Benefits of therapeutic communities

RYinpragueAcademic notes

Drug sector veteran Rowdy Yates talks to David Gilliver about the value of therapeutic communities, and the therapeutic value of music

‘It’s kind of schizophrenic for me because one day I’m an esteemed academic doing my presentation and the following day I’m up on stage playing,’ says Rowdy Yates of last month’s annual conference at the San Patrignano community in Italy.

A passionate commitment to both therapeutic communities and music has defined his 46 years in the field, and although he resigns his post as senior research fellow at the University of Stirling at the end of this year, he’s staying on as president of the European Federation of Therapeutic Communities (EFTC) until 2017. And the community of San Patrignano (DDN, March 2014, page 8) is a shining example of what the sector can achieve, he believes.

‘It’s great,’ he says. ‘I mean, you’re talking about 1,500 people – it’s the biggest rehab in the world, really, and there’s a very strong, therapeutic community emphasis on self-help, self-governance.’

Is it a model that we could perhaps look at a little more closely in this country? ‘My view is that we could look at residential rehab much more closely and favourably than we do,’ he says. ‘We’ve had 20 years of thinking that residential treatment is profoundly expensive and therefore a last resort, and that means two things – one is that residential treatment has been marginalised, and the other is that it ends up treating the most chaotic, because you have to prove that you’re really, really messed up before you can get there.’

Much of the research comparing residential and non-residential models ‘doesn’t compare like with like’, he argues. ‘They’ll include the accommodation costs in the residential side of the equation, for example, but not in the non-residential side. I can understand why they do that, but the truth is that the majority of people receiving long-term methadone maintenance are probably also receiving housing benefit, so their accommodation is still costing the state. If you ignore that in an analysis then inevitably you make one side of the equation look more expensive.’ Studies rarely take account of the time window either, he states, with opioid-replacement therapy appearing affordable over the period of a year, but less so over ten.

One early ‘fundamental error’ of the harm reduction community was its failure to recognise, or effectively promote, the fact that it’s ‘actually about two things’, he says – reducing the harm that people do to themselves, and reducing the harm to other people.

‘The first is an entirely laudable aim, and one that’s entirely appropriate for drug treatment services. When I was running the Lifeline Project we were quite involved in needle exchanges and very clear that one of the major purposes was not just to reduce infection control, but also to look at how people were injecting and give them better advice. We kind of assume that long-term users know how to inject, but we forget that they were probably given inadequate advice when they started injecting, by people who’d also been given inadequate advice. We found long-term injectors who had appalling practices, which we were able to correct.’

Reducing harm to others, however, is something he’s ‘less convinced’ that treatment services ought to be involved in. ‘We can’t deny our responsibility to the community, but I know of a number of services who have workers going around giving clean needles and syringes to weightlifters who use anabolic steroids. Now there’s no indication that these people are addicted to those substances – so this is not addiction treatment, it’s not about resolving their drug problem, it’s about infection control.’

It’s possible that many people would be happy for treatment services to move away from a focus on addiction towards public health, infection control and crime reduction, he says, ‘but I’m not aware that we’ve ever had that debate. So that would be my reservation.’

An unintended consequence of harm reduction was to ‘effectively change the face’ of drug treatment, he believes. ‘Up until that point we were the good guys, taking people who were using drugs and making them better. After that, our priorities reversed. People who didn’t want to get better became our priority, and what we did with them in many cases, I suspect, was prolong their addictive experience. I continually meet people in therapeutic communities who tell me they were prescribed methadone for 15, 16 or 20 years. They feel angry about that and argue – with some validity, I think – that that prescription practice actually extended their addiction career.’

It’s a situation that in some ways reflects his entry into the field in the late 1960s, he says, which came via his own heroin use and a belief that if people wanted effective support they’d need to create it themselves. ‘A group of us ex-heroin addicts had been attending Alcoholics Anonymous, which at that time was about the only game in town. Drug dependency units, as they were known, were prescribing heroin and clearly didn’t believe in recovery, and really the whole of mainstream treatment in the UK and the states didn’t believe in recovery. So we decided we’d set up our own little support group.’

The spark was one member of the group coming across Lewis Yablonsky’s book, Synanon: the Tunnel Back, an account of a group of heroin users living together in a Santa Monica house – the Synanon community, later the subject of much controversy – but ‘not using’, Yates points out. ‘New York City probation department sent a group of experts out including Yablonsky, who was a sociologist, and he was so impressed that he didn’t come back. He stayed for a year and wrote the book. We read it and thought, “We could do this”.’ A priest provided an empty rectory building for very little rent and the group ‘just moved in, started doing it up and running our own therapeutic community – based on little more than Yablonsky’s description of how it worked’.

It was this community that ultimately led to the establishment of the Lifeline Project in the early 1970s, of which Yates later became director – ‘an addict who got lucky’, as he’s described himself, putting much of that good fortune down to the support of influential peers and mentors. ‘I’ve been very, very lucky in that respect’ he says.

Does he feel that the value of therapeutic communities has been properly recognised, or is there still a way to go? ‘No, there’s a very long way to go, and unfortunately I think the track we set out on was the wrong one, and we’re still reeling from the damage that caused. In my view, one of the major mistakes therapeutic communities made was to accept that they were about drug treatment. That effectively made them part of the health service, measured by those kind of randomised control trials that are very, very difficult to implement in such a complex intervention. There’s an argument that we took the shilling and became special hospitals, when really we should have become special schools.’

What such communities are really about is people learning to live and behave in a different way, he believes, and helping each other to do that in a structured environment. ‘That’s not really about drugs, and I’d like to see a big extension of therapeutic communities to many other areas – areas where, coincidentally, they’ve already begun to work,’ he says, pointing to those now seeing significant numbers of young women who self-harm as well as survivors of abuse or trafficking. ‘Those are areas that are entirely appropriate for that community-as-method approach. In some respects we’ve hamstrung ourselves into being simply about drug treatment, and I don’t think the approach is simply about that. I think it’s much broader.’

Is it too late to reverse that now? ‘I think so,’ he says. ‘One of the problems therapeutic communities and other residential agencies have faced over the last 20 or 30 years is the hijacking of some of the radical psychiatry notions about closing down big psychiatric institutions and moving people into the community. Right-wing governments – like Margaret Thatcher’s – hijacked that notion because they saw an opportunity to save huge amounts on health costs, not because they thought people could be cured in the community but because they thought, “We can close down this massive loony bin and sell it to Tesco”.’

That bred a notion of ‘residential bad, community good’ that still exists, he argues. ‘But I think we’re beginning to move out of that and recognise that it’s not really about residential and non-residential, it’s about treatment dosage. Some people will need a higher level of treatment intensity, a bigger dose, and the most effective way of delivering that is probably in a residential setting.’

The last decade or so has seen more and more people ‘fed up with being prescribed medicine for a social condition’, he says, or ‘seeing that happen to their relatives. It reached critical mass and they said, “We want something better”, something that mirrored the period in the late 1960s and early ‘70s when therapeutic communities originally appeared. You had a group of drug users, supported by radical psychiatrists, saying, “We can do better than this” and mainstream treatment saying, “No you can’t – the best we can do is control the whirlwind”. This belief in recovery is cyclical, I think, and we’re in one of those waves now.’

As the field continues to evolve and change, how does he feel about his imminent retirement from it? ‘I think it’s time, really, although I’m going to retain some of my responsibilities. Looking back, the major milestone for me was being made Phoenix Futures’ first – and only – honorary graduate. That was far more important to me than my MBE or other appointments over the years.’

His retirement will also give him the time to indulge his other passion, music, and his band Running wi’ Scissors plans to record an album to help raise money for therapeutic communities early next year.

‘I love playing music, but I kind of came out of it for a number of years and didn’t play at all, because for me my involvement in it was associated with my involvement in drugs. That’s where I started, when I was playing in bands in the ‘60s, so I kind of saw the two things together. I was frightened to play music, I suppose.’

The value of music and other creative activities in people’s recovery is something else that remains hugely under-appreciated, he says. ‘Music and drama and dance are often seen simply as ways of filling residents’ time – something they can do in the evenings. I think it’s much more important than that. We know from studies that playing music fires off synapses in the brain that don’t otherwise fire, so it has a profound effect on people’s thinking and self-esteem. That’s a really interesting area to explore.’