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Talking Heads

Posted on Tuesday, 25 May 2010 08:56PM by A.Joyce
Talking heads
 

We should be wary of the role of talking therapies in any new government direction on treatment, says Alan Joyce
 

I am a passionate advocate of GP-led care, as good GPs are the obvious candidates to provide treatment for concurrent mental health conditions and drug/alcohol use.
 
At the same time I fear that the evidence base for the effectiveness of psychosocial ‘talking’ therapies remains far from compelling and the long history of such therapeutic interventions could be read as a catalogue of passing fads. From the Scientologists’ ‘e-meters’ to cognitive behavioural therapy, one could be forgiven for asking what good and what harm has been inflicted on many of my most vulnerable predecessors and peers in the name of ‘treatment’.
 

A major problem I have with the evidence base for talking and abstinence based ‘treatment’ modalities is the lack of long-term follow-up studies that track patients over many years. What few studies there are have been with very small patient cohorts and utilise deeply flawed methodology – nothing like the rigorous studies and methodology that methadone and other agonist/partial agonist therapies have been subjected to across the world.
 

Moreover, talking therapies generally focus on the personal and exclude the social and the political. How could group therapy sessions-de-rigour in  the early 1980’s have insisted  we left outside the therapist’s door the geopolitical – Thatcher, unemployment, the Afghan war, the Iranian revolution – that facilitated the flow of junk in our blood and song in our veins.
 
No, it was ‘daddy, mommy, me’ and the more knowing among us just played the game for laughs – you could see the therapist’s eyes light up as you pressed the right buttons. In reality such groups helped augment and develop contacts and networks of users/user suppliers. Attending was good for business and good for scoring.
 
In essence, the abstinence obsessed, anti-maintenance practices of a number of the major drug dependency units of the past – the practices of 6-12 week methadone tapering which were deemed to convey the virtues of ‘the short sharp shock of involuntary withdrawal’ provided fertile grounds for the seeds of an impending blight that any reader of Gay News or The Guardian could foresee was heading our way and soon – about as long as it took a jet to fly from SF or NYC to the UK. And so Aids ripped the heart out of my generation’s most gifted, young, talented and bright – now all dust. If only the clinicians of the time had dared open the blinds on the clinic’s windows they would have seen the world outside – the one that ‘therapy’ precluded.
 
Those who could voted with their cash and sought sanctuary in private practice and the lifeboat of maintenance – so long as the GMC didn’t, as in my case, come along and withdraw your private doctor’s accreditation. The rug of stability was pulled from beneath me and many like me. By 1984 it was too late – the genie was out of the bottle and heroin was running rampant in the council estates and tower blocks, as millions became ‘surplus to economic requirements’, just so much dehumanised flotsam and jetsam.
 

My fear is that we now face the very real possibility of a zero tolerance style drug policy – zero tolerance for drugs, drug users and ‘morally indefensible’ agonist maintenance treatment. So as the cuts begin to bite what should we prioritise? Talking and other ‘alternative’ therapies or tried, proven maintenance treatment?
 
I fear that there lurks within the seemingly ‘inclusive' recovery movement a beating heart of malice, rightly identified as the ‘new abstentionist’ agenda. Indeed I suspect that the emergence of the ‘recovery movement’ enabled those that coalesced around the University of Stirling and the Centre for Social Justice to re-brand and re-present themselves.
 
I may appear to have veered off topic, but any 'zero tolerance' regime will be predicated on talking therapies and coercive ‘treatment’, including involuntary withdrawal. Some decry the fact that there is an increasing cohort of patients aged 45 and over 'parked' on methadone maintenance. But most, including myself, would have been dead a long time ago (I will be 51 this year) if it were not for the self-empowerment provided by a good maintenance prescription and practice – GP-led in my case.
 

Those who feel abstinence meets their best interests at any given time should have access to high quality, well-managed facilities. But such provisions should proactively track patients’ progress and offer post-withdrawal support.
Many users’ needs change over time – some cease using then start again, and later decide that maintenance best meets their needs. Some on maintenance may feel they wish to undertake managed withdrawal and stop using – these are not mutually exclusive ‘polarities’ but nodal points in an ever-changing matrix of desire, the personal, the political, the neurological, physiological, clinical, social and cultural.
 
So talking therapies, for me, remain unproven. The jury is much out and thus far I see little to convince me that they are of benefit to all. Of benefit to some, certainly – but a replacement for pharmacological-based treatment? Never.
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