Tuesday, 27 May 2008

On isolation and recovery – an excellent article by Ian Wardle

The past few months have been very interesting times for what I can only describe as an urgently needed recovery agenda in the UK.

Yesterday, we saw published online an erudite discussion on recovery and the UK treatment field by the CEO of Lifeline, Ian Wardle. He has written an excellent article, one which should be read by all people working in the treatment field, as well as by politicians and others who impact in one way or other on our efforts to help people overcome substance use problems.

I would love to devote a good deal of time discussing this article, but my three youngsters have come to stay for a week and have left me somewhat brain-dead. However, it would be wrong of me to say nothing about Ian’s article. So, ‘please keep quiet upstairs!’

I found Ian’s focus on the isolation of the treatment field and the implications of this isolation fascinating. In my opinion, there is no doubt that embedding drug treatment in the criminal justice system is greatly hurting our efforts to help people overcome substance use problems, as I will discuss in one my forthcoming Wired In Reflections.

The field is also hurting itself by getting bogged down in arguments about harm reduction vs. abstinence, as has been discussed in some of my other Blogs.  As Ian points out, we are isolating ourselves from each other. This is unnecessary, as the recovery writings of Bill White and colleagues reveal.

Ian emphasises that we are becoming isolated from people outside this field. People from outside the field that I know (and trust) who are aware of what I am doing are horrified by some of the dogma they read in our field. They cannot believe that some people seem more interested in looking after the system than the clients.

Ian also points out that we are isolated from the new personalisation and recovery-orientated philosophies that are inspiring people in other sectors of health and social care. It has surprised me how many people in the drug field are so inward-looking – they don’t look to learn from other fields, which is naïve given the relatively new discipline in which we work.

I believe it was an excellent idea of Ian to focus on the isolation issue. It has certainly made me think about this issue more explicitly. There are a number of suggestions for the future way forward that are indicated by Ian’s article.

However, I felt that two messages may not have got come through strong enough – I apologise to Ian, if I have misread things. Firstly, there is a lot we can learn from the writings and actions of the US recovery movement. We don’t need to reinvent the wheel, but at the same time our recovery efforts in the UK will take us in some different directions. 

Secondly, we must listen much more to people who are recovering or recovered from addiction – and learn from them. We generally do not do this well in the UK.

Thanks for a very thought-provoking article, Ian.


Ian Sherwood said...

Ian Wardle's article is impressive, it has depth and an accurate and timely grasp of the issues . Hopefully this will stimulate a wider involvement in the recovery debate especially by relegating harm reduction v abstinence argument to the level of medieval theological debate it deserves.

David Clark said...

Hear hear, Ian.

Peter O'Loughlin said...

Yes, it was and is a great article which contained a number of important messages, not the least of which appeared to be among my favourites, treat the addict, not the addiction.

Articles like Ian's and that by Neil McKeganey on methadone should show us the way forward Unfortunately the gap between those who consider harm reduction to be the ongoing use of of addictive psycho active drugs, and those of us who judge our outcomes by the ability of an individual to learn to live a drug free life, and become a useful member of the community, appears to be have widened, with neither side apparently prepared to compromise.

As someone who believes that recovery is a process, rather than an event, I freely acknowledge that there are some addicts for whom recovery as I understand it may not be a viable proposition. However I believe that they are in the minority, whereas judging by the statistics and comments in the EMCDA reports, under current treatment protocols, the vast majority of those 'in treatment', appear to believe, or have been led to believe that they are 'not ready'.

Whilst I can concede that a number of those 'in treatment', may truly believe that, or are terrified at the thought of attempting to live a drug free life, I feel that the phrase 'not ready', is not only judgemental, but also defeatist, inasmuch that it serves to reinforce the beliefs of those who think drug free recovery is beyond them, thus condemning them to live the rest of their life as 'dependent'.

I stress the above is my opinion, the only evidence for which I have are those who I have had the privilege and pleasure of working with, who having used the community services, felt their needs and requests were being ignored. The question is why and just how many of those 'in treatment', feel the same way.

Pavel Nepustil said...

"Drug services" are definitely isolated. And, as you mention, David, they are isolated from the people they were originated for as well. We had a similiar discussion in Czech Republic, at Brno conference, about the direction of drug services: should they go towards medical field or towards social field? The director of our organisation, Jiri Libra, said: drug services may go in both direction, but I think they should be less "drug". I do not know if it makes the right sense in English but this is what I find really important: people recovering from long-term substance use are socially excuded, marginalized, with broken relationships, they are poor, have debts, no job, health problems.... so why we are so concerned with "the drug"? We are fascinated with that as teenagers...

Paolo Lewkowicz said...

Ian's article talks eloquently about isolation and the place of recovery in overcoming that not just for the patients but for the drugs field as a whole. In the process he refers to the UK Drug Policy Commission (UKDPC) working group on recovery. That set me thinking.
No one can argue against recovery, but we can certainly differ over what it means for us – or can we? Fuelled with cash from the Esmée Fairbairn Foundation, the Commission is developing "A Vision for Recovery" through a process described as "Finding a Consensus". Their panel of 17 experts spiced with one "carer" and one "service user" has been chiselling out a statement they want us all to sign up to as (among other things) the new goal for treatment. More importantly, so does the National Treatment Agency for Substance Misuse, whose Director of Quality is one the organisation's 13 commissioners (making their claim to "provide independent and objective analysis of UK drug policy" less than convincing).
Now we all need a consensus on what to do when the traffic lights are red and which side of the road to drive – but do we need one on recovery, or is OK for us all have different ideas of what that consists of for ourselves and for other people? It would be absurd, for example, for a set of experts to try to hand down a consensus on what makes us laugh or what makes us happy and then expect us all to fall in to line. ‘Consensus' is a cosy sounding word and a cosy sounding process, but not if it cloaks an attempt to eliminate valid individual differences in what we value and how we see ourselves. Such attempts configure human differences as divisive boat-rocking, subverting a ‘consensus' most of us had no hand in developing.
So what have they come up with? Well, here's the rub. Carefully guarded drafts have been sent out for comment strictly in confidence, making it impossible to openly communicate about the text. The drafts are in confidence and so too are the comments and the comments on the comments and, as they intend, the whole process means that instead of open discussion and debate, all public communication goes through the UKDPC which can control what it does with it and how it presents it. Comments are to be made to them, not across the usual networks we all participate in. Consensus equals control.
But even Blairite control freaks have their unguarded moments (I suppose) and the core of the statement, the definition of recovery, was read out before an audience of several hundred by Professor Robin Davidson (on the UKDPC consensus group) at the Drug and Alcohol Today exhibition on 1 May in London. So it's OK to talk about that. Here's how it goes: Recovery is a process, characterised by voluntarily maintained control over substance use, leading towards health and well-being and participation in the rights, roles and responsibilities of society.
It might change, may already have done so, but it's interesting that behind doors closed on sound proof rooms, this is where they had got to towards the end of the process. I'd like to be able to expand on what that sentence means but even if I had seen them I couldn't refer to any amplifications or justifications because they would be ‘In Confidence'. So while I'm sure that can't be all there is to it, I'm going to have assume that it is.
Before you sneeringly wipe the motherhood and apple pie off your lips, consider the problem they had: to come up with a definition which at least looked like something which could be broadly applied to the 200,000 odd addiction patients in Britain, who may have their own ideas of what recovery means for them, but narrow enough to be able to distinguish between the recovered and the UN-recovered. After all, if everyone can claim to be ‘recovered', it doesn't mean a thing.
That takes us to the invidious bit. If we are going to anoint some people as recovered (ie, you can rejoin our society, you are now once again fully human), at the same time we have to deny it to others, even if they themselves might think they've done pretty well and, in their own terms, are recovered.
That's a pretty big thing to set to one side, but for the moment, let's do so, and focus on the definition itself. We just have to hope, don't we, that the relevant health services and charities for the relief of suffering already realise they are in the health and well-being business. God help us if they don't.
So let's turn to the rest, the three ‘r's. You can't help being struck by the strong echo of the new English drug strategy's insistence that patients must fulfill their responsibilities and perform the roles the state desires of them: get out of treatment, get off welfare, get a job, pay their taxes, stop burdening ‘us'. Does this mean that our doctors, enjoined in the name of recovery also to aim for these heights, will have to check our wage slips and benefits status at the same time as they check our pulse? That might not be what the UKDPC mean (if I could see the damn statement/report/analysis I'd know). Still it would be handy for the government, wouldn't it, to have us all signed up to that in the name of recovery – and who, as I said, can argue against recovery? What a change it would be from doctors signing us off as sick or backing our disability claims. Instead they get us back to work and it's all for our own good, a Blairite wet dream.
One final thing – I thought (didn't you?) that we all had "rights" just by virtue of being human beings and citizens or whatever legal status we have in this country – so what's this business of recovery being a process "leading towards ... rights" etc, after drug use has been controlled? Does it mean that if we haven't yet controlled our drug use, or haven't yet gone far enough along this "leading to" road, then by the same degree to which we fall short of recovery as they define it, we also forfeit our rights? They can't possibly mean that. If I could just read that statement in full I'm sure they'd explain that's not what they meant, but (again) you guessed it ...
One more final thing (alright, I lied), I do hope those broad-shouldered people at the NTA and UKDPC take these tongue-in-cheek comments in the spirit in which they are intended. I think they are all doing a wonderful job and I can't wait for the wraps to come off so I can see if I too am ‘recovered'. Got a horrible feeling I'm not.
Paolo Lewkowicz lewkowicz@live.co.uk

Tim Leighton said...

Great article Ian, thanks! Paolo's comments on the UKDCP "consensus statement" on recovery are interesting and raise some good points.

As a member of the consensus group I can say that as far as I can tell the group doesn't intend the statement to be used in a manipulative, political way to advance abstentionism or to disenfranchise people. Quite the opposite in fact.

As Paolo points out it is extremely difficult to come up with such a statement that a) will satisfy a wide range of people and b) not be seriously misunderstood. There is work going on to adjust it a bit and it seems to me that we need both a more elaborated explanation of what the statement and its terms are supposed to mean, and a series of commentaries on the issues that the statement raises. For example the bit about participation in society is (in my view) intended to convey that drug dependency is in many ways disempowering and that recovery as envisaged here involves increasing opportunities both to claim the rights that of course have been a person's all along, but also to be an more active participant in all kinds of social and relational activities. These were not I think meant to coincide with 'government targets'.

It is easy to be cynical (and I can see that Paolo was not being), and imagine this venture is either a Machiavellian plot or a trivial, impotent and naive piece of wishful thinking. I believe there is a real opportunity to try to heal some of the isolation and polarisation in our field. I would appreciate any ideas as to how the 'consensus statement' can be strengthened to play its part in an integrating process.

nicola singleton said...

I too think Ian's paper is a really useful contribution to the debate. However, as the person at UKDPC responsible for co-ordinating the recovery consensus work, I would just like to add to Tim's response to Paolo's comments on that process and confirm that we really are operating completely independently from the NTA, government or any other vested interests.

The UKDPC felt that we were uniquely placed (because of our independence and evidence focussed remit) to facilitate a process aimed at turning the potentially damaging debate within the field into something that might result in positive change. We chose to use a consensus process because it seemed best suited for a hotly disputed topic, but this inevitably limits the number of people who can be involved initially - but we did try to ensure all perspectives were represented.

The increasing focus on recovery is extremely welcome and we hope our statement will make some contribution to this and help to provide the impetus for positive change - but we most certainly do not see our deliberations as being the last word on the subject! I have found all the contributions here extremely useful and as Tim has made clear, we are interested in everyone's views on the matter and will consider them all. While we have been circulating the draft statement and accompanying paper under a "confidential" banner that is because we are still working on it and wanted to be involved in discussions on it so that we could consider all comments as part of that process. Perhaps mistakenly, we have preferred face-to-face discussion and far from concealing our work we have done presentations on the statement at the D&AT event London (a full seminar as well as the contribution to the plenary) and the UKESAD conference. If people are interested, we are also doing presentations at the London Drug Policy forum conference this Friday, and the D&AT event in Glasgow and NTA conference next week.

We hope to finalise the paper shortly and get it published alongside the commentaries Tim mentions that look at the implications of the adoption of such a statement for individuals, services, commissioners, research etc. I think these other papers are particularly important because they will help to deal with the important point that Paolo makes about the danger that people will look at any definition and say "we do that already". But of course there will be continuing comment and discussion after that - this will be just one contribution to a complex area but we hope it will be constructive.

Paolo Lewkowicz said...

How wonderful it is when someone says what you think for you but better and more convincingly than you ever could. As The Band sang it, "I don't have to speak ‘cause she defends me, a drunkard's dream if I ever did see one." So here's some better voices:

Dr Steve Coulter reacting to Paolo's post:
The major unstated assumption in the "recovery" language is that the clinician's role is to decide what constitutes "recovery," and therefore goals of treatment. This is a form of paternalism, and is intrinsically unethical for any licensed professional. For essentially all other conditions, and certainly any chronic illness, the overarching goal of a clinician is simply to apply his craft to be of help to the sufferer. What constitutes "help" for the sufferer can only be decided by the client, ultimately. One may have a professional target of remission or some other defined outcome, but the choice of destination belongs to the client, not the clinician.
To state this another way, a clinician should seek "to cure sometimes, to relieve often, to comfort always." Both the rigid, abstinence-only approach and the more flexible "recovery-oriented" approach fail to adequately respect (and therefore empower) clients and their wishes, and overlook the relieving and comforting roles of a good clinician.

Stephan Arndt and Pat Taylor on behalf of Faces and Voices of Recovery commenting on the Betty Ford Institute Consensus Panel's definition of recovery (Commentary on Defining and Measuring ‘Recovery'. Journal of Substance Abuse Treatment 33 (2007) 275–276):
We also worry about the use of the term citizenship [Paolo – US equivalent of the ‘r's - roles rights and responsibilities] ... We do not define recovery from any other disorder or disease based on an individual's "citizenship," and we do not, in general, scrutinize "citizenship" for other populations for any scientific rationale. Why are we inventorying people's citizenship in recovery?
The definition is also of great importance to recovery advocates and policymakers who want to understand the effect of barriers in obtaining jobs, housing, and education that many individuals in "early, sustained, and stable sobriety" face ... People in recovery often have a difficult time finding decent jobs that pay reasonable wages. Thus, external — and some will say discriminatory — factors affect this definition ... There also needs to be careful consideration of the external policies impinging on the recovery community that affect such things as potential job availability, health, and financial status. Although recovery may make individuals able to work does not mean that they can find work. The definition, in this context, needs to be fair and realistic, while not furthering discriminatory practices. [Paolo – in other words you may be willing and able to take on your social roles rights and responsibilities but what if stigma, poverty, discrimination, a criminal record, withdrawn driving licence etc prevent you doing so? – then you can't be recovered, helpfully adding one more stigma to the list]

William L. White Addiction recovery: its definition and conceptual boundaries. Journal of Substance Abuse Treatment 33 (2007) 229–241:
A particular definition of recovery, by defining who is and is not in recovery, may also dictate who is seen as socially redeemed and who remains stigmatized, who is hired and who is fired, who remains free and who goes to jail, who remains in a marriage and who is divorced, who retains and who loses custody of their children, and who receives and who is denied government benefits.
It is important to recognize that rational arguments for particular definitions of recovery may mask issues of professional prestige, professional careers, institutional profit, and the fate of community economies ... defining recovery could generate unforeseen and harmful consequences [Paolo – well Bill, isn't that just what I'm saying – you mean it's like that stateside too?]

Paolo back again. So Tim and Nicola, what you intend with this definition and from whom you say you are independent is neither here nor there – what matters is the purposes, the agendas, to which it lends itself. And for that we need look no further than the English drug strategy (as mentioned already) and the new Scottish one whose title (The Road to Recovery) no doubt you would cheer. And what do they mean by that? Amazingly, in his foreword Fergus Ewing, minister for community safety, mentions just one objective for this new recovery strategy. Is it improved health, quality of life, indeed, is it anything at all to with what the patients might want in their lives? No, it's this: "to increase sustainable economic growth. Tackling problem drug use ... will make a significant contribution to achieving this. Reducing problem drug use will get more people back to work; revitalise some of our most deprived communities; and allow significant public investment to be redirected."

Paolo Lewkowicz lewkowicz@live.co.uk

tim1leg said...

Palao I have to comment on your comments regarding the minister in Scotland who said "to increase sustainable economic growth. Tackling problem drug use ... will make a significant contribution to achieving this. Reducing problem drug use will get more people back to work; revitalise some of our most deprived communities; and allow significant public investment to be redirected.
We all know the bottom line is money, why then do other agencies or organisations pretend otherwise. I for one see the sense in this upfront bottom line honest approach. Problem is though there is no new money regardless of the spin and different funding structures now taking place in Scotland which will make the road to recovery a tad more complicated for local authorities alone to try and implement. Don’t mention where all these people if they get on the road to recovery are going to be employed and the impossible hoops most will face because of stigma and prejudice of what they/we suffer/sufferered from.

Paolo Lewkowicz said...

Well tim1leg fair point and one made also down here - see Mike Ashton's Flag in the Breeze at:
The really clever thing he seems to suggest is that it won't matter (except of course to the patient) if reintegration fails due to lack of resources and/or lack of will because we simply won't measure it. Hear no evil ...

Here's a riddle as well. If money is all that matters, why does money matter?

Paolo Lewkowicz lewkowicz@live.co.uk