‘I do believe that the best care for people who use drugs and alcohol is in their own GP surgeries where possible,’ says Dr Judith Yates, who – although retired from her GP practice since 2010 – is far from retired from the drugs field.

She’d wanted to go into medicine since childhood but dropped out halfway through medical school to ‘explore the world and myself a bit’, an experience that helped her decide that it was being a GP – as opposed to other areas of medicine – that would provide the most interesting challenge. As a young trainee in the late 1970s, and her practice’s only female GP, she soon discovered that the only way to see male patients was though consultations with those who had drink and drug problems. ‘At that time the psychiatric addiction services were struggling to find their way and the heroin was flooding in, and by the ’80s the waiting lists for treatment by the psychiatrists were rapidly building up,’ she says. ‘People were falling out of their care and turning up on my doorstep.’

Her other discovery, however, was just how rewarding helping this client group could be. ‘It just seemed to be something that I could easily do. The rest of general practice – which I was doing as well, of course – often involves the long-term care of physical ailments, some of which are quite gloomy, whereas these were young people with lots of potential who’d struck upon hard times and with a helping hand could get on with their lives. The transformations could be quite rapid.’ She went on to spend three decades as a Birmingham GP, working in the city’s first community drug team in the early ’90s at the same time, and after a while the group of patients at her surgery who used drugs numbered around a hundred. Clearly, not all practices were – or are – as accommodating. Does she feel that the stigmatising attitudes of some GPs are starting to change?

‘I think it’s very patchy and postcode-y,’ she says. ‘In Birmingham we were lucky in that when all the crime money came in with the NTA all the GPs working in this field – only about four or five of us – joined the newly formed shared care monitoring group and managed to use that money to set up probably one of the biggest primary carebased drug treatment services in the country. It’s been very effectively organised and managed in that drug workers go out into GP services as opposed to sitting in a centre somewhere waiting for patients to come to them. Around half the people who are scripted in Birmingham are treated in primary care, which is good but it does need proper focus. GPs on their own can’t do it – they need properly organised key workers coming in because there just isn’t the time in ordinary primary care.’

She still does a weekly clinical session with the community drug team and also helped to plan and set up a new residential detox and rehab clinic, working there for two ‘enormously enjoyable’ years after retiring from her surgery. But it’s policy work that’s been taking up most of her time lately.

‘I had a bit more time to pick my head up from the coalface and look around so I started to look at ways to reduce drug related deaths in Birmingham and work on our take-home naloxone project,’ she says. ‘I thought I’d be able to just put on a couple of training the trainer sessions and then someone else would take over and it would run itself, but that didn’t happen. I discovered that you have to chip and chip away at all these little tiny local barriers that prevent any change.’

It was through the naloxone project that she met Philippe Bonnet (DDN, October 2013, page 16) and started investigating the growing international evidence base for consumption rooms. Is she confident that the Independent Consortium on Drug Consumption Rooms (ICDCR) can achieve its aim of establishing a facility in Birmingham?

‘We’ve been waiting for the Birmingham re-commissioning to finish because – quite rightly and reasonably – we were asked to not take our plans forward in any concrete way while all the services were going through this enormously time-consuming recommissioning round, and we didn’t know who was going to be running treatment services anyway. So we’ve been collecting information and improving our understanding of what could be done and what would be costeffective. We’ve spoken to some people among the police and the local authority who are cautiously interested, but we obviously need the clinical arm.’

The city’s main clinical provider is likely to be announced this month and ICDCR is confident that they’ll be interested if it can be shown that consumption rooms are both necessary and value for money. ‘I think we can prove that it’s costeffective if we don’t have grandiose ideas. The Vancouver and Sydney ones are big, all-singing, all-dancing versions but we see a Birmingham version as being part of the existing needle and syringe and outreach programme – there’d be no new staff or new budget. If we could find a backroom associated with the existing services, with a few sinks for people to wash their hands and a kettle to offer people a cup of tea and a listening ear, that would be fine. It’s not a high-tech answer to anything – it’s not like heroin-assisted treatment, which is very expensive.’

What about the legal status of consumption rooms – how much of a barrier could that be? ‘In parts of Europe allowing your premises to be used for taking drugs is still against the law but there are local accords with the police, and we see that as the way it could happen in the UK, although we’d obviously like to change the law eventually,’ she states. ‘If you think about needle and syringe programmes, the police don’t arrest everyone going into those, which they could because they know they’ve got heroin on them. The same would apply to consumption rooms – they’d know they were people who used drugs but they’re not the big dealers, they’re people with a dependency who are street injectors.’

The international evidence also shows that people ‘tend to up their game’ once they start using consumption rooms, she says. ‘The staff wax lyrical about the transformation in their behaviour, and they carry on those learned habits when they’re not in the centre – their health improves, they no longer attend A&E and they begin to re-engage with society.’

Being able to provide the service without a new budget could clearly go some way towards making it more attractive in today’s environment – how optimistic is she about the state of the sector overall? ‘There’s no doubt that the money is tight and not ring-fenced any more, so we have to be smarter with it,’ she says. ‘Obviously the more resources you have the more quality you can offer but there isn’t any choice about it, I suppose. But in terms of human beings I tend to be an optimist and I’m hoping that we’re still learning.’

Indeed the whole of her involvement with the sector has been a learning curve, she states. ‘It has been for all of us – before the 1980s there wasn’t a big heroinusing population in the UK. It was small numbers of people, mostly dependent on pharmaceuticals – they’d blag their GPs for Diconal and all those things. So the huge flood of heroin that came into the country and the huge increase in people using it involved us initially working out how to keep people alive and help them with substitution treatment.’

As has been widely documented, that heroin-using population is now growing older, and so far the indications are that it’s not being replaced by a significant younger one. ‘I do hope that’s a societal change and gradually people will not get into this dependency on opiates, because it’s such a long-term trap,’ she says. ‘Some of the stimulants and novel psychoactives have their own problems but – even with cocaine – they’re things that you can walk away from a bit more easily than an opiate habit. So I’m hoping that we won’t be seeing families affected quite so much, and the policies have kind of followed that learning curve in a way. We’re kind of all learning together.’

She’d long been part of SMMGP (Substance Misuse Management in General Practice) and when SMMGP’s Chris Ford set up IDHDP (International Doctors for Healthier Drug Policies) she was asked to become a director. This year has seen her visit the Commission on Narcotic Drugs (CND) in Vienna, representing IDHDP’s rapidly growing membership of almost 600 doctors from more than 70 countries who ‘believe we need health-based rather than criminal justice based drug policies’, she says.

And it’s in arenas like this that real change can be brought about, she believes. ‘I’ve always supported the test-and-treat approach to hepatitis C and HIV, for example, but while you’ve got to do it on a one-to-one basis you do also need to have it as national and international policy to make a real difference. If you can get people into treatment you can also defeat the disease, because even if they’re not immediately completely cured their virus count goes down so they’re not so likely to pass on the infection, and it’s the same with HIV. The liver specialists are now very excited, saying that we’re on the “cusp of a new dawn” and that the new treatments mean that we could eliminate hepatitis C within 15 years.’

She praises the Scottish plan to treat more people for hep C each year than are becoming infected with it as a way to ultimately eradicate the virus. ‘Also you don’t end up bankrupted by the exponential growth of cirrhosis and liver failure,’ she says. ‘And they’ve got a national naloxone programme of course – if they vote to opt out of the UK, we should all vote to join Scotland!’

While there’s ‘no simple step’ to eradicating drug-related deaths or harm it’s essential to be part of the ‘international conversation’, she stresses. ‘Take-home naloxone has been shown to reduce drug-related deaths in parts of the US by up to 50 per cent, and I hope there’ll be new regulations to allow its even wider provision in the UK.’ It was also announced at the Vienna CND that forthcoming WHO guidelines will state that everybody who could potentially be at the scene of an opiate overdose should have access to naloxone, she adds.

‘I believe that it may come to be seen as negligent to prescribe methadone without also prescribing a take-home naloxone kit. Drug consumption rooms have also been shown to be a cost-effective step as part of existing treatment services around the world, and I believe we should look seriously at small pilots in parts of the UK where there’s a need. Applying a criminal penalties to drug use has never made any drug safer, and the sky hasn’t fallen in on countries like Portugal and the Czech Republic where steps towards decriminalisation have been in place for many years.

‘These are all areas where policy and central guidance and leadership are needed to drive change. I see my pension as a government grant that allows me time to apply my past clinical experience to these broader areas, where policy change can make such a difference to the wellbeing, not just of individuals, but of populations.’ www.idhdp.com

Things are changing fast at the Care Quality Commission (CQC) this summer. In the light of previous negative publicity there is a new structure and a new approach developing. CQC say that by October there will be a new inspection methodology in place, so inspectors will be looking for different things and writing different reports.

The big news for the substance misuse sector is that all treatment services, whether residential or community services, will be based within the hospital directorate; more specifically within the section of this directorate that deals with ‘community based services for people with mental health needs’. This means that there should be a similarity of approach to community drug and alcohol services and residential rehabilitation services.We wait to see whether this means that the methodology being developed will be more similar to clinical treatment services than adult social care. For a long while residential services battled to be thought of as ‘treatment services’ rather than ‘care homes’, so maybe this will lead to a more realistic and ‘joined-up’ approach to inspection?

Another piece of good news is that CQC has appointed a ‘national professional advisor and policy manager for substance misuse’. Her name is Violeta Ainslie and she used to work as treatment provider with Cranstoun Drug Services until very recently. I am personally very encouraged on two counts. Firstly, this is a full-time post dedicated to this sector. In my previous role, the substance misuse sector was only a small part of my job; now there is someone dedicated to the sector, who can join up all the dots within CQC and be a point of reference for external agencies. Secondly, as someone who was recently working within the sector, she is well placed to understand the unique characteristics of substance misuse treatment.

Part of the national advisor’s role will be to set up an ‘expert group’, which will be a reference point for the development of the new methodology for this sector. At the time of writing, this group was due to begin its deliberations at the beginning of July. The next step will be publishing a ‘signposting’ document which will chart the way forward and explain when the new methodology is likely to be implemented. So, while the adult social care sector is planning to implement in October 2014, the substance misuse sector may have to wait a while. The message is, ‘watch this space!’

Having completed the first consultation phase on 4 June, in which CQC tested various elements of the new methodology in hospitals and care homes, CQC will now no doubt use some of the feedback and incorporate it in the new approach to the substance misuse treatment sector.

New Methodology

There is no doubt that the new methodology will focus on the ‘five questions’, which are: Is the service safe, effective, caring, responsive and well led? You may have seen the provider handbooks and appendices on the CQC website, which set out the proposed framework. There are some key features which mark a change from the previous approach:

• The ‘provider information return’ will be sent out to services before the inspection, so that they can self-assess against the five questions.
• There will be ‘key lines of enquiry’, which will act as prompts to inspectors as they look at how the five questions are worked out in the service.
• There will be ‘ratings’ which will be published and will determine inspection frequency. These ratings extend from ‘outstanding’ to ‘good’, then ‘requires improvement’ and finally ‘inadequate’. There are complicated rules which determine how these rating are arrived at – however there are also helpful guidelines that tell you what each rating might look like for each question.
• There will be a greater reliance on ‘experts by experience’ to provide the service user perspective.
• There will be an emphasis on ‘intelligence monitoring’, which means gathering information from a range of stakeholders.
• Finally, although the Care Act 2014 has been granted Royal Assent, the new draft ‘fundamental standards of care’ and ‘regulated activity regulations’ are now awaiting parliamentary approval so cannot be enforced until that is achieved. It is expected that this will happen by October 2014 so that the new approach is fully grounded in law. 

Meanwhile, between now and October 2014 CQC will continue to undertake routine inspections, so if you have an unannounced inspection this will be according to the existing methodology. There will be one difference and that is that the summary at the beginning of the report will focus on the ‘five questions’ as a taster of what is to come. The possible reasons for an inspection before October are: that your last inspection occurred between April and October 2013; there are outstanding compliance actions; there have been complaints made to CQC which they may be following up in terms of compliance; or you have changed registered manager in the last 12 months.

When looking forward to the new approach, some of the most recently published inspection reports give clues as to what may be asked. However it is worth waiting to see exactly what is proposed for the substance misuse sector and, where possible, contribute to the debate through routes such as FDAP and your representatives on the ‘expert group’.

As CQC publish more information, such as the ‘signposting’ document with an outline of their new approach, it will be possible to look at the implications for your service more fully. To help this process there will be courses which will focus on the substance misuse sector this autumn, organised through DDN.

David Finney is an independent social care consultant. His course on everything you need to know about the new structure is on 6 November in central London. 

Mat Southwell opened the 2014 Kaleidoscope Conference by linking harm reduction to mindfulness: ‘I find injecting ketamine helps me with mindfulness.’ The challenge he gave delegates was that governments may define recovery as one without drugs, but as a service user he wanted to set his own agenda. The challenge of harm reduction has always been one where the service user sets their agenda for change.

The need for harm reduction is as true now as it ever has been in that we need to keep people safe, so naloxone and needle and syringe exchanges are focused on doing this. Mat talked about a time when he was using drugs chaotically, which badly impacted on his life. He sought to change, but that change led him to consider what drugs he could take and what drugs he was not able to live with. The problem today is that many commissioners are focused on recovery, which they see as primarily moving a person to being abstinent from drugs. The harm reduction message is being disinvested in, which means many services are not being empowered.

Harm reduction, according to Dr Julia Lewis, is like Marmite – you seem to either love it or loathe it. Its importance must not be minimalised, however. It is an evidencebased approach that has saved millions of people – a principle that originates fromthe UK and is now globally accepted. The development of needle and syringe exchanges alongside substitute prescribing has made a real difference to people. Yet many people find it a difficult concept as it seems that one is condoning behaviours that many feel are immoral and destructive to society, as well as to the individual. 

The use of drugs among drugs workers is a topical issue. Should staff not set an example and advocate the perceived ideal of a drug-free lifestyle? If workers talk about their own safe using does this not cause problems for someone who is chaotically using drugs? The experience I have had does not bear this out. One of the most successful programmes Kaleidoscope has run, Simplyworks, included a staff member on a methadone programme, and that person had the best engagement and outcomes of any of our staff.

In Wales, drug agencies have come together and established a peer mentoring project, which has included substance users and has achieved staggering results; Kaleidoscope in Cardiff found more than 200 permanent jobs for service users. In India, one agency has active drug users providing needle syringe exchange and substitute prescribing and again meets the needs of that drug-using community. When we look at naloxone, it works best when we empower service users and I would argue that we also give the dealers clean needles so at least people injecting for the first time do so as safely as possible. Harm reduction is not an ideology, it simply is based on what works – and that was the key message of this conference. Service user empowerment is a fundamental part of harm reduction and in Gwent Kaleidoscope has been delighted to work closely with The Voice, a proactive service user group that has just opened its own Newport service, called the Hub. 

What is critical to them is ensuring people receiving services are able to challenge treatment providers and commissioners in designing the right services for their needs. The service again is not driven by one theme, such as recovery, but looks practically to support the user in the changes they wish to make. It has also managed to reach out to an open prison, developing a very strong link with HMP Prescoed, where some prisoners have volunteered to support the Hub with their unique skills and at the same time address their own issues through peer support. The workshop they ran at the conference gave space for service users to talk about their own personal journeys and was one of the highlights of the day.

Workshops enabled proactive debate as well, from looking at the place of alcohol in society to how service providers can be more effective when they provide integrated services with the service users’ needs placed at the centre. Many of the pioneering drug takers took drugs to look for profound mindaltering experiences. Psychonauts are people seeking to push the boundaries of mindful experience and certainly Mat Southwell would consider himself in this category. The desire to push human mind experience is in many ways part of the human tradition, be that through taking substances, or by travelling, or even excessive sport.

The problem for treatment providers is that this dash for experience is often forgotten, so treatment focuses on the medical aspects of addiction. It may help someone deal with a traumatic experience, but in a dash for secularism has forgotten that, for many, drug use is about finding the meaning of life – a profound experience.

So where is the place for the spiritual element – is it religious or can meaning be found through other means? Mindfulness is becoming a major force, not just in drug treatment but as a tool when working with any group of people, from education to boxing. To enable people to experience mindfulness, we provided a workshop run by Eluned Gold, head of personal and professional programmes at Bangor University.

Eluned was also one of our main speakers on the subject of mindfulness, looking at support for parents and carers, while Dr Paramabandhu Groves, consultant psychiatrist at Camden and Islington NHS Trust (see page 13), looked at mindfulness for addiction recovery.

Dr Groves reminded us that the concept comes from a Buddhist tradition but is not one that requires a person to be an adherent of a religious perspective. Mindfulness creates time to reflect, to contemplate or meditate, enabling a person to understand issues in a different way. For some they may experience a spiritual enlightenment, for others it may be a better understanding of the self. The importance of the metaphysical, however, is a vital component of our human nature.

The day ended in style, with a panel discussing the place of spirituality or faith in the recovery journey. The meeting was chaired by the former chief executive of Newport City Council, Chris Freegard and included Dr Groves from the Buddhist tradition, Bishop John Davies of Brecon and Swansea, Roderick Lawford from the humanists in Cardiff, Tazlim Hussain from a mosque in Newport, and the founder of Kaleidoscope, former Baptist minister, and my father, Eric Blakebrough, who made the case passionately for harm reduction from a theological perspective. 

Martin Blakebrough is chief executive of Kaleidoscope, kaleidoscopeproject.org.uk

‘A people are as healthy and confident as the stories they tell themselves. Sick storytellers can make their nations sick. And sick nations make for sick storytellers.’ Ben Okri, Birds of Heaven.

This was a quote I threw into the room when I presented to DDN’s national service user conference in Birmingham in February – because I believe we live in a sick nation, full to the brim with sick storytellers who dominate our mainstream media and political discourse. It’s a reflection of the deficit world we live in. A world of needs and gaps and experts that is increasingly apportioning blame to the other, the alien, the vulnerable, the undeserving poor, whether that be the Muslim, the immigrant, the benefit scrounger, the homeless or the drug user.

We live in times of great fear and anxiety, times of austerity, and this narrative, this story, now permeates every aspect of our lives. The wealthy and privileged, rather interestingly, have got richer during these times as they’ve retreated even further into their gilded gated communities. Meanwhile the poor have got poorer and the ‘squeezed middle’, those hard-working families, anxiously scrabble to hold on in this era of zero-hour contracts, flexible working and creeping neo-liberal privatisation.

We live in interesting times, and in Birmingham I offered a perspective that I’m sharing with you now. It’s a perspective that seeks to place ‘recovery’ within a historical context, and position the future British ‘recovery movement’ as something with the potential to be positive, inclusive and, rooted in the promotion of social justice, truly transformative.

I’ll start with a little recovery history. There are many who recognise recovery as a term within the 12-step movement going back 79 years, and others who think it popped into treatment land with the drug strategy in 2010. As Larry Davidson from Yale University illustrates in The Roots of the Recovery Movement in Psychiatry (2010), recovery’s roots as a service orientation (putting aside recovery within communities for hundreds of years) can be traced back to 1793 and the groundbreaking work of Philippe Pinel and Jean-Baptiste Pussin.

In recognising the importance of mutual aid and a meaningful life, giving jobs to the inmates of a Paris asylum, Pinel and Pussin lay the foundations of the peer support we see today. In the US, Dorothea Dix (1840), a tireless advocate for the mentally ill within prisons and Jane Addams (1889), the founder of the resettlement movement, were instrumental in advancing the notion that healthy environments promote health, and their work emphasised the key importance of ‘living with’ and ‘doing with’ in communities as opposed to the usual defaul deficit setting of ‘doing to’.

The psychiatrist Adolf Meyer (1900) went on to make a number of significant observations which at the time – and perhaps still today, in some quarters – were regarded as radical. People can and do recover; even those in the midst of illness possess valuable strengths and it’s our interactions in the social world, in the everyday, that are key to recovery.

The founding of AA in 1935, with its emphasis on mutual aid and self-help, has major significance in this recovery history, as does the civil rights movement of the 1960s and the consumer/survivors/ex-patient movement of the late 1980s and early 1990s. Phil Hanlon, professor of public health at the University of Glasgow, outlines another kind of history in his book The Future Public Health (2012), which I believe also has deep significance for the British recovery movement. He suggests that there have been four waves of public health, which have brought significant improvement to health over the last 184 years.

Each new wave begins while the previous wave is at its peak. The first wave of public health (1830-1900) saw the rise of ‘classical public health interventions’ – a recognition, before the science caught up, of the importance of clean water and sanitation. In this period we see the growth of municipal power and influence, and the beginnings of the rise of the ‘expert’. The second wave (1890-1950) sees the continued ascendency of the expert, the flowering of ‘scientific rationalism’, expansion of hospitals, health visitors and the germ theory of disease. The third wave (1940-1980), born of a deep demand for change and a post-war consensus, sees new forms of social solidarity and collective responsibility leading to the creation of the NHS, the welfare state and social housing. While the fourth wave (1960-2000), which also sees the rise of neoliberalism (perhaps a partial response to the third wave?), focuses on individual risk factors and lifestyle issues.

These four waves have had a significant impact on health and continue to do so. However Hanlon is very clear, as are many others in the fields of public health, economics, environmentalism and politics (to name a few), that we are now, all of us, in an age of crisis, staring into the abyss and facing the ‘challenges of modernity’. Across the developed world and increasingly in the ‘majority world’, people are getting sicker in increasing numbers. As communities continue to fragment and social ties fray (something Bruce Alexander describes eloquently in his book The Globalization of Addiction: A study in poverty of the spirit, 2008), levels of unhealthy dependency – drugs being just one among many – and mental distress are rising dramatically.

Needs are rising and resources are dwindling. Hanlon contends that currentinterventions are failing to address societal issues because they are grounded in an acceptance of cultural norms that are fundamentally part of the problem: ‘economism (the belief that money will sort things out), individualism, consumerism and materialism’ – all of these driven and sustained by the deficit world we live in. Modern society is unequal, inequitable and unsustainable, says Phil Hanlon in The Future Public Health.

It’s not all doom and gloom and this, I believe, is why the British recovery movement, if it learns from its history and puts social justice at its heart, has a major role to play in the response to this crisis of modernity. Hanlon suggests there is a need for a ‘fifth wave of public health’ which will challenge the rampant individualistic consumerism that underpins a dominant economic model based on endless growth – a model that is taking us, as I commented in Birmingham, ‘to hell in a hand basket’. While we have been encouraged to focus on the ‘canaries in the mine’, those who are the first visible casualties of a sick society, fixing them and returning them to productive life, we have been discouraged, interestingly, from looking at the mine itself. So while we rebrand and tinker at the margins, all of us ‘users’ within a dysfunctional system, we remain silent as to the really destructive addictions.

As George Monbiot put it in the Guardian on 27 May, this issue is ‘the great taboo of our age – and the inability to discuss the pursuit of perpetual growth will prove humanity’s undoing… The inescapable failure of a society built upon growth and its destruction of the Earth’s living systems are the overwhelming facts of our existence. As a result, they are mentioned almost nowhere. They are the 21st century’s great taboo, the subjects guaranteed to alienate your friends and neighbours.’

Hanlon believes that our current system, with its acceptance of modernity’s ‘norms’ and overriding emphasis on the objective (evidence and science) at the expense of the subjective (the many meanings found within the ‘I’ and the ‘we’) is failing. He calls for new ‘integrative’ approaches that will bring the subjective and objective together on equal terms, valuing the stories and wisdom found within families, neighbourhoods and communities. He suggests that we need new approaches that are ‘creative, ecological, ethical and beautiful’, which will reintegrate ‘the good, the true and the beautiful’ – grand language that needs to be turned into reality within communities, which is where I believe the British recovery movement comes in.

In positioning ‘recovery’ as the ‘remaking of meaning’, and a shift from a deficitbased world to new strength-based ways of being, it is possible to see the movement as central to the search for the ‘good, the true and the beautiful’. Where else would you start if not with those who still struggle in this deficit world, with the people who are trying to recover, with the ‘canaries’ and with the people who have managed to ‘remake’ themselves? Where else will we find the wisdom and the learning that will enable us all to deal with our damaging dependencies?

Which is why the UKRF is promoting a recovery month in September that supports movement toward a strength-based world founded on community resilience and potential; a month that will write new hopeful stories. And it’s why we’re gathering in Leicester on 26 September at an event entitled ‘Creating Narratives for the recovery movement: the good, the true and the beautiful’. We believe we will make the path by walking it. So we’ll do a little walking together. I hope some of you can join us.

Alistair Sinclair is UKRF director. The UKRF’s event, ‘Creating narratives for the recovery movement: the good the true and the beautiful’ is on 26 September in Leicester. Details at www.ukrf.org.uk

Acceptance and Commitment Therapy, known as ACT, is the first evidence-based treatment for addiction that shares the same philosophy as the recovery model. It is also perfectly compatible with the 12 steps. ACT is founded on the idea that treatment is about building a life of meaning and purpose.

ACT is a modern form of CBT that has been around for just over a decade (Hayes et al, 1999). It is part of the new wave of treatments based on acceptance and mindfulness that have been growing in popularity over the last 25 years, and is a principle-based therapy rather than being driven by treatment protocols. This means that it is suitable for more complex conditions such as addiction, where the client needs to learn only six basic principles: acceptance, defusion, mindfulness, taking perspective, values, and commitment.

Acceptance

When repeating a behaviour leads to increased problems over the long term then the best solution is to let go of it. Addiction is one example, but also more normal behaviours like avoidance can become problematic, for instance social anxiety. Acceptance means letting go of behaviours that do not work.

Defusion

All people get caught up in thoughts that are not necessarily true, for instance thoughts about the world – ‘if I go to the meeting nobody will talk to me.’ Or thoughts about ourselves – ‘I am stupid.’ When people buy into their thoughts, ACT calls that being fused and it often produces behaviour that leads away from values. Defusion is about learning to stand back from these thoughts, and choose behaviour that is towards your values.

Mindfulness

In ACT the mindfulness component is about learning to be present in the here and now. By noticing the reality of the situation people are better able to choose the behaviours that will work in the current context.

Taking perspective

All people get caught up in their lives and lose perspective. Taking perspective is about learning to stand back and see the bigger picture. From this ‘observer’ perspective it is usually easier to see the right moves and make the right decisions.

Values

This describes what is important and meaningful to you as an individual. It is the direction you want your life to go in so that it has purpose and feels satisfying. This is not the same as trying to be happy, rather describing the types of activities that feel right at a deeper level, for example family, work, recreation.

Commitment

Committed action is at the heart of ACT. Instead of trying to feel better, ACT emphasises carrying on with your values even when it feels uncomfortable. For example if you feel anxious about going to a meeting then go, and take the anxiety with you so long as this is important to your values.

The six components are fluid and summed up in a metaphor called the passengers on the bus:

Imagine that your life is like a bus and you are the driver. On the front of the bus is the route you want to take (valued direction). As you start the bus up a bunch of unruly passengers get on board and start making a noise (your thoughts and feelings). As you set off some of them come down and start harassing you, so you start telling them to sit down. But they don’t, so you stop the bus and try to make them.

ACT uses lots of metaphors like this to help people understand that it can be futile to struggle with unwanted thoughts and feelings, and that when you do it can bring your life to a halt. The alternative is to live with them and learn to drive the bus.

There is an extensive evidence base for ACT across many conditions, and also a specific evidence base in addiction. More than 50 randomised control trials (RCT) have been published and six of these are in addiction. The overall evidence base has been independently reviewed and compares favourably to CBT (Öst, 2008). In the United States the model has been evaluated by the Substance Abuse and Mental Health Services Administration (SAMHSA) and approved as a recognised treatment for addiction in the USA. There is evidence for use in residential rehabilitation, with methadone maintenance and for recovery across alcohol, opiate, stimulant and cannabis use.

For groups, a very simplified version called the ACT Matrix has been developed by myself and Dr Kevin Polk and used throughout the addiction services in Portsmouth. Over the last five years groups have been run across multiple agencies – the hospital, family centre, probation, community drug team and beyond. In that period attendance and outcomes have improved more than 100 per cent year on year. The matrix is also being used as a model for rehab at the Addiction Recovery Centre (ARC), and has been developed into a model of peer recovery.

ACT is compatible with the 12 steps and a perfect fit for the recovery model. It is easy to use through the matrix format, yet highly evidence based. While relatively new, it is now established in the UK within the mainstream treatment agencies, in rehab and in peer recovery. It is a simple model, which can join up the treatment journey for the client and deliver reliable results.

References:

Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford Press.

Öst, L. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), 296-321.

Polk, K. L. & Schoendorff, B. Eds (2014). The ACT Matrix: A New Approach to Building Psychological Flexibility Across Settings and Populations. New Harbinger.

Wilson, K.G. & DuFrene T. (2011). The Wisdom to Know the Difference: An Acceptance and Commitment Therapy Workbook for Overcoming Substance Abuse: New Harbinger.

Wilson, K. G., Hayes, S. C., & Byrd, M. (2000). Exploring compatibilities between Acceptance and Commitment Therapy and 12-Step treatment for substance abuse. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 18(4), 209-234.