KNOT HEART - Almeida Theatre

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Heroinproblems. Rates of divorce are high and children of substance-abusing parents are at increased risk forsubstance-use disorders themselves as well as mood and anxiety disorders. Individuals often have legalproblems from driving under the influence, disorderly conduct drug distribution and other illegalactivities because of the need to obtain money to acquire drugs; in the most severe circumstancesleading to homelessness and unemployment.Risks of overdose become high in regular users because the body's tolerance builds up and the desiredeffect reduces so that users have to keep taking larger doses to get the same effect.In 2009, a total of 1,000 deaths were attributed to heroin - more than half of drug related deaths in theUK.Heroin is a Class A drug: possession of heroin can lead to a prison sentence of up to seven years. Userspleading guilty on the first occasion are often able to avoid custody but being sentenced to a DrugRehabilitation Order which requires a strict drug-testing regime and co-operation with social workersand report monthly to a judge; failure to be drug-free can result in immediate imprisonmentPsychology and AddictionHistorically, addiction to drugs was seen to be a result of psychopathic characteristics but now it is seenthat addiction is indiscriminate: it affects all people of differing social-economic backgrounds; gender,racial and financial. There are multiple and complex factors that contribute to whether one personbecomes addicted or not, however there has been some research suggesting very strongly a geneticpredisposition through a difference in the way the frontal lobes (the decision makers) of the brain arebuilt. Alongside this, the two main factors that lead to likelihood of addiction are exposure to traumaalongside availability of certain substances that are used as a way of dealing with that trauma.Interestingly, it is very common for addictions to exist alongside a number of other psychiatric illnesses,in particular depression and anxiety disorders.Over recent years there has been a marked increase in drug use among higher society, and while menare typically seen to be significantly more likely in men than in women, this difference has decreasedover time.Thomas de Quincy's quote below, from his 1822 book Confessions of an English Opium-Eater, definesmuch of how drug use, particularly heroin in this instance is used to numb pain. Concealed in deQuincy's statement, a quote by one of the most famous addicts the world has ever known, is therelentless search for an ideal existence not unlike a ‘nirvana’ state (there being an interesting link toheroin though the term nirvana, the name of a band who's former lead singer, Kurt Cobain, sufferedwith a severe heroin addiction before his death in 1994); the denial of anything that might interfere withthe believing that such a state exists. Many psychologists believe there is some magical thinking in anaddict who believes that a chemical substance would make everything right and that it would solve themost complex personal problems, including the matter of simply existing.The following interview with Dr Owen Bowden-Jones, a consultant psychiatrist and specialist inaddictions, investigates some of the facts that are currently known, and examines Lucy’s condition inThe Knot of the Heart.‘I hanker too much after a state of happiness for both myself and others;I cannot face misery, whether my own or not...and am little capable ofsurmounting present pain for the sake of any recessionary benefit.’Thomas de Quincy: Confessions of an English Opium-Eater (1822)37Resource Pack: The Knot of the Heart
<strong>Almeida</strong> Projects visited the Chelsea and Westminster Hospital to speak toconsultant psychiatrist Dr Owen Bowden-Jones, to ask him about the factsbehind drug addiction, substance abuse, and his involvement advising the castduring the rehearsal process of The Knot of the Heart.<strong>Almeida</strong> Projects: Firstly, why do people become drug addicts? Can you explain the condition ofaddiction and its causes?Dr Owen Bowden-Jones: There are many different reasons why people run into trouble usingsubstances. People use substances in different ways, so when you use the term ‘drug addict’ you’retalking about a person who’s addicted to the substance; but the way we classify a person’srelationship to a substance can vary: you can use it recreationally, without any significant harm; youcan use it harmfully where it’s beginning to create problems either in your home life or in your worklife, or physical or psychological health; and the step beyond that is when you become addicted to thesubstance, and that’s typically a process where you become physiologically addicted, so that whenyou stop taking the substance, your body misses it, and it tells you that it’s missing it, by a series ofphysical symptoms known as withdrawal symptoms. The other thing people notice when they’readdicted is that they tend to use more and more of the substance, often not gaining any particularbenefit from increasing the dose. The substance becomes the focus of their life, above everythingelse. Rather than going out and seeing their friends, they’ll stay in and use the substance; rather thangoing to work, they’ll find ways to use the substance instead.In terms of why people reach that addiction stage, there are a many different reasons. What we doknow is that you can carry a genetic vulnerability to substance use. It’s particularly strong aroundalcohol, but it is present for other substances as well. This is not to say that if a person who’s had arelative with a substance abuse problem will definitely have a substance problem themselves;however, there is evidence that what they may carry is a vulnerability, in the way their brain is puttogether.There have been a lot of advances made in the understanding of addiction particularly in the last 10years, but we are still not there in having a perfect theory. The science at the moment is focusing on abit of the brain called the orbital frontal cortex. This is the decision-making part of the brain, the bitthat weighs up risk and makes judgments about what’s good or bad for you. There’s increasingevidence showing that this part of the brain is different in people who become addicted tosubstances. And there’s emerging evidence that people with addiction problems make poor choicesaround their substances and other areas of their life. And that there’s something that’s happening intheir frontal lobes that leads to this.Another theory of addiction is that people take drugs because they make them feel good. So whenyou take a drug, it releases chemicals in your brain and those chemicals make you feel nice, different,the feelings are good, and the brain gives you a reward for that. There are lots of other things we doin life that the brain rewards us for, and so we do them again; for example, drinking a glass of waterwhen you’re thirsty. But what the brain does is it shuts off that reward system when you’ve hadenough. So when you drink the water, your brain gives you a reward for that, but when you’ve hadenough, it shuts the reward off so you stop drinking. Now with substances, the rewards of the drugsof addiction are so powerful that they overwhelm this reward system, and so people have problemsswitching it off. People get a very intense reward from using a drug, which makes them feel reallygood in the moment but then they lose the ability to switch off the reward. So even though over time,people’s reward from using drugs decreases and decreases, the brain gets tricked into this cycle ofcontinuing use. If you ask someone who uses heroin what the effect of their drug is, almosteverybody will say, ‘the first few times I used heroin were amazing, and I’ve spent the last 10 yearschasing that first hit, but I never really got back to that first intensity of hit that I did in the first fewweeks I was using.’ And that’s because people develop something called tolerance, where they haveto use more and more of the substance to get the same effect. We see it very typically where peopleInterview with PsychiatristResource Pack: The Knot of the Heart 38
Page 4 and 5: Team- u. KapitänsübersichtLiga: C
Page 6: CharactersLUCYLucy formerly worked
Page 10 and 11: Plot SummaryLisa DillonPhoto: Keith
Page 12 and 13: Plot SummarySophie Stanton and Lisa
Page 14 and 15: 13Plot SummarySophie Stanton, Lisa
Page 16 and 17: 15Plot SummaryLisa Dillon and Margo
Page 18 and 19: DesignThe Knot of the Heart is desi
Page 20 and 21: Interview: David EldridgeAlmeida Pr
Page 22: Interview: David EldridgeAP: How lo
Page 25 and 26: It has neutrality that allows us to
Page 27 and 28: Sophie Stanton in rehearsalPhoto: M
Page 29 and 30: Margot Leicester in rehearsalPhoto:
Page 31 and 32: moments like these, when standing w
Page 33 and 34: The run is followed by notes and th
Page 35 and 36: Gibson SquareA classic late Georgia
Page 37: Heroin is an illegal opiate drug, w
Page 41 and 42: Dr Owen Bowden-Jones talking to Mic
Page 43 and 44: of your drug use and treatments tha
Page 45 and 46: Margot Leicester and Lisa Dillon in
Page 47 and 48: in with problems related to substan
Page 49 and 50: telling a joke, telling a story, wa
Page 51 and 52: tobacco, prescribed drugs, illegal
Page 53 and 54: BOOKSBrand, Russell My Booky Wook (

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