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“I dont want to go to Rehab: Amy Winehouse and the Rehab Debate
Article Type: News From: Advances in Dual Diagnosis, Volume 4, Issue 3
Opinion by Liz Hughes
I was very saddened to hear of the death of Amy Winehouse. At the time of writing, the cause of death is still not known, but as the press are saying repeatedly “she has a long battle with drugs and alcohol”. So the implication was that it was substance related. However, this may not be the case and we will have to wait for toxicology reports to reveal the answer. However, whatever the cause, it is always a tragedy when someone so young loses their life and for those not in the limelight a more personal and private tragedy for their friends and family.
I have been following the reaction to her death in the media and the debate that has arisen about how we should be treating people with addictions. There has been a call (led by Amy’s father; Mitch Winehouse – BBC News, 2011) for increased funding and access for residential rehabilitation in particular for young people.
However, in the media, there seems (to me) to be a lack of clarity about what people mean by “rehab”. In some cases, I have been unclear whether people mean inpatient detoxification or rehabilitation. The two are related but different. Detoxification refers to the (mainly) clinical management of physical withdrawals in a planned cessation of the drug of dependency. This usually takes seven to 14 days. This often occurs in the community services now, as only the most complex and severely dependent people need to be in a inpatient setting for detox. My understanding of residential rehabilitation is that it is a longer term (at least a few weeks to a year in some cases) abstinence-based residential programme where people go AFTER detoxification from their substances (i.e. get clean). The aim is to build up their drug/alcohol free lives and working through any issues that they may have, in other words: recovery. To be able to complete a residential programme such as this, people need to be psychologically as well as physically ready. Miller and Rollnick (2002) propose that change requires being ready (resolved any underlying ambivalence), willing (have identified own reasons for change) and able (have capability, skills, support, and practical solutions in place).
There are many excellent residential drug and alcohol rehabs in the UK, and for some people (at the right time in their lives) they can really turn their lives around. I have worked with ex-user colleagues who are the success stories of such programmes. However, I would argue that there are many people for whom residential rehab is not an option – this group of people have complex mental health problems and in some cases, severe personality disorders, that need addressing simultaneously to their dependency on substances. In other words, they may feel “ready and willing” but are they “able”? Being motivated is not enough; people need to have a lot of cognitive and behavioural skills to overcome cravings, coping with stress and peer pressure to use in order to remain abstinent. People with complex mental health problems may need more input on developing these skills and also in coping with their mental health problems (Bellack and Diclememte, 1999). Many rehabs cannot support that level of psychiatric need, as they do not have specially trained staff, and another barrier is the requirement of complete abstinence from all substances including prescribed medications. In addition, the regimes (highly structured, therapeutic groups, lots of expressed emotion) are not suitable for someone in a fragile mental state who may be at risk of self-harming, or even becoming suicidal at times. Many people who fit this category have significant trauma in their past, which they battle to come to terms with. Being in a drug-free state without appropriate psychological support and treatment, can exacerbate distress, and lead to self-destructive outcomes such as relapse to substance use (and risk accidental overdose) or some form of self-harm. Some facilities do offer a suitable environment for people with complex needs, but because of this, they tend to be expensive and often require joint funding from both drug and alcohol and mental health commissioners. This is not always easy to negotiate, and can be time-consuming. I attempted to obtain funding for a specialist rehab for a client who had severe mental health and poly-substance use problems, but it took around eight weeks to agree the funding, and by that time, the client had relapsed and lost motivation. This person is now dead; he died before the age of 40 from a drug use related health complication. I still wonder what would have happened and what possibilities could have opened up, had my client managed to get to rehab in a timely way. This occurred ten years ago, but I wonder have we moved much further with this issue.
I don’t know Amy’s circumstances other than what was reported in the press, but it seemed that her substance misuse problems were entrenched, extreme, and interwoven with some form of mental health issues as well; in other words “dual diagnosis”. A more useful debate in the media would be about how we can help those with very complex needs, that do not fit neatly into the current schism of substance misuse services and mental health services. In addition, we need to do more research into prevention of complex problems by looking at risk factors in young people, and also in developing effective and accessible treatments (residential or community) for all people with substance use problems and other complex needs.
BBC News (2011), “Mitch Winehouse urges more drugs help”, 1 August, available at: www.bbc.co.uk/news/entertainment-arts-14364002
Bellack, A. and Diclememte, C.C. (1999), “Treating substance abuse among patients with schizophrenia”, Psychiatric Services, Vol. 50, pp. 75–80
Miller, W.R. and Rollnick, S. (2002), Motivational Interviewing: Preparing People to Change, 2nd ed., Guildford Press, New York, NY