Student Writer Competition winners

Social exclusion  – an addictive context

Matt Baker, joint winner in our student writer competition, shares his views on drug use and rehabilitation

Despite much expense and debate, substance misuse remains a contentious issue that successive governments and strategists have failed to successfully address. Despite considerable media coverage, addicts themselves remain marginalised and often demonised. The fact that their condition is often symptomatic of other unaddressed issues, such as abuse and neglect, often appears forgotten. This does not excuse any individual from taking responsibility for themselves, but does suggest that the answers lie in inclusive, supportive communities and therapeutic responses, not in the punitive/medical modelling that has so far failed to address the problem.

It could be argued that this generation lacks a significant political commentator, an Orwell or a Ruskin for the tensies, or whatever name consensus has now applied to this decade. Their focus would still be on social exclusion, updated to reflect modern drug culture – 'Stoned and out of it in Liverpool and Manchester'; perhaps. Orwell, in particular, would have found the January issue of The Psychologist particularly relevant from this point of view. The picture of social inclusion was in many ways bleak, including as it did an indictment of mental health services in our prison system (Shepherd, 2010). The sense of exclusion felt too familiar and is arguably representative of mainstream support services for offenders in general, an impression which this article will probably do nothing to dispel.

Support services for offenders tend to consist of a punitive criminal justice system, alongside some level of practical intervention. In the case of those with substance misuse history – our main focus here – this will usually include substitute prescribing. Studies have shown that this often amounts to punishment plus as little as 10 minutes of structured intervention a week (Best et al., 2009). Locally, this has been dubbed the 'Jeremy Kyle' treatment model (as in: 'Give them a bottle of methadone and send them home to watch…'). From experience, the most frightening part of this is that more time is spent recording what was said (back covering and reporting so-called outcomes) than is spent considering psychological needs, literacy, numeracy, training, work and housing put together. The sense of self-worth and progress that recipients feel can be imagined, and arguably amounts to a form of organisational reinforcement of what is in part a socially constructed condition.

This last point perhaps needs explaining. If we accept that the majority of drug use among young people is experimental and unproblematic (Livingston, 2005), then it is clear that addiction results from some problem underlying or alongside the drug use, not from the use alone. Although there is evidence for a level of biological predisposition to addiction (e.g. Hasin & Katz, 2010), it is by no means clear cut. There are, however, overwhelming similarities in social situation between the majority of people with addictive issues. These include unstable family background, negative/non-existent community or social identity, history of abuse, poor literacy skills, low educational achievement and attendant low self-esteem – the basis of our current psychosocial model of addiction (e.g. Macleod, 2010).

It is impossible to rate these factors in order of impact, but the community element is clearly of importance. Individuals who associate with a drug-using peer group are likely to follow the same trend (Andrews & Hops, 2010). One study suggests that the most common reason for people to drop out of treatment is the failure to establish good social relationships with a substance-free peer group (Nordfjaern et al., 2010). Note that this is just one study: there is a distinct lack of research into what individuals in this situation actually think of their treatment. However, anecdotally it is clear that clients who are supported to establish good social networks (involving others in recovery and others with positive goals) tend to do well. Conversely, when an individual repeatedly encounters agencies that regard them as time-consuming and who set out to 'process' them, their negative experience is reinforced. This suggests that the role of addict is in part socially constructed, perpetuated by interaction with/attitudes of organisations and individuals.

Regardless of any personal or political bias towards enforcement or support (the fruitless 'We must punish' versus 'We must sympathise' debate), a quick review of statistics tends to show that current strategies do not work. The Joseph Rowntree Foundation puts the number of problem heroin users in the UK at 200,000 (http://bit.ly/d1VWgK), a number that looks conservative set against other estimates. According to the Office for National Statistics, one in five male offenders is arrested for an offence involving drugs, and drug-related crime nationally is the second most prevalent form of crime (http://bit.ly/b4UG6S). Estimates for the cost of methadone treatment for heroin users vary between £3000 and £5000 per person per year (http://bit.ly/6X78H7). The Home Office puts the cost of drug addiction at over £20 billion per annum when crime, sickness and absenteeism are taken into account (http://bit.ly/cm7AJm). These figures are hard to verify, but they are united in one trend: spending (and presumably therefore drug use) rises year on year. The impression created is that you cannot commission recovery any more than you can commission good temper and a general sense of well-being. To date, this has not stopped strategists from continuing to attempt to do so.

Despite this picture, our emphasis is towards the positive. Writing in January's edition of The Psychologist, Fabian Davis pointed to the importance of helping people to help themselves, a principle of ownership and inclusion that underlines most successful recovery (Davis, 2010). In my area of the country – North Wales – examples are easy to find. There is a strong 'grass roots' movement among service users and staff. Alternative projects flourish. DARE (Drug and Alcohol Recovery Expeditions) is one example – a client-led mountaineering group that ostensibly does nothing about recovery, but offers an invitation to those who want to take part and who are in a similar situation. This has led to the establishment of an intervention called Evolve Outdoors, who run therapeutic outdoor education programmes. An organisation called TAPE offers various music and film projects; there is a strong service user group called Channel; the list goes on. This has been made possible by a number of factors, including sponsorship from a forward-thinking probation service and a flexible, support-centred approach by the local Drug Intervention Programme. It has been made successful by the extent to which it is owned and run by the community of interest that it serves.

These projects differ from the norm in a number of ways. Some are clubs, societies or completely unconstituted, a loose arrangement of mutually supportive individuals who share a purpose; others are specific but non-conventional interventions. Most of them do not set out to deal with substance misuse, to prevent drug use or tell people to stop offending. They all, however, share in offering individuals a change of status: they become a participant not a recipient, an individual with a sense of control over their journey, a 'doer' rather than a 'done to'. The result of this sense of inclusion is often predictable: a strong recovery based on a sense of self-worth, created by positive interactions that focus on a possible future. Frequently, the words 'drugs' or 'offender' do not occur at all. If you work on the factory floor in a project of this type, it rapidly becomes mystifying why these projects – which are usually run on a shoestring and in large part by volunteers – have to fight so hard for funding and recognition. It also becomes mystifying why so much mainstream delivery continues, unless it is simply from a sense of moral outrage on the part of a society that sees 'drug addict' as a choice similar to 'airline pilot' or 'sheet steel fabricator'.

Rehabilitation, then, seldom results from an imposed order, a restriction on the individual, a punishment or a threat. This reflects a motivational concept which occurs across a number of training and counselling models: a journey towards is always more powerful than a journey away. Implicit or explicit, this message is clear in cognitive behavioural therapy, reality therapy, neurolinguistic programming and the human givens . The 'done to' are empowered by 'doing' – running away is undirected, whereas believing that today is okay and tomorrow can be better is the beginning of a powerful sense of well-being. The root of this sense of ownership can be attributed to the same reason as the root of the addiction – essentially a need on the part of all individuals to identify and share characteristics with an in group (Turner, 1987).  

Occasionally, a small project grabs national attention. Monty Don's sorties into market gardening aided by a group of prolific offenders became the subject of a television series and a book (Don, 2006), briefly capturing the national imagination. If we are serious about rehabilitation and social inclusion, this focus has to become the norm. We need to see a proliferation of small projects that belong to their participants, individually designed to take account of local interests, geography and needs. Arguably, methadone should be an intervention in the short term, but against the various costs of keeping a heroin addict on substitute prescribing the cost of encouraging local service-user led or influenced projects begins to seem quite small.

Alongside – or as part of this – we need a coherent psychological approach. This means an understanding of what works for the client group based on past outcomes rather than political opinions: a form of psychological/motivational modelling. Whilst sharing Elizabeth Holford's reservations about CBT as a panacea for all social ills (The Psychologist, January 2010, p.23), it also means better access to counselling and therapy. Locally, there are a relatively large number of homeless/addicted/directionless/unemployed clients who eventually manage to see a psychiatrist and – in some cases – are given a prescription after a seemingly short appointment. Only a small number of clients in these categories gain access to a psychologist or counsellor. Antidepressants may help someone with substance-misuse history who has suffered abuse and is homeless, but evidence is scarce. What probably will help is directed counselling alongside access to help and self-help based services that offer a real sense of inclusion. The latter option offers personal and social benefits: the development of a positively defined personal identity and a genuine sense of inclusion. Arguably, the instatement or reinstatement of those human essentials which were previously absent.

Despite appearances, this article is not so much about addiction as it is about alternative approaches to inclusion. It aims to replace the conventional question 'How do we change them?' with the alternative thought 'How did society create them?'. This taking of responsibility replaces a more conventional placing of responsibility. It also, ultimately, asks us all to challenge the concept of 'them'. Writing this in a week which has seen a 10-year-old and an 11-year-old jailed for what amounted to the torture of two other children of similar age, and a report from the National Equality Panel emphasising rapidly increasing inequality in British society, it seems necessary to revisit strategies of inclusion across all social groups. A challenge, perhaps, both for the profession of psychology and for every socially minded individual.

Matt Baker
is a psychology student with the Open University
[email protected]

References

Andrews, J. & Hops, H. (2010). The influence of peers on substance use. In L. Scheier (Ed.) Handbook of drug use etiology: Theory, methods, and empirical findings (pp.403–421). Washington, DC: American Psychological Association.
Best, D., Day, E., Morgan, B. et al. (2009). What treatment means in practice: An analysis of the delivery of evidence based interventions in criminal justice drug treatment services in Birmingham, England. Addiction Research and Theory, 17(6), 678–687.
Davis, F. (2010). Can we sustain the 'magic'? The Psychologist, 23(1), 32–33.
Don, M. (2006). Growing out of trouble. London: Hodder and Stoughton.
Shepherd, G. (2010). A lifetime of exclusion? The Psychologist, 23(1), 24–25.
Hasin, D. & Katz, H. (2010). Genetic and environmental factors in substance use, abuse, and dependence. In L. Scheier (Ed.) Handbook of drug use etiology: Theory, methods, and empirical findings (pp.247–267). Washington, DC: American Psychological Association.
Livingston, W. (2005). As one psychiatrist said to another. Addiction Research and Theory, 13(1), 93–94.
Macleod, J. (2010). Drug taking and its psychosocial consequences. In S. Macgregor (Ed.) Responding to drug misuse: Research and policy priorities in health and social care. London: Routledge.
Nordfjaern, T., Rundmo, T. & Holi, R. (2010). Treatment and rehabilitation as perceived by patients with substance addiction. Journal of Psychiatric and Mental Health Nursing, 17(1), 46–64.
Turner, J. (1987). Introducing the problem: Individual and group. In J. Turner, M. Hogg, P. Oakes et al. Rediscovering the social group: A self-categorization theory. Oxford: Blackwell.

 

Images of the future, drawn from the past

Stefania de Vito, joint winner in our student writer competition, on episodic future thinking

The constructive nature of episodic memory could be better suited to the job of imagining scenes that might occur in individual future. Such a system allows people to extract bits of information from past experiences and subsequently to combine together these pieces into imaginary episodes. Everything a person can imagine is real, as Pablo Picasso suggested. A substantial body of research supports the idea that simulations rely on memories and that, like memories, they are inaccurate. 

Eyes half-closed. Painted smile. Gaze lost in space. The landlady's words turn into a smooth background noise. Tim can see himself with his friends drinking and having fun in that living room. Two girls are near the window, behind the curtain, smoking and chatting playfully. Music is played at full blast, people dance and laugh. 'You don't smoke, do you?' enquires the landlady. Trapped in reflections, Tim doesn't answer. 'What... sorry... what were you saying?' 'You won't be allowed to smoke in this flat, and I won't tolerate a lot of noise...' Tim thanks the landlady and leaves; he won't rent the room.

Now, Tim could get two insights from this experience. First, he could realise that the brain is not idle in the absence of external task direction (Ingvar, 1979).

The second insight, definitely harder to get, would be that this default (passive) cognitive state is usually associated with planning and episodic memory – the kind of memory that enables us to recall our autobiographical experiences (Buckner et al., 2008). Tim's decision depends on his awareness of his personal history and on his ability to imagine future scenarios. Like most people, he can shift his perspective from the immediate environment to vividly and richly imagine himself in situations before they happen.

Indeed, we all know that we can predict the consequences of events we have never experienced before, by creating mental representations in our mind (Gilbert & Wilson, 2007). And, according to some authors, we do so continuously. Moshe Bar (2007) proposed that the human brain is spontaneously and constantly engaged in devising predictions that approximate real future situations, instead of passively waiting to be activated by perceptions. This happens either when people are not otherwise busy in perceiving the immediate environment (Buckner & Carroll, 2006) or when they voluntarily project themselves into personal future scenes. This peculiar kind of thinking, or episodic future thinking, as it has been labelled by Atance and O'Neill (2001), allows us to place ourselves in hypothetical scenarios in order to explore possible consequences by using imagination.

Different cognitive processes are involved. First of all, if you wish to place yourself in a hypothetical scenario, you need to construct such a scenario, framing the available information within a coherent spatial context (Hassabis & Maguire, 2007). Then, such information is to be maintained for later manipulation and visualisation in order to build a complex story structure (Rubin et al., 2003). Moreover, some executive processes are to be engaged to oversee a successful performance (Simons & Spiers, 2003). These simulations are always temporary, goal-directed, self-referential and achievable (Hassabis & Maguire, 2007). Furthermore, they necessarily involve autonoetic (i.e. self-knowing) consciousness, a special kind of consciousness that allows one to be aware of their existence and identity in subjective time extending from personal past to personal future, passing through the present (Tulving, 1985).

However, at this point, one could wonder where personal simulations of future events come from. It is obvious that they are not exact replicas of past episodes, but they cannot completely come out of the blue either. As Aristotle suggested, there is nothing in our intellect which was not, at some point, in our senses. How can we make novel excursion into the future, then? A possible explanation might be that when playing future episodes our mind reshuffles episodic memories (Dudai & Carruthers, 2005), thanks to the constructive nature of episodic memory recall.

Episodic memories are indeed created by recombining pieces of information, rather than reproducing past episodes as a video-camera would do. For this reason, we cannot think of memory as an equivalent of Plato's etched-wax tablet. Our memory is inaccurate. In Oscar Wilde's The Importance of Being Earnest, Miss Prism, in a vain attempt to discourage her young ward Cecily from keeping a diary, suggests that memory is 'the diary that we all carry about with us'. However, the witty Cecily promptly retorts: 'Yes, but it usually chronicles the things that have never happened, and couldn't possibly have happened. I believe that memory is responsible for nearly all the three-volume novels that Mudie sends us.'

There are many explanations of such fallibility. It has been speculated, for instance, that the ability to envision the future might be to blame for the failure of our reconstructive memory (Schacter & Addis, 2007a); we need a flexible adaptive memory process that allows us to extract and put together pieces of information from the past into imaginary episodes that did not happen in that precise combination (Schacter & Addis, 2007b). The idea that past and future thoughts are so closely related is strengthened by a substantial body of research.

Morewedge and colleagues (2005) highlighted the tight interrelationship underlying past and future events. They argued that when people simulate their reactions to a future episode, they spontaneously rely on memories of similar events which were already experienced in the past. The researchers use the example of the destruction of the Twin Towers in New York on September 11, 2001. That was, indeed, the worst terrorist attack Americans ever endured. For this reason, it comes most easily to mind. However, it is also the least representative. If people make predictions and plan accordingly to such atypical, though memorable, event they may be in danger of making mispredictions. Indeed, in the final months of 2001 the increase in automobile traffic, due to the decrease of commercial airline passengers, killed more people than the attack itself. Furthermore, people generate more detailed and vivid simulations when asked to imagine future scenarios occurring in familiar settings (for example, home) than in presumably novel settings (for example, jungle). Spzunar and McDermott, who ran this study in 2008, interpreted the results as an indication that past memories are sampled during episodic future thought.

That we extract the content of memory in order to envision versions of what might happen provides insight into why patients suffering from episodic memory impairment are also unable to imagine specific future scenarios. For example, K.C., a quiet man who lost his episodic memory as a consequence of a traumatic brain injury in 1981, was not able to recollect any single personal event from his life. His intellectual functions were largely preserved. However, K.C.'s amnesia was total and complete and his autonoetic consciousness was grossly impaired. He could not imagine what he was going to do at any time in the rest of his life (Tulving, 2002, Tulving et al., 1988), and seemed to live in a 'permanent present' (Tulving et al., 1988, p.14).

In contrast to K.C., G.A. remembered 'another' past and planned 'another' future. G.A. was a 52-year-old housewife, married and with two children. She developed a relatively pure amnesic-confabulatory syndrome. Therefore, she was unaware of her memory deficit and confabulated not solely about her past, but also about her future. Her verbal statements  were unintentionally incongruous to her history, her background and present situation. She was living one and half hours from the hospital and since her disease she never cooked; nonetheless, when asked 'What are you going to do in a few minutes?', she did not hesitate to answer 'I will go home to cook the supper' (Dalla Barba et al., 1997).

A few years later, Stanley Klein and his colleagues (2002) documented similar difficulties concerning a 78-year old man with a profound episodic impairment, D.B. When asked 'Who are you going to see this evening?', D.B. answered that he was going to visit his mother, despite the fact that his mother had died almost 20 years earlier. He could not imagine what his experiences might be like in the future. However, in response to the question 'Can you tell me what you think will be the most important medical breakthroughs likely to take place in the next ten years?' he replied that secrets of the mind might be likely to be unlocked through brain research. In parallel with his difficulties imagining his personal future, D.B. showed a severe impairment in remembering personal past. By contrast, his ability to anticipate and remember issues in the public domain (i.e. non-personal) was completely preserved.

The cases of these three patients might suggest that episodic memory impairments interfere with episodic future thinking and corroborate the statement that being aware of the time in which our lives are played makes an enormous difference to what we are and how we live (Tulving, 2002).

The method of pre-viewing and pre-feeling future events is, indeed, very ingenious. However, being imperfect is another feature that episodic future thinking and episodic memory share. As Woody Allen said, in the movie Manhattan (1979), 'you rely too much on your brain. The brain is the most overrated organ, I think'. In its attempt to 'trick the rest of the brain by impersonating a sensory system' the cortex fails to produce simulations involving all the richness and the reliability of perceptions (Gilbert & Wilson, 2007, p.354). Simulations rely on a few memories and they do not take into account many features. For instance, when imagining pleasurable and painful events, people tend to underestimate how efficient our capacity to adapt to a wide range of situations might be. Therefore, when people are asked to think of a painful event, like losing mobility, and to predict how they would feel in that condition, they tend to imagine the initial, and as such the worst, moment of the event. They consequently represent themselves as much less happy than people who actually experienced this event are (Gilbert & Wilson, 2007).

There has been little psychological inquiry into the ability to mentally travel into the future. However, more than 100 years have been spent in trying to carefully understand human memory. On the basis of this knowledge, we can envisage in the next years an increase in the number of studies conducted to understand how our mind enables us to simulate our future. We can imagine, along with D.B., that brain research will be unlocking as many 'mind secrets' as possible. Our awareness that this might be a wrong prediction is still a scientific conquest.

Stefania de Vito
is a PhD student at the
University of Edinburgh and at the Suor Orsola Benincasa University of Naples
[email protected]

References

Atance, C.M. & O'Neill, D.K. (2001). Episodic future thinking. Trends in Cognitive Science, 5, 533–539.
Bar, M. (2007). The proactive brain: Using analogies and associations to generate predictions. Trends in Cognitive Sciences, 11, 280–289.
Buckner, R.L., Andrews-Hanna, J.R. & Schacter, D.L. (2008). The brain's default network. Anatomy, function, and relevance to disease. Annals of the New York Academy of Sciences, 1124, 1–38.
Buckner, R.L. & Carroll, D.C. (2006). Self-projection and the brain. Trends in Cognitive Sciences, 11, 2, 49–57.
Dalla Barba, G., Cappelletti, J.Y., Signorini, M. & Denes, G. (1997). Confabulation: Remembering 'another' past, planning 'another' future. Neurocase, 3, 425–436.
Dudai, Y. & Carruthers, M. (2005). The Janus face of Mnemosyne. Nature, 434, 567.
Gilbert, D.T. & Wilson, T. (2007). Prospection: Experiencing the future. Science, 317, 1351–1354.
Hassabis, D. & Maguire, E.A. (2007). Deconstructing episodic memory with construction. Trends in Cognitive Sciences, 11(7), 299–306.
Ingvar, D.H. (1979). Hyperfrontal distribution of the cerebral grey matter flow in resting wakefulness: On the functional anatomy of the conscious state. Acta Neurological Scandinavica, 60, 12–25.
Klein, S.B., Loftus, J. & Kihlstrom, J.F. (2002). Memory and temporal experience: The effects of episodic memory loss on an amnesic patient's ability to remember the past and imagine the future. Social Cognition, 20, 353–379.
Morewedge, C.K., Gilbert, D.T. & Wilson, T.D. (2005). The least likely of times: How remembering the past biases forecasts of the future. Psychological Science, 16, 626–630.
Rubin, D.C., Schrauf, R.W., & Greenberg, D.L. (2003). Belief and recollection of autobiographical memories. Memory and Cognition, 31, 887–901.
Schacter, D.L. & Addis, D.R. (2007a). The ghost of past and future. Nature, 445(4), 27.
Schacter, D.L. & Addis, D.R. (2007b). The cognitive neuroscience of constructive memory: Remembering the past and imagining the future. Philosophical Transactions of The Royal Society, 362, 773–786.
Simons, J.S. & Spiers, H.J. (2003). Prefrontal and medila temporal lobe interactions in long-term memory. Nature Reviews Neuroscience, 4, 637–648.
Szpunar, K.K. & McDermott, K.B. (2008). Episodic future thought and its relation to remembering: Evidence from ratings of subjective experience. Consciousness and Cognition, 17(1), 330–334.
Tulving, E. (1985). Memory and consciousness. Canadian Psychology, 26, 1–12.
Tulving, E. (2002). Episodic memory: From mind to brain. Annual Review of Psychology, 53, 1–25.
Tulving, E., Schacter, D.L., Mclachlan, D.R. & Moscovitch, M. (1988). Priming of semantic autobiographical knowledge: A case study of retrograde amnesia. Brain and Cognition, 8, 3–20.

 

Judges' report, and developing new voices

This was the 12th annual Student Writer Competition of The Psychologist. Articles were rated blind on quality of writing; clarity of argument; and accessibility, relevance and interest for The Psychologist's audience. The competition was tight this year, with novel approaches and fascinating topics. The two winners get an expenses-paid trip to the Society's London Lectures or Annual Conference.

Budding writers might also be interested to hear that in the September issue we're launching a new format which will be of interest to students. 'New voices' will be our attempt to unearth psychology talent. Write about anything: your degree, your postgraduate research, life, the universe and everything.

The only criteria will be that the articles should
I    engage and inform our large and diverse audience,
I    be sole authored, by someone who has not had a full article published in The Psychologist before,
I    be written exclusively for The Psychologist, and
I    be fewer than 1800 words.

The emphasis is very much on writing talent: Can you grab the reader's attention and hold it throughout? Can you step up to the mark and announce yourself on a large stage? In 20 years' time, when an eminent psychologist is changing the way we think about ourselves and our discipline, we want to be able to say that they 'cut their teeth' in The Psychologist.

The successful authors will reach an audience of 48,000 psychologists in print, and many more online. And as if that wasn't enough, we are also lining up some great Society prizes for the best contributions to 'New voices'.
So get writing! Submit your work to [email protected].

Dr Jon Sutton
Managing Editor, The Psychologist

Dr Paul Redford
Outgoing Chair,
Psychologist Policy Committee