Treatment

This section is broad and encompassing since treatment means anything from a prescription of medication to case management. It meant practical direct intervention based acts to the principles and philosophy underpinning those acts. Most participants viewed treatment in the ‘doing’ sense. They were less likely to define the style or manner of treatment but more inclined to state what had been functionally helpful.

Analysis of the ‘Treatment’ subcategory enabled a clear idea to emerge as to what intervention was helpful. This meant deconstructing the major category ‘Help’ and separating actions of helpfulness from helpful attitudes. Comparing helpful and unhelpful actions, citing them and then superimposing them on an attitudinal or value- based foundation served to reconstruct the properties and dimensions of ‘Help’ in an explanatory format.

The analysis listed the treatments that were found helpful by participants, here it contrasts them with unhelpful examples and links them for contextual purposes with

other categories and themes. The key theme of treatment then emerges at the core as Figure 9 below illustrates.

Figure 9. Treatment and its Core

General Practitioner Counselling / CBT

Antipsychotics Consistency

Substitute prescribing Goals and aims

Antidepressants Encouragement

Cravings Cravings alleviation Pharmacological Psychological management

Hypnotics / Health Trustworthiness Anxiolytics

Harm reduction

Practical Needle exchange

Drug free Money / benefits Self treatment / peer support

Home, family and accommodation

Crisis Support

The core of this treatment focused subcategory appeared to relate to health because virtually all the helpful incidents reported were in pursuit of better health. Even the role of substances (see ‘Role of Substance(s)’ in Part 1) cited the alleviation of unhelpful feelings, symptoms or circumstances. Whilst circumstances and history (for example someone attempting to numb the pain of, or forget, trauma) were not reported to have responded to drug use in any practical way, persistent emotional, psychological or mental health states did. A connection between drug use and helpful intervention therefore emerged, a goal of identical properties, the goal of feeling

better. In other words from which ever angle ‘Drug Taking’ (the studies core category) was examined, the goal was to remedy illness or alleviate distress.

To support this emergence further similarity with other categories was noted. The ‘Level of Knowledge’ (Category 2) was seen as important where participants wanted to use drugs more safely (a subcategory of Category 7). The ‘Role of Substances’ (Category 10) and Category 5 (‘Policy, Service or Practice Development Issues’) contained clear responses associated with improving health also.

Treatment therefore was a concept not defined solely by who (doctor, nurse, carer for example) or what (psychological, social or pharmacological intervention). However its properties were revealed as almost exclusively health orientated as the passages below reveal. Health was then an emergent concept, the reconstruction of the treatment data are depicted in Figure 9, ‘Treatment and its Core’. The practical orientation of this subcategory being significant for advice, information and theory development.

Drug Free - First time I noticed that the drugs were giving me a big problem was when erm, I did go to the HDU (High Dependency Unit)

because I was off them completely, I was completely free, from drugs for two and a half years near enough, and the first night out, still, you know in them two and half years, I clocked a big change in myself, because I wasn’t on drugs, cos it was a locked ward, high dependency unit – like this one, but a lot, bit more securer. (Noel)

Harm Reduction (Safer Use) - The safety of ecstasy you know like make sure you’ve got enough fluid in your body when you’re out and not to do too much (take drugs excessively) when you’re out. (Daisy) Family and Health - I think if I did go back (on drugs), I would lose my family and my health would deteriorate….they help me get my benefits sorted and stuff like that. (Karen)

Peer Support - I’d like to get to know more people that have been in my situation and say, they have started counselling or something like

(Karen).

Harm Reduction - On the subject of choosing a drug after several ‘bad trips’. That’s through choice, do you know what I mean, cos, its like, its like, there’s times when I’ve been feeling for it and I’ve just thought to myself there’s nothing going right for me at the moment so I’m just going to go and buy, buy one, one, one, one substance of what I want to take, you know what I mean so, I’ve gone into a few peoples’

places and asked them, you know, have you got this and have you got that. (Floyd)

Antipsychotics - Risperidone injections err, it helps with the internal voices, yeah….its great, getting better and better on that score, but I worry about putting weight on with the injections. (Sid)

I was more like… me friends used to say to me ‘don’t take the medication, don’t take the medication’, they used to think that the medication was making me worse, cos I was sleeping so they thought they was making me worse. Sometimes – I don’t take them tablets, don’t take them tablets – so I wouldn’t for a bit. Then back in, I ended up back in (readmitted to hospital).(Noel)

Pharmacological - I think its easier letting people do things for themselves or trying to do things for themselves, rather than, what do you call it? Prescribing a pill all the time. (Jake)

Psychological - The staff, encouragement, talk to me and all that, advise not to do this, don’t carry loads of money er do your meetings, talk how you feel cos I never used to talk to them even though I’m craving I would just be sat in the meeting like that and just go and do one… You’ve got to admit it, own up and tell the truth when you have had a slip. (Bill)

Services saved my life – gives you hope, a sense of identity, a problem shared is a problem halved. I derived satisfaction from the sharing at the unit (day treatment unit), other patients helped me and so did one- to-one sessions… and group work (Mathew concluded with) I sustain hope by believing that there is life without drink.(Mathew)

This section has identified quite distinct forms of treatment. It has collated them, deconstructed them and finally formed the properties into a more defining model of treatment which simplifies the complexities of ‘Help’. The model (Figure 9, Page 176) does not list the comprehensive range of treatments within the field of dual diagnosis - given that it stems from research participants and not the wider research literature that would be an unlikely outcome. The model and this section illustrates that complexity can be simplified. That the individual elements once grouped and categorised can provide clarity rather than confusion.

8. Goals

‘Goals’ emerged as a subcategory of ‘Treatment’ initially because the conversations participants had with professionals were related to reducing the amount of their drug use. The focus on reduction however was frequently taken by practitioner not service users as discussed previously. ‘Reducing drug use as a goal’ was therefore regarded as a legitimate label in the study yet was not always shared by participants and practitioners. This section examines goals of drug reduction in the context of dual diagnosis. It returns to the motivational model, Stages of Change (DiClemente & Prochaska 1985) as a model upon which to understand goals and associated conflict. Furthermore goals and rewarding consequences are noted since the absence of drug use in many participants required a replacement commensurate with the gains they experienced whilst using substances, for example possessing an alternative coping strategy.

Below Karen indicates that her goal of abstinence would be reinforced by re- establishing contact with her family. In addition the threat of the reward being removed was regarded as helping her sustain abstinence. Jake’s statement however possesses pride and determination which inevitably helps sustain abstinence rather than material or actual reward.

Mark - And do you ever find yourself craving or having urges to use again?

Karen - About twice a week something like that, haven’t had any for a while now

Mark - How did you manage to dismiss them?

Karen - I go to France once a year to visit my mum and dad and I wouldn’t be able to do that (if drug relapse occurred).

…anyway, they came back and they said we’ve got you booked in for a detox on Thursday morning. So at ten past five on 25th April, that was my last drink – 1989. (Jake)

In response to a question related to drug induced mental health decline, below Daisy gave a double barrelled explanation of achieving the benefits of ecstasy use whilst avoiding the dangers. Her goal was one of harm reduction not abstinence. This she

elaborates upon when she describes the significant gains from drug use. In addition the difference between her view of drugs and those of the health practitioners demonstrates that harm reduction goals (Daisy’s) were not considered compatible with mental illness treatment goals (practitioners). An area upon which conflict and disengagement was apparent. This position was commonly expressed among service user participants.

Err, I’ve had that before. I had that when I took the three E’s

(Ecstasy), I got really depressed and couldn’t remember my name and I couldn’t remember what I was getting up to and I got really depressed and I couldn’t see and I stopped sleeping and speaking and I woke up, and I was sort of like, I was awake but I was like over awake. I was getting depressed, that’s why I won’t take more than a certain amount now.

I go through six months of partying and then I stop, or three months of partying and then I stop. I don’t continue using all the way through the year because I don’t feel benefit of the E’s sometimes. Sometimes I take E and I go out and it’s like I’ve not had one because I'm so used to it.

They’re (practitioners) beginning to think there is a relationship

(between mental illness and ecstasy use) because I keep coming in and drying out and they want to change my diagnosis to say its drug induced. (Daisy)

A point of contention. Daisy would not agree with the diagnosis of drug induced psychosis, partly because she did not want to attribute her mental health problems to the drug (ecstasy) which she cherished.

Yeah it keeps solid cos I get to meet people and that, and I get to see everybody and that’s what (inaudible) I'm only stuck in the flat and I’ve got nobody to talk to and I'm bored, I’ve got no neighbours and then I’ll only see doctors and nurses coming up and I don’t get much people round in my community that will talk to me cos they think her ‘she ill’, and I get out and I meet students that come to Manchester every year! That’s how I meet people. It is good for me! (Daisy)

Choice and autonomy appeared as a recognisable theme in relation to goal setting. Participants were assertive about their drug use, practitioners were generally perceived by participants to be too assertive about treatment and abstinence goals. The choice to use drugs and the freedom to do so was partially curtailed as a result of

inpatient admission for many participants. The consequence was either secretive drug use or staff collusion (“turning a blind eye” if drug use took place off the hospital premises and was not overtly detrimental) or head on confrontation. The latter often resulting in conflict, absconsion, discharge or some form of sanction.

It emerged that goals could only be set by service users. They could be facilitated or influenced by practitioners and carers but ultimately the choice and participant autonomy dictated the outcome.

I certainly say that to advise them (service users), to be pushy but not to extremes in forcing people to do things they don’t want to do. If I get forced into doing something I don’t want to do I would tend to get more anxious and agitated about it. (Simon)

The benefits of reducing or abstaining had to be immediate in most cases such as saving money otherwise spent on drugs to buy new clothes or household items, some cited holidays as a longer term reward. The immediacy of rewards was emphasised. The time frame for goals, be they abstinence or reduction based, was frequently short term.

You know just go to centres and you know like Turning Point and go er.. do things in craft you know arts and things like that but that doesn’t bring any income in you know what I mean Mark and it just causes more stress on a person when you know like me I’m struggling every week trying to get through every week and it makes it difficult and it makes you anxious and makes you know, your head spin and so myself I still have a smoke at night (cannabis) , I still have a smoke at night and then once in a while I have a couple of drinks. (Alan)

In summary, goals were not referred to in the concrete terms of an objective to cut back at specific rates, or to stop using and do something else as a replacement. Goals were implicit in lifestyle changes or aired whilst contemplating lifestyle changes. Aspirational statements such as the one below by Sid captured the essence of goal orientated comments. They frequently contained implicit criticism of drug use without fully condemning it, they had to contain hope or optimism and finally there had to be conceptualisation of the reward(s). A good example to end this section is the following quotation from Sid whose reward was the return to his normal life.

…err, lots of things, these people (delusional belief) need to go and leave us in peace and I can concentrate on getting rid of amphetamines which I will do. I’m confident in that, but the guidance has got to be right….you know, so I can have, at least live, a normal life like everybody else. (Sid)