treating causes not symptoms

It is a good general principle to treat the cause rather than the symptom, although in modern medicine we seem to spend more and more times and money treating symptoms whilst acknowledging, but refusing to deal with, the causes.

However what spurred me to write the previous post ‘losing a baby’ was listening to the radio yesterday and hearing a discussion about women whose babies were removed from them into care. Many of these women are stated to be ‘serial offenders’ I listened to the tone of voice that was used when describing women who ‘had their fifth, sixth, seventh or eighth babies removed – even a 14th baby, and even a 15th baby from the same mother’ – and what I heard was disdain and contempt. These were the same voices that I used to hear when I was a medical student, the same voices that advocated smothering disabled babies at birth and compulsory sterilisation for ‘people who don’t have the brains and money to bring their children up properly.’ Of course these were all male voices. Admittedly this was a long time ago, but I strongly suspect that the sentiments have changed remarkably little – the speakers are now wise enough to make their utterances in the private company of like-minded friends.

The report also stated that the average time between a mother presenting in court to have her baby removed, and then presenting in court again for the same reason was 17 months. “It suggests to us there’s a very short interval between pregnancies, which gives mums very little time to engage in their own rehab.”

In the majority of these cases the mother has drug or alcohol addiction, or both. Evaluation of drug and alcohol treatment programmes is complex as there is no standardisation across programmes, and no homogeneity amongst people accessing treatment.Residential programmes in the UK, usually lasting 28 days, have reported success rates of up to 50% or higher. It is repeatedly emphasised that even residential programmes do not provide an easy answer. “Rehab is not always an ‘exit door’from the treatment system. People frequently require continued support from other parts of the system”

It is well known amongst the mental health community, both service users and providers, that access to outpatient rehab programmes is limited by long waiting lists and lack of geographically convenient facilities. Access to residential programmes with NHS funding is even more difficult to obtain. Thus the odds are stacked against addicts who want treatment – they may well be motivated to change, but have no realistic hope of getting help to do so. In a ghastly parallel with obese patients who are told that they are not yet fat enough for surgical treatment (and who therefore go away and try to get fatter), access to the limited NHS resources that exist for drug and alcohol rehab tends to be limited to the most severely ill people. As in other areas of life, the growing wealth gap plays a big role. Drug and alcohol addiction generally results in a downward socioeconomic spiral – except for the wealthy. It is hardly a secret that cocaine is used widely in the City and in that the drug and alcohol culture plays a big part in celebrity lifestyles. These people often make overt statements about ‘entering rehab’ at some very expensive clinic.

If NHS access to drug and alcohol rehab is limited, then NHS access to inpatient mother and baby mental health units is equally difficult.There are currently (last available figures 2013) only 11 mother and baby inpatient psychiatric units that have linked perinatal psychiatric teams in the entire country. Yes, eleven. As far as I know none of these would take a mother with drug or alcohol addiction.

Clearly a very large part of the problem is very limited NHS budget available, and if mental health services in general are an easy target for commissioners, then drug and alcohol rehab is going to stay at the bottom of the list of mental health conditions that merit treatment on the NHS.

Why should this be? Surely it makes sense to treat mothers effectively and enable them to keep their babies. Placing children into care is very expensive, and the outcomes for the children are not good. Children staying in care have lower levels of academic achievement and higher rates of emotional and behavioural health problems. This government report does not deal with sexual behaviour, but my psychotherapy experience leads me to understand that children in care are likely to have earlier sexual experiences, and are more likely to experience sexual abuse and rape. All of these factors carry extremely high emotional and financial costs to the young people and to the taxpayer, and cycles of deprivation are well recognised.

If it doesn’t make economic or emotional sense to remove babies from their mothers why do we do it – and as the report that triggered my writing states, we do it repeatedly to the same women. I am convinced that this is not just a financial issue. It is a part of the deeply confused attitude that not only lay members of society but also the medical profession has to mental illness. Is it real? Is it really an illness? Why can’t the depressive pull herself together? Why can’t the anorexic just eat? Why does the addict ‘choose’ to get addicted in the first place, and having done so, why not just stop?

Within the mental health debate addiction disorders have a special place. Even for those who accept the reality of psychotic disorders (manic depression, schizophrenia) there are questions about addicts. Even the term is derogatory. An ‘addict’ conjures up an image that is rarely accompanied by compassion and a desire to heal. The Spectator debated the motion ‘Addiction is not a disease’ and concluded that it was not. I think that the use of the word ‘disease’ muddied the waters – it is more helpful to think of addiction as a mental illness (as with other mental illnesses). There is far too much judgement going on in this field (from within and without) and far too little understanding or compassion.

I suggest that it would not only be cost effective, but also humane to provide mother and baby units dedicated to mothers with addiction disorders. These would be residential units with programmes lasting between 28 days and six months. In addition to treating the mother’s addiction (and the baby’s if necessary) mothers could learn parenting skills. They could also learn how to cook cheap and nutritious meals for themselves and their families, and those without adequate education skills could receive some help. Such residential units would need to be backed up with ongoing community support from a consistent team of workers who could establish trusting relationships with their clients. Of course this model would be expensive, but it offers promise for the future. It offers hope of breaking the cycle of deprivation and abuse. It offers mothers and babies an opportunity to grow up together and to develop good relationships. It offers a way out of addiction, with its accompanying criminality and associated physical illness. It offers children a way out of a life in care, which may be no better than the life that they are being removed from.

Finally there needs to be acknowledgement that there is such a thing as a stable addict. There are people who are maintained on long term methadone. There are people who remain casual drug users, especially of non-opiate drugs, for decades. I am not aware of good evidence that such people make uniquely bad parents. Many of the judgements about addicts stem from a protestant morality. Perhaps it is time to rethink our own positions.

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