Addiction Lives

On 15 November 2022, Duncan Raistrick interviewed consultant clinical psychologist Robin Davidson for the Addiction Lives series. Here they talk about Robin’s first introductions to transformative change and recovery through his father’s work, ‘standing on the shoulders of giants’ in the addiction field, and the need for comprehensive, theoretically-based interventions.

Duncan Raistrick: I’m Duncan Raistrick formerly of Leeds Addiction Unit where I was a consultant psychiatrist and I worked there with Robin Davidson, who I’m talking to now. Robin was a consultant clinical psychologist. Robin, I wonder if you can look back on your formative years and tell us a little bit about how they might have steered you towards your interest in addictions.

Robin Davidson: Thanks Duncan, and just to say thank you very much for giving your time up, so we can have this chat. You know it reminds me slightly of conversations we had in the olden days about the nature of dependence, usually in the pub I have to say. So, it’s nice to be chatting again a little bit more formally. I always think that my interest in addiction stemmed from my dad. He sadly passed away at the age of 96 several years ago, but he was an evangelist in a Dockside City Mission in Belfast and that’s where essentially I spent my childhood and early teens.

As a child I would see these men come into his Mission, who were basically serious drinkers and usually serious gamblers and they would become, in the local vernacular, ‘saved.’ I suppose it’s what Bill Miller would call a ‘quantum change’, or a ‘religious conversion’, or something like that. But these seriously heavy-duty drinkers and gamblers, with all sorts of other vices, would become saved and spend the rest of their lives working in the Mission. They would invariably stop drinking, they would ascribe the change to the Holy Spirit, but also to my dad, who sort of worked with them over the years. These men fascinated me and that kind of sudden transformative change in these dockside men from working class Belfast was amazing.

There was one man particularly called Buck Alec Robinson. He was what we would now call a ruthless paramilitary gunman in the 1920s during [The Troubles] but was saved under my dad’s preaching in later life. He famously kept a lion in his small dockland backyard. He died quite some time ago, but this man was an example of transformation through this type of religious conversion.

That’s very interesting and you say most of them were also gamblers, I guess at that time probably not drug users, would that be right?

Yeah, there were very few drug users if any. Their primary vices as they viewed them were gambling. Obviously not online gamblers in those days; their day would be in the Bookies and then going to the pub every evening and so on. That was a typical day of these men until they were, as we put it, ‘saved’ and suddenly transformed.

And your father sounds to have been an amazingly effective practitioner, so what can we take from his methods?

Well he once told me later on, you know that, when I tried to explain to him Prochaska and DiClemente’s transtheoretical model of change (1), he just looked at me wisely and said, well you know Paul, in the Acts of the Apostles, it talked about the spirit working with people, which is your contemplation, and then he said people became saved, which is your action. And then he said people grew in grace he said, which was the post-contemplation, and some he said back-slid, which is your relapse. But he said you know your fancy model was really invented by the Apostle Paul 2,000 years ago.

I was going to say, we didn’t really need Prochaska and DiClemente did we, we should have had the translation from your dad.

Yeah, if we’d just read the New Testament.

So, I guess you did get involved with AA meetings, I mean you obviously saw a lot of seriously problematic drinkers. Was it other self-help groups then, or was it really just the spiritual conversion?

It was primarily, almost exclusively, Duncan, the spiritual conversion. But it was really quite profound, because these guys did embark on a lifetime of abstinence and self-help. They went out and evangelised, themselves.

That’s interesting, isn’t it?

What I was interested in a little bit, and it was a slightly different thing, but related to that, was the Oxford Group at that point; now it had changed obviously after the war. It was Christians who met in each other’s homes. It was founded in the US but was big in Northern Ireland in the 30s. They believed in surrendering one’s life over to God’s plan. The group’s modus operandi and beliefs greatly influenced Bill W. Anyway, some of my dad’s contemporaries were members of the Oxford Group and as a teenager I was able to talk to them about the impact of the Oxford Group on Alcoholics Anonymous and how all of that evolved, which then interested me later in life. But I did get an introduction to the history of the Oxford Group at that time.

Interesting. Shall we just move on then a little bit. So you then went onto university where you were reading psychology. Did your interest in addictions grow as a result of reading psychology, or diminish, or were you thinking of a career elsewhere?

I’m not sure I, to be fair Duncan, did a lot of reading at university (laughs). But I was always interested really in how, after the formative experiences we’ve just been talking about, even at school and so on I was interested in what made people tick. I seemed to be that bloke, who wasn’t the greatest rugby player in the world and who wasn’t one of the in-crowd, but who people came along to when they had sort of problems. I don’t know why, but that seemed to happen in later years at school and I’m always intrigued about what made people tick. I think there was only one subject that I would have done at university and that was psychology, that was the kind of ambition I had from maybe Form 5 onwards. I wanted to add some of the technical issues to what I knew about informally at school. So that’s what attracted me to psychology at that stage. Then obviously clinical psychology was an important next step.

Yes. And where did you train in clinical psychology? Was that also in Belfast?

No. I wasn’t getting on any courses, so I went to my professor at that time and said, ‘Look, I want to get on the clinical psychology training programme somewhere’, and he said to me ‘Where?’, and I said, ‘Leeds’, because I actually supported Leeds United at that stage. And for one reason or another, which I’m not completely sure of yet, to this day, I got an interview at Leeds and was successful and got on the clinical programme training there and so left.

They were probably delighted to find somebody who supported Leeds United!

Probably, I guess so. So, I left Belfast and went to Leeds to train at the University of Leeds and there were several very eminent people involved in our training, like Alan Dabbs, Professor Hamilton, Don Bannister and people of that ilk, at that time. Max Hamilton was a significant influence and a formidable lecturer.

Hamilton of the Depression Scale?

Hamilton Depression Scale (2).

And did that also get you interested in what was a later interest of measuring things and scale development, or not at that time?

No, I was always interested in measuring things. One of my A Levels was Maths anyway, so I always had an interest in numbers and mathematics. So I kind of liked the idea of measuring things. I suppose at that time when I trained in Leeds it was very prevalent. I mean there was so much in and around the sort of the Hamilton Depression, HADS (3), and how these were validated and the issues around reliability and so on, were hammered into us at that stage.

Okay so you really had a very good preparation for what came next, which I think was working in general psychiatry, but with an ongoing interest in addictions, and then really moving into the business of service delivery in addictions exclusively.

Yeah.

Why’s that?

Well at Leeds at that time there was very little for addictions, basically. So, they asked me to start up some relapse prevention groups, basically for alcohol-dependent people, and focus these in the community, you know in various places like Horsforth, there are various places around Leeds, but that was all. Then they decided that they had to develop addiction services and appointed a young psychiatrist at that time, who was working in the Maudsley, to come up, whose remit was to develop, initially he was only half time and of course I’m talking about you, whose initial remit was half time and eventually of course it became full time. But the bottom line was that I was running these little groups and you came up to Leeds and there was essentially only the two of us doing then, anything in addictions and so I sometimes think that the Leeds Addiction Unit was basically, at one point, for several months, just you and I, standing talking about the nature of addiction and the nature of dependence and service development issues. And then of course, we worked together over the next few years and I’ll talk about that in a minute, but that’s how the interest clinically started in Leeds.

Yes, so as you say, it was essentially the two of us wasn’t it and we spent a lot of time talking about dependence, which we might come back to. I think we also spent quite a bit of time thinking about how we might run assessments and what a service might look like. And that was, it was a very interesting time wasn’t it? Because things were moving from mainly in-patient units with a totally abstinence-based model, to what we were more interested in, which was running a more of a community service and looking at alternatives to abstinence, although abstinence has always and will always remain an important possible goal.

Absolutely. I mean I think that we did move to the community. I remember at one time when I think you and I got into trouble in the Leeds Evening Post, I think it was, for taking what they called ‘alcoholics’ to the pub.

Yes, I remember that (laughs).

And there were other times when we were invited onto programmes then, like the James Whale programme on Radio Leeds. We were saying well we don’t actually necessarily believe that in-patient treatment is the best thing. We don’t even necessarily believe at that time in AA, although I’ve moved back to the idea that abstinence is probably the optimum golden choice, but at that time we were interested in the whole notion of controlled drinking, whatever that meant, and the sort of journey of addiction, rather than preconceived icons. So yeah, we did quite a lot of media things and talking to the public and talking among ourselves as to what a proper comprehensive, service would look like. Obviously, it moved to the Leeds Addiction Unit and changed, but there was a lot of thinking about how the service would evolve.

Yes, it was quite exciting times and along with that there was a lot of thinking as we’ve alluded to several times about the nature of dependence and we spent a lot of time struggling with that and eventually we were both involved with producing a questionnaire, called SADD – the Severity of Alcohol Dependence Data (4). Have you got thoughts about how that process went?

Yeah, I think that the development of the SADD was one of the very important things in my career. I think essentially my understanding is that Griffith Edwards developed this ‘alcohol dependence syndrome’ and he wanted to look at how it could be measured and came up with the questions and the interesting thing, and I’m biased because it was essentially, there was some sort of competition almost, between the SADD and the SADQ [Severity of Alcohol Dependence Questionnaire] at that time, possibly even still, because the SADD is used widely, internationally still and, I think both of us can be very proud. But the slightly interesting thing was that I think, and you noticed this too, that the SADQ was and continues to be widely used, but essentially focuses on the physiological aspects of dependence. Now the seven components of dependence that Griffith Edwards articulated were three or four physical and three or four psychological. The SADQ was developed primarily by psychologists, but focused on the physical. Our SADD questionnaire, which I think measures six out of the seven components of dependence, as we often preached, focused as much on the psychological components of dependence and yet it was a psychiatrist and a psychologist. So, and I still to this day think that the SADD is legitimate and relevant to measuring, as the DSM V and ICD11 incorporated Edwards original ideas, I think in our questionnaire is probably the best at encapsulating all the components of dependence. It was a piece of work over several years that we struggled to get a psychometrically legitimate, many factor analyses, many outcome studies and correlations and, which was fun to actually validate and make this questionnaire not only psychometrically legitimate but clinically legitimate.

Well unsurprisingly, I totally agree with you.

(Laughs)

It was an interesting time, because as you know I started thinking about the nature of dependence and the SADD when I was working for Griff in London and as he does, he said ‘Duncan why don’t you go and invent a questionnaire to measure dependence’. So, I set about doing that, but at the same time, Ray Hodgson was interested in controlled drinking and sort of overtook us and rapidly put together the SADQ, which for the reasons you’ve just said, I think is now rather misused, because the reason he was creating it was as a tool to look at people’s suitability for controlled drinking. So, in a way, although it seems strange that psychologists were looking at those more, well the withdrawal symptoms particularly, I guess you could argue they were maybe the more potent, or the more obvious perhaps measures for relapse from controlled drinking and therefore the unsuitability for people to go to controlled drinking. I think people, I mean the important lead-in, I’m sure you remember, to the SADQ is, ‘think about a period of heavy drinking in the last six months’ and that makes it not awfully suitable as an outcome measure, which it was intended to be. So anyway, so we are both agreed that the SADD was a truly excellent um…(laughing).

A truly excellent psychometric!

It took us a lot of work and I guess shows the value of, as we know of collaborations between different disciplines.

Absolutely, absolutely.

But maybe enough of Leeds then. So, you did move on then to develop and indeed deliver services in Northern Ireland as well, if you want to enlarge on that?

I think before we leave Leeds, there’s another stage in my career; there was a question around what’s the most important thing that you’ve written, or done and I think the most important paper that I wrote was the shortest paper I’ve ever written and it was [an] editorial for Addiction, in I think it was 1992, on a critique of the Prochaska and DiClemente model of change (5). That was just when I was leaving the Leeds Addiction Unit. I think the circumstances were that you and I had written a book – the ‘Alcohol and Drug Addiction’ for the Churchill Livingstone, I think it was (6).

Yes.

And just as it was about to go to the publishers, we read this paper on Prochaska and DiClemente’s model of change and thought, my goodness me that’s very interesting and it was. We had about a two or three day’s grace and we stuck in half a page on the model. And by the time of course the book was published, this model was all-singing and all-dancing on everybody’s wall and everybody was talking about it – the model of change. Griffith Edwards asked me to do an editorial critiquing the model in 1992. I think that was the first critique of this motivational model of change and I look back on that article, and I talked to other people and think called it, ‘A taxonomy of dispositional stakes,’ or something like that, which was a phrase that of course I could never dream up now. But I think probably, that critique of that model was kind of pivotal, just before I left Leeds and then went to Northern Ireland. And then I, yes, then I went to Northern Ireland.

Yes, so you felt that was perhaps one of your most important publications.

I’ve always been a believer, Duncan, in brevity. I’m now the National Assessor for the senior addictions appointments for the [British Psychological Society’s] Division of Clinical Psychology and before every interview they used to do a 15-minute presentation and I lost the will to live usually after seven minutes in these interviews. So, I suggested that we bring it down to 10, and then more recently five minutes, because I think if you can’t say something in five minutes that’s worthy, you are not going to say it in 15. So I guess I like brevity, so maybe that’s why I’m thinking that that particular two-page article was perhaps the pivotal one in my career.

It did stir up some controversy. What are your feelings about the stages of change model now? I think it’s lost some of its popularity, but it’s still quite widely used and alluded to in one way or another.

It is you know and I kind of got into trouble with Prochaska and DiClemente, we had some written altercations in one of Nick Heather’s books about the nature and the critique of the model. My position is that the model is now a friendly grandfather, who sits in the corner and we refer to him when we want to know about things from the olden days and sometimes wisdom. I think it’s accepted. I actually work in the courts a lot now, since I retired from the health service, and very often social services would refer to this model in court. So it’s almost got that sort of set in stone thing and it is used extensively and the words are used and the semantics are used and I think it’s probably okay to break motivation down into those components. Although clearly there’s been very significant theoretical additions to the notion of motivation in addictive behaviours since.

I guess the key thing for people to remember is that a model is just a useful tool, it’s not necessarily the whole truth and perhaps taking your point about brevity, it’s a very simple way of making some sort of judgement about where people are at and maybe that’s still quite a useful thing, but not to put too much weight on it perhaps.

Yeah, I agree entirely. So yes, I went to Northern Ireland after that.

So, then you went back to Northern Ireland and continued to provide services and develop services, did you want to enlarge on that a little bit?

Actually, the formative years when we talked about how to develop an addiction service, as was then, and the issues that you had to begin to be in control of as a service evolved and after, and of course the Leeds Addiction Unit became massively successful under your tutelage, and it developed over the years. I have to say those initial discussions about how a service should look, how it should evolve helped me enormously and it gave me the confidence at a young age, basically to apply for a, what they used to call a ‘top grade’ clinical psychology job, in Northern Ireland, to develop the service there for psychotherapy and psychological services. I probably wouldn’t have had that confidence had I not had the conversations about how services should look. So, I applied and was successful and then went there to develop what became one of the largest clinical psychology services in Northern Ireland, while still keeping an interest in addiction, which was important to me. So, part of my remit was also to develop an addiction service there too a little bit, nothing like [Leeds Addiction Unit] of course. So, I kept an interest in addiction, but more in the kind of operational side of addiction, rather than necessarily working as a clinician.

I mean it’s nice to hear you say that those early conversations were useful, and I guess some of that is a legacy that I took from Griff and he very much taught me how to apply for money basically and I think we did some of that together in the early days of developing the service and that’s a very useful lesson isn’t it?

It is, it is. Yeah.

So, I wonder if we should look at some of the other, you’ve mentioned one sort of controversial, not exactly battle that you fought, but one controversy that you were involved with, but I think more in your time when you were in Northern Ireland, there were a number of battles that you fought, taking on vested interests and in my view rightly so and moving the field forward. I don’t know where to start, but maybe if you wanted to, I know you were Chair of the Alcohol Educational and Research Council (AERC) and took it through the transition to Alcohol Research UK, which I think was not a straightforward transition and I wonder if there are things that you could tell us about how that worked?

Yeah, I seem to get into arguments with people and yet I’m not an argumentative person. I think of myself as a gentle quiet soul, who doesn’t really like confrontation. But I remember when I was aligning myself with, for example the alcohol dependence syndrome, I was kind of persona non grata at times with my contemporaries in clinical psychology, who thought I was going over to the other side, you know, the ‘medical model’ as it used to be called. Then I, you’re right, I got into…

That’s interesting, before you go on from there, I mean it’s interesting that idea of dependence, which you and I see as the psychological phenomenon was seen as the other side.

I think at that time…

It’s important that there was an idea of the other side I suppose as well but that’s …

Yeah, I think there were other sides and at that time there was psychiatry and clinical psychology a little bit and then there was the South of England and the North of England and so on, the London elite and those of us who worked in the North. There were a few kinds of other sides. I think that the more radical clinical psychologists who were writing books on controlled drinking and so on at that time, didn’t like the word ‘syndrome’. I think the idea of the alcohol dependence syndrome, which very modestly Griffith Edward called ‘usefulness of an idea’, question mark, as I remember, was taken as gospel and that was seen as, oh well this is just ‘medical model-lite’, and of course the medical model was a bete noire at that time. So that’s probably why I was seen to be slightly going to the other side. I think that was short-lived.

It always puzzled me what people mean by the medical model, I think they just mean maybe doctors, rather than an approach to things.

Yeah.

As you say, Nick I think was very critical of just the one-word syndrome, but actually Nick Heather very much agreed with our view on the nature of dependence that it was essentially a psychological phenomenon and much as withdrawal symptoms come into it, it’s not the withdrawal symptoms themselves, but how people respond to it.

I think you are right. I think it was more sort of silos at that stage and the use of the word ‘syndrome’, which basically most of us, most of us certainly north of Watford, agreed with what you’ve just said. And coming onto the question about AERC, to be based in Northern Ireland and to be asked to be, first of all a member of AERC and then I was lucky enough to be invited to be the Chairman of the Research Committee of AERC at that time, was interesting and humbling in a way. I did get into trouble as you alluded to, because there was quite a famous editorial in Addiction, by the Addiction board essentially, in and around 2005, I think, to say that the AERC was ‘sipping with the industry without a long spoon’, and two reps of the industry were sitting on the Board and obviously the industry was toxic. So, they were advising researchers not to take AERC grants. Clearly as Chairman of the Research Committee, I felt that we had built in loads of safeguards. We had an infrastructure which prevented the two members of the industry influencing decisions on the nature of research grants and I wrote quite a long piece in support of the AERC at that time, trying to suggest that, yes, we know that the industry can contaminate research and it mustn’t, but nonetheless, it probably wasn’t a hanging offence at that time anyway to have a couple of industry members on AERC and I have to say they did not work on the Research Committee and as I say all sorts of safeguards were built in at that time. But that was AERC and latterly and then I left and then was asked to come back as Chairman of AERC, in 2010 or around that time, and, maybe earlier. It was during my time as Chair we morphed into Alcohol Research UK and that was a very interesting time. I had some animated discussions with civil servants at that time about this transition from the Alcohol Research Council into Alcohol Research UK. It was a very interesting learning experience.

I’m intrigued by the conversations you had with the civil servants. Are you allowed to say?

I guess I realised that there’s a lot of…I was introduced to the idea of bureaucracy and regulation and the time that things took, as probably as a Type A personality, I guess I think I’m Type A, disguised Type A personality, I found it difficult, which I now appreciate was necessary, but the time that things took and the detail that things took. I sometimes find detail difficult. Maybe I’m more style than substance…

I don’t think so…

I do find detail sometimes difficult and of course there was a lot of detail in the transition from the Alcohol Education Research Council to Alcohol Research UK. Having said that I wouldn’t have swapped those six years as Chair, during that transition for anything, it was fascinating.

I think this question of bureaucracy continues today doesn’t it, and probably even worse than it was then? And if there’s one thing that does really make people angry, it’s not, well you need some bureaucracy, but it’s bureaucracy that seems not to have much point and it’s there for its own sake, because I know and I think you’re not a person that gets angry at all and if anything could make you angry, I could see it might be bureaucracy.

Yeah, I think Alcohol Research UK just after I left as Chair, was quite simply a research organisation. There was no policy influence whatsoever and just as I was leaving, I thought, it’s one thing giving out research money and so on, but we felt slightly that we had one hand behind our back, that we didn’t have any influence on policy, which just as I left, the talks begin to merge Alcohol Research UK with Alcohol Concern, which clearly was a policy organisation. And now that’s evolved into a joint organisation, as you know, Alcohol Change UK, which essentially is Alcohol Research UK with Alcohol Concern and I think that that makes sense.

Yes, I agree. But the primary issue that you talked about of taking industry money let’s say continues today doesn’t it and people have very strong views and different fields related to addiction are not taking industry money. Do you think the safeguards that you looked at did work, are they adequate, is it totally okay to take industry money, provided those safeguards are in place and the process is transparent?

I think, I hope that’s not a trick question! (Laughs) Now I absolutely think and as I said in my correspondence to Addiction at that time, with Alcohol Research UK that, I called my article, ‘Two wrongs don’t make a right’ and I thought that advising the research community not to use AERC money, because it was tainted by the industry, was the wrong advice, because I felt that there were sufficient safeguards. It’s only a small part of it and clearly there’s a much wider agenda here, but at least from our point of view, we went to massive lengths to create a situation in which the industry did not have any say whatsoever in the research money and topics. And those safeguards were thought through at length. They were incorporated as time went on into the whole structure of the organisation and I’m long enough in the tooth to feel that I wasn’t being manipulated, that clearly there’s a wider issue and so on. But I kind of wouldn’t be on the radical end of the view that ‘the industry is completely toxic’ as we’ve moved on and particularly with the alcohol industry, we can’t just eliminate any conversations.

No, I entirely agree. I think there’s a similar debate going on about the pharmaceutical industry, which people tend to think that any research done by Big Pharma should be ignored, which I think is probably folly. The research that they do tends to be of pretty high quality I think usually, it’s the way that the research is then interpreted by their marketing departments and presented to practitioners and indeed the public that becomes more problematic I think. But I don’t know, have you strayed into the pharmaceutical ‘Big Pharma’ controversy at all?

A little bit. Clearly the way that some opioids were marketed, particularly at the beginning of this century, was absolutely criminal and I tend to agree that it’s the marketing of the…the research in itself that I’ve read seems to be in technical terms, proper research. But as you say the way that the results were interpreted and marketed. Having said that I’ve been out of that debate for some time now.

Sure. Moving on then perhaps, because you then I think you became Chair of SMART Recovery and that was not an entirely straightforward business, I think of bringing SMART Recovery to the UK, really. I know that SMART Recovery is an evidence-based approach to addiction recovery. And SMART stands for ‘self-management and recovery training’.

Yeah, it was a difficult time for SMART Recovery in the UK, because there were various things going on. It didn’t translate terribly well from America, where of course it blossomed and was hugely influential. It didn’t translate perfectly to the UK market. So, I think they wanted me to be Chair, this will have been maybe 10 years ago now, as they needed this organisation now to translate to the UK. I was attracted to this and this is a full circle, Duncan, because of my interest in mutual aid, my interest in the Oxford Group, which I later actually explored and did some work on its relationship with the Fellowship. And as the years have gone on of course. I mean I, like everyone else was a bit suspicious of AA, because it didn’t meet my criteria as an empiricist and as a scientific psychologist, all of this anonymous stuff and six of the steps being spiritual and all this kind of thing. As a mathematician and psychometrician and psychologist it didn’t go down well in the eighties and so on. I then developed more sympathy for the Fellowship and the work that the Fellowship does and then I did look at the history of the Fellowship and particularly the history of the Oxford Group. So in a way becoming Chair of an evidence-based, but mutual-aid organisation like SMART Recovery was a very natural step for me and I liked the idea. I began obviously to enjoy the idea of mutual aid and to appreciate what the Fellowship has done for our speciality. So actually, trying to help translate the idea of evidence-based mutual aid, which essentially is what SMART Recovery is, to the UK, was six years, which I thoroughly enjoyed. It wasn’t without its difficulties. We needed outcome studies very badly, we needed to get money from various research organisations, or even clinical agencies and to go about actually ensuring that this evidence-based mutual-aid organisation could be bedded in, in the UK. And I think it has, I think the prison programme is working very well. It’s all over the four countries now of the UK. I see it even in the prison I work in, in Northern Ireland now. So, it’s lovely that SMART Recovery has been part of the language of recovery and addiction.

Yes, I think it is firmly embedded now, isn’t it? I wonder why, in general, or maybe you won’t agree with this, but in general, it doesn’t feel like mutual aid has taken off, or is greatly appreciated in the UK, as compared to say the United States. It all seems a bit of a struggle to get services to routinely refer people to mutual aid. Would you agree with that, or do you think I…?

I think maybe as we move and there’s lots of third sector agencies, this is something we’ll perhaps talk about in a minute, but I think that they are perhaps a little bit more responsible. I know that in our time there was a lot of suspicion, I mean clearly America and the USA accepted the Fellowship and, in a sense, there was some suspicion at our end of the nature of the Fellowship, the anonymity, the fact that many of the steps had a spiritual component and all of this. I suspect now, and I’m picking this up from information that I’m getting from working with various third sector agencies, working on the national assessors as I’ve said with the [Division of Clinical Psychology], and looking at this during interviews and so on, that on the ground there’s much less suspicion and there is an acceptance. I like to think that the Fellowship and SMART Recovery, well basically the Fellowship and SMART Recovery, are part of the fabric of what we offer now. There’s less hostility I like to think to that. I think of course, bearing in mind what I said at the very beginning of this chat, that the nature of mutual aid and the essence of mutual aid is an important part of our portfolio and delivery of addiction services.

Indeed, and it’s very moving to go to an AA meeting and I haven’t actually been to a SMART Recovery meeting, but I’ve been to several AA meetings and it’s very moving listening to people’s stories.

Yeah. I was at a talk a couple of years ago by a consultant psychiatrist called Conor Davidson and Conor Davidson is, well he calls me his grandfather when he’s presenting, but he’s actually my son.

Another distinguished consultant.

Another distinguished consultant. And of course, worked in Leeds Addiction Unit for a year as a registrar.

Indeed.

Which is like interesting in itself how these things go round in circles. But he was telling the audience as a registrar in Leeds Addiction Unit how he went to [a Narcotics Anonymous (NA)] meeting as an observer. He said that he was moved, you know he’s an empiricist, he’s a clinician, but he said that he was very moved by the nature of the dialogue of the meeting and the atmosphere of the meeting and he put it over, to what was essentially a fairly cynical, clinical audience, very well. I couldn’t agree more. I find, I have relatives who the first thing they do when they come from America to Belfast is seek out the nearest AA meetings. And we have an enormous number of chats about the process of recovery and the essence of this. So, I agree entirely, I think it can be moving at that emotional level.

I mean that’s very good to hear that story of Conor going to an NA meeting when he was working at the Addiction Unit. I think that’s what every practitioner should do, they should go to a couple of AA meetings and I guess now also a couple of SMART meetings. In that way I think they understand a lot more what is on offer at these different mutual-aid groups. But I was wondering if you see a difference in the kinds of people that go to AA, or NA, or 12-step programmes, as compared to SMART Recovery?

Ah that is interesting and I am sure there’s a literature which, since I stepped down as Chair of SMART. We were trying to get money actually to look at this very thing. Are there demographic, clinical, personality, whatever, differences between an individual who chooses SMART and an individual who chooses the Fellowship? My impression was and I defer to anybody who has done research in this area, but my impression was that, the one thing I tried to do as Chairman of SMART Recovery was not to be competitive with the Fellowship, and so we enjoyed the idea of people dipping into both, backwards and forwards as necessity called, or their individual needs, called. I suspect the demographics are slightly different between those who attend, particularly AA and SMART, I suspect SMART are younger, there’s clearly no spiritual element whatsoever. With SMART it’s very, very much based on the contemporary ideas of relapse management, motivational interviewing and all of the rest of the things. So, I suspect that there is possibly a demographic difference, but this is something which I actually was interested in, but I enjoyed the idea of these two mutual-aid organisations working in tandem as needed.

So, pressing that, I’m wondering whether the spiritual element is actually much more potent than the scientific approach, going back to where we started with your father’s very effective work as a practitioner almost. It does seem, I don’t, perhaps, I don’t have your experience of SMART Recovery but it does seem that if people take to that spiritual transformation, or conversion, however you would call it, it is very powerful.

Yeah, I think that it is. There’s a significant literature on post-traumatic growth for example, which is interesting and clearly Bill Miller has written about quantum change and these sorts of ideas. It is, as I said at the beginning, powerful and the six so-called spiritual steps in the 12 steps are central to the delivery of the Fellowship mutual-aid programme. I think, Duncan, it’s horses for courses and you’re quite right, but I think the problem that we had, perhaps, during the eighties is that we threw babies out with bath waters and that because of the spiritual component and all the rest of it, we lost sight of the wider goal.

Yes, you could well be right.

Yeah.

Shall we get back to the role of psychology just for a little while, because an enduring memory that I have from when we worked together was a demo video that you made of how to, well not how to, it was setting up interventions as we called it in those days and what struck me particularly and I remember very well, is just how easy you made it look and how you did it in a conversational style. So the person who was receiving the intervention wouldn’t even feel that it was an intervention. And my point is really that surely the addiction field really needs experienced psychologists like yourself and I really wonder why it is that psychologists, who really dominated the field perhaps back in the eighties shall we say, left in such large numbers and also I wonder what’s happening to psychology now, what you see is the future for psychology in addiction?

I think you’re right; I mean I think that any success I had in my career was on the shoulders of giants. I think that people like Jim Orford and Ray Hodgson, Nick Heather and Tim Stockwell influenced the field enormously and I’m sure I’ve left people out like, Ian Robertson. I think he and Nick’s book on Controlled Drinking and Jim’s ‘Excessive appetites’ really did set the psychology stall out and made an enormous contribution to the field at that time. (7 8). I think that various organisational things happened in clinical psychology for a while, after ‘Agenda for change’, people were attracted to the specialities to get quick promotion, and addictions was less popular. There was a tendency then for a while to appoint a psychologist to addictions units, who were relatively junior. For quite a long time actually the idea of appointing a consultant to an addiction unit became the exception, rather than the rule, unlike when the people I mentioned were around. So, I think that there was less interest in developing addiction services, or less interest to clinical psychologists for really, for quite a long time and I find that very distressing. Then I think as you and I know, of course the third sector organisations began to play a much more of an important role in addiction. The NHS agencies were reduced enormously as you know from Leeds Addiction Unit. I’m led to believe that there is only one NHS unit within the radius of the M25 and so on. And we saw the massive growth of the third sector providers in delivering addiction services.

 Yeah, that is perhaps more recent isn’t it, because I mean way back in the eighties a lot of psychologists left, or perhaps weren’t recruited, or was that the beginning of the process you just described do you think?

I think it was the beginning. Addictions became less attractive, because it didn’t offer the career opportunities of say child and adolescent clinical psychology did, that certainly the neuropsychology did, that adult mental health, even sort of highly specialist areas that were taken over by psychologists offered career progression, I’m thinking here of the neurodevelopmental disorders that psychology owned in the nineties and the 2000s. So, these were more attractive career opportunities. I also think that maybe people felt that psychology had made a contribution and what more could they do and clearly [cognitive behavioural therapists] and all of the rest of the growth of this made the therapy world much more divergent too. So, I think all of these things combined and then if I may move onto now, I mean I’ve had some experience with some of the third sector organisations and you know more about this than me, as the service evolved there were various third sector agencies offering bits and pieces, often expecting the increasingly smaller NHS unit to do the highly specialised work and there was a sort of silo mentality. It didn’t augur well at that stage for psychologists either.

Yes I mean it’s interesting because as you say we’ve recently over the last 10 years or so shall we say seen the loss of almost all NHS addiction services and that has now made addictions unattractive to medics. There’s no career path in addiction, unfortunately. I wonder now how you, what you make of the current state of addictions in the UK, perhaps thinking of what Carol Black had to say in her report, which in some ways sounded as if it was a bit of a correction from what’s happened and whether you see we need yet another change of direction?

I read Dame Carol Black’s report with interest (9), though strictly speaking it only applies to England and Wales. I felt that she was saying things that the likes of you and I were having conversations about several years ago and that’s a good thing. I felt that the silo mentality with this one agency presenting one little bit of addiction and another agency presenting another little bit and so on meant that there was little cross-agency communication. Again at an individual therapeutic level, I felt that you know basically an individual was carved up into their depression and their addiction and their autism and so on and treated by different people. So I think that there was a silo mentality in terms of agencies and a silo mentality in terms of individual therapeutic endeavour. What I think now Duncan is that, and I get my experience again from working as National Assessor for Addictions and interviewing for senior clinical psychology posts, and I’ll take Change Grow Live as an example, they’re now, after a fallow period, investing in consultant clinical psychologists. I think with Dame Carol’s report and there is an understanding in some of the big third sector providers that we need experienced people. You mentioned the work that I did before. As I say I think there’s a realisation now that we can’t have one person treating the individual’s anxiety, another person treating the individual’s addiction, another person treating the individual’s autism, another person treating the individual’s ADHD. It’s a bit of alliteration, my father always had alliteration in his sermons, so I always feel that I have to include it in any conversation. But you know what I mean, I think the idea that…

I do, absolutely, I totally agree with that, but as you say we’ve been saying that for a long time. But I’d be interested to know what the role of the new generation of addiction psychologists is going to be.

Well, I think exactly this. I don’t think that the new clinical psychologists are going to write ‘Excessive appetites’ or ‘Controlled drinking’ again. But I think what they’re doing is bring a comprehensiveness to the individual care. I think that if you have a consultant clinical psychologist, they can do just that, they can treat the whole person that perhaps technique-based therapists can’t do. Now I’m going to run into trouble here because one of my other areas of interest is critiquing acronym single modality therapies like Eye Movement Desensitisation Reprocessing (EMDR) or neuro-linguistic programming (NLP) and critiquing the idea of a therapy that’s based on a technique, rather than it based on fundamental psychological principles. I think the difference between a senior clinical psychologist and a technique-based therapist is the fact that the senior clinical psychologist can bring to bear a comprehensive intervention for an individual and they can relate things back to theoretical psychology and they can work on all of these things that I’ve just mentioned. So, I think why psychology is, why I’m optimistic about this is, while I think technique-based interventions with acronyms have their place, we’re now realising that we need comprehensive, theoretically-based interventions, therapists who can understand this. I’m a big believer that clinical psychologists must relate to their parent discipline and that means we can treat the whole person.

I hope that your optimism is well founded and all that you just said comes to fruition. But I was wondering as we get to the end, whether you had any particular thoughts about how we should approach the problems of dual diagnosis as people call it. I mean on the one hand you might think that almost everybody with an addiction problem, also has a dual diagnosis problem, albeit of varying severities and it seemed to me that one of the big problems for specialists, particularly specialists at NHS Psychiatry Services, is that huge numbers of people get referred, who really don’t have a mental health, or mental illness problem, but do have what people like to call issues of mental health. I wonder if your thoughts about having experienced psychologists are going to get round this problem and improve the efficiency of addiction services.

Yeah. I always feel slightly uncomfortable about dual diagnosis, since the idea, because I think many of us, there’s multiple morbidities with practically all of us. I read something in The Lancet one time that everybody over 50 had about four chronic illnesses, you know something like this.

Multiple morbidity is quite snappy, but I guess people like dual diagnosis because it’s snappy, but as you say it really means multiple morbidity doesn’t it?

I think that it’s always going to present a problem. We’re always going to have chicken and egg arguments, ‘does depression proceed the addiction, or the other way round?’ and so on. But I’m committed and I think Dame Carol Black is too actually, to this idea that I’ve tried to articulate earlier, that sometimes it’s important to see the whole person and the whole person is a complex mixture of, I’d not even call them morbidities, we’ll just call them emotions and so on. By the way I don’t like the idea of mental health issues and I don’t like it when people like Prince Harry go round and say well one in four of us have mental health issues. I think it’s quite demeaning for people who have serious mental illness.

Yes, I agree.

But I do, coming back to what I said about the kind of dealing with the complexity of the human condition, I do think that we need to be driven by proper theory and by properly experienced clinicians. I think, just as I felt that clinical psychology wasn’t making the contribution to addictions that it should have done for maybe 20 years, I also felt the demise of psychiatry in addictions as you quite rightly say over more recent time. I think that that’s a sad indication of the way that our field kind of went down the pecking order. It’s changing I’m hoping. I defer to your views on a career in psychiatry in addictions now, but I think we’re moving towards looking at a career structure in clinical psychology in addictions at the moment.

Well, I think that’s very good news and I hope the same will happen for psychiatry. Robin that’s been a very interesting conversation, just before we finally we wrap up, is there anything, one thing you want to say, a final message, one thing you want to change in the world of addictions? I expect there’s a lot of things you want to change.

I think we’ve probably covered it. What I would say one thing is that I made a choice to work in addictions when I qualified, that was literally a choice, because there was nothing going on in Leeds at that time and I kind of lobbied for some help for people with addiction problems and I’ve made a career out of it since then. If I was living life over again, I wouldn’t change it one bit. I think that our speciality has so much to offer in terms of behavioural change, in terms of this motivation, commitment and all of these sorts of things, that it’s a joy as a clinical psychologist to work in addictions and I think that yeah, I don’t think I would change it.

I think that’s a wonderful note on which to end and I would totally agree, a career in addiction is full of interesting problems and has so many different aspects to it. I fully recommend the career to anybody contemplating it. So, Robin, thank you very much for this very interesting conversation we’ve had for addiction.

Thanks Duncan.

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