Tony Machin (4th from left) is a Principal Lecturer at Northumbria University, Faculty of Health and Life Sciences. He is a mental health nurse by background, and spent several years working with people with addiction problems, before moving into an educational role at Northumbria University. He continues to foster a strong interest in issues relating to addiction, its conceptualisation, and its management from policy level to street level.
Tony visited Live Theatre on Friday 13 September and observed the rehearsals for Wet House and shared his knowledge and experience with the cast as part of the research into their roles. The following notes are informed by this rehearsal observation and Tony will be part of the panel for the free Addiction and Homelessness Discussion on Sunday 29 September, 6.45pm.
This blog post contains spoilers so, if you haven’t seen Wet House yet, you might not want to read this until after you have been!
I thought it would be useful to set the context with the two frameworks for thinking about addiction which I referred to during the post-rehearsal discussion. I then summarise an application of these ideas in three key themes; issues relating to the three client/resident characters, the context (Crabtree house itself), and finally issues relating to the three staff characters.
A useful framework for thinking about ‘addiction’ and change
Physiological dependence upon substances e.g. Heroin (in Kerry’s case) or Alcohol (in ‘Dinger’ and Spencer’s cases) is actually quite easily handled (from a medical point of view, in the right context) by controlled and supervised detoxification with medication (Methadone in the case of Heroin, and Librium/Valium in the case of Alcohol). The real issue at the heart of addiction is how people make decisions to change their behaviour in the longer term (stop using drugs/alcohol destructively), and maintain their resolve.
In the 1980’s, William Miller, an American Psychologist, proposed a framework called ‘Motivational Interviewing’ as a helping approach for people with addiction problems. It has since been applied to a lot of health-related behaviours.
He noticed that people with addiction are often in a ‘no-win’ situation in that:
- If they achieve change, then the therapist or agency takes credit (‘we did well with him’).
- If they don’t change, then it is because they are not motivated enough.
The motivational approach emphasises client responsibility (for change or not), which goes to the heart of building ‘self efficacy’ (see below).
He drew upon a ‘cycle of change’ (Proposed by Prochaska & DiClemente around the same time) expressed in the diagram below:
When people approach working with people with addiction, they often assume that the person is (or at least should be) ready to change. The idea of the above cycle is to match the approach to the appropriate stage, as in the table below.
People can move around these change stages quite rapidly, like watching an anti-smoking advert, briefly moving to contemplation, then back to pre-contemplation once the ad finishes.
The other central idea within a motivational approach is the idea that people with addiction problems will have psychological conflict regarding their drug or aclcohol use (framed in psychology as ‘cognitive dissonance’). People cannot live with this discomfort, and must resolve it somehow. One way of resolving the conflict is to stop the problem behaviour. Unfortunately, there are also other ways of resolving the conflict. Imagine being in an uncomfortably hot room which you must get out of, and with four doors through which to exit, as in the diagram below.
Denial: Where the person minimises or dismisses their substance use, persuading themselves, for example, that they ‘aren’t that bad’, their behaviour is no worse (perhaps even better) than others (NB: Perhaps the character Mike might employ this by comparison to the residents?), or that problems were only one-off’s. Denial includes procrastination (putting off behaviour change to a future point, tomorrow, next week, next month … ), thereby reducing the conflict (getting out of the room) in the here and now.
Low Self Esteem: If you look at the picture of a stereotypical ‘gutter’ homeless addict, what you see is probably what they see/feel. Having poor self image and low esteem for self results in feeling they are ‘not worth changing’, they deserve to be in the circumstances they are in (perhaps the character Spencer echo’s here?). Of course with much addiction related behaviour (violence, criminality, relationship breakdown etc) this becomes a self-perpetuating cycle.
Low Self-Efficacy: Associated with low self-esteem, this is a person’s perception of their ability to change their behaviour. Feeling that change is beyond their ability. Previous failed attempts to chage fuel this in another negative cycle, together with negative expectations of others.
Behaviour Change: It logically follows that the goal of working with people with addiction is to use any strategy which challenges denial (not always in a direct-challenging way, but often using subtle feedback and information), and which enhances self esteem and self efficacy (e.g. pointing out achievements, creating opportunities for people to achieve things).
Thinking about these ideas in relation to the three resident characters in the Play
- In terms of stage of change, she probably tries to ‘maintain’ at a level of Methodone, but relapses into alcohol/drug use in a chaotic fashion.
- In terms of her background: In care (?limited affection, ?abuse- ‘don’t do cuddles’), prostitution, drug use: Her self esteem and efficacy are likely to be fragile to say the least, and her ongoing interaction with services is unlikely to change that?
- In terms of being judged, as a pregnant mother – alcohol/drugs (imagine care staff attitudes in e.g. maternity services etc).
- She will have a treatment regime to stick and agree to, with many ‘hoops’ to jump through and lines drawn on any failure. It has been said that many women in Kerry’s position are almost set up to fail.
- So seeking regular ‘oblivion’ is kind of understandable (self-medicating to oblivion)
- Also understandable is a feeling of outrage at being so cornered?
- If people with addiction problems are an unpopular client group, then people with a history of sexual offending against children who also have drinking issues are doubly flattened in this sense.
- The likelihood is with such an individual, they have been sexually abused themselves within their own childhood.
- For someone in such a situation (coming out of prison on license, where he will have had a bad time as a ‘nonce’) the ‘self esteem’ factor is going to be at rock bottom, if not dead?
- To get the treatment he gets in the wet house only serves to reinforce this factor.
- Seeking regular ‘oblivion’ via alcohol is absolutely understandable (self-medicating to oblivion). He certainly isn’t going to be concerned with his physical health?
- Or an even more permanent oblivion, perhaps implied by his room being empty at the end of the play?
- Hail fellow, well met.
- You can imagine how well met he is over the years outwardly, whilst inwardly his family set-up imploded.
- I could see him as a heavy drinker within a heavy drinking culture (North-East), normalising his alcohol use and the problems associated with it (wife unhappy – ‘everyone’s wife nags’ – denial in the form of normalisation).
- Perhaps not the abusive/neglected background that the others have, but heavy drinking modelled regularly via significant figures (father, family, sub-culture).
- Critical point – wife has finally has enough, he is ejected, tries to assert himself back in, backfires (Patio door incident).
- Negative downward spiral ensues, drinking more to cope with banishment from family, the more he drinks the more he is ostracised.
- From a self esteem and efficacy perspective, the negative spiral of wife/children seeing you or knowing of you for what you are, and being ‘written off’, spiraling down, would see a fairly hopeless situation.
- But at the end of the play, we have him not just in ‘contemplation’ or ‘determination’ (see first section above), but he has moved himself into ‘action’ (all be it unwisely – ‘cold turkey’). Motivating factor being contact with his daughter.
- It may be possible for this man, if he maintains his change, and despite his liver/nervous system damage to achieve a level of recovery, should all the positive factors continue. Relapse (as ever) would always be a danger (which is where the relapse planning mentioned above comes into play).
Thinking about the Context (‘Crabtree House’) Itself
The Sociologist Irving Goffman, in the 60’s of the last century, first highlighted the negative aspects of ‘Total Institutions’, the factors being:
- De-humanisation of people. De-personalisation (‘room q?).
- ‘Block treatment’ of everyone: e.g if you are due a bath, then you will get a bath. No trying to sort it later when the person might be more amenable, it happens because it is listed.
- ‘Pecking’ order of both staff and inmates.
- Generally the institution comes first, individual second (staff & in-mates)
- Staff have to comply or they leave.
- ‘Closed’ culture; ‘us’ = institution members, ‘them’ = anyone else, which might include senior managers in organisations (even if they like golf).
- You ‘become’ a member of an institution, staff or inmate.
- Negative practices such as sexual harrassment can be normalised as institution members (thinking of the particular scene between ‘Mike’ and ‘Helen’).
- Control imperative from staff who run the show, but are also as locked into the institution as the inmates.
The large institutions (the ‘big bins’ or ‘asylums’) closed down in the era of community care. But ‘Institutional’ effects can be (and are) still apparent in smaller scale units, like Crabtree.
- Significantly, the Army can be seen as an ‘institution’ initself (relating to the character Mike)? We know increasing numbers of ex-service personnel are having difficulty adjusting to civilian life? Post Traumatic Stress Disorder being common (Mike’s graphic stories are perhaps wrapped up in this territory?)
There is a concept of a ‘therapeutic millieu’ whereby just being in a context is therapeutic (‘therapeutic community’). Crabtree seems to be the antithesis of this, though Dinger’s intervention with the distressed Kerry, and his attempts to cheer Spencer up demontrates how residents can support and encourage each other.
People working in high emotional intensity roles with distressed and challenging people can be prone to ‘Burnout’ (sometimes called ‘professional disengagement’ or ‘vacarious trauma’). Stereotypically, idealistic beginners end up cynical, pessemistic and dismissive about people they work with. They may avoid or minimise contact with the client group, e.g. Mike explicitly acknowledges this is what he does, though Mike would seem never to have been idealistic in the first place. There is a danger that new and enthusiastic staff (as in the play) have an accellerated path to disengaging or burning out, via contamination from the burned-out attitudes of other more senior staff. If staff in this position do not reverse the trend via support and supervision (see below), then they may often leave (as in this case), or if they stay, they do so to the detriment of the organisation.
In mental health/care type settings, supervision is essential in supporting people. Three aspects are commonly cited:
- Normative: More about ‘line’ management, giving directives
- Formative: About learning skills and knowledge
- Restorative: About handling the emotional side, de-briefing, unloading all the feelings relating to casework.
There can be a ‘macho’ culture around the emotional support element of this (not neccesarily just men). For some, to be seen to seek or accept such support is a sign of weakness. The character Mike would probably see the emotional aspect as a waste of time and an attempted intrusion. It strikes me that Andy and Helen would readily engage with this kind of support given the chance (or provide it informally for each other – which is kind of implied in one scene).
Core values Required of Care Workers
‘Counselling’ and general therapeutic theory advocates (e.g Carl Rogers) ‘core conditions’ for therapeutic relationships in terms of a carer being:
- Genuine (yourself)
- Empathic (ability to appreciate the perspective of ‘the other’ from their frame of reference).
- Having ‘unconditional positive regard’ for the client.
- ‘Reject behaviour’ not the person.
It would be a tall order to be able to achieve this in every case, thinking of, for example, Spencer’s character’s history. But professional care workers would at least ‘aspire’ as best they can to this, and utilise ‘supervision’ (see above) to discuss their issues around this. These are the core conditions, for instance, that should create the climate for a key-worker’s contact session. Within the play, Mike’s session with Spencer is a stark contrast to that of Helen?
Thinking about these ideas in relation to the three care staff characters in the Play
- Ex army (corporal or Seargent – ?). Post Traumatic Stress Disorder (PTSD), not that he would ever admit it or seek help?
- Established a confident control/dominance over 4 years in role.
- Could end up a ‘Dinger’ in 15-20 years time??
- Displaced aggression from home taken out on residents at work?
- Not so much ‘burned out’ as cynical from the outset?
- Thinking about carer’s role as helping to enhance self esteem and self efficacy (see earlier), perversley, Mike actively seeks to undermine esteem and efficacy to varying degrees with the different residents (and staff).
- Basically caring persona?
- Would probably be amenable to training and putting principles into practice (does allure to having some training)?
- Doing some good intuitive work with people, re the frameworks above
- Still a member of the institution at the end of the day, and under pressure to conform.
- Personal probs/issues can only spill into work-life. Institutional loyalty still (reluctantly) holds the biggest sway, but conflict is evident.
- Good portrayal of someone coming in new to a situation, and being ‘drawn in’, reluctantly, to the institution.
- Falling under the influence of a more experienced worker, but with innapropriate attitudes, combined with the genuinely challenging aspects of the care role in a wet house.
- Ultimately leaving reduces his own conflict?
I have tried to reflect upon the Play from the three interacting themes of:
- The residents
- The context
- The care staff
It has been interesting to apply these theoretical perspectives to the production in this advanced stage of rehearsal. The ‘fit’ evident in the notes above, which are based upon these theoretical considerations together with my own experience of working in the field of addiction, for me attest to the authenticity of the production, from conception through to performance.
Northumbria University, September 2013