Kilbarrack Coast Community Programme

The front cover is apainting by Conann FitzpatrickE. Mail - conann.fitzpatrick@gmail.com

The inside covers show a photograph supplied by St. BenedictsMulti-Media GroupTel - 01 8670167.

© Kilbarrack Coast Community Programme Ltd. 2007

Layout and Design by Ray JonesTel : 087 7778791E. Mail - rayj@kccp.net

Printed by Dual Printing Ltd.Tel : 01 - 830 8799E. Mail - sales@dualprint.ie

KCCP has funded this report. The views expressed in this report are the author’s ownand do not necessarily reflect the views and opinions of KCCP. However, KCCP. aredelighted to assist in its publication in the hope that it can start a debate that may leadto improved services.

Kilbarrack Coast Community Programme Ltd. (KCCP) is a drugs rehabilitation andaftercare project based in northeast Dublin. It was established in 1997 in response tothe increasing use of drugs in the Kilbarrack area and its emphasis is on a quality,user-led services for drug users in recovery. KCCP runs a three-year support andaftercare programme for recovering drug misusers; a Parents Support Group; and ayouth service for 10 to 18 year olds in the area

Kilbarrack Coast Community Programme (KCCP) Ltd.

Kilbarrack Coast Community Programme (KCCP) Ltd. Kilbarrack Community Hall, Greendale Rd, Kilbarrack, Dublin 5.Tel: 01 8324516Email: info@kccp.net

Forging a NewTemplate

Proposing a more effective way of working withdrug users.

Report written by Declan ByrneOn behalf of the Kilbarrack Coast Community Programme Ltd.

The Author

About The Author

Declan Byrne began working forKilbarrack Coast Community Programmein December 2000 as a CommunityEmployment Supervisor. In 2005 Declanwas awarded a Masters Degree inAddiction Studies from Dublin BusinessSchool. Declan believes that the servicescurrently being provided to problematicdrug users are totally inadequate. Declanis firmly in the “beyond maintenance”camp.

“Beyond Maintenance” was a book pub-lished, which detailed the proceedings ofa conference held in June 2000 organisedby the Catholic Bishops’ Conference inconjunction with the Irish Times to look atthe challenge facing those who wished toprovide a service to problematic drug mis-users. Dr. Jane Wilson from the ScottishDrugs Training Project was the keynotespeaker.

In her address she dealt with the complexissues and the challenges involved forservice providers. She sets out a frame-work for programmes hoping to meetindividual client needs. Her paper‘Substance Misuse in the NewMillennium’ had the power to questionexisting services and the courage to makepractical suggestions for future models.

In 2004 the National Advisory Committeeon Drugs commissioned MacGabhann etal from Dublin City University to bringout a groundbreaking report entitled“Mental Health and Addiction Servicesand the Management of Dual Diagnosis inIreland”. (Dual diagnosis is defined as“the co-existence of both mental healthand substance misuse problems for anindividual”). The report highlights ‘theinadequacy of services for dual diagnosis’the ‘exclusion’ from the services for peo-ple with dual diagnosis and the current‘gaps’ that exist. The report concludes‘Clinically effective service models andtreatment approaches need to be devel-oped that fit the context of people inIreland with dual diagnosis at (both)regional and local level.’

In April 2006 official statistics show thatthere are 8,039 problematic drug users in‘treatment’ throughout Ireland butDeclan’s experience over six years has ledhim to question the nature of this treat-ment.

Declan Byrne

About the Author

Foreword

Acknowledgements

Executive Summary

Chapter 1: INTRODUCTION

Chapter 2: METHODOLOGY

Chapter 3: THE PROGRAMME

Chapter 4: THE PARTICIPANTS

Chapter 5: THE UNDER-UTILISED TOOL OF TRANSFERENCE

Chapter 6: CONCLUSION

The Final Word

References

Table of Contents

Contents

2

44

88

99

1100

1111

1122

1155

1188

2244

2255

2266

ForewordDr. Rik Loose

Fore

word

Addiction is characterised by a sense of urgencyor immediacy and it concerns a need to feelgood, to be without pain or even to acquire anideal state of feeling. But are these needs notsomething that most people can identify with?Indeed, addiction is a very human phenomenon.However, what sets addicts apart from others isthat they do not just want to feel a certain way,they also demand these feelings and, moreover,they have found something in the effect of alco-hol and drugs that will give them these feelings(at least for a while). These chemical substanceswill provide addicts with the sought-after feelingbecause that is the effect they have on them. It isimportant not to forget the simple fact that drugsand alcohol do not affect everyone in the sameway: for instance, addicts do not get the sameeffect from drugs as non-addicts do.

Drugs and alcohol are chemical ways that (moreor less) immediately influence body and mindvia the toxic route of the organism. Taking drugsor alcohol addictively is an activity that is close-ly related to an avoidance of the social bond withothers. Active addiction is largely a matter ofsidestepping the realm of language and speech.Indeed why not call it a-diction? The sidestep-ping of this realm is the very reason why it isextremely important to get addicts to speak at allcost.

What happens in addiction treatment is the fol-lowing: addicts are asked to abstain from - or atleast put a limit to - that which provides themwith a good feeling. If they have to abstain orlimit themselves in terms of access to pleasure or

lack of pain (which comes down to the samething as experiencing pleasure) they will oftencome to depend on a substitute mechanism,namely, the dynamic between them and thecounsellors (or institution). In other words, thepathology is drawn into the relationship betweenaddict and counsellor. That means that in this sit-uation addicts demand something of the coun-sellors (or institution) that drugs or alcohol hadgiven them in the past. What they found in drugsor alcohol is an enjoyment that is situatedbeyond the mediation of speech or language. Intreatment this “more-of-enjoyment” has to begiven up.

What addicts repeat in the transference relation-ship is indeed something that is related to thelost immediacy or the lost satisfaction (enjoy-ment) that was part of taking drugs. Now theywant to regain some of this via the transferencerelationship. The crucial thing is that this rela-tionship (the relationship between counsellorand addict) does not lend itself very well forregaining this lost enjoyment or satisfaction.

Addicted clients will demand something of thecounsellor that cannot - and indeed should not -be given to them. The pathology of the clients isforced into a realm in which it is uncomfortable.The reason for this is that the social bond of thetransference relationship is the realm of lan-guage and speech and this realm is structurallylacking in terms of being able to provide the pos-sibilities of immediacy and full-satisfaction.Again, addicts will demand something that can-not be given to them within an institutional

4

Fore

word

framework. This will lead to frustration, aggres-sion, “us-and-them” situations, a toxic atmos-phere, and so on.

In addiction treatment relationships are alwaysambivalent. What we encounter here rangesfrom a demand for recognition, trying to please,being good, wanting to be loved, to, accusation,irritation, aggression, transgression, behavingbadly, “acting-out”, and so on. However, it isimportant to understand that all these emotionalexpressions are signs of the pathology of addictsthat manifest themselves in the relationshipbetween addicts and staff.

These emotions, thoughts and behaviours areforced by the institutional setting to expressthemselves within the transference relationship.In other words, they are not interfering by-prod-ucts; they are the very essence of addiction treat-ment. These are the phenomena that addicts haveto experience such that they can work throughthem. These phenomena are therefore the veryway into - and indeed very way out of - a treat-ment. Institutions and their staff have to allowthese phenomena to occur. But that is of coursenot always easy.

The only way to manage this process is by main-taining a function as object of transference foraddicted clients. To maintain this function is attimes extremely difficult because the pathologyof addicts will try and move beyond the socialbond of the transference. It is in the very natureof addiction to undermine the (symbolicallystructured) pact that exists between people. Thisis what staff or counsellors have to be able towithstand and when this becomes problematic itcan lead to what is called counter-transference.

The demands of addicted clients on staff can behuge and often impossible. The question weshould ask ourselves is: why do addicts provokeso much negativity or counter-transference inothers who try to help them? To some degree most people identify with theideals that addicts implicitly pursue with theiraddictive behaviour. Indeed it may very well bethat some aspects of addiction “act-out” whatnon-addicts dream or fantasise about (I deliber-ately emphasise some because most aspects ofaddiction ultimately end up in tragedy). We can-not afford to ignore those aspects of addictionthat we may perhaps unconsciously identifywith. In that sense addiction is able to expose anunconscious fascination in others. Curiously, ifthis is the case we may well ask ourselves thefollowing question: why are we not all addicts?The answer is that some of us have other symp-tomatic ways of coping, but more importantlyperhaps, most people can indeed accept that lifeis not a matter of unlimited pleasure or a totalavoidance of suffering; most of us can acceptthat total satisfaction is not attainable and thatimmediacy does not exist (except via the chemi-

5

6

Fore

word

cal substance). For most people total and imme-diate satisfaction only exist in fantasy. However,it can have a disturbing effect when these fan-tasies meet their real counter-parts in addictsone works with. When this happens it can leadto counter-transference and that often impliesthat anxiety is provoked, which frequently leadsto a reaction rather than a carefully consideredresponse. This reaction is often aggressive innature.

Briefly summarised, for a lot of addicts drugsand alcohol represent something in relation toan ideal and this ideal is transmitted onto therelationship with the counsellor (or institution)when the addict enters treatment. The relation-ship with the counsellor can become an addic-tive one but it should be acknowledged that thissituation is part and parcel of addiction treat-ment and that it is a necessary phase in a treat-ment. That means that the addicted client has tobe given an opportunity to work-through thisaddictive relationship. In other words, depend-ency on drugs or alcohol is transformed into adependency on staff and/or treatment centre andit is on the basis of a working-through of thisrelationship that the addict can recover. Whatoften happens is that staff are idealised byaddicts. The problem related to this is the fol-lowing: it can happen that at an unconsciouslevel staff members identify with this idealisa-tion by clients. In other words there is a need inthem to be admired and revered by their clients.In fact, it is even difficult sometimes to escapethis process in an addiction treatment centrebecause the transference of addicts and theirdemands can be very subtle and at the sametime forceful. Moreover, as just suggested, thereare staff members whose desire is to be suscep-tible to being positioned in this way by theirclients. If that desire of the counsellor feeds into

the pathology of the addicted clients the treat-ment can become destructive. This will create atherapeutic deadlock and the treatment willstagnate because it will not lead to a desire inaddicts to take responsibility. It means thataddicts are forced to remain within a relation-ship of dependency on their counsellors andinstitution. In this situation transference andcounter-transference will become destructiveforces; it will lead to toxicity on both the levelof the therapeutic relationship and the therapeu-tic community. To some extent treatment cen-tres and institutions dealing with addiction haveto go through phases like this, but is has to beproperly recognised, managed and therapeuti-cally dealt with, at both an individual level aswell as a group level.

Treatment centres and staff always function assubstitutes for drugs and alcohol. This new sub-stitute position forms the beginning of a treat-ment for addicts. The chemical route does notallow for a therapeutic way out; only the socialbond of speech and symbolisation does. Theonly way out for addicts is via verbalisationwithin a relationship where very difficult andanxiety provoking experiences can be articulat-ed and worked-through.

It is indeed of crucial importance that space iscreated in the policy of addiction treatment foraddicts in such a way that their experiencescan be openly articulated within a social bondwith others. On that basis, what is problematicfor addicts in terms of the social bond can bere-experienced within a therapeutic context.The creation and maintenance of a space oftransference within society is absolutelyessential, not just because addiction is not onthe wane, but especially also because we areincreasingly confronted with a culture in

Fore

word

7

which the immediacy of enjoyment is forcedon us. A dire consequence of this is that there isincreasingly less space for dissatisfaction,desire and the social bond. In other words,more and more we are being dominated by anenjoyment-and-consumption culture in whichwe should be feeling satisfied (after all haven’tall conditions for satisfaction been satisfied?)but in which the “not-feeling-so-good”becomes increasingly unbearable. This is thekind of culture that becomes less demanding ofits subjects in terms of making them responsi-ble for finding solutions to suffering in waysthat are radically singular. These are the kindsof solutions that need to be discovered by peo-ple themselves through being confronted - andcoming to terms - with the problems of life. Inreality rather the opposite is the case: cultureincreasingly forces external solutions onto peo-ple. One of the consequences is that peoplebecome more and more dependent on theseexternal solutions and this could possibly her-ald what can be called the addictification ofour society.

The creation of space for the singularity ofaddicts is more necessary than ever because theparticularity of the human being tends to dis-appear under the uniformity of external solu-tions for the problems of life. The uniformityof external solutions often leads to a relativelysimple and straight forward image that peoplehave of addiction. However, it is of crucialimportance that we are not fooled by the illu-sion that this image might indeed represent thetruth. This document written by Declan Byrneis an eloquent defence of the argument that it iscrucial that a transferential space is created foryoung addicts and, moreover, it demonstratesclearly that it is wrong to consider that all(young) addicts are the same.

Once you open yourself up to the possibilitiesof the transference relationship you realise thatpeople’s life-stories are different and onlyrecognition of that difference will lead to atreatment that is ethically grounded.

Dr. Rik Loose is the director of several post-graduate programmes (including an MA inAddiction Studies) in Dublin Business Schoolof Arts and is also Head of the Unit ofPsychoanalysis. Dr. Loose is a psychoanalystand clinical psychologist with ten years expe-rience of working with addicts in a residentialsetting. He also lectures on the Masters inPsychotherapy programme run by UniversityCollege Dublin in association with St.Vincent’s Hospital. He regularly holds semi-nars on his research in psychoanalysis andaddiction in England and on the Continentwhere he was involved in a research project onaddiction treatment. In addition to numerousbook chapters, journal articles and reviews hepublished his book The Subject of Addiction:Psychoanalysis and the Administration ofEnjoyment in 2002.

Ack

now

ledgem

ents

8

AcknowledgementsI would like to thank the lecturing staff at theDublin Business School. In particular Rik Loosewho inspired me, Siobhan O’ Donnell whoencouraged me to stay focused, Barry O’Brienwho was always available to give me advice andAndrew Honeyman who shared the wealth of hispractical experience and knowledge. I would liketo acknowledge Louis Farragher (Health ResearchBoard) for all the help that she provided. I wish tothank Sean McDermott (HSE counsellor-Kilbarrack) for repeatedly coming to my rescue.Also Anna Quigley (CityWide), Fergus McCabe(formerly of the National Drug Strategy Team)and Conor Rowley (Crosscare) who were all therewhen I needed someone to bounce half-bakedideas off. FAS support KCCP financially but I amparticularly grateful for the hands-on support Ihave received from Dermot Reynolds. I wouldalso like to thank everyone in the Health ServicesExecutive and in the voluntary and communityorganisations that have engaged with me in anopen and honest manner. I would like to recognisethe work of Noel Ahern (Minister of State withresponsibility for tackling the drugs problem) andhis predecessors Eoin Ryan, Chris Flood and PatRabbitte who have attempted to keep the drugsissue high on the political agenda.

A debt of gratitude is owed to the founders ofKCCP, people like Brenda O’Connell, MarianClarke, Kevin Arnold and Stephen Reid who hadthe courage to confront the problem in the 1990s.Likewise people who have served through thickand thin on the management committee, giving uptheir free time to deal with the on-going problems,people like Michael Finn, Fr. Cathal Price, BrianStewart, Martin Timmons and Paul O’Brien.Currently community drugs programmes enjoy alevel of cross community support however in theearly days they met with fierce resistance fromcertain sectors of the community. In Kilbarrackone politician supported the project when it wasfar from popular - Dr. Michael Woods. Without alltheir contributions KCCP would not be in exis-tence. Credit is also due to the staff because theyare prepared to critically evaluate their work andhave shown a refreshing desire for change. I

would also like to thank the Co-ordinator, MarianClarke for her constant support.

I would like to thank Carol, Adam and Denise (nottheir real names) – three participants who haveallowed me to tell their stories. In over five yearsof work with KCCP I have been privileged towork with thirty-five participants. I really appreci-ate their honesty and integrity. Some have dis-cussed their drug addiction with me at great lengthand all have contributed to my knowledge of thesubject. From early on I realised that addiction isa highly complex area not amenable to any quickfix solutions. Through my studies I have come torealise that the prognosis for drug addiction is notgood but this should not deter us from trying toimprove the way we work with problematic drugmisuses

I would like to dedicate the report to my wifeMargaret and to my children Jenny and Lorcanwho keep me sane (well half sane).

Management Committee & Senior Staff L-R :

Back Row: Paul O’Brien, Brian Stewart(Treasurer), Garda MartinTimmons, Declan Byrne.Front Row: Fr. Cathal Price (Vice Chairperson), Michael Finn(Chairperson), Marian Clarke (Co-ordinator)

Exe

cutive

Sum

mar

y

9

Executive Summary This report set out to investigate how KCCPrelates to its clients. Does the transference/count-er-transference problems dominate the life of theprogramme and does the management of the trans-ference present the greatest opportunity for trans-forming the project? This was no utopian exercisebut an effort to increase the effectiveness of acommunity drugs programme, which is workingunder serious constrictions.

The report suggests a better way of working withproblematic drug users and this has policy impli-cations not only for other voluntary/communityorganisation but also for the Health ServicesExecutive (HSE), who has a statutory obligationin this area.

The design of this report draws on all the tools ofqualitative research including the examination ofall material documentation and the use of keyinformants in order to place KCCP in its social andhistorical context. Then it used participant obser-vation, interviews, life histories (treatment histo-ries) and questionnaires to capture the current sit-uation, the failures, problems and challenges. Thereport looked at the theory and practice of trans-ference and arrives at the conclusion that as wellas it being the biggest problem it also presents thegreatest opportunity to forge a new template.

It concludes by making practical suggestions forimproving the programme.

KCCP must make the management of the transference / counter-transference central to its programme.

Through experiential learning the staff should be trained to use the transference/ counter-transference relationship as a tool of recovery.

Staff supervision must be seen as essential.

KCCP should build up a core of experienced full-time staff.

KCCP should be used as a pilot to look at the effectiveness of employing psychotherapists particularly with those with dual diagnosis and trauma histories.

The treatment should be designed around each individual client rather than every client being expected to fit into a system. The relationship is everything.

Intr

oduct

ion

The Purpose

The purpose of this report is to focus on the phe-nomenon of transference. The report argues thattransference can be seen in all forms of therapy butcan be witnessed in its starkest form in programmesthat attempt to deal with addiction. It sets out toprove this point by drawing on the evidence fromone programme - Kilbarrack Coast CommunityProgramme (KCCP). The author feels that there isan onus on all those working in the statutory, vol-untary and community drugs programmes to recog-nise that this problem exists and to accept that if wedo not learn to address the problem that our pro-grammes will continue to have limited success.Transference in drug programmes presents a majorproblem yet the proper management of the transfer-ence and counter-transference presents the greatestopportunity for these programmes to increase theireffectiveness.

The Context

KCCP was set up eight years ago with an absti-nence model in mind. The practical experiencegained from dealing with the hard cases has led toa shift in emphasis. KCCP is now looking at help-ing people move from chaos to a more stablelifestyle. KCCP attempts to empower their clients,to give them more independence, to develop theirabilities and to help them re-establish relationships.Success is no longer measured in the numbers thatbecome ‘drug free’ or the numbers who enter full-time employment.

The Therapeutic Context

In the clinic of addiction you find ambivalence,contradictions, non-linear change, chaos and uncer-tainty. The report sets out to look at transference,examining both the challenge and the potential thatthe proper management of the transference/counter-transference presents. It will attempt to devise amore appropriate framework that will allow KCCPto improve the way that it works with its clients.

The theory of transference is well documented and accepted in orthodox psychotherapy and psycho-analysis. The possible reason that it is not recog-nised nor addressed in drug programmes in Irelandis that the treatment of drug addicts has in the mainbeen relegated to the realm of the non-professionals(or untrained). This results in certain cases in thestaff becoming part of the problem or worse still theproject itself becomes a major obstacle. The prob-lem persists because staff members are unaware ofthe problem. They need training not only to recog-nise it but also to work with it. Transference canand needs to become a tool of effective treatment.Rawson (1995) said that ‘psychotherapy as a singu-lar treatment method with actively addicted ordetoxifying opiate addicts has produced very littlesuccess”. Rawson argues that elements from psy-chotherapy can be combined with broader treat-ment approaches to produce more effective results.He maintains that psychotherapeutic techniqueshave been and can be adapted to suit the needs ofdrug treatment programmes. This report is an effortto see if a psychoanalytic technique - the manage-ment of the transference can be borrowed and usedto make a community drugs programme moreeffective and by extension all drugs programmes.

This report rejects models that try to fit all prob-lematic drug users into a rigid system or modelsthat take an authoritarian approach. These modelstend to use rules in an attempt to eradicate thepathology of addiction. Programme efforts shouldnot be directed at control and uniformity. This newmodel or template starts from the basis that no twoproblematic drug users are the same and thereforethat all treatment to be effective must take accountof the individual. In particular recognition must begiven to those with dual diagnosis and particulartrauma histories. This report locates addiction in thepsyche of the individual and it advocates that it is atthis level that it must be tackled.

Chapter 1: Introduction

10

Met

hodolo

gy

Chapter 2: MethodologyMethod and Sample

The research was conducted in 2005 when therewere sixteen participants on the programme. Thereport is partly based on participant observation(the author has worked on the programme since2000). Three participants were selected for moredetailed examination, all three gave consent alter-ing their names to protect their identity. A struc-tured interview was held with Carol, a life historywith Adam and a treatment history was undertakenwith Denise.

Taking the Context Seriously

The author gained unrestricted access to all docu-mentation held by the programme. The report uses‘key insider informants’ firstly by drawing on theinsights of the current Co-ordinator Marian Clarke(Marian was one of the original founders). Thenbetween 2004 and 2005 two meetings were heldwith the entire group, participants and staff. InMarch 2005 the sixteen participants filled out ageneral questionnaire. Three participants were cho-sen for more detailed examination. In November2004, an in-depth interview was conducted withCarol. In December 2004, Adam’s life history wasrecorded and in July 2005, a detailed treatment his-tory for Denise was drawn up.

Research as a Tool for Action

This report follows in the footsteps of Samson et alwho in their article Qualitative Research as aMeans of Intervention Development (2001) set outin an Indian context to “focus on an example ofhow qualitative research can be useful for inform-ing the design of drug treatment interventions in alocality where drug use is a rapidly growing phe-nomenon and where resources for interventiondevelopments are extremely scarce.” In their expe-rience “this is best achieved by developing andevaluating interventions on the basis of qualitativeresearch, including via ethnographies, unstructuredand structured interviews, focus groups and obser-vations.”

Their research was driven by “the aim of empow-ering members of the community to effect and sus-tain improvement in the quality of their lives.”

11

Chapter 3: The ProgrammeThe

Progra

mm

e

Introduction

This chapter introduces you to the area ofKilbarrack. It places KCCP in its historical con-text. It explains how FAS has adapted CommunityEmployment (CE) Programmes to help communi-ties support problematic drug users. Then it iden-tifies some of the major problems facing KCCP.These include, unsuitable premises, lack of quali-fied staff and the absence of professional supervi-sion. Finally it focuses on the transference/count-er-transference problems that exist within the pro-gramme.

Kilbarrack the Area

Kilbarrack is located in Dublin North East. AsFarrington (2004) points out, “The area consists ofa mix of local authority-built and private housingestates…using the Index of Relative Deprivation(2002), the area shows low to moderate levels ofsocio-economic deprivation. The local authoritybuilt estates show the highest levels of deprivationand it is in these areas that the heroin problem tookroot in the 1990s.

History of Kilbarrack Coast CommunityProgramme (KCCP)

KCCP was set up as part of a process of commu-nity action. In the early 1990s a group of commu-nity activists came together to form KilbarrackCommunity Families Against Drugs. This groupcame together to organise against the sale of hero-in in the area. Then they began to negotiate withthe Health Board to open a drugs clinic in the areaand they also began the process of setting up acommunity based aftercare project.

The Health Board opened a drugs clinic in May1996. In December 1998 the Kilbarrack AftercareCommunity Programme was set up. The groupreceived funding from FAS and the Health Board.In January 2001 at the request of its clients thegroup changed its name to the Kilbarrack CoastCommunity Programme (KCCP).

Core Programme

Since opening in 1998 KCCPs’ function was toprovide rehabilitation, care and training to recov-ering drug mis-users. From December 1998 until2005 the client group has risen from twelve totwenty-one. Since KCCP started it has had forty-one clients linked in on a nineteen and a half hoursper week basis. During this time KCCP has alsolinked in with another thirty-five drug users. Thesepeople would have received support around suchissues as their health, drug use, childcare, employ-ment, police and courts. From December 1998until February 2001 KCCP operated an afternoondrop-in service. Due to the decision by KCCP toexpand its youth programme (in 2001 KCCP setup a youth initiative called Youth Matters) thisservice has been discontinued. At the start theclient group was predominantly female but thishas changed over time (65% female in 1999 to35% in 2004).

EEnnttrraannccee ttoo KKCCCCPP

12

The

Progra

mm

e

What are ‘Special Status’ CommunityEmployment Programmes?

Community Employment (CE) Programmes arelabour market training projects designed to helpthe long-term unemployed. In the late 1980s com-munity leaders pleaded with the government toallocate resources to the areas most affected byproblematic drug use. FAS (the National TrainingAuthority) were authorised to run a number ofpilots using CE for problematic drug users.Following the pilots these programmes were rolledout and by December 2003, fifty-four community/voluntary groups had been set up and were run-ning what was now described as ‘special status’CE (catering for 1,119 participants). In the past tenyears most of these programmes have secured asecond source of funding.

The Problems Facing the Programme.

This section of the report looks at inadequate facil-ities, the lack of professional staff, the absence ofsupervision and the mismanagement of the trans-ference.

The Building

KCCP operates from premises, which is totallyinadequate with no dedicated training or coun-selling rooms. The programme primarily runs allits activities from a large room (46.68 sq. m.).

Lack of Professional Staff

KCCP has never employed anyone who was pro-fessionally trained in addiction (the majority ofthose working in CE drugs programmes on thefrontline of addiction do so with no prior training).The most vital workers are the support staff. Theseemployees work the same hours and receive thesame pay as the participants (their rate of paymentranges from €160 to €230 per week). The partici-pants and staff on CE are allowed to remain forthree years.

Absence of Supervision

Missen and May (2005) Hawkins and Shohet(2000) and Page and Wosket (1998) have devel-oped models that “emphasise that successful out-comes in therapy are often achieved through theeffective use of supervision”. Garland (2005) dis-cusses the sheer necessity of supervision to dealwith how people can become “stuck in their clientsdilemmas”. It is therefore regrettable that for themental well being of the staff and the increasedtherapeutic potential that KCCP never had theresources to provide supervision.

Mismanagement of the Transference

In CE drugs programmes transference/counter-transference presents a problem. In KCCP it is aproblem because of the way the group deals withthe transference and how it fails to manage thecounter-transference. Some CE programmes havetried to address this problem by introducing an “authoritarian model”. They attempt to regulate all

MMaaiinn RRoooomm iinn KKCCCCPP

13

The

Progra

mm

e

behavioural problems out of the programme. Ruleupon rule are introduced and enforced with strictdiscipline. Serious questions must be raised aboutthe use of this model with problematic drug users.Drug addicts ‘act out’; this is part of the pathology.An administration requires certain rules but theserules should not be so stifling to suppress the emer-gence of the pathology. KCCP in the beginningattempted the ‘rules and regulations’ way of doingthings. In more recent years it has retained somebasic rules but it has attempted to be more flexiblein its dealings with clients. Here are two examplesof how KCCP has failed to deal with transfer-ence/counter-transference issues. On joining someparticipants made steady progress. They addressedhealth and criminal issues. They became less sus-picious and more communicative. They could bedescribed as being on the verge of personal change.Then without any apparent trigger they wouldbegin to ‘act out’, starting a process that wouldinevitably lead to their dismissal from the pro-gramme. When they were eventually dismissedthey were at pains to point out that they would nothold it against the programme. These cases wouldindicate that KCCP did not have the ability to man-age the transference.

Managing the counter-transference is a majorheadache for KCCP. An instance occurred where aparticipant was cheeky to one of the support work-ers and a support worker who was not involvedinterjected “ You are not going to let him get awaywith that?” I have recognised counter-transferenceissues in myself and I can see them each time aworker acts in a defensive way.

Conclusion

The programme operates on very modest resources(it cannot afford to employ professionally trainedstaff or provide supervision) in grossly inadequatepremises. This chapter also looked at the problem,which may represent the greatest stumbling blockfor KCCP increasing its effectiveness that is deal-ing with the transference and managing the count-er-transference.

Despite all this, the numbers using the programmehas doubled. A safe haven has been developed,where the participants are treated with dignity.KCCP has attempted to build up the group so thatthe group dynamic would act as an influence toreduce or stop drug taking. This has not happened.However through a policy of self-empowermenteach year individuals do have the ability to reducetheir drug taking and in the exceptional cases somepeople have shown the ability to give up drugsaltogether. This chapter raises the issue, which willbe dealt with in subsequent chapters. Could theproper management of the transference/counter-transference transform KCCP as a drugs pro-gramme?

CCoouunnsseelllliinngg RRoooomm aatt KKCCCCPP

14

The

Part

icip

ants

Introduction

In this chapter four methods are used to give thereader a glimpse into the lives of the participantsof KCCP. They are, general questionnaire, semi-structured interview, and life history and treat-ment history. This hopefully will provide theinsider perspective that will power this report.

Meet the Participants

In March 2005 a general information question-naire was administered to the then sixteen partic-ipants on the programme. Some of the informa-tion gleaned from this exercise included the factthat the age profile of the group ranged fromtwenty-three to thirty-eight years.

The earliest two to leave school were both thir-teen, while the oldest two to leave school wereboth seventeen. None of the sixteen had stayed inschool to do their Leaving Certificate examina-tion. All sixteen had held full time jobs at sometime in their lives. Fourteen had reduced theamount of methadone that they were using sincejoining the programme (two in dramatic fashion).Two had remained on the same amount. Five hadnever attempted a drugs detox. This would meanthat eleven had detoxed but had failed to remaindrug free. All participants were asked to list thesix main activities of the programme, only sevenincluded counselling. The group were also askedto name the one most successful activity and onlyone from the seven picked counselling.

Loose (2002) made the point that “behind themanifest uniformity of addiction one encountersthe complexities of the subject and addressingthose should be the ultimate aim in treatment.”The next sections hope to zoom in on the subject.

Carol – Not Getting What She Needs From TheClinic or KCCP.

On the 22nd November 2004 a semi-structuredinterview was conducted with Carol. Carol is atwenty-seven year old mother of two. To the out-side world her petite frame presents a quite spo-ken nature. When you get to know her you dis-cover that she possesses a steely determinationespecially concerning her children and she pos-sesses a nature that bristles whenever she encoun-ters injustice. Carol took her first illegal drugwhen she was about ten or eleven, when herbrother gave her cannabis. She went fromcannabis to LSD and then when she started goingto discos with her friends she started drinking. Itwas during this period that she began taking E andspeed and soon afterwards cocaine and then tocome down off these drugs she began using hero-in. She was fifteen when she began using heroin.She linked in with the Health Board drugs clinicin 1997 and as she says herself “it was meant tobe for a detox and I’m on it ever since.” She stilluses heroin on a weekly basis (sometimes moreregularly) and avails of the clinic to get weekly‘take-aways’ of methadone. On her years attend-ing the clinic she has reduced her methadonedosage from 50mls to 25mls. It is apparent fromher interview that she gets on well with the HealthBoard counsellor but is inclined only to link inwith him when she is trying to stay clean “Andwhen I’m not then, I don’t really want to go intohim because I don’t want to face the truth.” Fromvarious comments she makes she would like theclinic and KCCP to be stricter, to impose sanc-tions when she is caught using heroin. “ I wouldlike to be on a programme, which tells you to stopusing.” It could be argued that Carol is trying toestablish a transference relationship that is she islooking for an authoritarian father figure, whowill tell her what to do (or rather what not to do).

Chapter 4: The Participants

15

The

Part

icip

ants

The Life and Times of Adam

Pelto & Pelto (1993) point out “the richness andpersonalized nature of life histories afford a vivid-ness and integration of cultural information thatare of great value for understanding particular lifeways.” Therefore the objective of conducting alife history with Adam was to secure an in-depthpersonalised account. It was explained to himbeforehand that the life history covers all aspectsof his life but he took the opportunity to concen-trate on those parts of his life that were linkedwith his drug use. He seemed driven to explainhow he had begun to take drugs. He described hisearly experiences of sniffing petrol. He then wenton to describe how at the age of sixteen/seventeenhe became a heavy solitary drinker (averagingfourteen cans of beer, seven nights a week). Hespoke of how up to the age of twelve his parentshad been protective and he was not allowed toplay with other children. Asked if this might haveplayed a part in his pattern of solitary drinking?He replied, “Never even thought of it. Sort of usedto being alone” but he then went on to form a linkbetween his heroin taking and his ‘aloneness’.Though he clarified in detail how drinking had notstarted out as a solitary pursuit and explained indetail how this habit came about. Asked if at thatstage if he was drinking to get out of his head? Towhich he replied that he was. He explained howhe begun to smoke heroin when he was twenty-

one/twenty-two. He explained how he hadstopped drinking when he started injecting heroin(he put this down to the fact that he needed a lotmore money for the amount of heroin he neededto inject). He explained in detail the circum-stances in which he went from smoking heroin toinjecting. He describes how good taking heroinwas, “I really have to say that I don’t ever remem-ber feeling as good as that before or since to behonest with you. Yeah I can’t even think of any-thing that could come close to it, some people saysex…but no way.” Asked if ever thought of com-ing off heroin ? He explained in some detail thetwo times when he tried to quit. The first timetook place after he discovered a friend of his, deadfrom an overdose. He stayed off heroin for six orseven months but explained that he was thendrinking between one and two bottles of spirits aday. He joined the local drugs programme –KCCP in order to stay ‘clean’, only to discoverthat no one on the programme was ‘clean’ andwithin a few weeks of listening to ‘drugs talk’ hewas back using.

The second time happened in January 2000, whenhe got a great opportunity to do a television pro-duction course in Tralee. From the time hestepped onto the train he stopped using heroin. He(unlike the other trainees) remained in Tralee atthe weekends. He said he “didn’t feel strongenough to stay away from heroin” so he stayed inhis flat in Tralee. He explained that Monday toFriday he did not drink but that he “just drankSaturday and Sunday away.” He explained how hecame to Dublin to do a job interview but nevermade it out of Heuston Station. He met some onewho offered him a “turn-on” and “being well gar-gled” he took up their offer.

Once back on heroin he ended by saying,“Nothing’s changed since, still here! Adam is thir-ty-three, highly intelligent and highly gifted. Heshares a number of characteristics with the largergroup (such as the fact that he left school early).This life history shows that everyones experienceis unique and that this should lead to the under-standing that any efforts to improve drugs pro-grammes will require taking all the clients indi-vidual needs into consideration.

16

The

Part

icip

ants

Is Denise Being Treated Properly?

The typical profile for thosewith dual disorders makes themsystem misfits. The range of inter-connecting problems they possessextend outside the specific remitsof any of the services they areinvolved with. (Wilson 2000: 29)

In my opinion it is now impossible to say ifDenise’s bouts of depression pre date her drug useor are a direct result of her drug use. Denise hasbeen taking drugs now for thirteen years. Theamount and range of drugs that she has taken istruly staggering. Her initial drug of choice washeroin. Since 1996 she has been combining thiswith methadone. At various times she receivesprescribed drugs from her family doctor, the HSEprescribing doctor and for the past two years fromthe local psychiatric services. In recent years shehas tried ‘crack’ cocaine but in the past two yearsher stable diet of drugs is made up of cocaine,methadone and a range of prescribed ‘sleepers’and anti-depressants. She has been a participanton KCCP on three occasions. The first time shewas put off the programme for six months forbeing ‘too chaotic’. The second time she complet-ed her three year term and the third and currenttime FAS made an exception because of her gravemedical condition and allowed her back in thehope that she could complete a ‘stabilisation’.Denise is a client of the HSE Drug TreatmentServices. She has undergone regular assessmentsand has completed several detoxs and stabilisa-tions. She is a client of the counsellor attached tothe HSE drugs clinic and a regular client of thehealth nurse. On the three occasions that she gavebirth she became a client of the HSE social workservice. For over the past two years she has beena client of the HSE local psychiatric services.Since beginning her problematic drug use she haslinked in with her family doctor and has been aregular patient, both on an inpatient and outpa-tient basis with the general medical services for arange of issues related to her drug use. Each timeshe links in with a service it appears as if they dealwith a bit of Denise. There has never been anattempt in Denise’s treatment history to take amulti-disciplinary or multi-agency approach. Inall her years of being linked in no attempt has

been made to come up with an individualisedtreatment plan. She has a long history of beinglinked in and at times of severe crisis the systemdoes respond but for the rest of the time she justfalls through the cracks. Some of the servicesinvolved try to blame Denise (“she failed to turnup for her appointment”) but though nominallylinked into treatment she has never experienced aconsistent joined up treatment service. The reasonDenise’s treatment history is used is to underlinethe issue that those who engage in problematicdrug use usually have severe behavioural prob-lems not amenable to quick fix solutions.

Conclusion

In this chapter you were introduced briefly to six-teen participants. Greater detail was given onCarol, Adam and Denise. Hopefully you havecome to see that drug users are not a homogeneousgrouping. Their uniqueness and the ‘complexitiesof the subject’ are there to see. No matter howsimilar they appear to be they all have their differ-ent histories, stories and reasons for taking drugs.Corrigan (2000) made the point “I have alwayshad great difficulty with the concept of treatment‘slots’, which conveys to me the idea of slottingindividuals into a conveyor-belt treatmentprocess, when the treatment programme shouldideally be built round the individual. The artshould be to find which treatment is most appro-priate for a given individual at a given point intheir drug-using career.”

17

The

under

-utilis

ed t

ool Introduction

Loose (2002) “argues that aspects of the ethics,method of treatment, and experience of psycho-analysis should be seriously considered and,where possible incorporated into the treatment ofaddicts, irrespective of whether this treatmenttakes place on an individual, group, communityor institutional basis”. Part of his theoreticalframework incorporates working with the trans-ference. This chapter traces the origins of the con-cept, looks at how professionals in the treatmentof addiction have used it as a tool and examinesthe authors’ experiences in this area. An impor-tant factor in this discussion should be the treat-ment urgency. Since KCCP was set up sevenyears ago two former clients have died from drugrelated causes (both in the past six months) andone additional person from the Kilbarrack area(who did not link in with KCCP) has died in sim-ilar circumstances. KCCP has dealt with two seri-ous cases of self-harm, one of which culminatedin a suicide attempt. One current client has beenreadmitted onto the programme in the hope thatshe will reduce her drug intake following a lifethreatening attack of cellulites brought on by herdrug taking. As Loose (2002) points out “theurgency of their need for treatment is in directproportion to the time they have left.”

Beginning with Freud and the Classic Cases

Freud was an ardent student of the relationshipsthat developed between his professional col-leagues and their patients. It was through thisroute that Freud discovered transference. He dis-covered it with Bertha and Breuer, he found itwith Otto Gross and Jung and he came across it inhis own work in the first instance with Dora. Thissection refers to a number of classic cases, whichthrow light on the phenomena of transference.Kahn (1997) dealt with how Freud discoveredtransference in the case of his mentor JosefBreuer and his patient Bertha. It was clear toFreud that Breuer was fascinated by Bertha andthat the fascination was by no means one-way.Freud came to the conclusion that Bertha relatedto all male authority figures in the same way andthat this was a consequence of her relationshipwith her father.

Loose (2002) dealt with the case of Gross and hisrelationship with Jung and Freud. From corre-spondence between Freud and Jung, Loose main-tains, “One can glean… that the relationshipbetween Gross and Jung was not very good.Freud suggested that there was a negative trans-ference on Gross’s part and that this was a symp-tomatic repetition of the relationship with hisfather. As Loose points out this ‘gross episode’ isinteresting in that it highlights how both Jung andFreud viewed Gross as the “waste product of thepsychoanalytic establishment.” “Gross had been‘too much’ for Jung and Freud; Freud did notwant to analyse him and Jung’s treatment of himwas at times unbelievably farcical.” In this exam-ple we have not only encountered transferencebut counter-transference as well.

Lacan (1966) studied the relationship betweenFreud and Dora. It is important because it was“the first case in which Freud recognised that theanalyst played his part.” Freud believed that at theearly stage in her treatment, Dora begins to relateto him as if he were her father, then after the firstdream it is from Herr K that she makes her trans-ference. Freud places the failure for the treatmenton his own inability to recognise this latter trans-

Chapter 5: Transference

18

The

under

-utilis

ed t

ool

ference before her abrupt departure. It is interest-ing that Lacan sees the mistake in the realm of thecounter-transference. “As regards Dora, Freudadmits his personal involvement in the interestwhich she inspires in him.” Lacan maintained thatit is not the failure to recognise the transferenceearly enough but the failure to give proper consid-eration to the counter-transference that caused theproblems in this case.

The Theory of Templates and the RepetitionCompulsion

Kahn (1997) explains “According to Freud, whenpeople enter therapy, the way they see andrespond to the therapist and the reactions they setout to provoke are influenced by two tendencies:they will see the relationship in the light of theirearliest ones, and they will try to engender replaysof their earliest ones. To these perceptions,responses, and provocations Freud gave the nametransference, meaning that the client transfers ontothe therapist the old patterns and repetitions. Kahnmakes the point that he comes across this phe-nomenon constantly in his work with clients.Explaining “Since the repetition compulsion oper-ates everywhere, it is no surprise that it turns up inthe clients’ relationship with the therapist.”

The Roundabout Road to the Unconscious

Kahn feels that Freud first became interested inthe transference because he felt that the transfer-ence was a tool of the resistance and as such inter-fered with the ‘real work’ of analysis. His positionaltered radically when he discovered that thetransference could be used as a means of penetrat-ing the unconscious. Freud described his treat-ment as surgery (the knife that cuts) as comparedto other treatments that were cosmetic. Freudargued that dealing with the symptom alone wasinadequate (this would still leave “all the process-es that have led to the formation of the symptomsunaltered” (1916-17: 504). “Analytic treatment(working through the transference) makes itsimpact further back towards the roots, where theconflicts are which gave rise to the symptoms”(1916-17: 504). Freud stated that “In order toresolve the symptoms, we must go back as far astheir origin, we must renew the conflict fromwhich they arose, and, with the help of motive

forces, which were not at the patient’s disposal inthe past, we must guide it to a different outcome”(1916-17: 507). Freud’s goal was for a “perma-nent cure of the neurosis” (1912: 108) “a perma-nent improvement in his (the patient’s) psychicalsituation” (1912: 106). By managing the transfer-ence properly the ‘suppressed impulses’ (1916-17:497) “can be traced back to its unconscious ori-gins” (1915:166) and through the analytic treat-ment can be brought “back into consciousness andtherefore under her control” (1915: 166). Freudemphasises that “The decisive part of the work isachieved by creating in the patients relation to thedoctor in the ‘transference’ – new editions of theold conflicts, in these the patient would like tobehave in the same way as he did in the past, whilewe, by summoning up every available mentalforce (in the patient), compel him to come to afresh decision. Thus the transference becomes thebattlefield on which all the mutually strugglingforces should meet one another.” (1916-17:507).

Learning from the Professionals

In order to gain insights into the phenomena oftransference/counter-transference and to learnhow its proper management can produce benefitsfor problematic drug mis-users the report turns tothose who have worked in the field of addiction.These include Brown (1950), Fine (1972),Gustafson (1976), Selzer (1967), Davidson(1977), Imhof et al (1983) and Imhof (1995)

Brown (1950) examined the transference phenom-enon in alcoholics. Brown maintained that the“familiar tool of therapy, the transference is notbeing utilized for all its worth” in the treatment ofalcoholics. He made the observation that “itappears that the relationship with the therapist isof major importance and that the nature of thetherapy itself is of much less significance.” Brownillustrated this point by providing a case history.Brown also touched on counter-transferenceissues when he wrote, “It is possible that a preva-lent and unfortunate attitude of those undertakingthe care of alcoholic patients may be a majorobstacle to favourable results.”

Fine (1972) decided to contribute to the litera-ture on the psychoanalytic treatment of drugaddicts by describing a case from his practice.

19

The

under

-utilis

ed t

ool

From this case we can see the positive transferenceoccurring from the very beginning of treatment.We learn that soon after this “every aspect of thetransference, though specifically positive, sooneror later became a source of resistance” and thenafter about two months “came the first significantbreak in his pattern, an intensification of the trans-ference drama.” Fine realized that with this clientinsights would have minimal value but that it wasby working with the transference that changes inbehaviour could be achieved, which is what hap-pened over time.

Gustafson (1976) uses a client’s case report todemonstrate the “successful application of theideas of Kohut and Balint to the psychotherapy ofa very self-destructive alcoholic patient whosecore disturbance proved to be that of a narcissisticpersonality disorder.” The article underlinesGustafson’s recognition of counter-transferenceissues in his provision of treatment. Like similarpatients he displayed “an intensity of rage”, whichresulted in Gustafson’s “subtle withdrawal”.Gustafson hid this from himself with the idea thathe was being “consistently and strategicallyempathic concerning his situation.” Whereas infact he was “being empathic from a considerableand cool distance.” The treatment benefited fromthe “transference interpretation”(in this case deal-ing with Gustafson’s reaction to his client). Thisallowed him to overcome the “counter-transfer-ence reaction” and this subsequently allowed thepatient to “re-experience in the transference” someof his childhood traumas.

Selzer (1967) put the spotlight on “the feelings thatthe alcoholic engenders in those attempting to treathim with psychotherapy.” In a previous paperSelzer examined the psychotherapist’s hostilitytoward his patient, these feelings arose from “(a)unconscious envy of the hedonistic aspects of thealcoholic’s behaviour, and (b) a tendency to regardthe patient’s relapses as the therapist’s personalfailures.” He then focused on four aspects of thealcoholic, his/her dependency, egocentricity,depression and hostility. He concluded by sayingthat “psychotherapy alone does not constituteeffective treatment for most alcoholics, it never-theless remains an invaluable treatment modalitywhen used in conjunction with other therapies.”

Davidson (1977) stated “there is now widespreadacknowledgement…that attempts to treat heroinaddiction by chemical means alone have failed.”She referred to what she considers to be the domi-nant trend in the treatment of addicted patients –“the wish to locate the cure for addictive illnessoutside the patient’s psyche.” Her article describes“certain recurring patterns of behaviour” that sheobserved while working in a methadone mainte-nance clinic over a thirty-four month period. She isparticularly interested in describing the transfer-ence phenomena in a clinical setting. She definedtransference as “a term that the patients’ behaviourat a given moment in treatment is determined moreby his early experience with significant others thanby the reality stimulus of the present setting” and“counter-transference…will refer to the totality ofthe therapists’ response to the patient.” In the outpatient clinic where she worked she observedpatients exhibiting extreme rage and hatred. Shethen noted that the staffs’ most common responsewas “to retaliate”-“most commonly expressedthrough the dosage of methadone.” In conclusionshe said, “Much of the ‘difficult’ behaviour isoften seen as part of a constellation of undesirablesocial characteristics attributed to addictedpatients. Staff may try to eradicate this behaviour(usually through elaboration and enforcement ofclinic rules) with the associated hope that thepatient will become more compliant, and thenamenable to therapy. This is somewhat akin to stat-ing that if the patient did not have psychologicalproblems he/she would be easier to treat.”

20

The

under

-utilis

ed t

ool

Imhof et al (1983) set out to address the situationwhere “scant attention is given to one factor thatmay affect the positive or negative outcome ofany treatment provided: the counter-transferen-tial and attitudinal posture of the treatmentprovider. “ They wish to focus on the role of thetherapist. The purpose of their paper was to“explore the concept of counter-transferencespecifically in relation to its presence, utiliza-tion, and impact in the evaluation, diagnosis,and therapeutic management of the drug-involved patient. The article showed how sometherapists view this client group as both“untreatable and unmanageable.” They showthat part of the challenge lies with “the initialtransference reactions of the patient (which)may be of such an intense nature that the thera-pist is overwhelmed by the ensuing assault.”The article went on to study certain “therapeuticmisalliances.” You have the example of the ther-apist who assumes the role of “good parent res-cuing the bad impulsive child.” You have thepatient who “deftly manoeuvred two staff psy-chiatrists into providing neuroleptic medica-tion… twice resulting in life-threatening over-doses.” You also have the therapist “identifyingwith the ‘victimised’ patient and joining forcesin a ‘you and me against the world’ scenario.” Intheir conclusion they found that “in the majorityof all treatment outcome studies reviewed, thecause of treatment failure is viewed as a failurewithin the patient, resulting from his own psy-chopathology, rather than from any negativederivatives of the patient - therapist interaction.”

Imhof (1995) starts with Wurmser’s (1972)observation that “drug abuse is the nemesis tohaunt psychiatry itself…sheer mass of ‘emo-tional problems’ substance abusers bring totreatment ‘dwarfs our skills’.” This articlemakes two core points (1) that the negative atti-tudes of the treatment providers continues toimpede progress in treatment, and (2) that thereis a need to stress patients individuality –“Gallant (1990) has argued persuasively forrecognition that “each…patient and family hasunique and distinct backgrounds and character-istics which deserve different therapeuticapproaches”.

Loose on Managing the Transference

Loose (2002) examines three aspects of trans-ference in the context of addiction. (1) The dif-ficulty with the management of the transference,(2) The imperative for treatment centres to workwith the transference, and (3) The need to keepthe levels of toxicity within workable limits.

(1) Loose (2002) highlighted “The fact that themanagement of the transference is very difficultin the treatment of addiction. Often addicts donot seek help because they have a ‘perfect’ solu-tion at hand.” He also focused on the other sideof the coin “It is not difficult to see how addic-tion can easily lead to counter-transference,especially where we take note of the fact thataddiction as a fundamental human problem,highlights the impasses of human existence andthe shortcomings of the subject, including thoseof the therapist.”

(2) Loose stresses the need of working with thetransference. “To maintain the transference andto allow it to develop is, however, an ethicalimperative and it is the only way out of a lethalimpasse for the addicts.” Similarly he wrote “Atreatment centre or therapeutic community is setup in order to bring the pathology of addictionwithin its realm…The pathology of addictionwill manifest itself in the transference and it iscrucial that the transference is allowed to takeplace.” He goes so far as to state that “thedynamic of transference has to be allowed todevelop or else therapy is not possible.”

21

(3) Loose refers to levels of toxicity – “In thera-peutic communities this structure can lead to, what Snoy (1993, p.48) calls, a ‘toxic space’. Atoxic space can take many different forms in thiscontext. There can be a bad atmosphere, aneuphoric one, an aggressive one, a secretive one orwhat is called an ‘us-and-them’ situation. Snoyargued that when the toxicity rises above a certainlevel the therapeutic work becomes impossible,even in an orientation of therapy in which thesebehaviours are considered to be symptomatic oftransference. The ‘toxic space’ in the therapeuticcommunity is a manifestation of negative transfer-ence. Too much toxicity stops the work of trans-ference. The level of toxicity has to be kept withincertain workable limits, “

Personal Experience of Transference/ Counter-transference.

In just over five years I have gone through the fullrange of transference and counter-transferencephenomena. I have experienced them myself orhave witnessed them on the programme. LikeFreud I have to admit to experiencing fascinationwith some of the participants. I have come torealise “the interest which (they) inspire in me.” Imhof et al (1983) refer to the “good parent rescu-ing the bad impulsive child”. In the first few weeksand months, I was like a mother hen trying to solveall the participants’ problems. On the other end of the scale Gustafson (1976) talked of “subtle with

drawal”, while I have been guilty of the not-so-subtle withdrawal with participants who are con-stantly negative, egocentric and complaining.Despite my best efforts I mirror Kohut’s (1971)description, I suffered from “boredom…and theprecarious maintenance of attention.”

Davidson (1977) talked about denial – the denial ofentire segments of reality especially involving behaviour concerning drug usage.” These remindme of a time when I felt total frustration dealing with a participant. He/she was a problematic druguser (using on a daily basis) telling me how greathe/she was because he/she was off drugs for somany months.

Brown (1950) described the case where the clients “frequently manufacture situations” in which they“suffer retaliations.” This has happened in KCCP,where a participant for no apparent reason beginsto act out with the inevitable consequence that theyare asked to leave the programme. I have also wit-nessed a similar case to the one described by Imhofet al (1983). A participant in KCCP invoked a sim-ilar response in everyone he met. He was ‘poor’…… (everyone felt sorry for him). In the examplefrom Imhof et al (1983) two staff psychiatristswere prescribing for the same client, resulting in anear fatal overdose. This led to an investigationwhere one psychiatrist admitted, “I had to give hersomething, I felt sorry for her.” I maintain that our‘poor’ participant elicited the same reaction, whichresulted in the same disastrous consequences. Ihave experienced what Kohut has described as the“idealized parent imago”. Here a participant waslooking for an external control, a father figure.Selzer (1967) describes it thus, “wanting someauthority figure, parental figure or surrogate to takeover the responsibility of guiding him, directinghim, and making decisions for him.”

I have experienced or witnessed a range of count-er-transference feelings. I have witnessed angerand resentment. I have witnessed people becomingmoralistic and judgemental. I have seen all thestaff; myself included becoming drained with thelevel of negativity within the group. In its first yearin existence KCCP closed down the programme forone week to try and reduce the pressure that hadbuilt up on the programme. There has only been T

he

under

-utilis

ed t

ool

22

The

under

-utilis

ed t

ool

one incident of a physical assault between partici-pants. There have been so many altercationsbetween participants and between participants andstaff, that at certain times it can become a regularoccurrence. In the context of KCCP the situationcan go from zero to a hundred in a matter of sec-onds? A serious incident can be sparked off by whatappears to be a throwaway remark. I have also seenthe bushfire affect. One person displays aggressionand instead of having to deal with one particularincident, fires breakout throughout the groupinvolving totally different individuals. I have seenthe same happen with depression. It creeps into thegroup and spreads. The depression then becomes sostrong that you could feel and touch it.

Another source of increased pressure is if the groupperceive that the staff members are showingfavouritism (this sometimes manifests itself in‘pairings’, where a staff member pairs with a par-ticular participant). KCCP has experienced the pres-sure cooker exploding but more commonly it is thepressure cooker ready to blow that would bestdescribe the situation.

Conclusion

The atmosphere, the underlying currents and theacting out represent a problem for communitydrugs programmes. These programmes are set up todeal with the pathology of addiction so it is nonsen-

sical to ban manifestations of the pathology. Thepathology cannot be dealt with in abstentia.

This chapter has set out to explain the concept oftransference, it has tried to learn from those whohave worked with alcoholics and problem drugusers and tried to bring the authors experiences tobear on the subject. This chapter set out to groundthe subject both practically and theoretically. Thisreport argues that in the clinic of addiction noefforts should be made to suppress the transference– it should not be interpreted as bad behaviour(within limits of personal safety). Treatment institu-tions that use punitive structures to deal with addic-tion stand little chance of success.

In the case of KCCP a safe space was created but when people sought help through the transferencetheir pleas were ignored because of a lack of under-standing. Loose in his book refers to the ‘toxicspace’ and in his lectures referred to the clinic as a‘pressure cooker’ (to cook the food pressure needsto be applied, too much pressure and the cookerexplodes). In its current context KCCP could bedescribed as a pressure cooker where the lid isready to blow.

23

24

Concl

usi

on

Introduction

I have used a community drugs programme KCCPas a case study to demonstrate the need for changein the way we work with problematic drug users.By looking in some detail at three participants Ihope that I have been able to convince you that"The cause of addiction is not a general cause, but a cause that is specific to the subject, and thiscause can only be approached through speech in atransferential relationship. That is why treatmentthat is based on the transference is an absolute pre-requisite in addiction treatment." (Loose 2002). .

Training and Supervision

KCCP held a half-day training course on the 13thJune 2005 to examine the issue oftransference/counter-transference (in five yearsthis would be only the second time that all theystaff had been brought together for a training ses-sion). Has it solved counter-transferential prob-lems within the programme? Certainly not, it hasproved to be a first step in increasing awareness,further steps now need to be taken to build on thisfoundation. KCCP in the short to medium termwill not be in a position to employ trained psy-chotherapists or psychoanalysts. It can howeverthrough experiential forms of training ensure thatits' staff are psychoanalytically informed. A struc-tured training programme over time could result inthe staff being able to manage thetransference/counter-transference in order to helpthe individual clients. The training would have tobe accompanied by the clinical supervision of allthe staff.

The New Template

I believe that the report has demonstrated the needfor KCCP to take a number of steps in order toincrease its effectiveness.

(1) KCCP must recognise the central role thattransference and counter-transference plays in the proper treatment of addiction. KCCP should place

at the centre of its programme the management ofthe transference.

(2) Staff training needs to be prioritised. Fundingshould be provided so that training in transferenceand counter-transference should be provided to allstaff working with problematic drug mis-users.

(3) KCCP and the HSE must recognise the valueof supervision. I believe that no matter howstretched the resources are within KCCP thatexternal supervision should be an imperative.

(4) The current financial position of KCCP doesnot allow it to employ a qualified psychotherapist.Additional funding should be sought to employ apsychotherapist on an hourly basis to work withclients who have severe problems (particularlythose with dual diagnosis and trauma histories).

Conclusion

I intend no criticism of community drugs pro-grammes, for without them problematic drug userswould be in a more isolated and more stigmatisedposition. I do not want any part of the report to beused to criticise FAS. In my opinion FAS came tothe assistance of deprived communities in theirhour of need and have been left holding the baby ever since. The Health Services Executive (HSE)has financially supported KCCP and a range ofother community programmes but to date theyhave limited their input into these programmes.The HSE must take more responsibility for therunning of these programmes. By taking a morehands-on approach, they could ensure that all staffare professionally trained and that clinical supervi-sion is provided.

I hope I have made a good case for working withthe transference in the clinic of addiction, and Ihope that I have demonstrated that by so doingKCCP could increase its effectiveness in its workwith its clients.

Chapter 6: Conclusion

Declan Byrne (086-8138618)

25

The Final Word

The Final Word

This report gives a very comprehensivedescription of the work of the KilbarrackCoast Community Programme which wasestablished in l998 in response to theincreasing use of drugs in the area. It isobvious that the project is successful inattracting clients with a wide range of socialand addiction problems. The case studiesdescribed give detailed accounts of this.

The author makes a strong argument foraddiction being located in ‘the psyche of theindividual client’ and that the issue of trans-ference and counter transference should berecognized and become an integral part ofthe training for all staff.

There are a number of glaring gaps in theservice provision, which I think warrantattention. It seems imperative that trainedstaff are recruited or that existing staff areseconded to addiction training. An agreedmodel of supervision needs to be imple-mented with all staff. There are blurredboundaries if staff and clients are on similarFAS programmes.

Many of the clients presenting to the pro-gramme are active drug users in addition tothose on methadone programmes. Manyhave immediate needs regarding treatmentand access to detoxification and rehabilita-tion. Dealing with addiction issues I would

argue needs a multi-faceted approach ofwhich awareness of transference and count-er transference is a component rather than aone-dimensional approach. A variety ofstaff should be considered ie. project work-ers, addiction counsellors, outreach staffetc. It is also possible that KCCP is beingtoo ambitious in trying to meet too manyneeds. While the appointment of a psy-chotherapist or any other professionalwould enhance the service delivery to theclients. I think, as a first step an overallevaluation needs to look at current clientneeds in addition to a training needs assess-ment for all staff.

Mary O’Shea is Assistant Director ofMerchant Quay Ireland since l999. Shepreviously worked as Head SocialWorker with the Drug Treatment CentreBoard and prior to that worked for anumber of years with the Probation andWelfare Service in court and prison set-tings.

Mary O’Shea

Addiction Research Centre. (2002) DebatingPublic Policies on Drugs and Alcohol. Dublin,Trinity College.

Agar, M.H. (1973) Ripping and Running: a formalethnography of urban heroin addicts. London,Academic Press.

Bourgioisie, Philippe. (1995) In Search ofRespect. Cambridge, Cambridge University Press.

Brown, Claude. L. (1950) A TransferencePhenomenon in Alcoholics: Its TherapeuticImplications (269-275) In Yalisove, L. Daniel (Ed)Essential Papers On Addiction. New York, NewYork University Press.

Bruce, Alan (2005) Drugs Task Force ProjectActivity for FAS Community EmploymentParticipants: A Review. Dublin, FAS.

Butler, Shane. (2002) Alcohol, Drugs and HealthPromotion in Modern Ireland. Dublin, IPA.

Corrigan, D. (2000) Response to Jane WilsonPaper In Beyond Maintenance (Ed. Walsh).Dublin, Veritas Publications.

Coveney, E., Murphy-Lawless, J., Redmond, D. &Sheridan, S. (1999) Prevalence, Profiles andPolicy: A case study of drug use in north inner cityDublin. Dublin, North Inner City Drug TaskForce.

Cullen, Barry. (2003) Community and Drugs: Adiscussion of the contexts and consequences ofcommunity drug problems in Ireland. Dublin,Addiction Research Centre - Trinity College.

Davidson, Virginia. (1977) TransferencePhenomena in the Treatment of Addictive Illness:Love and Hate in Methadone Maintenance (284-291) In Yalisove, L. Daniel (Ed) Essential PapersOn Addiction. New York, New York UniversityPress.

Dillon, L. (2001) Drug Use Among Prisoners: Anexploratory study. Dublin, Health Research Board.

Drug Misuse Research Division (2004) Report tothe EMCDDA by the Reitox Focal Point: Ireland,drug situation 2002. Dublin, Health ResearchBoard.

Farrington, D. (2004) Drug Prevalence in a MixedSuburban Area. Dublin, Government.Publications/National Advisory Committee onDrugs.

Fine, Reuben. (1972) The Psychoanalysis of aDrug Addict (217-242). In Yalisove, L. Daniel(Ed) Essential Papers On Addiction. New York,New York University Press.

Finestone, Harold. (1970) Cats, Kicks and Colour.In The Other Side: Perspectives on Deviance(281-297) Ed. Howard S. Becker. New York, TheFree Press.

Freud, Sigmund. (1905) A Case of Hysteria In J.Strachey (Ed.) the Standard Edition of the com-plete psychological works of Sigmund Freud.Volume 7. London, The Hogarth Press.

Freud, Sigmund. (1912) The dynamics of transfer-ence. In J. Strachey (Ed.). The Standard Edition ofthe complete psychological works of SigmundFreud. (Vol. 12, pp97-108). London. The HogarthPress.

Freud, Sigmund. (1915) Observations on transfer-ence love. In J. Strachey (Ed.). The StandardEdition of the complete psychological works ofSigmund Freud. (Vol. 12, pp157-171).London.The Hogarth Press.

Freud, Sigmund. (1916-17) Transference InIntroductory Lectures on Psychoanalysis (448-463) J. Strachey (Ed.) the Standard Edition of thecomplete psychological works of Sigmund Freud.Volume 16. London, The Hogarth Press.

References

26

27

Freud, Sigmund. (1916-17) Analytic Therapy InIntroductory Lectures on Psychoanalysis (431-447)J. Strachey (Ed.) the Standard Edition of the com-plete psychological works of Sigmund Freud.Volume 16. London, The Hogarth Press.

Garland C (2005) The Sheer Necessity ofSupervision In Eisteach Journal of the IrishAssociation for Counselling and Psychotherapy(Vol. 3 No.5 Spring)

Geertz, F. (1988) Works and Lives. Stanford,Stanford University Press.

Gustafson, James. (1976) The Mirror Transferencein the Psychoanalytic Psychotherapy of Alcoholism:A Case Report (243-264) In Yalisove, L. Daniel (Ed) Essential Papers On Addiction. New York, NewYork University Press.

Hawkins, P and R Shohet (2000) Supervision in thehelping Professions, Buckingham: OUP.

Hunt, G. & J.Barker (1999) 'Drug treatment in con-temporary anthropology and sociology' EuropeanAddiction Research 5:126-132

Imhof, J. Hirsch, R. & Rickard E. Terenzi (1983)Countertransferential and Attitudinal Considerationsin the Treatment of Drug Abuse and Addiction (292-311) In Yalisove, L. Daniel (Ed) Essential Papers OnAddiction. New York, New York University Press.

Imhof, John. E. (1995) OvercomingCountertransference and Other Attitudinal Barriersin the Treatment of Substance Abuse. In Washton,Arnold. M. (Ed) (1995) Psychotherapy andSubstance Abuse. New York, Guilford Press.

Kahn, Michael. (1997) Between Therapist andClient. New York, W.H. Freeman and Co.

Keenan, Dr. Eamon. (2002) ' Methadone mainte-nance treatment in an Irish context' from DebatingPublic Policies on Drugs and Alcohol. Dublin,Addiction Research Centre Trinity College.

Lacan, J. (1966) 'Interventions on transference'. In:J.Mitchell and J.Rose (Eds), Feminine Sexuality:Jacques Lacan and The Ecole Freudieene (J. Rose)(61-73). London, Macmillan Press.

Laurent, Eric. (1998) 'From saying to doing in theclinic of drug addiction and alcoholism'. Almanac.GIEP.

Lawless, Marie and Caroline Corr. (2005) Drug UseAmong the Homeless Population in Ireland. Dublin,National Advisory Committee on Drugs.

Loose, Rik. (2002) The Subject of Addiction.London, Karnac.

Marshall, M. Ames, G. & L. Bennett (2001)Anthropological perspectives on alcohol and drugsat the turn of the new millennium. Social Scienceand Medicine, 53:153-164.

Mayock, P. & Moran, R. (2001) 'Social Issues andPublic Attitudes Associated With Drug Misuse' (79-94) In Overview of drug issues in Ireland: a resourcedocument. Dublin, Health Research Board.

MacGabhann et al. (2004) Mental Health andAddiction Services and the Management of DualDiagnosis in Ireland. Dublin, National AdvisoryCommittee on Drugs.

Missen C and C May (2005) 'Supervision' InEisteach Journal of the Irish Association forCounselling and Psychotherapy (Vol. 3 No.5Summer)

Moran, Rosalyn et al. (2001) A Collection of Paperson Drug Issues in Ireland. Dublin, Health ResearchBoard.O'Gorman, A. (2000) Understanding the SocialExclusion-problem Drug Use Nexus. In Springer, A.& Uhl, A. (eds). Illicit Drugs: patterns of use pat-terns of response. Proceedings of the 10th AnnualESSD Conference on Drug Use and Drug Policy inEurope. Innsbruck: Studienverlag.

O'Gorman, A. (2001) From Research Design toExecution: Maintaining consistency and validitywhile responding to contingencies in the field.Addiction Research and Theory 9: 575-585.

Page, S and V Wosket (1998) Supervising the coun-selor, London:Routledge.

Patton, M.Q. (2002). Qualitative Research andEvaluation Methods. London, Sage Publications.

Peele, Stanton. (1995) The Diseasing of America.Lexington, MA: D.C. Heath & Co.

Peele, Stanton. (1998) The Meaning of Addiction.Lexington, MA: D.C. Heath & Co.

Peele, S., Brodsky, A., & Arnold, M. (1992) TheTruth About Addiction and Recovery. New York,Simon & Schuster.

Pelto, Peritti. J. and Pelto, Gretel.H. (1993)Anthropological Research. Cambridge, CambridgeUniversity Press.

Preble, Edward and John Casey. 1969. Taking Careof Business-The Heroin User's Life on the Street.The International Journal of the Addictions 4(1), p 1-24, March 1969.

Rawson, Richard. A. (1995) Is PsychotherapyEffective for Substance Abusers? (55-75) InWashton, Arnold. M. (Ed) (1995) Psychotherapyand Substance Abuse. New York, Guilford Press.

Sans, A.J. and Brendan Bartley (1998) Social exclu-sion and Local Responses: Life-Histories of Drugusers and Drugs in the Community (unpublishedreport), Dublin.

Samson, Luke. Singh, Reenee & Padmaja Barua.(2001) 'Qualitative Research as a Means ofIntervention Development.' Addiction Research andTheory. 9 (6): 587-599.

Selzer, Melvin.L. (1967) The Personality of theAlcoholic as an Impediment to Psychotherapy (276-283) In Yalisove, L. Daniel (Ed) (1997) EssentialPapers On Addiction. New York, New YorkUniversity Press.

Shaffer, Howard. J. & Melissa Robbins. (1995)Pschotherapy for Addictive Behavior: A Stage-Change Approach to Meaning Making (103-123) InWashton, Arnold. M. (Ed) (1995) Psychotherapyand Substance Abuse. New York, Guilford Press.

UISCE. (2003) Methadone: What's the story?Dublin, UISCE.

Walsh, Eamonn. (Ed). (2000).Beyond Maintenance. Dublin,Veritas.

Washton, Arnold. M. (Ed) (1995)Psychotherapy and Substance Abuse.New York, Guilford Press.

Washton, Arnold. M. (1995) ClinicalAssessment of PsychoactiveSubstance Use (23-54) In Washton,Arnold. M. (Ed) (1995)Psychotherapy and Substance Abuse.New York, Guilford Press.

Wilson, Jane. (2000). SubstanceMisuse in the New Millennium. InBeyond Maintenance. Dublin,Veritas.

Yalisove, L. Daniel (Ed) (1997)Essential Papers On Addiction. NewYork, New York University Press.

Ref

eren

ces

28

Other Publications by Kilbarrack Coast CommunityProgramme (KCCP) Ltd.

In 2004 the National Advisory Committee on Drugs(NACD) published ‘ A prevalence study of drug useby young people in a mixed suburban area’. This wasa report based on research conducted by KCCPunder the community/voluntary sector researchgrant scheme. This study established the patterns andtrends of alcohol and drug misuse in the Kilbarrackarea by young people aged 10-17 and examined theirattitudes to alcohol and drug use, and the risk factorsaccompanying their use. The study also assessed thealcohol and drug use among a sample of early schoolleavers and examined the views of community mem-bers on the alcohol and drug situation in the area.

‘The Raheny/Kilbarrack Report -Young People andDrugs’ was a synopsis of the NACD report, which wasdistributed to over 2,000 homes in the Kilbarrackarea.

Both reports are available on request from KCCP - (ph. 01-8324516).

“I would like to warmly congratulate you on the completion of this report. It provides a valuableaccount of what has been achieved by KCCP and the Kilbarrack and District CommunityAssociation and also of the very real difficulties under which it had to operate over these past sev-eral years.

I note particularly your own insights into what is needed to improve the effectiveness of KCCPand I very much hope that it will be possible to put these ideas into effect, for the benefit of allconnected with the programme.”

MMiicchhaaeell WWooooddss TT..DD..--FFiiaannnnaa FFaaiill-- DDuubblliinn NNoorrtthh EEaasstt

“This excellent piece of research by Declan Byrne is timely and very welcome.

Ten years ago I chaired the Cabinet Sub-Committee on Drugs Mis-use that led to the setting up ofNational Drugs Strategy and the Local Drugs Task Forces. There is now a need to revamp theNational Drugs Strategy to take account of changed conditions and altered patterns of drugabuse.

In doing that, new research like this is vital in order that we can best understand the phenomenonof drug dependency and its treatment and respond as effectively as possible.”

PPaatt RRaabbbbiittttee TT..DD..--LLaabboouurr PPaarrttyy LLeeaaddeerr

“ In doing a Masters in Addiction Studies, Declan has applied his learning to his place of workand engaged the interest of colleagues to change and improve the way they work with drug users.This report clearly shows the value of professional development and lifelong learning. “

MMaaiirrééaadd LLyyoonnss-- DDiirreeccttoorr--NNaattiioonnaall AAddvviissoorryy CCoommmmiitttteeee oonn DDrruuggss

“ Rather than mis-diagnosing the problem and mis-prescribing the cure, Byrne centralises the con-cept of addiction, (as opposed to drugs), critiques current orthodoxies, and highlights the inade-quacies of a system which fails to account for the tool of transference in the treatment of addic-tion/therapeutic alliance. ”

CCoonnoorr RRoowwlleeyy-- DDrruuggss EEdduuccaattiioonn CCoo--oorrddiinnaattoorr--CCrroossssccaarree

“This report focuses on an important aspect of working within therapeutic relationships, whereinterpersonal challenges are the norm rather than the exception. It is presented in a user friendlynarrative style and there is a message here also for services beyond the context of KCCP.”

LLiiaamm MMaaccGGaabbhhaannnn--DDuubblliinn CCiittyy UUnniivveerrssiittyy ((CCoo--aauutthhoorr ooff ‘‘MMeennttaall HHeeaalltthh aanndd AAddddiiccttiioonn SSeerrvviicceessaanndd tthhee MMaannaaggeemmeenntt ooff DDuuaall DDiiaaggnnoossiiss iinn IIrreellaanndd’’ ((NNAACCDD)) 22000044))..