Recovery Voices: Dr. David McCartney of LEAP

Dr. David McCartney of Lothians and Edinburgh Abstinence Programme (LEAP) talks to David Clark about the development of his drinking problem whilst working as a GP in an inner-city practice in Scotland. He describes an unsuccessful attempt at sobriety, which involved a medical approach focused on prescribing. In crisis, he later called the Sick Doctors Trust Helpline and was told a doctor’s personal recovery story. That telephone call gave him hope and the opportunity to take his own journey to recovery. David talks about setting up LEAP and about facilitating recovery in the community. [15 films, 76 mins 11 secs]

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Helping Others: Dr. David McCartney

David Clark asks David McCartney whether he found himself helping others, in the way he was being helped by others, when he was in the rehab. David stated that when he found himself functioning more healthily as a human being, and felt that he had some useful things to share, he did start contributing in a way that could help others.

However, he had to first dismantle the veneer of a doctor identity he was using as a mask and shield. This was difficult at first, as a lot of his self-esteem was tied up with this veneer, even though it was holding him back. He had to stop being a doctor and be a member of the rehab community, and then gain the identity of being a recovering person.

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Being Held Back… by a GP Identity: Dr. David McCartney

Another film clip from the second of our Recovery Voices, Dr. David McCartney, the Founder of Lothians and Edinburgh Abstinence Programme (LEAP) in Scotland. David is someone who has inspired me greatly over the years.

When he finished medical school, David wanted to make a difference and work where the greatest problems were evident. He joined an inner-city GP practice. The job was extremely stressing as the need (medical and social) was so overwhelming.

In retrospect, David felt he was naive and had not learnt to create distinct boundaries. He started to go to work earlier and earlier to be able to deal with all that needed doing in the practice. With the benefit of hindsight, he can now see he was not equipped to deal with all the tragedy he saw.

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The Culture of Addiction: Part 1

This is the first of two blog posts on the culture of addiction that I first uploaded to the website back in 2013. They are strongly based on the seminal writings of William (Bill) White, in particular from his stimulating book Pathways from the Culture of Addiction to the Culture of Recovery. In this book, Bill provides key insights into how we can help people move cultures—essential in their journey along the path to recovery.

‘Culture’ generally refers to patterns of human activity and the symbolic structures that give such activities significance and importance. Wikipedia

Drug users often seek out and build relationships with other people whose drug use is similar to their own. They become part of small groups within which they can nurture the rituals of drug use. These groups interact with other drug-using groups, ultimately forming a broader network of users who share common goals and attributes. These social networks constitute a fully organised culture, one that has an existence and power that transcends individual membership.

In his book, Bill White emphasises the importance of understanding the culture of addiction. He emphasises that many addicts find it easier to break their physiological relationship with the drug than to break their relationship with the culture in which they use the drug. Clearly, one needs to understand how to move someone from the culture of addiction to the culture of recovery.

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Stephanie Brown on Recovery

A series of my blog posts based on Stephanie Brown’s wonderful book, A Place Called Self: Women, Sobriety, and Radical Transformation. In her book, Stephanie talks about what happens to women in recovery, how they think, how they feel, their problems, the good things, etc. (The book is relevant to men as well!)

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Factors That Facilitate Addiction Recovery

Recovery is something done by the person with the substance use problem, not by a treatment practitioner or anyone else. Whilst there are a multitude of pathways to recovery, there are a number of key factors that facilitate recovery from serious substance use problems. (9,586 words) *

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Factors that Facilitate Recovery (Short Version, 2013)

The importance of these factors has been demonstrated by listening to the narratives of recovering people about their journeys into and out of addiction (1,116 words). *

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Journeys, Part 2: Living With Heroin Addiction

Heroin addiction often leads to changes in a person’s relationships, lifestyle, physical and psychological health, values, and identity. Some heroin addicts engage in criminal activity to maintain their habit. Heroin addicts are stigmatised by wider society. (5,643 words) *

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Stopping Heroin Use Without Treatment

Research by Patrick Biernacki reveals important insights into how people recover from heroin addiction. It also illustrates the major challenges that people with a heroin addiction face on their journey to recovery (2,283 words). 

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What facilitates recovery from mental health problems?: Scottish Recovery Network

It is important to note the close similarity in the nature of elements that underlie recovery from serious substance use problems and recovery from mental health problems. 

An excellent 2007 paper published by the Scottish Recovery Network by Wendy Brown and Niki Kandirikirira, entitled Recovering Mental Health in Scotland: Report on Narrative Investigation of Mental Health Recovery, provides important insights into the latter. This research involved the recovery narratives of 64 individuals in Scotland who identified themselves as being in recovery or recovered from a long-term mental health problems. Here is what the authors write in the Executive Summary of the Report (NB. That I have broken up one long paragraph for ease of reading online]:

‘Across the stories consistent internal and external elements could be found. For a recovery journey to begin and continue to prosper, narrators accounts of their experiences suggest that six basic internal (individual and self controlled) elements were required (though not necessarily in this order and not necessarily seen in every case):

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Factors That Facilitate Addiction Recovery

Describes the nature of addiction recovery and the factors that facilitate the process, using the Stories and quotes from our Storytellers and research conducted by members of the Wired In team. (12,698 words)

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The Challenges of Recovering From Heroin Addiction

When you ask people what difficulties a person faces when trying to overcome heroin addiction, most will focus on the early withdrawal symptoms, which comprise both physical and psychological elements.

There are potentially far greater challenges that lie ahead in a journey to recovery from heroin addiction. It is important that people know this (users, family members, practitioners, etc), although it is also important that people with a heroin problem are not put off by these challenges. Many people have overcome heroin addiction.

One of my favourite pieces of addiction research focuses on the recovery journey from heroin addiction and I have described this research in the article section of this website. In the 1980s, Patrick Biernacki interviewed over 100 people in the USA who had overcome their heroin addiction without treatment. These were some of the major challenges these people faced:

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The Drug Experience: Heroin, Part 10

The research conducted by Patrick Biernacki, with 101 former heroin addicts, showed some of the courses that people take in their lives when they give up using the drug without the aid of treatment.

When people resolve to stop using heroin, they face a variety of problems that go beyond the cravings for the drug and the temptation to use again. These additional problems are related to their attempts to fashion new identities and social involvements in worlds that are not associated with drug use.

As Biernacki pointed out, ‘The manner of termination and the course [or courses] that follow withdrawal from opiates are closely related to the degree that the addicts were involved in the world of addiction, to the exclusion of activities in other, more ordinary worlds, and to the extent that they had ruined conventional social relationships and spoiled the identities situated in them.’

Former users of heroin may be reluctant to engage with ordinary people because they feel socially incompetent and stigmatised, and they may feel shame and guilt for past actions. Society has a very low opinion of drug addicts, which creates a formidable barrier for those wishing to move on from their heroin addiction.

For some people, the transformation from being a problem heroin user to being a non-user can appear to happen abruptly and be quite simple. However, for many others the process is prolonged and very complex.

Biernacki described three major courses through which the interviewees naturally recovered from their addiction, involving different forms of identity transformation.

Some interviewees reverted to an old identity that had not been damaged too badly by the period of problematic heroin use. They had not ruined all their conventional relationships and therefore did not spoil the social identities situated in them. When they resolved to quit drug use, they attempted to re-establish an old relationship and revert to the identity rooted in it.

Other interviewees extended an identity that was present during the period of problematic heroin use and had somehow remained intact.

This course of transformation was typically taken by someone who managed to maintain other identities during their addiction—examples given were jazz musician and poet—that were not spoiled as knowledge of their addiction became widespread. Alternatively, the person may have compartmentalised different parts of their lives and maintained roles in social worlds unconnected to their drug use.

A third course of recovery involved the engagement of an emergent identity that was not present during or before the period of problematic heroin use.

Biernacki pointed out that a successful transformation of identity requires the availability of identity materials with which the non-addict identity can be fashioned. These identity materials are aspects of social settings and relationships (e.g. social roles, vocabularies) that can facilitate the construction of a non-addict identity and a positive sense of self. He emphasised that the availability of these materials is in part related to the stigma associated with the addiction.

It is worth quoting the full last paragraph of this chapter of Biernacki’s book, although I have broken it up into smaller paragraphs:

‘Those addicts wishing to change their identities may first have to overcome the fear and suspicions of nonaddicts before they will accepted and responded to in ways that will confirm their new status. Gaining the recognition and acceptance of the nonaddict world often is a long and arduous process.

Eventually, acceptance may be gained by the exaddicts behaving in conventionally expected ways. Following ‘normal’ pursuits, remaining gainfully employed, meeting social obligations, and possessing some material things will often enable nonaddicts to trust the abstainer and, over time, to accept him and respond to him in ‘ordinary’ ways.

At the same time, the addict’s feelings of uncertainty and doubt will lessen as he comes more fully to accept the new, nonaddict life.

Ultimately, the self identity and perspective as an addict can become so deemphasized and distant that cravings for the addictive drug become virtually nonexistent. For all practical purpose, the addict can be said to have recovered.’

Biernacki described several implications of his research in relation to therapeutic interventions. Firstly, addiction is not a uniform phenomenon, but rather, ‘a variable condition reflecting different levels with the world of addiction and different courses of recovery.’

Secondly, addiction is not necessarily an irrevocable and everlasting affliction. Some people stop using heroin and do so through their own resolve and initiative.

Contrary to what might be expected, people who recovered on their own were relatively easy to locate and interview. Biernacki pointed out that natural recovery may be more common than often thought. Most of the people who recover on their own may not be socially visible because the stigma associated with heroin use prevents them from revealing this aspect of their lives.

Since these recovered addicts are not available as role models, people who currently have a heroin use problem rarely believe that they can successfully stop using drugs on their own.

Recommended Reading:

Patrick Biernacki (1986) Pathways from heroin addiction: Recovery without treatment. Temple University Press, US.

> pdf document

> Some of My Favourite Reads

The Drug Experience: Heroin, Part 6

In the last Briefing, we started to look at the recovery process for people who become dependent on heroin. Analysis of the interviews with 70 recovering addicts in Scotland emphasised the importance of the person wishing to restore a ‘spoiled identity as being key to a successful recovery. The person must not only desire a new identity, but also want a different style of life. They must also believe that this is feasible.

Nearly all the interviewees described previous attempts at trying to stop taking drugs which ended in failure. These failed attempts are not simply a waste of time and they may play a significant role in the process of recovery.

A period of abstinence can clarify and highlight the extent their identities have been damaged. During abstinence, addicts can examine their drug-using lifestyle from the perspective of a non-user. Also, the addict’s residual identity (non-using identity) can re-emerge and comparisons can be made between it and the drug-using identity.

Addicts not only acquire first-hand experience of an alternative lifestyle, but also potentially see its feasibility. If they can abstain from taking heroin for a time, why not for good?

Despite knowing that they need to stop taking heroin, a person may continue because they fear the pain and discomfort of withdrawal. Ambivalence is a striking feature of addiction, particularly when the person has made a rational decision to stop using and makes attempts to do so. There is a conflict between wanting to change on the one hand and a reluctance to give up the drug on the other.

In people who have become dependent on heroin, the vast majority of periods of abstinence are followed by relapse (mind you, this is the same with smoking!). It is much easier to stop taking drugs than it is to stay stopped.

Factors that are known to precipitate relapse include: craving or continued desire for drug; negative emotional states such as depression, boredom and loneliness; the experience of stressful or conflicting situations; and pressure from others to resume drug.

However, these risks, or predisposing factors, do not lead inevitably to relapse. Many addicts recover successfully despite these negative experiences. Why?

McIntosh and McKeganey emphasise that ‘… the key to successful recovery from addiction is the construction by the addict, of a new identity incorporating non-addict values and perspectives of a non-addict lifestyle.’

The construction of a new identity, or a renewed sense of self, has to be built and constantly defended against a variety of often-powerful opposing forces.

‘One of the reasons why the transition is so difficult is because the individual has to get used to an almost entirely different way of life. The drug using lifestyle has provided much of the meaning, structure and content of the person’s life, often for many years, then all of a sudden it is gone and something has to take its place.’

It is generally very difficult for addicts to re-enter conventional life—they often feel strange, incompetent and lacking in important practical and social skills. They have been detached from mainstream activities and culture for a long time, and have often done ‘every-day’ things under the influence of the drug.

‘The second thing that makes managing the transition out of drugs so difficult for addicts is the unrelenting nature of the task of ensuring that they remain abstinent.’

In establishing a new identity, addicts have to distance themselves from their past lives and their drug-using networks. Interviewees emphasised that a continuing desire for drugs—which does abate over time—and a lack of confidence in being able to resist, makes them vulnerable. They wanted to put as much distance as possible—socially and physically —between themselves and those who might seek to tempt or pressurise them into using again.

Recovering addicts also have to develop a range of new activities and relationships both to replace those that they have given up and to reinforce and sustain their new identities.

One of the major problems that addicts face when giving up drugs is how to occupy their time. The drug-using routine —getting the money, acquiring and then taking the drug – took up a major part of the day.

Interviewees recognised how important it was to keep themselves as fully occupied as possible, both mentally and physically. However, simply occupying their time was not enough. They want to do something that provides a sense of purpose and gives their life some meaning. The ideal solution is paid employment.

Recovering addicts also need to develop new social relationships in order to fill the social vacuum. These relationships must reinforce the new identity, support the alternative lifestyle, and help provide the recovering addict with a new sense of purpose.

The acceptance by non-addicts of the recovering addict’s new identity is especially important in sustaining its development and, thereby, maintaining abstinence from drugs.

Once the person’s new life begins to develop—with new activities, relationships and commitments—this creates a powerful barrier against temptation to revert back to drug taking.

New activities and relationships impart a sense of normality and progress and help to reinforce faith in both the desirability and in the probable success of rehabilitation.  They also provide positive reinforcement for the recovering addict’s attempt to develop a more positive sense of self and self-worth.

The new life provides a stake in the future.

Recommended reading:

James McIntosh and Neil McKeganey (2002) Beating the Dragon: The Recovery from Dependent Drug Use. Prentice Hall.

> pdf document

> Part 7

The Drug Experience: Heroin, Part 5

In the last three Briefings, we have looked at the experiences of people whose lives are seriously affected by heroin. In the present Briefing, we will take a first look at the recovery process for those people who  become dependent on heroin. We will focus on the research described in the seminal book Beating the Dragon: The Recovery from Dependent Drug Use, by Professors James McIntosh and Neil McKeganey.

These researchers interviewed 70 recovering addicts (the term used by the authors) to gain insights into their views of the recovery process. Whilst the vast majority of the sample had been dependent upon opiates, most would have been classed as poly drug users at the height of their drug use. The average length of time that interviewees had ceased using their drug of choice was 4.3 years (range: 7 months to 12 years).

For this sample, the process of giving up drugs was not a single, once- and-for-all experience. The great majority had made several attempts to stop. A variety for reasons were given for attempting to stop use: impact of use on partner, children or family; threat to own health; to prevent children being removed from them; a sense of tiredness of demands of maintaining habit; death of someone close; threat of prison, etc.

The researchers pointed out that the experiences and events that interviewees cited as reasons for stopping use did not ‘appear to differ in type or quality as far as successful and unsuccessful attempts were concerned. The same sorts of reasons were given for both.’

They propose another factor—centered on the addict’s sense of identity or self—that distinguishes successful attempts from unsuccessful attempts at stopping drug use.

More specifically, the person wishes to restore what is described as a ‘spoiled identity. The central feature of a spoiled identity is the realisation by the person that he exhibits characteristics that are unacceptable to himself and to significant others.

McIntosh and McKeganey emphasise that the theme that dominated their interviewees’ accounts ‘is their concern to recapture a sense of value and self-respect; in other words, a desire to regain a positive self. Whereas earlier attempts to abstain tend to be utilitarian in nature and geared to achieving a particular practical outcomes—such as getting one’s partner to return or avoiding losing one’s children—what characterises the successful attempt is a fundamental questioning and rejection of what one has become, together with a desire and resolution to change.’

Of course, this desire to restore one’s identity is not sufficient to lead the person to stop using, but it is in most cases a necessary condition.

The negative impact which a person’s life as a drug addict had upon their sense of self was expressed in various ways: a deep unhappiness, sense of self-disgust, and a revulsion of the drug-taking world they inhabited. There was a recognition by the individual that their drug-using identity was no longer acceptable and had to change.

A memory of the person’s drug-free existence remained and this could play a role in the decision to quit in two ways. Firstly, it acted as a comparison for the addict to realise how bad their life had become. Secondly, it provided a basis for hope, as they had been different in the past and could be so again.

The process of recognising and acknowledging a spoiled identity and the subsequent decision to give up drugs were usually the result of a gradual process of realisation.

The circumstances which forced addicts to review their identities could be single events, ongoing experiences, or usually both. Often, it was the impact that their drug use was having on people close to them that forced addicts to confront what they had become.

The decision to quit was often precipitated by certain ‘trigger’ events. However, for most addicts the trigger came at the end of a period of reflection and review that had been going on for some time, sometimes months and even years.

The recognition that one’s identity has been spoiled is not sufficient for one to give up drugs. The person must have a desire for a new identity and a different style of life. Positive occurrences (e.g. birth of child) can re-awaken an addict’s perspective on the future and show that it can be better than the present and be worth striving for.

Addicts also have to believe that it is feasible to develop a new identity and life.

Some of the sample decided to quit following a rock-bottom crisis. The person had deteriorated to such an extent physically, socially and psychologically that there were only three possibilities open to them. Firstly, continue, but this would lead to total degradation of identity and likely physical damage as well. Secondly, exit through suicide, which was given serious consideration by many addicts at this stage, and tried by some. Thirdly, try to beak the addiction and thereby exit a drug-using career.

Despite the role of rock bottom experiences, the majority of the sample exited on the basis of what appeared to be a rational decision. This decision generally involved a conscious balancing of the pros and cons of continuing drug use.

Recommended Reading:

James McIntosh and Neil McKeganey (2002) Beating the Dragon: The Recovery from Dependent Drug Use. Prentice Hall.

> pdf document

> Part 6

Learn the Signs and Symptoms of PTSD: Dr. Bessel van der Kolk

Bessel van der Kolk is one of the world’s leading experts on trauma and the healing of trauma. His book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, is a classic in the field, one of the best non-fiction books I have ever read.

Bessel starts this seven-minute film clip by describing how the diagnosis for post-traumatic stress disorder (PTSD) was created to remind the Department of Veterans Administration in the USA to take care of war veterans. It was quite clear that a large of number of Vietnam veterans were traumatised by their war-time experiences.

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Quitting Use of Cocaine

For a period of four years from 15th November 2004, I wrote a series of Background Briefings for Drink and Drugs News (DDN), the leading UK magazine focused on drug and alcohol treatment. I am slowly uploading these briefings on Recovery Stories as I have time.

Three of these briefings are focused on cocaine—The Drug Experience: Cocaine. In the first part, I explore the dynamic world of heavy cocaine use as revealed in a provocative, high-quality study by Dan Waldorf and colleagues. This research, conducted in the US in the 1980s, challenged many of the prevailing myths about cocaine.

In the second part, I point out that while cocaine is generally portrayed as having a very high addiction potential, the majority of people who use the drug do not have a problem. The research by Dan Waldorf and colleagues reveals a number of social and social psychological factors that influence how a person uses a drug.

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Marion’s Film Story, Part 2

I continue the series of films made by Mike Liu and I when we spent a day with Professor Marion Kickett, former Director of the Centre for Aboriginal Studies at Curtin University, in York in September 2103. Marion is a Noongar from the Balardong language group. On this day, I learnt a good deal about Aboriginal culture, the experiences of an Aboriginal person in a white dominated society, and about the healing of trauma.

Marion talked about her strong sense of belonging she feels for her country, the Western Australian town of York and its surroundings, and the strong connection she has for the Native Reserve where she was brought up. She describes the racism she experienced as she grew up, and how she overcame her various adversities and challenges. She talks about the shocking events experienced by Aboriginal people which have impacted on health and wellbeing. Over time, Marion came to realise that she had to forgive non-Aboriginal people for the terrible things they had done in the past. Forgiveness is a key element of healing. You can find the first six films of this series here.

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Marion’s Film Story, Part 1

I first became interested in Aboriginal culture and in Indigenous healing after reading Judy Atkinson’s wonderful book Trauma Trails: Recreating Song Lines – The Transgenerational Effects of Trauma in Indigenous Australia. I soon realised that western culture can learn a great deal from Indigenous culture and healing practices. I also learnt the key importance of connecting to culture for the healing of trauma and its consequences (e.g. mental health problems, addiction) amongst Indigenous peoples.

I was lucky enough to spend a good deal of time with Marion Kickett, who at the time was a lecturer at the Centre for Aboriginal Studies at Curtin University in Perth, and through listening to her I learnt some important aspects of Indigenous culture and history. She later became Director of the Centre for a number of years. She is a Noongar from the Balardong language group and spent the early years of her life on a reserve.

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Learning From the Experts, Part 1

Well, I’m back in the ‘office’ after my long overdue break. It was great to have a serious ‘time-out’ and also sit back and enjoy the Olympic Games. They were awesome and many performances stunning. What stood out most was the camaraderie between the athletes.

Anyway, here is today’s blog which focuses on a piece of research we conducted years ago, research of which I am particularly proud. Gemma Salter, who conducted the main analysis I describe, was one of my star undergraduate project students in the Department of Psychology, Swansea University. She had gained an outstanding First Class Honours Degree and won the prize for the best project of the year for an earlier piece of research she conducted on the impact of substance use problems on family members

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