Imprisoned by addiction

Peter Bond, the founder of the Rehabilitation of Addicted Prisoners Trust (RAPt), died in August.

It was Bond who pioneered full-time treatment programmes in Her Majesty's Prisons for alcohol, drug, and compulsive gambling related offenders. After three years of lobbying, inmates began the first course run by what was then called the Addictive Diseases Trust in April 1992. Peter Bond himself was a business man who recovered from chronic alcoholism through the 12 Step Programme of Alcoholics Anonymous. He became involved in voluntary work with alcohol-related offenders through the Hertfordshire Probation Service in 1982. Peter was also the founder member of two local alcohol services and was Development Director of Hertfordshire Alcohol Problems Advisory Service (HAPAS).

Having studied abstinence-based treatment programmes which had proved successful in the United States, Bond attempted to sell the idea in the United Kingdom. He approached prison governors, members of parliament, successive Home Secretaries, and even the then Prime Minister, Margaret Thatcher.

The first 18 months were critical. Through patient diplomacy, both the prison staff and inmates came to accept the Substance Abuse Treatment Programme (SATP) as a very effective method of alcohol and drug rehabilitation, which had a dramatic effect not only on the behaviour of inmates who participated in the programme, but also on the prison culture itself. Eventually, a 'partnership' emerged which has developed to the point where the RAPt and HMP Downview have become synonymous. The programme now operates in five prisons in the United Kingdom employing some 30 therapists. Michael Howard, when he was Home Secretary, said that RAPt had done more to promote rehabilitation in British gaols than any other initiative in living memory.

In the last months of his life, Peter wrote an article on RAPt's work, an edited version of which we print with the kind permission of the Editor of Alcohol and Alcoholism.

ALCOHOL AND OTHER DRUGS

More crime is related to alcohol than to any other drug. Most offenders who enter prison with a single problem of alcohol dependence return to the community with an additional drug habit. This is because, although 'hooch' has been brewed by inmates since time immemorial, drugs are easier to acquire than alcohol. In addition, many heroin addicts will, if their regular drug is not available, use alcohol as a substitute, and amphetamine, cocaine, and 'crack' addicts will use alcohol to 'come down'. This has made it necessary to address 'cross addiction' as part of the treatment plan.

The Substance Abuse Treatment Programme (SATP) operated by RAPt has been a pioneer project. In common with AA, we look on addiction as a disease and we explain to our participants, who are called Members, that we regard them as sick people trying to get well, not bad people trying to be good. Clinicians may protest that, by telling addicts they have a disease, we give them a perfect excuse for past behaviour. We would say that possession of this knowledge requires the individual to accept responsibility for the consequences of any return to active addiction.

The focus of the SATP is not on addiction: addiction awareness courses are wasted on habitual alcoholics or addicts, who probably know more about the real effects of abuse than any clinician or research worker. Rather, SATP is about countering the 'mental obsession', as the founders of AA called it. This involves dramatic changes in thought, behaviour, and reaction. It is designed to give the alcoholic or addict a mental defence against picking up that first drink or drug which will perpetuate the decline to infirmity, insanity, or premature death. Therefore, the treatment process is a biopsychosocial model which encourages the Member to adopt a healthy lifestyle to help repair the physical ravages of addiction; to uncover, with the help of group peers, behaviour patterns which need to be altered to avoid relapse; and to acquire the skills to become more socially active with people who are also in recovery or do not find it necessary to use alcohol or drugs. In our experience, all addicts also suffer from low self- esteem. Our job is to help them discover their assets and build on them. It is incredible just how much talent remains untapped, imprisoned by drugs as well as iron bars.

THE TREATMENT PROCESS

In order to deliver the best therapeutic and economical package, the SATP, which started as a 28-day block, has been adapted and developed into a 12-week rolling programme. This means that Members are at varying stages of treatment and those further along help the newcomers to break down barriers to the help available. The following have proved to be the essential and successful elements of substance abuse treatment for prisoners as they have been developed by the staff of RAPt.

Pre-admission group

As the programme developed, the news spread through the prison grapevine and applications poured in. A waiting list was established for both HMP Downview residents and prisoners from other establishments. The impact has been so great that, at this moment, it can take up to 12 months from initial application to actually starting the course. Basic application forms, which give offending and using histories, are often accompanied by a letter from a personal officer or probation officer. All applicants are eventually screened in depth, assessed, and judged for motivation. Successful applicants enter the pre-admission group, preparing them for the intense 12 weeks ahead. It is in this environment that more screening takes place and some suspect aspirants make the decision to quit.

12-Week primary treatment programme

(1) Induction: When Members are inducted, they complete self-assessment addiction questionnaires, sign up to the Rules and Expectations essential to the smooth running of the programme, and are briefed on the 12-week syllabus and weekly timetable. The dynamics of group therapy are briefly demystified and details of assignment expectations are explained. No Member is ever rejected because of illiteracy. Our graduates include total illiterates; a Tibetan with no English; African, Italian, and Chinese Members. We pair them with a 'buddy' or a trainee peer counsellor.

(2) Community group: This is a weekly meeting of all Members and counselling staff and is a forum for reflection. Staff comment on Members' progress or lack of it. Both staff and Members challenge on slipping boundaries. The Rules and Expectations are read around the room so that no Member can plead ignorance. Members take responsibility for the cleanliness of the treatment premises so, at this time, domestic jobs are rotated. Newcomers present a brief life story as an introduction to their peers. Key rings and medallions are presented for Clean Time and the psychological impact of gaining these low-value items is powerful. They are greatly prized by recipients, who may not have experienced the freedom of drug-free living for many years.

(3) Group therapy is the most important and effective tool for change in the entire programme. Apart from breaches of security, threatened self- harm or harm to others, and child sex abuse, absolute confidentiality is guaranteed by the staff and is expected from all the Members. Here, the addict is confronted with their previously unchallenged behaviour. They are encouraged by their peers to drop their defences and the gangster image to let the real person emerge. They learn, through identification and empathy, to give and accept trust. It is in group therapy where social skills and respect for others develop. Issues other than addiction emerge when the Member feels safe enough to disclose and people are relieved to find that they are not alone in suffering from secret behaviours, experiences, and 'hang-ups'. Examples include physical, sexual, and mental abuse, rejection, abandonment, fostering, adoption, and even sexual orientation. Both staff and inmates help to process these potential triggers to relapse.

(4) One-to-one counselling: Each Member is assigned a personal counsellor who may become the first individual with whom they will develop an open and honest personal relationship. The counsellor will tease out from the Member's background details which will assist in developing an individual treatment plan. The counsellor also encourages the Member to take some of his 'secrets' to the group and trust its reaction. The majority of RAPt counsellors are in recovery from addiction. Some have experienced prison. So the excuse, 'You don't know how it is', rarely crops up.

(5) Goals group: Members give one another behavioural changes to work on during the coming week. The previous weeks' goals are reviewed and peers assess whether or not the individual has achieved the target set. As in group therapy, the staff facilitate, rather than participate. Incarceration tends to emasculate inmates, taking away the responsibility for providing for themselves and their families and for making day-to-day decisions. A major focus of the SATP is to try to redress this anomaly by encouraging Members to accept responsibility for their actions and to make better choices rather than blaming other people or institutions for their problems.

(6) Assignments: Assignments of self-examination, which include a detailed and frank life story, help the addict to end the denial syndrome. Only then can they hope to see that their behaviour has been chaotic: it contributed to loss of jobs; to an inability to sustain relationships; it led to crime and, of course, loss of liberty. Cross-addiction with other drugs is examined, enabling the addict to see how quite innocent use (including prescribed and over-the-counter drugs) has led to relapse to the original drug of choice. The life story reveals destructive patterns of behaviour of which the addict is often unaware. These can be modified with the help of the group. Inmates readily admit that criminal behaviour can, for some, also be addictive. This behaviour needs to be examined because, for the majority, alcohol and drug abuse and crime go hand in hand. Assignments are necessary for the staff to assess if what is being taught is being assimilated.

(7) Relapse support group: In order to establish an abstinent, safe environment, and after negotiation with the governor and doctor, drug testing was introduced when it was a very controversial issue politically. All test samples are identified only with an SATP number and results remain confidential to RAPt staff. From the moment we started voluntary drug testing, the dynamics of the environment improved dramatically. Unfortunately, relapse is a hazard of recovery. Nobody is regarded as a failure and the function of the relapse group is to explore triggers and patterns of behaviour which lead back to active addiction. It is called a support group simply because, in the event of breaches of any of the Rules and Expectations, Members are required to stand down for a predetermined time to reflect on motives and re-assess commitment. Members all attend the support group but, as confidentiality is guaranteed, the reason for being stood down is not disclosed to the prison staff.

(8) Peer-evaluation group: Peer evaluation takes place towards the end of the Member's treatment. Evaluation questionnaires contain suggestions for change which are more likely to be noted and acted on coming as they do from those with whom the Member is in daily contact rather than a semi-authoritarian figure such as a counsellor.

(9) Aftercare group: Completion of the 12-week programme is not the end of treatment. The SATP gives a template for the future pattern of behaviour. The weekly aftercare group reinforces what has been learned and the accent is on relapse prevention. One-to-one counselling is available on request.

(10) Peer supporters: Graduates with the right motives are selected for training as peer supporters. They become part of the staff team in every respect, except for access to confidential client information. As well as taking over much of the routine work from the regular staff, they are 'buddies' to the illiterates and the non- English speakers. Available 24 hours a day, they are also invaluable in crisis intervention and have helped to prevent many relapses. They are also excellent examples and advocates for the treatment programme.

(11) Families: "Families who get sick together, need to get well together". With this maxim in mind, immediate families are invited to family conferences. The Member emerging from treatment will be a very different person to live with than the chaotic drunk or addict. A spouse may be a user, which will make life difficult for the Member on release, or may wish to set boundaries for future life together. These issues and many more need to be aired and attempts made to resolve them. Research reveals that even the smallest investment by families in the treatment process has a positive impact on sustained recovery.

(12) Continuum of care: Research and our own experience show that the longer alcoholics or addicts are in some form of continuum of treatment in a safe environment, the better the prognosis for long-term recovery. RAPt maintains contacts with secondary care facilities which follow an abstinence policy and many Members, having pursued this route after release, are now in their own accommodation, in gainful employment, and involved in further education. We always encourage our people to make regular use of the international support of the 12-Step Fellowships which are free.

TUMIN

After 3 years during which the Trust raised £250,000 in order to prove that our programme could run successfully and concurrently with sentence, Her Majesty's Chief Inspector of Prisons, Judge Tumin, inspected HMP Downview. He submitted a glowing report on the project and his team recommended that RAPt be funded for 3 years and that the Home Office fund an outcomes study. Following a 6-month study, Home Office researchers reported over 50% successful completion of the first year and more than 50% of those followed-up in the community were still abstinent and had not re-offended.

EXPANSION

RAPt has been approached by a number of prison governors to replicate the SATP in their establishments. Money is usually the only barrier to these requests. However, with some Home Office funding and some partnerships, programmes are now operating in four other prisons and the 50 per cent plus programme completion rate has been maintained overall.

OUTCOME

Because of the changing culture in HMP Downview, the governor was persuaded to designate areas of 'drug-free' accommodation to RAPt Members, graduates, and the few non-drug users. The landing staff found that relationships with clean and sober inmates were vastly improved, confrontations greatly reduced, and that the residents became more interested in keeping fit and in education. A decision was made to aim to become the first 'drug-free' prison and this was accomplished by having a voluntary cotract with the inmates that total abstinence and submitting to voluntary testing would be a condition of residence at HMP Downview. Positive tests dropped from 98 to 8 per cent and disciplinary incidents fell in proportion. In 1993, the RAPt Fellowship was inaugurated to encourage all those who had participated in the programme to keep in touch with RAPt and with one another. There have been three annual reunions at Downview and on each occasion an increasing number of graduates have returned to a visits area, packed with still serving Members, as living proof that, if the teachings of the programme are practised outside of prison, life without alcohol or drugs can be enjoyable and fulfilling.

CONCLUSION AND COMMENTS

A proposal which was initially rejected as impracticable, unworkable, and unnecessary has been a real success, mainly because the end user, the addict, has voluntarily presented, used, and benefited from the treatment programme. The cost of putting an inmate through the SATP averages £1,500. However, it costs the taxpayer about £20,000 to keep an inmate incarcerated for a year. The SATP has had a dramatic effect on Home Office and Prison Service thinking and policy. At a recent conference held in Bristol on the way forward for treatment in prisons, the programme heading the list flagged up by a Home Office keynote speaker was the 12-Step Model.

We have treated 'lifers', armed robbers, and many other types of violent prisoners and all have to some degree responded to the treatment process. Dr Andy Keay, Governor at HMP Downview, declared that it is the first time in 20 years of prison service that he has actually seen men change. The impact may be slow but SATPs in more prisons can and will reduce the prison population.

Many inmates who recover want to make some reparation to society. At my suggestion, the Governor at Downview has, for the past 3 years, allowed selected inmates to go into schools under escort and share their experiences. Judging by the unsolicited letters from both teachers and pupils, the impact has been dramatic. Youngsters from 8 to 18 have been shaken out of their ignorance of the consequences of the drug culture and, hopefully, some of them will be deterred from substance misuse.

Some graduates have taken up counselling training. Two who have served their sentences have qualified and returned to become valued members of the RAPt therapy staff. Others have chosen further education. More are in gainful employment and are repairing damaged relationships. So the impact radiates outwards from the treated individual.

Of the responses to the most recent Aftercare Follow-up Questionnaire received so far 80 per cent were still abstinent from all drugs, including alcohol and, considering that these prisoners were all long-term chronic abusers, this is remarkably encouraging