The Coronavirus crisis has had a devastating effect on all aspects of our society but for those whose problems are psychological and invisible, this might prove to be a tipping point.
Right now we are concerned that many people who already had some level of a drinking problem will find their use increasing in these horrible circumstances and with this, increase their risks of fitting in withdrawal. This is why we are now making an online withdrawal evaluation tool available to anyone in a simple and accessible format. It is also why we are doing everything we can to keep our clinics open to continue to be able to help people.

Alcohol withdrawals are medically the most dangerous detoxes that hospitals and clinics manage. Suddenly stopping drinking can cause people to have seizures with life-threatening consequences. People can start to go into withdrawals within a matter of hours after stopping drinking and hit their peak risk for having a fit is within a couple of days. This is why it is advisable to gradually reduce drinking rather than suddenly stop it. If you see someone going into withdrawal then the quickest way to ease the danger and the pain is for them to drink again and then consider reducing more slowly ( although obviously we still advice you seek medical advice and support ).

Treatment staff are medically trained to monitor alcohol withdrawal symptoms every few hours. This way they can judge when someone is going into withdrawals and lessen the risk of fitting by administering medication. The most commonly used scale for measuring withdrawals and the risk of fitting is the Clinical Institute Withdrawal Assessment for Alcohol ( CIWA ) which evaluates many of the common indicators of withdrawal. There are 10 questions and the maximum score is 76. In general, if someone has a score close to 10, a clinic will use medications to reduce the withdrawals. Scores between 10 and 16 are considered moderate and are a cause for concern and a score greater than 16 is considered severe.

People who drink regularly are advised to gradually reduce their alcohol intake over a few weeks rather than stop suddenly but it’s obvious that people in a crisis with their drinking may just suddenly stop. As a friend family or a loved one, it will be very worrying to watch someone risking going into withdrawal and so we feel it is important to share a quick clinical withdrawal evaluation tool on our website in an easy to use format.

The test works well on a smartphone web browser so it’s easy to use. At the end of the test you will see the score, all the answers you gave and to make it easy for you to re-reference the scores, we will let you have a link at the end of the test to be able to recall the score at a later date but please bear in mind that we will be clearing out data older than approximately 30 days in line with our GDPR commitment not to keep unnecessary data so please save your recordings if you want to store your results beyond a short time.

You are invited to enter a name or a reference at the beginning of the test but this isn’t necessary and we don’t record any data such as IP addresses so your scores shall remain anonymous.

Just to remind you again, if someone you know stops drinking suddenly and starts to exhibit these withdrawal symptoms, it is safer for them to return to drinking until the symptoms stop and then try and reduce their consumption more slowly than it is for them to go on into more severe withdrawal. It is also important to seek direct medical advice before detoxing.

To make it easy to access the form from a mobile phone we have created a short link for you:

ciwa.ro.fm

 

From the outset of the current outbreak, PROMIS Clinics have been quick to respond to this emergency as it evolves. Both of our clinics offer a great deal of space (3 buildings in London and 12 acres with many separate areas in Kent) and we take only 9 clients in London and 14 in Kent. This means that clients all enjoy individual rooms with plenty of opportunities for privacy and the ability to decide the level of interaction they are comfortable with. In addition to this, we provide 24-hour nursing and our doctors are on call day and night to manage and oversee any medical needs you may have

We have also introduced a number of additional measures to ensure that our clients are safe and well cared for and to ensure that your experience at PROMIS will provide you with the positive start to recovery that we are renowned for:
– All clients are carefully screened for COVID-19 prior to admission.
– Both staff and clients are monitored continuously for any symptoms.
– We are minimising physical contact with the outside world whilst providing additional activities on site.
– We have restricted access to our sites to essential staff and clients only.
– We have also made additional preparations by securing other isolated properties as a precautionary backstop to safeguard against the possibility of interruption to the service we provide.

Our staff are experienced, responsible, dedicated healthcare professionals who take every care to ensure their own good health, thereby reducing the risk to our clients.

We are aware that this is an international problem that will be with us for some time to come and so we are ready to carry on providing first-class care and support through these challenging times.

In 2004 Scott Miller studied the effect of therapists working in an American College and found quite a large variation between the effectiveness of different therapists. Some did considerably better than average for their clients but some did considerably worse. You can see it from this chart of their outcome:

The verticle lines represent the range of scores that clients achieved with each therapist and the blocks mark the mean scores. At the bottom, you can see the number of clients each therapist had worked with. 

You can see there is quite a sizable difference in outcomes.

Okiishi et al (2006) found even more of an effect. In their study, the clients of the top 10% of practitioners were *twice* as likely to recover and 50% less likely to deteriorate than clients seen by the least effective therapists!  

In case you thought this was simply a matter of how much experience each therapist has, this study in 2015 showed that the top 1/4 of therapists were always significantly better than the remaining 3/4. In fact, as time went on, this difference got even greater.

So, what does all this mean for clinicians and clinics? It means we should be routinely monitoring our personal work and our individual outcomes as clinicians. How can we know we need to improve something if we don’t know it could be better? From feedback, we can improve our own individual practice. As clinics, we can use this monitoring to ensure that only the highest performing therapists are working with our clients. 

We use many measures of progress at PROMIS. Amongst them are the CORE-OM (Evans et al, 2000) and another is the ORS / SRS (FIT) system developed by Scott-Miller. 

There are also many other possible outcome measures you can use, the BACP has a review of outcome measuring here:

https://www.bacp.co.uk/media/2355/bacp-cyp-prn-toolkit-for-collecting-routine-outcome-measures.pdf

The Royal Society of Psychiatrists has also given advice for Psychotherapists here:

https://www.rcpsych.ac.uk/docs/default-source/members/faculties/medical-psychotherapy/medical-psyschotherapy-fr-mp-01-outcome-measures-for-psychodynamic-psychotherapy-services.pdf?sfvrsn=1dc5057b_2

Whichever method is used to measure the outcome, we owe it to our clients to be measuring so we can offer the best service possible.

Traumas are far more common than many people imagine. Estimates range that from 60 to 90% of the population will experience some form of terrible trauma in their lives. Thankfully, humans have an amazing natural capacity to heal and to heal remarkably quickly.

Unfortunately, a small proportion of people who have had a trauma will remain traumatised, experiencing many awful symptoms, including flashbacks, nightmares, anxiety and depression for months, years and even decades after the event.

In a study to compare the effectiveness of trauma treatments including Cognitive-Processing Therapy and Prolonged Exposure Therapy, it was found that treatments were very effective very quickly. It was also found that they were just as effective if the person had had the symptoms for as short as 3 months or even as long as 30 years. The treatment ‘stuck’ too. The analysis showed that the recovery was still working when the clients were retested 3 months and 9 months later. In the treatment graph below, you can see just how quickly and how dramatically people were helped. A second two groups of clients had to wait the 6 weeks until the first group completed treatment, but they were monitored and immediately responded well to treatment also.

Given that 3.7% of men and 5.1% of women screened positive for PTSD in the UK in 2014 ( Adult Psychiatric Morbidity Survey ) it is striking to think just how many people could be helped so effectively and so quickly. The treatment above only took 13 hours of therapy sessions over 6 weeks to have this lasting effect.

If you feel this sort of treatment experience might be helpful to you, please call our admissions team on 0207 581 8222.

Reference: A Comparison of Cognitive-Processing Therapy With Prolonged Exposure and a Waiting Condition for the Treatment of Chronic Posttraumatic Stress Disorder

Hi

I attended Promis Recovery in 2005 for just over 2 weeks when you were based in other larger premises nr. Canterbury. I had hit bottom as an alcoholic with my life spiralling out of control. I could only afford 2 weeks of treatment using my savings but these 2 weeks provided the safety and support that I needed to take my first steps on the road of recovery.

I am writing this 14 years later ….14 wonderfully happy years of sobriety…..I never realized just how good life could be without alcohol and my wife and I have now had more time together with me sober than when I was drinking.

Promis gave me the springboard to recovery and I will be eternally grateful for the second chance of life it gave me…….without this I would have lost everything.

Please feel free to use the above including my name in any way that it helps others to take the first step to recovery.

Yours sincerely

Richard  

The Lifecycle of Addiction and Recovery

Addiction problems seem to be something that comes to everyone’s attention because of the crises that it causes. Possibly the first few crisis situations pass by and are excused to circumstances but soon enough of a series of crisis shows there is a deeper problem. At the time that people first become aware that addiction could be an underlying cause of these crises, it is really important to understand as quickly as possible how recovery works. Failing to understand this in a comprehensive way early will allow the problem to persist for much longer than it needs to with devastating and debilitating consequences. Unfortunately, getting friends and family to agree on what needs to be done can be quite a challenge, which we will reference in another article. Let’s focus here on what the ‘lifecycle’ of addiction looks like and what we can learn from that in terms of the correct interventions we should make.

At the point when someone first develops a problem with addiction, there is a phase where they encounter problems from the addiction and make a series of attempts to stop on their own. On average this period lasts about 5 years. These first few crises could be things like being caught drunk driving, being caught in possession of drugs, being repeatedly late for work etc. Any one of these on their own could just be bad luck, but a succession shows there is a deeper problem. After an average of 5 years of these ‘self-initiated cessation attempts’, the person asks for outside assistance

At the point where someone first accepts the need for outside help, they may have a number of treatment episodes, residential treatment, day-care and self-help support. From here it takes on average about 8 years before someone can successfully achieve one continual year of sustained abstinence. That may sound a bit dispiriting but it must be emphasised that the overwhelming majority of this period of time is spent abstinent, it’s just that getting to the point where that lasts consistently for more than one year takes time. 

Finally, once one year of abstinence has been achieved, it takes a further 5 years until the risk of relapse drops below 15%. The reason this figure is so significant is that 15% is that this is the same risk percentage that the general population have of ever developing an addiction problem in the first place, so if our group have gotten down to a risk of 15%, then at this point in their recovery they are at no more risk than the general population.

So what can we learn from understanding this Lifecycle of Recovery?

1. In the first phase, there is a good opportunity for outside agencies such as doctors surgeries, lawyers offices, A&E departments and even friends and families to help bring the problem into someone’s consciousness earlier. The earlier that they can be helped to see it is a problem, the sooner they can get to the next stage and ask for help.
2. During the second ‘treatment’ phase ( the 8 years of early recovery ) it is important not to become to dispirited or to be dragged up and down by the relapses. Don’t distract the process by looking for miracle treatments. This is a process, it will take time and lessons can be learned as they progress but rather than feeling that it isn’t working or something completely new has to be tried, it is more helpful to congratulate them for the progress made so far and to move back to recovery as quickly as possible. The sufferer may feel shame and the family may feel angry and frightened. These are times for cool heads and kind hearts.
3. Even once a year of recovery has been achieved, the first five years are still a risky period. It is important to maintain recovery during this time and for everyone to be aware of the risks. After 5 years continued abstinence, it is also important to acknowledge that the sufferer can be trusted to be in remission from their problem and trusted to behave as responsibly as any other member of society. Constantly monitoring or treating with suspicion will have a negative consequence. We must all embrace this new life.

References: This chart and data is taken from a talk given by Professor John F Kelly of Harvard Medical School

 https://scholar.harvard.edu/johnfkelly/home

It’s good to hear that the Middlesborough health service, alongside the police, is trying a new way to help people with severe heroin addiction. In a groundbreaking move, 15 people with heroin addictions are going to be provided with free Diamorphine ( medical heroin ) twice a day. Once they are stabilised, they will also be given help to manage other mental health issues, and help to find work and housing. 

People working in rehabs are often horrified at the prospect of sufferers being given ‘free’ drugs, or even being provided safe places to use ( shooting galleries, as they are sometimes known ) in case this encourages or prolonging the course of addiction. 

Even though abstinence is the best outcome, we need to be able to interact with sufferers before they come to that realisation for themselves and, even more essentially, we need to keep them alive. 

Critics might think that this approach is putting the cart before the horse. Most clinics work on the good principle of getting people abstinent first before working on all the other areas needing attention but for people at the extremes of society, extreme poverty and even extreme wealth, it can prove to be more effective to stabilise their use, build up their other resources ( sometimes referred to as ‘recovery capital’), and then move on to work on the detox further down the line. It’s also crucial to keep them alive! About 10% of the population took a recreational drug last year, 5% took cocaine for example. Only 0.5% took opiates but 75% of drug misuse deaths were due to opiates ( 2,208 deaths last year ). This is why we should look at this specific drug with a slightly different perspective. 

If we look at the experience of America during its recent opioid addiction epidemic, it has been painful to witness resistance to harm minimisation approaches which could have saved many lives. In comparison, Portugal has led the world with its practice, taking opiate addiction problems away from the criminal justice system and putting it clearly in the health arena, where they belong. 

The overarching lesson has to be that we should be careful to avoid dogma when it comes to helping people with mental health problems. We naturally have to have good guiding principles to the way we work but there are also many nuanced cases where we must be more flexible. The most important measure we should always be using to judge how we operate is whether an approach moves a specific individual towards better health and wellness, or away from it.

This will be an interesting project to follow.

References:

https://www.bbc.co.uk/news/uk-england-tees-49988727

How many people use drugs?

http://www.emcdda.europa.eu/countries/drug-reports/2019/united-kingdom_en

I have been interested to see the difference in approach to vaping between America and the UK right now.

Last week the British medical research journal ‘The Lancet’ published a review of the evidence around vaping and declared vaping to be “the most disruptive influence on smoking in decades”. They found the harms to be 1/20th of smoking, that the success of giving up cigarettes was approximately twice as effective vs other NRTs, and that it isn’t proving to be a gateway drug into smoking for youngsters. ( The Lancet )

I’m sure it can’t be great to be breathing in any smoke from any source but given that our treatment industry has spectacularly failed to come up with another effective solution, we need to work with and support what does work since cigarettes kill far more alcoholics than alcohol does:

“….. the death rate for alcoholics who seek treatment is 48.1% within 20 years compared with an 18.5% death rate for the general population. Of those deaths, more than half (50.9%) are attributed to smoking, and only 34.1% attributed to alcohol.” ( https://www.verywellmind.com )

Putting the current fears of vaping risks into context. The CDC estimate that in the USA cigarettes cause “1,300 deaths every day”. ( https://www.cdc.gov/tobacco/data_statistics ) whilst there are now 6 in total attributed to vaping ( https://eu.usatoday.com ) Surely we should really be panicking about 1300 deaths a day???

Vaping isn’t the end game for recovery from smoking but it seems the evidence around it isn’t being accurately reported and I feel we could do more to set the record straight and keep encouraging people to move away from tobacco.

If you are trying to give up tobacco then you are doing the one thing that will have the greatest positive impact on your health and we salute you for your efforts and we owe you better reporting about this.

People often wonder this, or it’s opposite, how much is ‘abnormal’ to drink. Sometimes this is quite hard to explain, especially the relationship between hard-drinking, alcoholic drinking and normal drinking.

In America, they broke drinking behaviour down by each 10 % of the population and the resulting graph is very revealing.

It is interesting to note how little most people drink but even more interesting to see how much is drunk by those who are alcoholic.

If we want to change any behaviour, it helps to know as much as possible about it, understanding the complex functions and roles it plays in our lives. The more we can understand about it, the easier it will be to pull away from it.

You could apply this analysis to any behaviour you want to change, gambling, drinking, taking drugs. It is known as a “Functional Analysis”. 

We can ask ourselves:

The Behaviour

What do you usually do?

How much do you usually do it?

Over how long a period of time do you usually do it?

Then we look at the ‘triggers’ for doing it:

External Triggers

Who are you usually with when you do this?

Where do you usually do this?

When do you usually do this?

Internal Triggers

What are you usually thinking about right before you do this?

What are you usually feeling physically right before you do this?

What are you usually feeling emotionally right before you do this?

Then the consequences, positive and negative:

Short-Term Positive Consequences

What do you like about doing this with (your buddies)?

What do you like about this where you most often do it?

What do you like about this when you most often do it?

What are the pleasant thoughts you have while you do it?

What are the pleasant physical feelings you have while doing it?

What are the pleasant emotions you have while doing it?

Long-Term Negative Consequences

What are the negative results of doing this in each of these areas?:

Interpersonal:

Physical: 

Emotional: 

Legal:

Job:

Financial:

Other:

Going carefully through these answers we can pretty quickly see situations we might want to avoid or replace, and where we might need extra support and other resources. 

Having a greater awareness of the complex roles that behaviours perform in our lives gives us a better chance to successfully move away from them.