Transcript of Listique's Interview with Dr Cosmo Duff Gordon and Dougie Dudgeon from Start2Stop
Elizabeth Greatrex: Can you tell me a bit about Start2Stop?
Cosmo Duff Gordan: We’re a private sector provider of addictions treatment. We sit in two niches. In 2010 I started up London’s first private sector evening outpatient programme. The classic stereotypical addict is some guy who is crazily out of control, possibly on the streets. That’s maybe 14% of people that have an addiction problem. 65% of being with an addiction problem are actually binge pattern. These guys, they’re not using every day. Maybe every week. It tends to be alcohol and coke. They’re kind of holding it together. They’ll see therapists. They’ll see psychiatrists. But they’ll probably carry on using, but probably just with more insight. The binges will carry on and they are problematic. These guys have sufficient enough problems that they need one-to-one therapy, but they wouldn’t see themselves as so bad that they need residential rehab. What’s called IOP, Intensive Outpatient Programmes, they’re designed really to meet the needs of this cohort of people. The proposition really is, you know you’ve got a problem, you want to do something about it. Because you’re a binger you’re not physically addicted, you don’t need a detox, you’ve still got a life. You’re working, you’re fairly functional. So you would stay at home, go to work and then you come in in the evenings.
EG: So, people would come in every evening?
CDG: It’s two nights a week and Saturday mornings. Plus, individual counselling. So it’s fourteen weeks long. It’s basically a four-month commitment. It’s designed to help you carry on living at home, living your life, build a recovery architecture. It sets the foundations for a really good long term recovery. Anyone can go to a private hospital for 28 days. And you can pay £10,000 for the privileged, £20,000, or even £100,000 if you want. But it’s not very difficult to stay clean there. Relapse happens when you come home. So if you could build your recovery in the real world, you’re likely to have a pretty good outcome. So that’s the evening programme which I started in 2010. In 2012, I opened a small 8 bed residential rehab here in Kendrick Mews. Which is providing what’s called secondary care. So residentially, we work with people that really have crashed and burned. Who are physically in danger, who do need residential rehab. Our job when they come back to London. We say come and live here in South Ken with us, and we’ll provide a safe place to live, while you build a life back in London and in recovery. We’ve expanded over time to about 27 beds.
EG: What made you both want to go into this industry?
CDG: In my case, I had a heroin addiction, and I got clean when I was about 35 and I was basically unemployable. I just fell into it. And then found out, you know the usual story, that I enjoyed it, I was quite good at it. That’s been my journey.
EG: What about you?
Dougie Dudgeon: I had 30 years in a completely different type of business. And eventually I succumbed to the inevitable of doing some treatment, I believe. For four weeks and I sustained for four months. Mainly because I got really, really good advice from my counsellor. Who happened to be, Cosmo.
EG: Oh really, wow. So it’s turned out well for you then.
CDG: He’s got Stockholm syndrome.
DD: Because I’d been in a completely different environment before, I retrained and I went to College. I’d never been to college before. That was exciting. And I trained as a therapist and I ended up going back to the rehab I’d already been to and then got the opportunity to come back to London and do Start2Stop.
EG: It must be so different, doing the music industry as opposed to doing this.
DD: Not really. It’s pretty much the same. People that are slightly delusional about the real world. Who want to get away with things without any consequences.
EG: But in the music industry they do get away with things without consequences, don’t they? And in here they don’t?
DD: Well, some people in the music industry do, I didn’t.
EG: Do you think it’s possible to recover from addiction? People have said in the past, ‘once an addict, always an addict’. Do you agree with this? Is it a lifelong illness that someone always has to some extent, and a matter of building your life back up around this problem, or can you actually get rid of it completely?
CDG: That’s a very interesting, very big question. When you say it’s an illness, is it a spiritual illness? Is it a biological illness? Is addiction a functional unresolved early childhood trauma? Maybe for some people it’s the function of just the drug. You know, if you take crystal meth often enough, crystal meth is the most powerful substance on the planet, you may well get addicted to it. If you drink a bottle of vodka a day for long enough you may well get physically addicted to vodka. Is it a habit? Or is it a limbic system problem? There’s all sorts of models. My understanding of stats would be quite a few people will mature out of addiction in their thirties. It’s called the ‘maturing out’ hypothesis. Quite a lot of people who meet the diagnostic criteria for addiction in their mid-thirties, without any kind of intervention will mature out. You’ve also got to ask yourself what does it mean to recover from addiction, what is addiction? Some people would say addiction is a relationship between you and the object of your addiction. The diagnostic criteria is more interested in impaired control if you look at the taxonomies. It’s more about impaired control. But it is a control problem, it’s a relationship. It fills a hole in the soul maybe for some. Or for many. Again, what does recovery mean? There’s lots of different definitions in recovery. The Betty Ford Foundation. They tried to formulate a definition for recovery. I seem to remember their definition was essentially the definition is abstinence, from all substances. A spiritual transformation, a spiritual journey. I think was their definition. Other people would say recovery is recovery back to control drinking. I would say my experience would be, some people can manage it. I’ve never seen an out of control alcoholic, manage to control alcohol. I’ve never seen that.
EG: You mean they never completely get out of it? You mean they have to stop completely to be able to manage it?
CDG: Yeah. It’s so difficult, I mean the safest thing undoubtedly is to abstain. If you think it is a spiritual hole, you are probably going to find that you have been trying to fill that hole long before you discover drink and drugs, in other ways, as a kid. Many people will run into problems, do some form of rehab, go to AA, NA, clean up and stay abstinent for a number of years and try to control drinking or drug use. And maybe for some people it works. I’ve seen many people who have tried to do that and it hasn’t worked. Ultimately everyone has their own journey.
DD: I think that’s the thing isn’t it. It’s a truly subjective experience. It really is. There’s lots of stats, lots of research. In fact, my favourite definition of recovery, which I can’t repeat word for word, is the Scottish Recovery Consortium. They have a really good definition. But it’s a subjective experience. I’m eleven and a half years clean and sober.
EG: That’s amazing.
DD: Particularly given how much I was drinking. But I had no interest in that at all, I don’t even miss anything. People say to me, ‘what do you do to escape?’. And I say, ‘escape what?’ It’s a subjective experience and that whole way through is I think.
CDG: It’s a tough one, I mean people have their own journey’s around that. A lot of people say to themselves, well I haven’t drunk or taken drugs in several years, I’ve worked on myself, I’m a different person. They say, maybe I can smoke dope now and again, have the odd civilized glass of champagne. And they try that out. And maybe for some that works and they can pull it off. However, we do see many fail to pull it off, but then, we would because we’re a treatment centre. This is the thing, there’s a circularity that we only see the people that haven’t pulled it off. It’s possible London is just crawling with people who have successfully pulled it off.
EG: What is the main substance that people have an issue with when they come here?
CDG: 92% it’s alcohol and cocaine.
EG: It’s not heroin at all?
CDG: Heroin, not at all. Heroin is still a minority drug. I say that, but in America there has been an epidemic of opioid use. I think in England, in the UK, doctors have been more controlled about what they can prescribe, so they haven’t seen the same epidemic. But maybe that’s coming.
DD: Well, although have been a lot of reports of it, up North in depressed areas. Well, we will see that coming because we generally do everything that the American’s do. At some point. So I’m sure we’ll see that. Heroin is not in fashion at the moment.
CDG: It’s not in fashion.
DD: It was a very fashionable drug, for a segment of people that wanted to live a certain way and be a certain way. There are some people that actively run towards addiction. There’s niche drugs that are problematic. When I was in Cape Town, I was working treatment there for ten years. All crystal meth addicts were from working class, blue collar, what they call coloured townships. Here, all the crystal meth addicts seem to be from the club and chem sex town. It’s a completely different set.
CDG: In any rehab, you’re at least going to see 50% almost certainly more of the clients will have an alcohol problem. Because alcohol is the most commonly available drug in the west. But I would say where it has probably changed is, as Dougie was saying, you see a lot of crystal meth addiction now. That seems to go with chemsex. Often in the gay community. Not exclusively so, but the majority of.
EG: What’s that?
CDG: What’s chemsex? Chemsex is when you associate the sex with injecting, often shooting up, crystal meth, sometimes into your penis. You take very powerful drugs like crystal meth that make you very disinhibited, that can give you very prolonged erections.
DD: It’s a subculture within a culture. So it’s not all the people within a culture. But that subculture, where you will see people getting ‘addicted’ to grindr. Because grindr hooks them up. And the wording is very specific. If the wording is, ‘party’, that means drugs. Various other wording within the messaging indicates what people are up for and what they’re not. And people take a huge quantity of drugs in order to take part in that.
EG: So you meet a different range of people here then?
CDG: We’re in South Kensington, so we’re without a doubt very well regarded as a private treatment centre. So out catchment area if you like is, Notting Hill, South Ken, Chelsea, Fulham, Battersea, Belgravia, Knightsbridge. We charge very reasonable treatment fees. So I think the paradox is you can have multi billionaires in treatment, at the same time as very normal people. Which is quite nice actually. We try and be Waitrose. We’re not Fortnum and Mason. Because we’ve got referrals from all over London.
CDG: We’ve had the odd rock star, the odd pop star. You know and so on.
EG: Do you think that people take drugs to be creative?
CDG: That’s an interesting one. I think if you’re a creative type, I think there’s often a lot of existential angst. And you’ll probably find that you were drawn to drugs long before you ever monetized your creativity. There is a certain creative sensibility that is drawn to drugs.
DD: I have very mixed things about this because a lot of people’s first great album is done when they can’t afford many drugs. That comes out as fantastic. Then they’re given a year to make the second album, and they’re given a lot of drugs. And the second album is almost always disappointing.
EG: I was under the understanding that the people that came here, that a lot of them were rich. Is it expensive to come here?
DD: I think expensive is a relative term. If you look at, as Cosmo pointed out, the evening programme, is very competitive. In terms of continue of drinking. Instead of a compress 14-week continuum. If you look at extensive residential treatment, there isn’t anywhere in the world that that is cheap. It’s always going to cost a certain amount.
EG: Who are your competitors?
CDG: We have no residential competitors. Over the years the odd entity has tried to copy. Especially our evening programme. But they’ve all failed. Put it this way. In terms of price. Three months with us residentially would cost the same as one month in a normal, residential rehab treatment centre. Yes, there is a cost. I suppose what it comes down to is, addiction can kill you. It really does, it can lead to death. So, if someone has a serious addiction problem, paying a discretionary expense, if you love someone and care about them, it’s something you need to do. However, the problem the public have got, they tend to equate high cost with excellence. They think because they’re charging £25,000 a month they must be brilliant. That is actually not true. There is not necessarily a correlation between cost and outcomes when it comes to private sector rehab. You should read the Sunday Times, the big expose. They named and shamed all sorts of people. They had a bank statement showing kickbacks by two doctors from rehabs. Exposed a lot of rehabs in this country that rely on brokers. Who essentially take a fee for referrals.
EG: People in positions of power or authority, do you think that their lifestyles, the stresses that they have, do you think that that is more stressful than the life of someone who doesn’t have a lot and has grown up without stability and money? What socioeconomic group would lean more towards addiction?
CDG: I think addiction is money. People with money have massive addiction. I think also, with the less privileged people of society, there is huge addiction. And always has been.
DD: What it probably is, is that if there is a lot of money to cushion the consequences of the addiction. So, if a guy that can only afford one car crashes his car, it’s a major catastrophe. But if someone very wealthy crashes a car, they can just buy another one. So it’s about the consequences. Oh, you’ve dropped out of university. For some people that means not getting funded, it’s a major catastrophe. If you’re wealthy, maybe it’s not. For people that are better off, I think they get more feather mattressing, as consequences happen. That’s problematic when you have to address the addiction. Whereas, perhaps, if there is less financial stability, the reality and the hard edges of life will hit them. That’s the difference.
EG: People with a lot of money can just go to the pub, and they don’t have to go home at any time because they don’t have work the next day because they don’t need to work.
CDG: You’re talking about the idle rich, about trustafarians. I think the trustafarians, it’s very difficult. There’s going to be complex family systems, there’s probably going to be a lot of control. There’s going to be trust funds, lawyers, family offices. There’s going to be a lot of cushions, a lot of enabling. And there’s going to be low self-esteem. Because I think if you haven’t made the money yourself…I think we only tend to value stuff that’s cost us something. If money just falls into your bank account every month, as a direct debit from Coutts, it gives you no meaning.
CDG: People that don’t have much money, when they run into serious problems, the consequences are very real. In that case it gives them the motivation to change. But with the very, very wealthy, where are the consequences? Ultimately it’s loss of time, it’s loss of self-esteem. Ultimately it has to be existential. I think there has to be a moment where you wake up and look at yourself in the mirror and think, I’m not happy with who I have become. But I would say in my experience, and I’ve been doing this about 15 years, that Ultra High-Net-Worth and trust fund type people are tricky clients.
DD: It’s interesting because they’re tricky, because there aren’t any consequences. Equally, if you’ve got someone who is a captain of industry or highly successful in the law or accountancy, or whatever it may be, any of the professionals, doctors. They can be really high earners. The fact they’re high earners and supporting the addiction makes them the field trip. Because they think, I’ve paid all my bills, look how well I’ve done, I earn all this money. But it’s completely the opposite, but with the same problem. It’s an interesting subject. There will be things in every segment. For me, the two biggest things are number one, that people’s denial systems stop them from realizing they actually have a problem. And number two, that the stigma of actually going and asking for help.
EG: Why do you think there’s a stigma of asking for help? Do you think people are embarrassed?
DD: They think it’s a moral weakness or a failing if they can’t control the amount they drink. Or if they can’t control themselves when they’ve been using drugs.
EG: How do you think it affects the person’s family when they’re going through this. Do you think it majorly affects all areas of their life, in terms of those close to them, those they work with, etc?
CDG: Imagine a pond, a really huge boulder is dropped into it. It’s going to ripple out everywhere, it just will. For example, if you’re an addicted mum, you will let yourself down as a mother when it comes to your kids. And there will be problems in your marriage. Whoever you are, if you have an addiction problem, it’s going to affect people that love you and people that care about you. The problem with addiction is, the addict is the last person to know that they are an addict because of their denial system. Addicts will always think something totally different is round the corner. The road to rehab is always paved with good intentions. But ultimately the addict is always the last one to know. Virtually everyone with an addiction problem is leveraged into treatment. There is a crisis of some sort that is existential or external. There’s some sort of crisis.
EG: Does the addiction come first before anything or anyone the addict cares about? Is it completely out of their control. Or is it something they can control?
CGD: It depends on the pattern of addiction.
DD: I would say inevitably, yes. Because I would say that addiction is a progressive illness. And as it progresses, the addict’s world gets smaller, and smaller, and smaller until there is only the relationship with the addictive substance or behavior.
EG: Do they see it as a friend?
CDG: Well it’s a relationship that meets the needs. Most people with an addiction problem are damaged as children, it’s what’s called attachment trauma. Not everyone, but the majority I would say, there is damage. And most people with addiction problems find relationships with other human beings tricky. And so, the beauty of addiction is that the addict has pleasure in the absence of others. It’s me and my vodka, it’s me and my heroin.
DD: But interestingly, if you look at the stigma, we say that most addicts have a problem childhood. Parents hear that, and they say, I think I’ll send them to addiction treatment. They think, I must have done something wrong. I think that’s what you come back in on with the disease model. We just say, listen, this is a disease that 10% of any given population will get. So there may be indicators. Adverse childhood experiences are big indicators. But they’re not necessary. But you can have addiction without having any adverse childhood experiences.
EG: It just really depends on the circumstances doesn’t it. In what circumstances do you think someone is more likely to make a full recovery when they come here? Have they make a full recovery when they come here?
CDG: Bingers do outpatient treatment from day one for four months. They carry on working. If however, you are more acute, more serious, more chronic. Life has totally fallen apart and you are physically addicted. You are bang at it all day, every day, you go for primary treatment for 28 days, somewhere in the world. And we take referrals from all over the world, and then you might come and live here for a few months, while you’re building your life back in London, while you’re in recovery. If you want good outcomes with addiction treatment, then time and managed care is your friend. Because the secret is to build the life, to build the recovery architecture while you’re being supported. That’s the tricky bit. Anyone can go to a private hospital, to a primary for four weeks, and stay sober. But not anyone can stay sober when they leave. The majority of people will relapse when they go home. But the people that come here, they will be here for a long time.
EG: How important are ‘sober buddies’ or ‘recovery buddies’?
CDG: You’re talking about recovery coaches. I think to some people they can make a real difference. They’re like extra glue, not everyone needs that extra glue, but I think if you are someone that needs the extra glue it can be really helpful. They’re part of an arsenal of recovery tools. I think many people have been helped by sober companions.
EG: Why 12-Step recovery and not smart recovery?
CDG: I personally think of addiction essentially as a spiritual problem. I think they are at it long before they discover any form of drink or drugs. They probably have a hole in the soul since they have been tiny. In other words, they have felt different, they’ve felt probably not good enough and a sense of unease. If at age 13 you have discovered booze, and then a spliff, it goes from there. I personally think there is a spiritual solution to an addiction problem. I ultimately believe that abstinence is the way to go, and I’m no means an expert on smart recovery, but from my understanding of it, it seems to me like it’s treating an addiction using Cognitive Behavioural Therapy. Whereas 12-step says it’s a spiritual illness, I think the smart model would be talking about attitudes, beliefs, cognitive behaviours, how you think about things, coping behaviours, coping mechanisms. So it’s a very different level of analysis that I personally don’t believe in.
EG: What is your outlook for each and every person that every person that you deal with?
DD: People have lost their way when they come to us. We want to find out what they want, what their outlook is? Once we’ve confirmed out their outlook, we can work with them, to support them. It doesn’t matter how much money you’ve got, if you are addicted to something, it’s going to make your life miserable. You’re either going to do something about it, or you’re not do something about it. There’s a lot of things that wealth can insulate you from, but it cannot insulate you from addiction.
CDG: Being an addict is an inconvenient truth. It’s not part of the plan. You want to be an abuser, someone who can dibble dabble. In other words, you have that kind of control. The ability to do that. That’s what every addict wants to be, especially the rich addict. So much of the rich addict’s life only really makes sense. So, you’re really loaded, you’ve got a house in Ibiza, a chalet in Verbier, a town house in London, a flat in New York. Maybe even a villa in Majorca. A lot of your life only really makes sense because you’re drinking and using coke and partying. You’re going to have big house parties. To be told that you’re an addict is really inconvenient. What I would say happens a lot is that a lot of therapists and psychologists don’t really understand addiction, and they will start going down rabbit holes of, well maybe the problem is that you’re a bit depressed? Maybe the problem is that you’re bored so you’re doing a lot of coke? But I think the truth of addiction is that a primary diagnosis is often not uttered. And if you’re being really cynical you could say that the really, really rich, and I’m talking about people that I have worked with that have not one, but two psychiatrists. These people are interested in it not being addiction, because then they’d be out of work. Because the thing about addiction is when you have an addictions problem, it’s a primary diagnosis. If you deal with addiction, other things in life tend to fall into place. Any other stuff, anxiety, depression, it’s all a different animal. A lot of these professionals are not needed.
DD: It’s quite interesting, part of our assessment process is there is a diagnostic set of criteria. When I’m doing an assessment and someone scores top marks, I’ll say, that’s great news. Because this person’s an addict, which means there is a solution. There’s a treatment for that. The other stuff, it’s an ongoing process.
EG: How many people do actually recover in these situations? Do some people never get through it?
CDG: Maybe one in three, never quite get there. Long term good outcomes are correlated with 27 weeks of managed care. There are quite big studies around that. There are a lot of companies that deliver bespoke, one-to-one. Starting price £40,000 a week. And I think a lot of very rich people are seduced into doing this. I think that group based therapy works best. Often the very ultra high-net-worth people don’t go to treatment centres like this one. We do get ultra high-net-worth’s, but they tend to go to clinics abroad like in Switzerland. Where it’s all one-to-one and very expensive.
EG: Is it not better to be in a group situation? To bounce off other people?
DD: 100%. Therapy in communities and group work along with a continuum of care that Cosmo was referring to, that is what gives the best outcome.
CDG: You can have ultra-high net worth’s with genuine confidentiality issues. It’s difficult to trust that a group can keep their secrets. Maybe it makes more sense to see one-to-one therapists. That does happen. It’s understandable.
EG: How does it feel when you have personally helped someone on their journey to recovery? Is it a really good feeling?
DD: I’ve been asked that question myself before, and I’m just mindful that Cosmo is sitting here with someone that he did help.
CDG: It’s a good feeling. The amazing feeling about rehab is that you see the most incredible turnaround in people’s lives. Not just after three months. Give it three years, for four, or five years down the tracks. It’s a good feeling obviously. But not everyone makes it, that’s the sad thing. As counsellors, we’re all invested in our clients. We do care.