The ABC of substance use is taking a fully trauma-informed approach to transforming prison-based drug treatment, say Alana Diamond, Deborah Franks, Danny Pearson and Steve Hartlands.
The ABC of substance use was developed to bridge the gap between substance use and prison treatment. We wanted to develop a compassionate and evidenced-based approach for people who use substances, and in May 2020 we carried out a gap analysis and explored what was available within Nottingham, Lowdham and Ranby prisons.
From this, we found that the treatment available was costly and identified that a treatment course was needed that incorporated accessible language and a person-centred approach with a compassionate facilitation style. At the heart of it should be a focus on shame, ACEs and trauma.
TRAUMA-INFORMED
In June 2020 we began to explore what was needed for service users as an addition to the pre-existing psychoeducation-based brief interventions around keeping safe and substance awareness. We found that for relapse prevention work to be more meaningful, we needed to combine trauma-informed treatment to address the root cause of substance use.
During 2023 the ABC of substance use underwent a national panel under the PSO4350 quality assurance criteria and the course was validated in Nottingham Prison. The PSO (Prison Service Order) 4350 is a policy which sets out the process by which rehabilitative interventions aimed at people in prisons and on probation are endorsed by HMPPS – this is a Ministry of Justice (MoJ) national framework for interventions.
Recovery is a complex problem. We felt that the difficulty is often not the substance itself but our relationship with it. So we wanted to create a safe and contained space in which our clients can start to build relationships, increase their self-awareness, develop skills for wellbeing and start to face the fear of change. We wanted to explore solutions to emotional difficulties by developing skills for life. We already know that recovery is a long and unstable road. The journey begins by understanding the difference between thoughts and stories, developing self-compassion and working with the past so we can live in the here and now.
NO QUICK FIX
The ABC of substance use is not a quick fix and is the start of the journey for our clients. Substance use is a life-threatening difficulty and requires many tools – a combination of support, psychoeducation, counselling, groupwork, trauma work and mutual aid – to regain a greater sense of freedom and power over our lives.
The course has 12 sessions, which are developed from a biopsychosocial model that includes Dr Albert Ellis’s ABC model. Also included are elements that have been used successfully in previous courses around the world such as mindfulness, psychoeducation, solution-focused brief therapy, theory of marginal gains, theory of hope, CBT and biological and motivational theories in psychology – all underpinned by a compassion-focused approach. Each element provides the framework to explore topics such as barriers and benefits to risk taking, self-esteem, identity, guilt and shame, the driving force, here and now, cognitive distortions, perspective taking, emotional regulation, communication, trauma and moving forward. The core element threaded throughout the course is to ensure that we work towards de-shaming and increasing self-esteem, and therefore allow clients to become more open to learning, new ideas and hope.
ROOT CAUSES
We feel the gap between this course and others is the identification of the root cause of ACEs and trauma, rather than primarily focusing on the triggers of the substance use itself. Instead of adopting the stance of being the experts, we’ve taken a more inclusive approach, developing a compassionate, experiential, non-shaming and relationship-based model which allows the clients within a safe and contained environment to develop responsibility and control of their journey.
We have so far delivered 12 courses, nine at Nottingham Prison and three at Ranby – 72 clients have started the ABC in total. In each group we capped the attendance to six clients due to the depth of the work that was being carried out, which ensures a therapeutic environment conducive to working with trauma. It has embraced a structure that limits grooming and manipulation of facilitators, and ensures a collaborative approach.
CHALLENGES
The challenges included a certain number of clients who were transferred, the environment (such as difficulties in finding rooms), a lack of understanding of trauma informed care, and the fact that it was written and piloted through COVID.
The psychometrics used for the first eight cohorts at Nottingham Prison were the Brief situational confidence questionnaire (BSCQ), the Cognitive and effective mindfulness scale – revised (CAMS-R) and the Emotional problems scale: self-report inventory (EPS:SRI).
The BSCQ indicated an average increase of between 14 per cent and 38 per cent in confidence dependent on situation, while the CAMS-R indicated an average increase in mindfulness of 5.1 on a scale with a maximum score of 40 (a 12.75 per cent increase). The EPS:SRI showed on average a general reduction in thought disorder, impulse control, anxiety, depression and low self-esteem with an increase in positive impression.
We are continuously developing the ABC and receiving feedback from clients, staff and the national panel in the psychometrics. To this end the BSCQ has now been replaced with the drug-related locus of control scale (DR-LOC), and we’ve also developed a training package to train staff to deliver and understand the models used.
We are now working towards validation at HMP Ranby and, in the future, accreditation.
Alana Diamond is substance misuse training facilitator at HMP Nottingham
Deborah Franks is senior counselling psychologist in the NHS
Danny Pearson is substance misuse training facilitator at HMP Nottingham
Steve Hartland is assistant psychologist in the NHS