The Reward is the Journey: When the fun has long gone but you can't stop

As a therapist with a special interest in our relationships with substances, it is important for me to remember the terrifying prospect that abstinence may represent to many people. As someone who works with many gender and sexual diversity clients, I have noticed the overlap between those who might identify as belonging to a minority group and those who are primarily interested in reducing, or controlling their usage of drugs and alcohol. From a therapeutic perspective, the distinction is all important. The goals and objectives look very different for the client, and therefore for our work together.

The Club Drug Clinic at Chelsea & Westminster Hospital and CODE at 56 Dean Street in Soho know this better than most. Working with LGBTQ individuals who use substances requires an appreciation of the particular contexts in which drugs are being used. Drugs have come to play an important part of the scene for many communities, and without this knowledge and understanding, therapeutic outcomes are likely to be significantly compromised.

Trends have changed over time. And will continue to do so. There are a multitude of different highs (and lows) out there. Antidote have gathered some scary stats. These are based on their actual experience of 9,000 contacts with LGBTQ people each year. They support 800 people through treatment for substance misuse. The biggest offenders of the moment are crystal meth, GHB/GBL and mephedrone.

Contrary to popular belief, crystal has arrived and is running riot in the community. In the last 7 years, use of crystal meth has shot up. And it is being shot up. High risk behaviours are common resulting in an explosion of HIV and Hep C. Research is playing catch up but we do now now that GBL is highly addictive, and detox from it requires medical supervision.

So, when is recreational use no longer any fun? The 5 day 'weekend' is a reality for many people whose usage has far exceeded what it first was. People are finding themselves crossing their own boundaries, and going further still. The impacts and consequences may be the only memories they have.

Common to all the work I have done around addictive processes, is the central position of shame. As a practitioner, it is very often the shame that underlies the addiction (which I see as a symptom of the problem, rather than the problem itself) that needs to be addressed within the therapeutic encounter. Should we bypass this and focus only on either stopping or cutting down, we run the risk of not only doing clients an enormous disservice; we may well take them to a worse place - in touch with the raw and perhaps long avoided shame, without the ability to adequately self medicate. In doing work of this kind it is vital to not only know the score, but to be very clear, as therapists, about where we are choosing to position ourselves.