Susan drank and took recreational drugs from a young age. In 2003, when she was 23, she left for the UK with her English boyfriend who also dabbled in drugs and together they increased their drug taking.

Two years later, while still in the UK, Susan (name has been changed) became pregnant and gave up drugs altogether, managing to keep clean for six years. But gradually she and her boyfriend relapsed; there were violent outbursts and even a spate in prison for her boyfriend.

Eventually her child was removed by social services, Susan left her boyfriend and met up with a businessman who helped her get her life back on track. But he died tragically shortly after. Susan began drinking again.

She returned to Malta. Meanwhile, her child had been put under the guardianship of their the grandparents in Malta.

Susan’s drink problem spiralled out of control and eventually she signed herself into the Female Dual Diagnostic Unit (FDDU) at Mount Carmel Hospital, for people who suffer from cross addiction and move from one addiction to the other.

After about seven weeks, Susan was discharged and sent home but she was unable to withstand normal daily stresses at home and, with minimal mental health service support, she had a relapse.

The same pattern – seven weeks at FDDU, discharge, relapse and re-entry – repeated itself three or four times after that first premature discharge.  Her cries for help when she felt she was slipping were slow to be answered and often too late, she claims.

After her seventh stint at the FDDU, Susan finally admitted how desperate her situation was and started looking around for a residential programme. 

Caritas and Oasi had to turn her down because she was taking methadone, which she had been prescribed in the UK for medical reasons to keep stable. Sedqa accepted to let her take part in a day programme. But Susan left after a few months because she says she found the environment unstimulating to her.

Once, when she was discharged from FDDU, she was sent to an overcrowded homeless shelter where ‘residents’ were asked to leave every morning around 9am to roam the streets till the evening when they were let in again. Once, she was beaten up by another ‘resident’ and ended up at Mater Dei. 

Finally contact was made with the Richmond Foundation where she was accepted despite being on methadone. This proved to be a godsend. It was immediately apparent, says Susan, that the staff had a genuine wish to help with a forward-looking, live-in programme and a professional outlook.

Susan, who has been struggling and suffering for so long, feels she has been given a lifeline.

The care available

The length of stay at the FDDU at Mount Carmel Hospital (MCH) depends on the care required and whether admission is voluntary or involuntary, according to psychiatrist Aloisia Camilleri Aquilina.

“Some are ready for discharge in a few days, others may stay for months,” she says.

Patients are never discharged against their will, she adds, refuting Susan’s claim. “There is no such thing as a seven-week deadline,” she says categorically.

In fact, the 2016 Annual Mental Health report says that if patients are not ready to leave FDDU after between six and eight weeks, they are transferred to another ward, so the seven-week deadline may be for FDDU and not for Mount Carmel.

Moreover, Mental Health Commissioner John Cachia says that the Dual Diagnosis Therapeutic Programme capacity is “in the process of being doubled to remove bottlenecks” which suggests that lack of space does in fact play a part in clients’ length of stay at FDDU.

We cannot force them to take medication

Besides, regarding the provision of treatment, Dr Camilleri Aquilina adds a caveat.

“The only reason we would suggest the patient leaves is if we feel that they don’t really have mental health problems, have no intention of ceasing their habit and are using MCH as a hotel, not a hospital – in cases where, for example, the patient repeatedly discharges himself, spends all his social benefits on drugs/drink and returns when s/he runs out of money for free boarding and lodging till the next cheque comes in, when he then repeats the same process.”

Dr Cachia confirmed this perception with his reference to “highly-manipulative persons [who] juggle their way through the system”.

However, both he and Dr Camilleri Aquilina speak of the need for a policy of harm reduction for persons who are not strong enough to come off drugs or alcohol. If they had space at FDDU, they would keep such patients, Dr Camilleri Aquilina says.

Once a patient is discharged, follow-up is provided at the detox centre outside St Luke’s Hospital. Many patients are reluctant to use these services because they think they are well or want to go back to their drugs or drink.

Dr Camilleri Aquilina says: “We cannot force them to take medication. Often they will change their SIM card every week or month because they fail to pay their bills, so it is impossible to get in touch.”

Again, she blames lack of resources for the fact that MCH services don’t contact responsible carers when clients cannot be traced.

A patient might spend up to four months at MCH to come off drugs or alcohol. Most will come off methadone and, in exceptional cases, a similar drug named buprenorphine which can be bought on prescription but is more costly if prescribed. The latter drug allows recovering substance abusers to bypass the detox centre. But Dr Camilleri Aquilina says: “We prefer that ‘chaotic’ patients – those liable to get into debt, involved in criminal activity to pay for their habit or are otherwise irresponsible – stay on methadone, because we can keep tabs on them as they have to get their dose daily from the detox centre where we keep a register, whereas  they can stop taking buprenorphine and go on heroin at any point without us finding out.”

It is questionable, however, whether a register to spot defaulters is of much help for a strapped service which doesn’t allow for follow-up.

Moreover, insisting on keeping a register may come at the cost of exposing shaky former substance abusers to drug peddlers and other undesirables who always hover outside the Guardamangia detox centre. Unsurprisingly, lack of resources are again blamed for methadone not being distributed at local pharmacies, where clearly a register could also be kept.

There have been complaints that apart from Villa Chelsea, run by the Richmond Foundation, other community programmes offer boring and repetitive programmes, making no allowance for different abilities and individual creativity.

Dr Camilleri Aquilina says these programmes purposely provide structure and routine to help clients and that participating in the running of the community has a therapeutic value in itself. However, there is certainly also a place for creative work, she adds.

She highlights the urgent need for more community services and centres for people with drug and alcohol problems, including help with harm reduction to avoid infections, HIV, overdosing and criminal activity. She laments the fact that drug and alcohol addictions are not catered for in community mental health services.

“We need to provide services to users with not too rigid a structure but with supportive staff who can interact with patients. Drug and drink abuse needs to be seen in the context of anxiety disorders normally played out against a social background, with financial or social problems at home or work, where it is common for people to self-medicate with alcohol or drugs instead of seeking appropriate medication.”

Gillian Bartolo is a member of the board of trustees of the Richmond Foundation.

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