Wednesday, 23 April 2008

We must modify our treatment system so that it can effectively help people recover from the chronic disorder addiction

In my latest Background Briefing for Drink and Drugs News, 'Nature of the problem: Addiction as a chronic disorder', I start to look at the time course of addiction and how it influences the way that we should be building systems, including for the delivery of treatment, that help people find recovery. 

In this lastest Briefing, I looked at acute and chronic disorders and how they are managed in today's medical world. I focused on a recent key article written by two of the leading addiction scientists, Bill White and Thomas McLellan.
The issues I discussed are fundamental to the substance misuse treatment system in the UK and to the considerable amount of money the country is investing in this system. A system has been built to manage an acute disorder - but addiction is not an acute disorder. 
Quite simply, we must modify our treatment system so that it can effectively help people recover from the chronic disorder of addiction.
Do you agree?

11 comments:

Anonymous said...

Dear Prof-I would like to support your statement. I have worked in the substance misuse field since 1991 I have always regarded addiction or dependency as a long term chronic relapsing condition that requires patience and time and a range of approaches. I have had many great teachers in my career and seeing treatment as a continuum with many facets and approaches has helped me to have an open mind to what works.
We have all witnessed the wonder of recovery and find it difficult to quantify and pinpoint the exact moment when change happens-I believe in and have witnessed the power of the 'drip drip' process of consistent therapeutic and medical interventions that do not carry judgement and are not punitive, but that realise that one day change will occur and it is our job to stick in there and remain optimistic for the long-term.

David Clark said...

What a wonderful posting! You have encapsulated so much of what is important (no, I should say 'critical') in this field.

Peter O'Loughlin said...

As Prochaska & DiClemente point out the journey of recovery is unpredictable.

It may be that current strategies are focused on treating the addiction, rather than the addict.

Where does one start? I take the view that is a client decision, what is it he/she wants? Is it realistic?

For anyone who has become addicted as defined in the criteria ICD-10 or DSM-1V, the belief that they can learn to control, or cut down their intake, is in my opinion, unlikely to occur for any sustainable period, therefore it would be unethical to allow the person to think otherwise; surely they have had enough disappointments,without them coming to believe they have failed yet again?

It is my view that the outcome of addiction is abstinence, whether one seeks that by choice, or whether it arrives by death or insanity is the only question.

Over the years, I have become convinced that the transtheoretical model is highly successful, providing one is willing to work with where the client is at, rather than where one thinks he/she out to be. Working within the framework, using therapeutic models that are most suitable to the client is rewarding, if only because there is no failure. Of course it can be frustrating, but that is the counsellor's problem, not the client's.

If the person is in the 'contemplation stage', and one works with them, sooner or later they'll move on to the 'preparation stage, but they will only do that when they feel able; when the belief that they will succeed in the next stage is greater than the fear that they will 'fail'.

Small adjustments, can help the person move on through the stages; for example it is often astonishing to the client to learn that they can become comfortable, a concept that we take for granted, but is more often than not, completely alien to those in active addiction. Helping them to discover ways in which they can become comfortable, is as far as they are concerned, a revelation. How long does it take? As long as it does, people have been known to stay in the 'contemplation stage' for up to 2 years. So if treatment strategy has a predetermined time scale, then the transtheoretical model won't work; That leaves the question, in terms of recovery are the present strategies working?



I have no doubt that if counsellors were given a thorough training in the transtheoretical model, together with the oportunity to develop a working knowledge of the therapeutic models in each stage, together with a fundamental change in outlook from those who commission services, and those engaged in delivering them, recovery would be more common than the doomongers would have us believe.

what is apparent the present strategies are not working, maybe that's because they're focused on quantity, rather than quality; treatment, rather than recovery; targets rather than outcomes.

Ann Stoker said...

I have worked in this field for over 20 years and all the users who have come to my agency wanted to get treatment in order to then be able to be abstinent from drug use. May I give three examples from my own family of how difficult this can be.

1. We had to fight our local authority for months in order to get funding for residential rehab for my grandson. They wanted him to visit a local counselling agency once a week ! He eventually was funded - spent 6 months in rehab and has now been clean and sober for 15 months and is about to embark on long term pschodynamic therapy to deal with the problems resulting from past use over nearly 20 years.

2. A nephew, aged 48, serious alcoholic was eventuall sent to rehab. He did very well and was looking forward to a changed life away from old contacts etc. The day he left rehab his local council placed him in a notorious hostel until they could find 'something better'. After 3 days he was found dead of an overdose. If he had not been living with other drug users and alcoholics I am convinced he would not have relapsed.

3. For over a year we have been trying to get a dual-diagnosis rehab place for a young man of 23.
Ealing has 11 different agencies who deal with drug users - all require money for premises and staff. We found a suitable place for him but Ealing refused to pay as it was not on their list...it was also not suitable for dual diagnosis clients. We found another and the young man was trying very hard to cut down use whilst his aplication was being looked at. Result - he was refused as he was 'doing well cutting down his use on his own'..since then he has been on a cocaine binge and has now been told he can't be sent to rehab. because his use is so chaotic and by the way he has to leave his mental health hostel as his behaviour is unacceptable......
We must modify our treatment system....definitely - for God's sake let the money be spent on getting users into long term rehab followed by good housing and aftercare. Ann Stoker NDPA

ps If anyone can advise me how to get help for one desperately vulnerable schizophrenic cocaine user before lst May please tell me.

Peter O'Loughlin said...

I suspect that Ann's experiences are not unusual. It seems to me that if the person suffering does not fit a 'tickable box', they're very much on their own.

Something like 60% of my business comes from people who have been through the local community drug/alcohol services, and have not had their needs met.

There appears to be two principle complaints.

1 They've been advised to cut down. If they could do that, it is unlikely that they would have been there in the first place.

2 The staff appear to be inexperienced, and rarely does the client see the same person twice.

In addition, I've lost count of the number of people who wanted to stop drinking but have been told, without the benefit of a medical opinion, that they must not stop drinking immediately, because they might die.

David Clark said...

Peter, I believe strongly in the Transtheoretical model and there will be a good deal on it in our multimedia guides.
What do you mean by clients becoming comfortable?

David Clark said...

Ann,
Such sad and frustrating stories, but so commonplace. Nothing can overturned overnight, but we need to continually highlight such stories and challenge the system all the time.
We are launching a recovery community website in summer where people can have their own profile page and be able to blog. We will then highlight most important/interesting/provocative stories on main channel home pages - users/ex-users, families and practitioners.
Our job will be to help you all shout LOUD.
Of course, we have no money for this project at moment, but we will find it (development is occurring anyway).
Please ask all your friends to sign up.
Take care, David

Peter O'Loughlin said...

David,

I use the word comfort a great deal in my work. I am of the opinion that most addicts are uncomfortable with themselves, and probably were before they started using.

I feel that unless they can develop a 'comfortable' relationship with self, not only will they always be looking for 'something' or someone to help them feel comfortable, they will have considerable difficulties in forming 'healthy' relationships with others, thus leading to increased, or increasing feelings of isolation, leading back to use.

I tend to use metaphors, with a view to helping them understand what feeling comfortable means, helping them to focus intially on making small adjustmments, leading to greater mental, physical and spiritual comfort.

The simplest way I can explain the latter is I ask them to recall times in their life when they did something that went against their personal values. How that made them feel, ie guilt shame conflict etc. From there I ask them to think about how they would have felt, had they gone with their own values, and acually get them to describe in their own words how that would have made them feel. From there it's not too difficult to ask them to put both sets of feelings into a 'vessel' of their choice; then to find something with which they can mix both sets of feelings together, and to keep mixing until they're satisfied that the result is something that's acceptable to them.

I's quite fascinating watching the changing facial expressions and the visible relaxing of the body as they go through the process.

From there it's not to big a leap to help them understand just how important their comfort is to them. How essential it is from time to time to 'adjust one's position', mentally and physically, in order that they might feel more comfortable with changing situations. finally helping them to understand that mental and physical comfort lead to feeling more at peace with themselves (the spiritual dimension)

It's time consuming sometimes it takes several sessions before they begin to feel at ease with themselves, other times I've had result in just the one session.

In either event it needs repeating, until they come to understand that they can change the way they feel, by changing the way they think. At that point 'the light comes on' and the feelings of helplessness that go with 'I can't help the way' I feel'is exposed for the 'lie' that it is.

The whole object as you've probably guessed is to alleviate the feelings of powerlessness that is so common among addicts.

The foregoing i stress is a summary of the process, it is a sensitive process that can only be achieved within the clients' time and mental processes.

James Parker said...

Dear Prof-one thing that keeps me motivated is the thought that one day treatment will be as good as it can be and poicy makers will understand dependency and what is required to properly change the tide of short-termism.

Whenever I go to conferences I get inspired by good practice but without a collective will local change is beset by politics between NHS providers and voluntary sector and is so often dependent on altruistic powerful and intelligent consultants who are not cowed by defensive practice and a culture of risk assessing to the point where clients are excluded from the equation.

I wrote a previous blog and was anonymous but now want to give my name because I so passionately believe in what you are saying and to find voices of support in this field is so vital.

I was told recently that a client is 18 times less likely to overdose when in treatment-so why do we make clients have 'therapeutic' breaks from prescribing because they continue to use on top when they are usually not being prescribed a sufficient dose?

What about the idea that dependency and addiction is characterised by loss of behavioural control yet we expect clients to attend appointments on time and in perfect control of mind, body and spirit.

Let me finish with a plea for us all to place the client back in the centre of our treatment mapping and planning and build it around them. Let us accept it is a long, slow and often frustrating process but that it is always worth it.

Prof David Clark said...

James, What a wonderful comment, makes this blogging malarky all seem really worthwhile!
Yes, the client needs to be centre-stage!
Yes, the day policy makers understand addiction and dependency will be the day we have a major change!
Yes, short-termism needs to go!
Yes, we have to fight the politics!
Yes, there is lots of good practice out there! And we must learn from it.
And YES we must unite the people who care into a powerful voice
That is what Wired In wants to do, which we will do in part via our new online community being launched late July - it will give people the tools to promote what they do and tell us how they feel
For now, we must best utilise these blogs
Can you contact me directly sometime, it would be good to know where you are based and what you do (david@wiredin.org.uk)

Catherine Harkin said...

Hi David - nice to meet you at LEAP last week and what a relief to hear you talk so much sense. I've been in recovery for twelve years and have worked in addictions for seven as a GPwSI. In no other speciality would such difficulties of access, such high mortality and morbidity, such poor measurement of outcomes and such patchy levels of staff training and support be acceptable. I've been fortunate enough to experience treatment for two life-threatening illnesses myself as a patient and it's very educational to note how differently you get treated if you have a "respectable" illness like cancer as opposed to an addictive disorder that many of our coleagues don't even realise *is* an illness. I agree with you that there is a huge educational job to be done to raise awareness and move away from punitive and short-term models of treatment, to develop models that also recognise the impact on families and their need to recover too, and to recognise the effect on staff working in the field of "vicarious stigmatisation". More power to your elbow.........