Our research focused on interviews of people in a prison treatment programme revealed insights into the elements that operate in the treatment process, and how they interact to facilitate recovery from addiction. (3,892 words)
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.
In another article, I described a qualitative research project conducted by Gemma Salter and myself in 2005 that examined the impact of different elements of treatment, using the experiences and views of clients in the BAC O’Conner structured day care programme.
In 2007, Lucie James and I were asked by RAPt (the Rehabilitation for Addicted Prisoners Trust) to conduct a qualitative analysis of the views and experiences of clients on the highly regarded RAPt treatment programme in one male and one female prison in the UK.
The RAPt treatment programme was a three-phase, abstinence-based 12-Step programme conducted over approximately 16 weeks. It aimed to facilitate cognitive, emotional and behavioural changes in inmates, so that they were less likely to use drugs and alcohol, and to reoffend, when released from prison. Our research was focused on identifying the processes that led to such changes
The induction phase of the programme, PreAds (women) and M.E.T. (men), had three main aims: to prepare participants for engagement in an intensive treatment programme; to continue the assessment of participants’ suitability for the 12-step treatment programme, and to build a rapport with the participants that increased the likelihood of their being motivated to tackle their substance dependency and offending behaviour. This induction phase was generally conducted over a two-week period.
The Primary programme focused on the first five Steps of the 12-Step programme. Some of the core components of Primary included group therapy, one-to-one counselling, assignment sessions, peer evaluations, group goals, and attendance of AA/NA meetings. Primary was complemented by formal motivational enhancement, as well as skills training, cognitive restructuring, and relapse prevention drawn from the cognitive-behavioural tradition.
The RAPt programme also comprised an Aftercare phase, but the analyses of this phase added little further information to that described here.
A total of 15 males and 15 females, who had a long history of substance use problems and criminal offending, participated in the study. For the women, 11 of them described crack/cocaine or opiates as being their drug of choice. The average time they had been using their drug of choice was 15.6 years. Twelve of the men named crack/cocaine or opiates being their drug of choice, and they had used this drug on average for 20.6 years.
Subjects participated in semi-structured interviews that covered their experiences and views prior to entering the RAPt programme, on the programme, and since completing the programme (where applicable). Transcripts of the semi-structured interviews were analysed with Grounded Theory.
Participants in this study described being desperate for help in tackling their substance use problem before they entered the RAPt programme. Many felt that they couldn’t give up using/drinking on their own. For some, this belief came from repeated failed attempts at ceasing use; for others, their low self-esteem left them feeling that they were not capable of achieving their goal alone.
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. They 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.
1. Induction Phase
The female participants expressed more positive views about the PreAds phase than the men did of their M.E.T phase, and they believed that many positive changes in their thoughts and behaviours occurred, or began to occur, during this induction phase. This was not the case with the men, who discussed only minimal thought or behavioural changes occurring in M.E.T, most of which were related to social interactions.
The women described how they had failed to understand why they could not stop taking drugs and/or alcohol until they were educated about addiction in PreAds. Learning about addiction led them to realise and admit that they were addicted.
Learning about the disease model of addiction helped the women to change their opinion of themselves as they no longer believed that their past behaviours were due to their being ‘evil’ or ‘weak’, but rather they were the victim of a disease. This enhanced understanding of addiction allowed them to begin to consider that they could address their substance use. [1]
Understanding and accepting that the use of any substance could lead a person back to using their drug of choice played an important role in changing the thinking of many of the women. They felt they better understood what was required to achieve recovery.
The women described how they had had difficulty in trusting others and with being honest, both with themselves and with others, prior to entering the programme. This had led to an inability to talk about their thoughts, feelings and problems with other people, and many found that they bottled up, or blocked out, many of their issues rather than sharing them with others.
A key element of PreAds (women) and M.E.T (men) was that they provided an opportunity for participants to get to know their peers, and more importantly to begin to relate to them. They learnt to adapt to a group environment, and the process of belonging to a group helped to boost their self-esteem. They stopped feeling so isolated in their addiction and began to share their thoughts and experiences with one another person. Participants stated that by learning that they were not the ‘only one to do bad things’, they felt that their self-esteem improved and they began to ask for help from their peers and counsellors.
Relating to their peers also led to the women learning to trust others, which further led them to be able to ask for help when necessary, and give help to others when needed. All of these factors helped to make the women more honest with themselves and with others, and helped to further increase their confidence and improve their self-esteem.
By developing relationships built on honesty and trust, the women found that they began to listen to others’ points of view, and learn from the feedback that they were receiving from their peers and counsellors. This led to an increase in respect for others, and the women continued to learn a great deal about themselves from others. This resulted in a further increase in confidence which was a key component in them deciding, and feeling able, to leave their old lifestyles behind.
During PreAds, the women began to realise that they needed to change their previous destructive thought and behavioural patterns. This realisation was further consolidated in Primary when they began their Step-work.
The women spoke highly of the education they had received about the disease model, the 12-step philosophy and cross-addiction. The men spoke less about their education programme (which was different) and their views were mixed, with some believing it was unhelpful and confusing.
Whilst all participants thought that the Induction phase helped prepare them for the Primary phase, and allowed them to get to know their peers and become used to being in a group environment, the men rarely discussed changes in thoughts and behaviour occurring in this phase. For the men, these sorts of changes occurred during the Primary phase of treatment.
2. Working the Steps
All of the interviewees talked very positively about the Steps and the Step-work. Although they all experienced low points where they found the work difficult or distressing, they all felt that they had benefited greatly from the Step-work by the end of Primary. They could clearly see that the Steps contributed to positive psychological and behavioural changes.
During Step One, the interviewees began to see how uncontrollable their lives had become due to their substance use. The written assignments were portrayed as making the participants’ past seem more real. The process of writing down their thoughts and memories evoked numerous emotions, and was described as difficult and upsetting at times. During the Steps, the interviewees were taught to identify and deal with specific emotions.
Whilst revisiting their pasts was an extremely painful process, the interviewees came to terms with the previous unmanageability of their lives, which gave them the determination and motivation to change their behaviours and futures. This motivation was further strengthened when they considered the harmful effects that their addiction had previously had on others. For some, this was the first time that they had considered that those around them were victims of their substance use. The Step-work helped the interviewees to deal with the impact of their substance on themselves and others, so that they were able to accept, and let go of, the past, and focus on their recovery and future well-being.
The peer evaluations were described as an ‘eye-opener’ by the women, as they had not previously realised how their behaviours were perceived by others.
Believing in, accepting and handing their lives over to their Higher Power, evoked important changes in the interviewees’ thinking in relation to their addiction and recovery. Many believed that Step Three was an important stage in further strengthening their determination to abstain from substance use.
As the participants began to put what they had learnt from the first three Steps into their everyday lives, they began to see what a difference it was making to their thinking and behaviours. Seeing evidence that the Steps were impacting on their lives, and that they were achieving change, led to further increases in the participants’ self-esteem and resolve to overcome addiction.
Whilst Steps Four [‘We made a searching and fearless moral inventory of ourselves’] and Five [‘We admitted to God, to ourselves, and to another human being the exact nature of our wrongs’] were emotional and difficult for all the interviewees, they evoked motivation for behavioural change. The subjects described being as honest and truthful as possible during these Steps, and they felt great relief and unburdening at sharing their most in-depth experiences and thoughts, despite the distress that this sometimes caused.
Some of the participants described completing Step Four as having a weight lifted off their shoulders. During Step Four, many of the interviewees felt that they were able to let go of resentment that they had carried through large portions of their lives. This was a huge relief and helped the participants let go of the past and focus on the future.
3. Group therapy
All of the interviewees strongly believed that group therapy played an essential role in their behavioural change and recovery. For many, group therapy, and the programme in general, provided them with the opportunity to ‘belong’ for the first time in their lives. This sense of belonging helped to build their self-esteem and therefore helped their journey through the programme.
Group therapy was an environment where many of the social skills leading to behavioural change were learnt. The interviewees learnt to speak in front of others, open up and share their problems, trust others, talk honestly and freely about sensitive issues, be challenged, and provide constructive feedback to others. A number of the participants stated that they had opened up for the first time in their lives. Many felt that it was essential to talk in depth about issues underlying their substance use.
Another useful component of group therapy was goal-setting, which led to group discussion of goal progress and specific behaviours. Group therapy was one of the most discussed topics during the interviews, and evidently played a key role in the success of the participants’ time on the programme.
4. Fellowship meetings
One of the key components to emerge from this study was the beneficial role that the Fellowship meetings played in the interviewees’ recovery. Although all the subjects discussed the meetings, the women went into far more depth and the meetings appeared to have a larger impact on them than the men. These meetings, which were held outside the prison, gave the interviewees further hope and determination that they could achieve abstinence and lead a healthy and fulfilled life. For many, it was the first time that they had interacted with people who were in recovery from addiction.
The participants emphasised that the meetings further enabled them to feel that they belonged to something, and they were not alone in the things they had done. Feedback from others during these meetings also enhanced the self-learning process, boosted self-esteem, and facilitated the learning of social skills. The interviewees stated that it was a great comfort and support to know that they would always be able to attend Fellowship meetings.
5. Staff and peer supporters
The RAPt staff and peer supporters were believed to play crucial roles in the changes that the interviewees experienced, and in their recovery. Staff members were praised for their ability to remain patient, helping the subjects to open up, and being there at any time to offer advice and support. Over time, the women looked to the staff as positive role models, who helped them to build up their confidence and self-esteem.
The interviewees also believed that the peer supporters provided them with essential support, guidance and advice, and hope that they too could achieve abstinence.
6. Counselling
One-to-one counselling was described as crucial in helping the interviewees to open up and share their problems. The counsellors provided the encouragement and support that the subjects needed so that they had the courage to later bring up difficult issues in group therapy—leading to additional support, advice and help from their peers.
7. Family relationships
The interviewees described a great improvement in their family relationships during Primary. They were proud that their families were noticing a change in their behavioural and thought patterns. They were grateful for the support that they received from their loved ones. This helped their self-esteem to grow further, and facilitated a more positive outlook of the future.
The family conferences during Primary were mentioned by nearly all of the women as being very useful—even turning-points in their recovery. Half of the women pointed out that the family conferences provided them with the opportunity to be honest with their families for the first time in many years. They were able to learn about the impact their addiction had had on the family, and educate their families about addiction and recovery. Family conferences were not a theme that emerged from the men’s interviews.
8. Other elements
The interviewees emphasised that it was the RAPt package as a whole that led to the positive changes in their thoughts, emotions and behaviours. They also indicated that the programme was hard work, and that people entering it had to want to change, since personal effort was required for beneficial changes to occur.
During the programme, the interviewees were educated in recognising their thoughts and behavioural patterns, which helped them to divert potentially destructive behaviours. They learnt coping skills and strategies to deal with problems that would otherwise have led to substance use.
They described a noticeable change in their behaviour, including an increase in honesty, trust, patience and confidence. These changes led to them being able to discuss their problems more openly with others. They also felt that they had learnt a lot about themselves and that they had ‘grown up’. Many of the interviewees learnt to like themselves and felt that they were beginning to understand who they really were.
The interviewees felt that one of the biggest improvements in their lives was the change in relationships that occurred during the programme, in particular the vast improvement in family relationships. Moreover, an extremely close bond was formed between the programme participants, and many felt that they had developed lasting friendships.
At the end of Primary, all of the interviewees had very definite positive plans for their futures. They wished to remain abstinent, and felt that that they had the skills, support and mindset to avoid drugs/alcohol and have a bright future. They felt confident in their ability to recognise and deal with different emotions, instead of blocking them out with substance use, as they had done in the past.
9. Grounded Theory Analysis
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.
Belonging: 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 changing their emotions, thoughts and behaviours, as well as feeling more confident they would address their substance use on release, 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.
Socialisation: 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: 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. [1] 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: 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.
10. Conclusions
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.
Of course, the ultimate ‘test’ for each of these participants was when they left prison and faced everyday challenges in their life in the community. Whatever challenges they were to face, we believe that they were in a much stronger position to deal with issues and problems as a result of the RAPt treatment programme.
[1] It is not necessarily learning about the disease model per se that is important here. It is likely that 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 ‘actionable’ to them.
The photograph above shows Lucie James (Left) and Sarah Davies, the two Wired In team members who conducted the interviews in the prisons. Lucy did the Grounded Theory Analysis and wrote the report for RAPt.