Untangling the elements involved in treatment

P4061087Here’s a summary of a piece of research that Lucie James and I conducted some years ago. I am very proud of this piece of work and it certainly opened my eyes to the importance of gaining a sense of belonging in the recovery journey.   

‘To understand how treatment helps people overcome substance use problems, it is essential to understand the elements that operate in the treatment process, and how they might interact to facilitate behavioural change and a person’s path to recovery from addiction.

Lucie James and I set out to gain initial insights into these issues by using a qualitative analysis of the views and experiences of clients on the RAPt treatment programme in one male and one female prison in the UK.

This successful and highly regarded programme has a 12-Step approach at its core, complemented by various other elements from different treatment types.

A total of 15 males and 15 females, who had a long history of substance use problems and criminal offending, were interviewed about their experiences and views of the treatment programme. Transcripts of the semi-structured interviews were analysed with Grounded Theory.

Our study participants believed that this treatment programme was life-changing. They had decided to stop using drugs and try to ensure that this decision was maintained once they left prison.

The participants found that a wide variety of elements operating within the treatment programme were critical in helping bring about the cognitive, emotional and behavioural changes occurring in themselves. They emphasised the importance of the programme focusing on all aspects of their lives, not just their problematic substance use.

Four inter-related themes were derived from the Grounded Theory analysis, labelled: ‘Belonging’, ‘Socialisation’, ‘Learning’, and ‘Support’.

Each of these themes impacted on a fifth theme, ‘Personal Change’, comprising two key components, motivation to change and self-esteem.

On the RAPt treatment programme, inmates met other people with similar experiences and realised that they were not alone.

A sense of belonging helped them to open up and share their thoughts and experiences. It enabled them to build trusting relationships, leading them to feel more able to be honest with themselves and others.

Belonging to a group of people who had similar experiences and problems, but who were successfully addressing their substance use, also enhanced the participants’ motivation and self-belief in overcoming addiction.

It facilitated the learning of new skills revolving around improved communication and better quality interpersonal relationships.

Participants got to know and relate to other people on the programme, and share thoughts and experiences.

They learned that they were not the only one to have certain experiences and beliefs – also, to ask for and give help, and listen to and provide feedback.

They became more able to trust, be honest, respect others, and learn about themselves. They began to feel they could talk to their counsellors and peer supporters.

Study participants described how their self-esteem and confidence increased as they learnt more social skills and became better at interacting with other people.

The development of social skills contributed to an increased self-awareness, an understanding that participants needed to change their previous destructive thought and behavioural patterns, and a belief that they could leave their old lifestyles behind and work towards a more positive future.

Learning about the disease model of addiction and admitting to being addicted helped to change self-image, as participants no longer blamed themselves for their prior destructive behaviours .

[I must emphasise that it is not necessarily learning about the disease model per se that is important here. It is likely that learning about anything that helps a person understand what underlies their problems and how it can be overcome is important.

The RAPT programme focuses on the disease model, but learning about another addiction model or combination of models as an explanatory framework would likely have been as important. The person must understand and relate to the model – it must be believable and ‘ctionable’ to them.]

Understanding that they would have to abstain from all substances if they were to attain the goal of recovery led to significant changes in the participants’ thinking.

During the Step-work, participants began to see how out-of-control their lives had become and how their substance use had impacted negatively on others.

They were helped to come to terms with, and let go of, their pasts and focused on a positive future free of substance use, a process which was facilitated by understanding and utilising the concept of a Higher Power.

As they learnt about addiction, themselves and their capabilities, the participants became more motivated and determined to change and abstain from substance use.

Meeting other people who had gone through the same stages also helped to motivate and give hope that recovery was attainable.

Participants began to understand the relationships between their drug use and their thoughts and behaviours.

They learnt a great deal about recognising certain thoughts, feelings and behaviours, and became better ‘armed’ to deal with any potentially destructive thoughts or behavioural patterns.

Support was a key factor in the perceived success of the RAPt programme, and in the changes that the participants saw in their thinking and behaviours.

This support came from various sources – staff, peers, peer supporters, family members – and involved different aspects of the programme, e.g. group therapy, one-to-one counselling, family conferences, Fellowship meetings.

In addition, the participants developed the ability to offer support to others, which helped boost their confidence and made them feel like a valued member of the group.

Support was paramount in enabling and encouraging the participants to open up about their thoughts and experiences, and let go of the past and focus on the future.

The participants received positive feedback at every step they made towards developing their new lives, and this reinforcement helped to boost self-esteem and confidence.

Personal Change
The participants frequently referred to their self-esteem and confidence, and to their motivation to change.

Other research has shown that these are critical elements influencing a person’s ability to overcome their substance use problems and find their path to recovery.

In the present research, a variety of elements related to the themes described above enhanced self-esteem and increased the participants’ motivation, and confidence in their ability, to change.

These elements included aspects related to the socialisation process and belonging, the education programme, and the feedback and support available from various sources.

Seeing others doing well in the programme and in Fellowship meetings also played a significant role in enhancing hope and motivation to change.

The interviewees emphasised that a critical element of the success of the programme was that attention paid to all aspects of the participants’ lives, not just their substance use issues.

The programme showed participants that their problematic substance use stemmed from issues that occurred in their lives. This completely changed the way that many viewed themselves, as they had previously thought that it was their own fault that they couldn’t stop taking drugs/alcohol.

Participants also obtained a better understanding of themselves, and the relationship between their thoughts and behaviours, and were taught how to divert potentially destructive behaviours.

This all enhanced self-esteem and helped them become more confident in their ability to abstain from substances.

As they implemented what they had been taught during the Step-work, they saw the positive changes that this made, and this acted as a further reinforcement to change.

Many of the participants described beginning to like themselves and understand who they really were. Seeing oneself differently (in a positive sense), and liking oneself, are powerful facilitators of recovery.

One final aspect of personal change emphasised by interviewees was that programme participants must want to change, and must work hard if change is to occur. Many of the clients described periods of emotional distress occurring during the programme, which they considered an important part of the change process.

In conclusion, our research revealed that interviewees perceived a wide variety of interacting interpersonal and intrapersonal elements to be important in changing their thinking, emotions and behaviours, and in contributing to the success of the RAPt treatment programme.

We concluded that treatment needs to involve a socially engaging environment with multifaceted activities in which clients can learn, implement new skills, and receive feedback from a variety of sources (practitioners, peers, others in recovery, and family members), in order to facilitate motivation to change and enhance self-esteem of clients.’

You can find out more about the factors that underlie recovery in my article Factors that Facilitate Recovery.