‘Addiction affects people from all walks of life’

As an undergraduate student I recall watching a lecture facilitated by an expert by experience, a woman who was in recovery and a member of the Alcoholics Anonymous fellowship. Her story and my interest in understanding addictions stayed with me, but I told others at that time that I could never imagine working with 'that type' of service user.

Fast forward to now, and as an Assistant Psychologist on an inpatient unit my time is spent supporting people who are completing drug and alcohol detoxifications and stabilisations. This role is incredibly rewarding, and I am thankful to say that my problematic perception of those struggling with addictions has long since been shattered.

A 'typical' patient

In my previous role as a Support Time Recovery Worker and now as an Assistant Psychologist, I have come to understand that addiction affects people from all walks of life, from medical professionals to artists working in the entertainment industry. It truly feels that no one is safe from the impact of alcohol and drug use or the potential consequences of ceasing using them without appropriate medical support. 

The only common factor that I can confidently apply to a large percentage of our patients is their having previously experienced at least one significant traumatic event. Literature suggests that approximately 75 per cent of individuals with substance use difficulties have experienced trauma (Mills et al., 2006), with a higher prevalence within populations actively seeking treatment (Farrugia et al., 2011).

A typical day

My time on the unit is split between supporting patients struggling with mental health concerns and completing neuropsychological assessments. I do so with the support and supervision of a Consultant Clinical Psychologist (0.4WTE) and a Consultant Clinical Neuropsychologist (0.2WTE).

My day starts when I arrive at the unit and join the daily board round meeting, an opportunity for the team of medical staff and allied healthcare professionals to divide tasks and discuss individual patient care. Here I represent the Psychology Team, contributing to updates regarding new and existing referrals.

Outside of protected times (Psychosocial Intervention [PSI] groups, mealtimes, and medication times) I meet with patients referred for additional one-to-one therapeutic support. Some common mental health concerns experienced include anxiety, low mood, suicidality, self-harm, nightmares, and poor sleep. I assess their immediate support needs and provide a space for them to communicate their thoughts and feelings without them having to explicitly discuss past trauma, so as not to retraumatise. 

I offer psychoeducation and use techniques including Motivational Interviewing, dream completion and nightmare rescripting (EMDR based), behavioural activation, CBT for anxiety management, and CFT. These sessions can also involve supporting people to identify, understand, and manage their emotions and to learn new coping skills, such as grounding and relaxation techniques. Often the removal of a person's only known coping mechanism causes them to think on past trauma or psychological stressors and some benefit from having someone to speak to. As such, we take a trauma-informed and person-centred approach.

My aims are to provide a positive experience of, and sometimes introduction to, psychological support; to make people's admission as smooth and supported as possible; and to identify and facilitate appropriate community referrals. 

I also complete brief neuropsychological assessments, although these are less commonly requested, with 4 per cent of all admissions being referred. These involve the use of behavioural and functional observations, interviews, and a variety of standardised tests. Some common referral reasons include concerns regarding forgetfulness (e.g. appointment non-attendance), establishing the role of substances in observed cognitive difficulties, and requests for additional information about a person's support needs.

These take place over several days and the aim is to better understand the person's cognitive strengths and weaknesses; to answer specific questions relevant to their care on the unit and aftercare; and to identify further assessment or rehabilitation needs post-discharge.

In addition to this I complete administrative tasks and write neuropsychology reports or patient summaries; providing those assessed with their own summary of results written in an accessible form.          

Challenges and considerations

One of the biggest challenges for the provision of psychological support and assessment in this setting is the short admission lengths. Patients are typically admitted to the unit for between one and three weeks. We are further restricted to seeing people outside of the protected patient times, when they are not being seen by medical staff, and when they feel physically and emotionally well enough to engage in discussion.  

Whilst completing their detox, patients are vulnerable to numerous physical health risks and problems, which may impact their mental and cognitive health and affect their ability to engage with psychology provisions. Some of these difficulties include poor mobility; increased risk of seizures, delirium tremens, and psychosis; and sleep problems to name just a few. We are fortunate on our medically led unit to have skilled medical professionals who support patients through these problems.

These time and health constraints make building trust and therapeutic relationships more difficult and limit the length and types of psychological intervention we can offer. This has required us to create bespoke materials to help keep sessions structured and containing. 

Short admission lengths also leave us little time to complete neuropsychological assessments – we want the person to have completed their detox and been given the best chance of physical and cognitive recovery possible beforehand.

Although this assessment timing is less than ideal, research such as that by Bates et al. (2005) suggests that some cognitive improvement within the first six weeks post-detox is possible. At present there are no local services who can offer an assessment at the six-week mark and there is a high risk of relapse for our patients within their first-year post-detox (40-60 per cent, McLellan et al., 2000). This means that our immediately post-detox window may be the only opportunity for assessment. Hence a snapshot of a person's cognitive strengths and weaknesses whilst substance-less, despite possible challenges to validity, is better than none. 

Further justifications for the use of neuropsychological assessments within this service include providing a baseline for monitoring change over time, and our being able to provide community services supporting our patients with current and relevant recommendations for post-discharge care planning.

On a systemic level, a significant challenge faced is the limited availability of onward referral options. People who use alcohol or substances are not always eligible to access community services immediately post-discharge, often due to expectations such as a significant specified length of sobriety, or lengthy waiting lists. These barriers in combination with high rates of relapses within the first-year post-detox mean that our patients often slip between the cracks upon discharge, returning to old coping mechanisms or routines before being able to access the support they need. 

This is really difficult to observe, especially given how physically and emotionally challenging completing their detox has been, and how hopeful they are for the future and to receive support upon discharge. Separating cognitive, mental health, and social difficulties from substance use is understandably challenging but our patients need less disjointed service provisions and better integrated working (treating mental and physical health conditions and substance use simultaneously). These problems were highlighted by Professor Dame Carol Black's two-part independent review of drugs in 2021 (Black, 2020, 2021) and are unfortunately still present today.

My hope for the future

Despite the challenges, it has been an honour to support people from all walks of life during a period of significant physical and psychological duress. I hope to have provided them with a positive experience of psychological assessment and support, made their stay as psychologically comfortable as possible, and ascertained and disseminated recommendations to assist their cognitive and mental health needs upon discharge. 

If I could give one piece of advice to other mental health care professionals, it would be that these service users are not 'complex', they are people like us who have experienced significant challenges and often trauma. My hope for the future is that the systems they need to navigate to access support can become less fragmented.

• Eleanor Newton-Hughes is an Assistant Psychologist with Greater Manchester Mental Health NHS Foundation Trust

References

Bates, M. E., Voelbel, G. T., Buckman, J. F., Labouvie, E. W., & Barry, D. (2005). Short‐term neuropsychological recovery in clients with substance use disorders. Alcoholism: Clinical and Experimental Research, 29(3), 367-377.

Black, C. (2020). Review of Drugs: Executive Summary. London: Home Office. 

Black, C. (2021). Review of Drugs Part Two: Prevention, Treatment and Recovery. London: Home Office. 

Farrugia, P. L., Mills, K. L., Barrett, E., Back, S. E., Teesson, M., Baker, A., ... & Brady, K. T. (2011). Childhood trauma among individuals with co-morbid substance use and post-traumatic stress disorder. Mental Health and Substance Use, 4(4), 314-326. 

McLellan, A. T., Lewis, D. C., O'Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. Jama, 284(13), 1689-1695.

Mills, K. L., Teesson, M., Ross, J., & Peters, L. (2006). Trauma, PTSD, and substance use disorders: findings from the Australian National Survey of Mental Health and Well-Being. American journal of psychiatry, 163(4), 652-658.