off provocative and useful debate as it is a different medium and in turn provides a further way for patients to comprehend their condition. There is a sophisticated body of information which, in conjunction with the steps, forms an important part of the programme. For instance side effects of chronic dieting, cognitive changes in semi-starvation, socio-cultural attitudes dealing with women’s attitudes about shape and weight.

The Feelings Diaries

Each patient is required to complete a daily feelings diary at the end of each day. Here they are asked to write about their most important feelings generated by the events of the day. In general this medium encourages an exploration of the ideas presented in treatment and permits an alternative way for patients to reflect on how they are doing by looking at their most pressing concerns. The diaries are read by the counselling and nursing staff the morning after they are written and thus are not only an exercise in self exploration but a medium where thoughts can be communicated to the staff.

Free Time and Evenings

The patients may spend their free time and evenings working on various written tasks that are associated with working through the steps and other group therapy related tasks, however the majority of their free time is occupied by on going discussions with peers. Evening attendance of the local outside Anonymous Fellowship meetings is also encouraged. There are allotted times for patients to watch the television, and at the end of the day newspapers are made available.

2.3 The Twelve Steps

The co-founders of Alcoholics Anonymous produced the Steps as a guide for others seeking recovery using the simple principles that they had found worked for themselves. The Twelve steps are often summarised in AA programs in the following way: Steps 1-3: Give up, Steps 4-7: Own up, Steps 8-9: Make up, Steps 10-12: Grow up. An even more simple summary is, "Trust God, clean house, and help others"

Step One

"We admitted we were powerless over... ( our addiction/compulsion/obsession)... and that our lives had become unmanageable."

The first step is seen as a crucial part of the programme as it assists the patient in seeing the need for treatment and long-term recovery through the unveiling of a realistic and honest picture of himself/herself. The major emphasis of this step is the confrontation of denial, in that this step requires the addict to accept their loss of control and the personal and social unmanageability that is associated with their use of alcohol/drugs/food etc. This is an important step as acceptance of the loss of control that the addict experiences is now recognised as a key factor in the establishment of motivation to change which is necessary for the recovery process to begin (Prochaska, DiClemente, & Norcross, 1992) Interestingly after this step the actual naming the manifest problem isn’t again seen until the final step where the member is encouraged to carry the message to others struggling with the same problem.

Step Two

"Came to believe that a power greater than ourselves could restore us to sanity"

The work on this step revolves around the realisation that long term recovery is dependent upon asking for help, that it is not possible for this to be achieved independently, and that there must be a belief that change is possible. In essence it is the step where hope and faith is established. It involves the further acceptance of the limited power that an individual holds, and the development of a belief that there is a greater source of power that can be used as a source of strength. Initially this source of power is commonly experienced through the strength of the peer group and the fellowship meetings.

Step Three

"Made a decision to turn our will and our lives over to the care of God as we understood Him"

This is an active step that involves "letting go" to permit a shift of focus from the self to occur and having an open mind about the possibility of a force greater than the individual. Initially, whatever or whoever is most important to the individual is said to define the main focus of a person’s spirituality. It does not insist that individuals accept a specific definition of God though there is a specific encouragement on the focusing on issues of spirituality. This is due to the fact that God is only one of many spiritual focuses and there is much variety and flexibility in the way individuals relate to an understanding of their "higher power".

This step confronts the addict’s grandiosity/omnipotence and attempts to establish the emphasis on dependency away from substances and behaviours into a more relational sphere. A person’s spirituality can be seen as closely related to their values, priorities, goals, preoccupations and commitment. When spirituality is viewed in this light, addiction can be viewed as a destructive process. Spirituality has to do with the quality of relationship to whatever or whoever is most important in life, and in the case of those who are in active addiction their drug of choice has become the main focus of their lives.

It is this step which is most often linked to the concept of "hitting rock bottom". Though controversial, in the fellowship this is thought to make the addict recognise where the addiction had taken them and thus give them motivation to change.

In these first three steps there is a paradox, on the one hand the inability to control the self is acknowledged though at the same time the necessity for the addict to surrender their control to another, the higher power, is called for. "The step embraces this paradox by acknowledging the reality of volition in the midst of the loss of volition" (Hopson, 1996) This element of self agency is thought to occur through the growing relationship and surrender to a power greater than themselves.

Step Four

"Made a searching and fearless moral inventory of ourselves"

This step is where the process of introspection continues the process of self-analysis. It requires the addict to look at his/her character defects and admit the wrongs and injustices that he/she may have committed. It involves taking full responsibility for himself/herself, and encourages the individual to look at events in the past that may have been blamed on others or justified incorrectly due to their addictive use.

Step Five

"Admitted to God, to ourselves and to another human being the exact nature of our wrongs."

Step five encourages the addict to share and discuss his/her inner most secrets and feelings and is the step where confession and catharsis starts. This process is continued in steps 6 and 7 and 10. This in part is seen as a cleansing and healing step as with the act of admitting the most pernicious aspects of themselves there comes with this a great sense of relief. Psychotherapeutic insights regarding the cost of repression are addressed here as contained in these steps are clear messages and encouragement to uncover, acknowledge and finally to let go of shortcomings and mistakes of the past.

Steps Six and Seven

"Made a list of all persons we had harmed and become willing to make amends to them all." and "Made direct amends to such people wherever possible, except when to do so would injure them or others."

These steps address penance and undoing and look at the possibility of reparation. Hopson, (1996) maintains that psychotherapeutic thought emphasises the importance of reparation as a crucial element in the development of the ability to hope and feel concern for one’s self and others. A further element which is tackled by these steps is that of lack of efficacy that is characteristic of the addictive experience. These steps achieve this through the offering of a possibility of viewing themselves as having the power to be an effective agent in the world thus addressing inter and intra personal alienation.

Steps Ten, Eleven and Twelve

"Continued to take personal inventory, and when we were wrong, promptly admitted it", "Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out" and "Having had a spiritual awakening as the result of these Steps, we tried to carry this message to (other addicts) who still suffer, and to practice these principles in all our affairs"

These final steps aim to maximise the addict’s conscious contact with themselves through giving back through helping others and the redirection of energy through altruism and sublimation. These activities are thought to be beneficial as it is thought that the process of recovery is a life long pursuit that involves constant acknowledgement of one’s shortcomings and limitations. In the "reaching out to others" the addict is reminded of their own path to recovery and therefore complacency is avoided. There is also emphasis on the embodiment of the steps into the whole life of the addict as they are called to practice these principles in all their affairs.

End of Treatment

There are three main ways that a patient can be discharged. The majority of patients are discharged, with staff approval this discharge indicates that they have fulfilled all the requirements of treatment to the satisfaction of the treatment staff. A further group of patients choose to leave the centre without staff approval, this method of discharge indicates that they are leaving before the treatment staff judge that they have completed the programme. The last group of patients are discharged at staff request. This occurs when it is felt that their continued stay at the treatment centre isn’t beneficial for the patient, this may be where there is continued reluctance to participate, or where their presence is thought of as too disruptive for the other patients. When an individual completes the programme a leaving ceremony is held for the patient where a medallion with the program’s logo is presented and a group photograph is taken.

From the previous two chapters a number of assumptions have been made regarding the status of addiction for instance, the idea that all addictions are fundamentally the same and that there is a phenomenon of "cross" addiction. These issues amongst others will be explored in the next chapter. It starts by addressing the concept of "behavioural inclusion", and looks at the persuasiveness of the current evidence and theoretical rationale for the inclusion of other behaviours in the addiction remit. In conjunction to this an exploration of the pattern of cross addiction in relation to a diverse range of substances and behaviours will be explored.

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