Working in drug and alcohol recovery – an overview

My role involves supporting individuals through their recovery journey. Often, I am expected to provide a range of one-to-one and / or group support to service users – facilitating in the development of life skills as well as supporting in the expansion of positive networks to enable independent living. During this process, I work with many different colleagues – to provide the best quality of care to service users, upholding dignity and ensuring that the support provided is safe and effective. Often, I am required to work as part of a team (as well as on my own) to ensure consistent support to service users – as per their individual care plan. Keeping accurate records and supporting service users in their dealings with external agencies is commonplace and I am, on a daily basis, using phones and emailing other team members. There are lots of different requirements within this role – dependant on where you are based and who you are working with. So, to expand your knowledge further around the role, it might help to read the job specification on the NHS Careers website.

When working in addiction, in any form, it is important to consider that different service users will often ‘use’ in different ways, and that some substances are more challenging to recover from than others. Some of these substances are legal; for example, alcohol.

Other substances are illegal. Heroin, for example, is made from the resin of poppy plants and refined to make morphine, and then further refined into different forms of heroin.

When I worked for Sussex Partnership Drugs Rehabilitation Services, I supported 6 users of heroin, who had accessed a voluntary live-in recovery programme. In one of the sessions, which were based around exploring the reasons as to why the service users were using, we talked through the reasons why there was a need to stop using. This involved writing a letter to heroin and telling ‘it’ why it was no longer wanted. The letters were powerful and emotional. One client talked about his need to rebuild bridges with all those he had stolen from. Another talked about how she wanted to find her own peace and bring closure to a 34-year addiction. What I remember from this group was their sheer determination and dedication, and their openness around how they were feeling. This sharing of experiences and expression of emotions and feelings around addiction is well established within the research (REF), with the language used being very important in the recovery process.

The change recovery model was developed to support those in recovery from addiction and recognises the many different stages in which a person would go through during the recovery process. The model focuses on a strength-based perspective, which means it offers praise around change and supports the person in making changes in their own time and way, with the help of professional contemplation, preparation and action. Additional stages of maintenance and relapse can also be included. The model is formed by a cycle of events, although people often go back and forth into different stages and sometimes even miss out a stage. This shows how varied and different we are during this process and how everyone’s recovery journey is different.

Precontemplation usually involves having no concern or worry around the addictive behaviour, even though there are problems developing due to, and as a consequence of, this behaviour – for example drinking in the day and missing work. Contemplation means that the person would start to contemplate these behaviours (or think about and consider them) as damaging and toxic. For example, missing work due to day drinking means the person gets fired and that the rent cannot be paid, and now the person is thinking about how the drinking in the day was a cause of this. The person then considers (or contemplates) cutting back or giving up drinking. The contemplation stage is when services and professionals are more likely to get access to the individual and the individual is more likely to want to find out information and seek out support. In the precontemplation stage the person is often in denial – assuming all will be ok, and the addiction is not the problem. When information has been sought, the contemplation stage often concludes with an agreement, with self, to start treatment or make a behaviour change. Once the decision has been made around making positive changes, the preparation stage is now in action.

However, it is important that correct support is in place to see these changes through and make sure there is a structured and well thought through plan of action. This could involve setting goals and targets; for example, to cut back on drinking from 7 to 4 days a week in one month. Medication may also be needed, especially around long-term addiction recovery, where the body has grown functionally dependant on the substance. Stopping without this added level of support could be dangerous, so make sure you are talking with other professionals about this. Things that could be considered are how much alcohol needs cutting back? Is this total abstinence? How to start this change and how to maintain it? Building a tool kit of information around what support is available and how this can be accessed should relapse occur can be helpful, but being realistic and honest are also very important. And recognising triggers and trying to remove them or decrease them would usually be beneficial. This brings me to the action stage. This is where the change happens.

For some this involves a full detox – possibly in a centre or at home – with medication to support with the detox side effects, which can range from sickness, diarrhoea, violent shaking, hallucinations, blindness, loss of taste and appetite, night terrors or insomnia. The side effects, over the first 3 to 5 days, can be horrific. And they can be hard to see, and very upsetting for family and new staff – so read around this stage and prepare yourself. Also, due to the psychological and physical pain and upset the person is going through, frontline staff, like ourselves, can sometimes bear the brunt of this upset and often experience verbal insults and attacks. What is important to remember is this is rarely personal. The person is going through a very challenging and different situation to anything that they’ve been used to, and experiencing a plethora of emotions and feelings, meaning upset and concern often plays out in how they are behaving. But, this intense physiological detox is usually pretty quick.

For those who are, for example, looking to cut back – there is a need to look at ways to deal with stress better – so alcohol is not used as a coping mechanism – as well as how to keep yourself occupied. Finding new things to do and meeting new people can be helpful – although isn’t for everyone. The maintenance stage of the recovery process is the most challenging. For example, 3 months down the line – no drinking, with the person feeling fantastic and looking great – will a few drinks hurt? Relapse is common, although does not always occur. Often, though, life is ‘up and down’, and how we cope with these challenges can also impact on how we manage addiction. For example, one of my clients lost his mum and this is the trigger which sent him into relapse – he was heartbroken and numbed the pain of grief with crack cocaine. This worked, temporarily, for him – but the situation was still there, and he was now back in precontemplation stage. When he self-referred 3 months later, he was 3 stones lighter, had lost all of his teeth, and was very unwell both mentally and physically. But, he was back in contemplation and ready to face the grief associated with this loss of his mum. This meant that the situation was far more complex and far more challenging, as before the addiction could be explored – fully – we needed to work through the grief cycle – as this was his biggest trigger.

Relapse can occur in little and often episodes, or can be a short or long-term binge, and then complete abstinence for months or years. Within the process of recovery there are often (but not always) relapses. For example, 3 days into an intensive recovery week – after working very closely with a group of service users – I found out that 2 had voluntarily discharged themselves from the programme and one of the clients, a 27-year-old man, had died of a heroin overdose. Even after years of working in this type of role, this still really hits home, and reaffirms how hard this process is for these individuals and how, sometimes, some people do lose their life to addiction, even when getting help. Sadly, this is not a rare occurrence. Currently, drug-related deaths are at their highest level since records began in 1993, with 3,756 deaths in England and Wales last year – 53% of which related to heroin use. Almost a third of all deaths from overdose in 2016 in Europe happened in the UK.

By talking about this, I am not trying to deter you from going into this type of work. Rather, I am trying to highlight the challenges that can develop and the intense emotional situations that are likely to occur. I have had gaps from working in these services, as there is a required emotional and mental engagement. This engagement can be tiring, and if left without ‘thinking and feeling’ how you are feeling – you are likely to burn out. Your place of work should ensure you have good quality supervision and, as per many in these types of roles, use reflective practice to help you recognise when you are feeling the strain (See – https://www.cambridge-community.org.uk/professional-development/gswrp/index.html).

Finally, I want to draw your attention to the language being used in recovery work and further afield. There is an ongoing debate regarding which words, in particular, should be used or avoided. Many words we still use today pertaining to addiction have long-held moralistic connotations, can create double standards and belittle the gravity of addiction. Part of the issue pertaining to substance use, is that people are viewed as choosing to use the substance, and therefore are perceived to be “doing it to themselves”, “indulging”, or “engaging in wilful misconduct.” It is true, people do choose initially to try a substance, whether alcohol or opioids. However, I have never met anyone who chose to become addicted. Such are the brain changes involved in addiction, that people in the end – in my experience – are using the substance against their will, and despite suffering terrible personal consequences directly resulting from use. It turns out, like many other illnesses which humans are likely to experience, addiction risk is conferred through personal vulnerabilities (for example, genetics – childhood abuse/neglect, trauma) coupled with exposure to environmental stressors or agents (for example, an intoxicating substance in the case of addiction). Research is clear in recognising that genetics and biology strongly influence how likely we are to become addicted with about half the risk conferred by genetics (REF).

Importantly, research has found also that our choice of language is not just about being polite, nice, or “politically correct”. Scientific studies conducted by Kelly and Westerhoff have found that exposure to certain terms can actually affect the attitudes of healthcare providers and may impact the quality of clinical care for addiction. In a randomized controlled study (Kelly and Westerhoff, 2010) it was found that describing someone suffering from addiction as “a substance abuser” compared to describing them as “having a substance use disorder” invoked significantly more stigmatizing attitudes in a large sample of mental health and addiction clinicians, and led them to prescribe more punitive measures (e.g. punishment). In a similar follow up study (Kelly, Dow, Westerhoff, 2010), study participants believed that patients described as “substance abusers” were less likely to benefit from treatment, more likely to benefit from punishment, more likely to be socially threatening, more to blame for their substance-related difficulties, and better able to control their substance use without help, than the exact same individuals described as “having a substance use disorder.” This research suggests that exposure to terms like “substance abuser” – invoking the idea that the person is engaging in wilful misconduct – may induce more punitive implicit cognitive biases against individuals suffering from substance-related conditions. Such research is critical to informing us all about the nature and magnitude of the impact of the use of different terms used in highly stigmatising conditions like addiction.

To conclude, being a drugs and alcohol recovery worker is challenging – but rewarding. Many of the benefits of the role are around meeting the amazing people working through their challenges and finding ways to manage and survive. Being part of that journey is a pleasure – even if at times hard work. This means that taking care of yourself – your own mental health and wellbeing – is very important, and supervision as well as good self-care are needed so that you can be the best you in your role and in your life. Reading further around the recovery model will help to further underpin your knowledge and inform your practice; and clearing up any uncertain terms you have in your head with other colleagues, as well as asking service users how they would like to be referred to, can be helpful in destabilising any negative connotations language and words are holding. Finally, remembering to show warmth, empathy and being non-judgemental are vital skills for you to be successful in this role.

References

Waldhoer, M., Bartlett, S, E., and Whistler, J, L. (2004). Opioid receptors. Annual Review – Biochemical. 73: 953–990.

Wang, X.; Li, B.; Zhou, X.; Liao, Y.; Tang, J.; Liu, T.; Hu, D.; and Hao, W. Changes in brain gray matter in abstinent heroin addicts. Drug Alcohol Depend 126(3):304–308, 2012.

Liu, J.; Qin, W.; Yuan, K.; Li, J.; Wang, W.; Li, Q.; Wang, Y.; Sun, J.; von Deneen, K.M.; Liu, Y.; Tian, J. Interaction between dysfunctional connectivity at rest and heroin cues-induced brain responses in male abstinent heroin-dependent individuals. PLoS One 6(10):e23098, 2011.

About the author

An experienced (c15 years) Mental Health Practitioner, Andi’s specialisms are autism and dementia care, as well as having a strong interest in disability advocacy, sociology and equality.

Andi currently works in education as a subject specialist and, as well as assessing achievement and participating in internal and external quality assurance, helps to develop qualifications for awarding organisations.

In September 2017, Andi commenced the Master of Arts in Social Work at Sussex University.