Monday, 19 May 2008

You want treatment?

I had an interesting Blog Comment from Pavel Nepustil, a Czech republic NGO worker and PhD student, currently in Houston, USA, on a Fullbright Scholarship. Pavel came over to see us in Cardiff last year and we decided we would work together. He is one bright ‘cookie’ and very dedicated to this field. He got a big thumbs-up from the team.

Pavel responded to the Wired In ‘Way Forward’ in a very positive manner. Thanks, Pavel!

Here, I quote parts of his comment, for which I would welcome responses:

Hope, passion, talent, change - these are the words that were missing in the drug field! The "deficit discourse" brought by medicine made us think about drug users in terms of illness, disorder, chronic, irreversible disease... and these words created our expectations and these expectations created self-fulfilling prophecy…’

‘When I was asking one former methamphetamine user who recovered without formal treatment about his ideas for the services, he told me: " should be designed in such a way so that people will not be afraid to go there. They should offer help, not treatment. A lot of people are afraid of treatment..."’

I have to confess I have been worried about this term ‘treatment’ because what exactly does it mean? Clearly, it means different things to different people. It means something different in the Wired In vision to what it is in today’s system.

What does it mean to a potential client and to their family? Are they afraid to go there as suggested by Pavel’s associate? We certainly know many people who have substance use problems who are very cynical and untrusting of the treatment system and what it represents.

There are many people who are very concerned to hear a senior member of the treatment commissioning system say that the government provides money for people not because of their personal problems but, ‘Because you are seen as a threat, the government is prepared to spend money on drug treatment.’ (quote from DDN, Feb 25th issue). Would you trust such a system to help you with your own problems, or those of your child?    

You might also like to think of something else. The term ‘treatment implies the existence of an entity (such as a drug) or a procedure (such as surgery) that is being applied to something else from without.' (cf. ‘How Clients Make Therapy Work: The Process of Active Self-Healing’ by Arthur C. Bohart and Karen Tallman, pp13).

However, recovery comes from within the person. Addiction is not fixed like a broken leg. The work required to achieve recovery is ultimately done by the person, not by a treatment agency worker or doctor.

The practitioner may facilitate a process that enables the person to achieve more recovery capital (some money, a roof over their head, etc) so they are better able to concentrate on the substance use problem. They may provide methadone to help take chaos out of a person’s life, or their ‘talk’ may help the person alleviate some crisis in their life, or better understand where they are and where they need to go. 

Ultimately, good practitioners are providing or enabling support, coaching, guidance, information and resources – or some combination of these.

Is this treatment? Or help? Or what? How we should term it? Any thoughts?


tim1leg said...

How many of us professionals in various fields have an opportunity during their lifetime to shape the destiny of their chosen fields. For some time I and others have been saying that this opportunity is at hand for addiction professionals.
Leadership vacuums have emerged that have to be filled. As a field, we have too often played the role of the chameleon, reflecting not character but context, constantly changing colour with the latest funding demand or regulatory site visit.
How many can say that this is not true?
All too often we have let forces other than the needs of our clients dictate who we treated; what, how and by whom treatment was provided.
It is time the field broke the chains of its passivity and once again advocated, not for itself, but for the needs of those it is pledged to serve to help end the suffering.
If there is anything addiction workers know it is that there are brief developmental windows of opportunity that, when capitalised upon, can forever alter the trajectory of one’s life.
The same is true for cultures, communities, and professional fields. That window of opportunity exists today, but it is narrowing.
The future of this field and the future of recovery in Britain will be shaped by our silence or our voice. Speak out about our need to remain client-centred. Lead the movement back into our communities. Where you see evidence of this treatment renewal movement, support it. Where this movement lies dormant, help incite it.

A new role is emerging to bridge the chasm between brief professional treatment in an institution setting and sustainable recovery within each client’s natural environment. This role is embraced under numerous titles, the one I suggest most appropriate is Recovery Facilitator.

•As with any new service role, the Recovery Facilitator role takes on a different character within different organisations and cultural communities. At the beginning, the fact that the RF role is defined somewhat differently between agencies may be less important than having the role clearly defined. Its the language that matters.
I for see within each agency, A clearer definition of the role will emerge from the collective experience of those working as and supervising Recovery facilitators. This evolving role needs to be supported in a number of critical ways via key technologies, including:
•further role definition and standards to assure its peer integrity,
•model criteria for screening, interviewing and hiring RFs,
•model compensation and benefit packages and career ladders,
•RF orientation, training and supervision models,
•a model RF code of ethical conduct, and manualized, evidence-based RF service protocol.

•The fate of the recovery Facilitator role will be influenced by the forces that shaped those roles that came before it. The future evolution of professional treatment organisations and recovery mutual aid societies, evolutions in the design of addiction treatment (e.g., from acute care models to models of sustained recovery management), trends in service reimbursement policies, and what may be the inevitable and much needed professionalisation of the Recovery Facilitator role.
• It will be hard to retain the role’s recovery focus, but history tells us that if this focus is lost, new roles will eventually emerge to recapture this focus. At the moment, the role of RF holds promise in elevating long-term recovery.
•Outcomes through the provision of pre-recovery, recovery initiation/stabilisation and recovery maintenance support services and by expanding the quantity and variety of recovery support services in local communities.
To fulfil that potential, those serving as recovery Facilitators will need to carefully distinguish their functions from those of the sponsor and the addiction counsellor/worker while exhibiting deep respect for these allied roles.
A facilitator to support you in your recovery rather than A worker that gets you your treatment.

David Clark said...


Anonymous said...

Treatment not a fixed set of special interventions or techniques. We don't have scratch our heads and try to decide is this treatment or is this? Treatment is anything (within ethical constraints) which has a treatment effect. If you accept to quote a draft Scottish Futures Forum document, that "those who misuse alcohol or drugs are not one homogenous group and people have different reasons for misusing alcohol and drugs" then it follows that someone's key problem (in this context, the thing which if fixed would make the most difference to their addiction problem) might be lack of employability, mental illness, poor housing, broken family relationships, loneliness and alienation etc. Addressing those issues IS therefore treating the addiction, not something added on. It's like doctors prescribing exercise – not normally thought of as a medical treatment but if it has a treatment effect, it qualifies as far as I am concerned.
What is a treatment effect? It is recovery in whatever terms make sense for and are possible for the person concerned within their environment. So it can be about changing that environment as well or instead of changing the person.

Anonymous said...

I agree that recovery has to come from within the person, but we tend not to lock addicts in cupboards and wait for spontaneous resolution to occur. (Actually, we don't know whether that is an effective intervention: I don't think anyone has done the work on it, though I'm guessing it's not going to work terribly well!)

The point is that we can intervene to help the process of discovering inner resources and the growth of self-efficacy. Motivational interviewing is one evidence based 'treatment', though where I work, we address physical, mental, spiritual, vocational, relationship and housing issues. We call that treatment and it seems to work. Recent research showed that treatment in general is not strongly associated with recovery, but that residential treatment and self help were two treatment types that did seem to make a difference.

There is nothing incompatible (in my mind at least), in addiction being a 'disease' with genetic predisposition and disordered neurophysiology, and with it also being a cultural/social/environmentally influenced issue.

I don't see treatment as something that is 'done' to you, but as a choice, something you participate in willingly with a sense of ownership and agency. Addiction impairs cognition and the ability to make healthy choices, recovery reverses that process, but many people need help in those early stages. Treatment should provide a place of safety, a bit of love and positivity and guidance in the use of the tools necessary to continue the recovery journey.

Long live treatment!

tim1leg said...

Mike your comment leads us then to what is recovery and with the new strategy due for release here in Scotland on the 29th I have concerns around the opportunity of a shift away from TREATMENT to RECOVERY being missed.

I have these concerns as I have seen lip service payed to many reforms across the health sector and believe that definitions of recovery will have to be put in place and not left open to each service or agencies interpretation.

I would agree with the New York state office of alcoholism and substance abuse services who appointed an Recovery Advisory Committee that clarified that vision by developing a consensus definition of recovery and by defining nine core recovery values:

hope; choice; empowerment; peer culture, support, and leadership; partnership; community inclusion/opportunities; spirituality; family inclusion and leadership; and a holistic/wellness approach.

Im very concerned that services currently in Scotland are a long way off what they defined and to scale the mountainous shift will be extremely challenging, due to both historical provision and cultural attitudes towards the suffering.
I am hopefull that the new stategy will not be like the new English strat where the business of this strategy is about spending something like £4 billion of public money over the next decade on drug treatment wherebuy funding for all of this is based on the same targets as the old strategy.

I am again hopefull that unlike the English Strategy wherebuy the new plan is very similar to the old one, based primarily on measuring how many people are signed up for treatment, and the problem with that is it doesn't tell you whether treatment is actually doing any good.

I really do hope for my own sanity it is not ‘like the rocket fired into the English drug treatment structure, an Emperor's New Clothes moment’.


I for one am very uncomfortable with the system we have in Scotland that encourages and reinforces dependency. Recovery for me is about empowering people to be in charge of their own destiny, not a service who knows whats best for CLIENTS as we have seen for the last 30 years but one that says your the expert in your addiction, how can i support you into negotiating the stigma you are up against, how can i facilitate you to building your social skills and networks again, How can I FACILITATE you in your finding employment and somewhere safe to live and how can I FACILITATE you with dealing with how organisations institutions people in general will react to you now that you are no longer using? I MEAN HAND OVER RESPONSIBILITY TO THE CLIET AND EMPOWER and FACILITATE THEM,not run about like a blue arse fly singposting to services that will ultimately singpost to someone else and all the boxes everywhere get ticked and no one actually recovers!

A final warning from our friend Mr WHITE
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.

David Clark said...

I'm with you on that, treatment is not a fixed set of things - and the things that are used or happen will vary across time, depending on what the client wants and needs (sorry good treatment!).
Yes, as you say, sometimes changes in the environment can be an effective 'intervention' (not sure intervention is right word) because, for example, it may free the person up to focus more on tackling their problem.
Whatever treatment is, it must be helping the person get somewhere - and that must be recovery. The person plays an important role in determining what their recovery is.
I'm trying to write something on addiction at moment, seeing it being underlaid by a set of 'abnormal' external and internal 'forces' on the person - these need to dealt with to help the person find recovery. Make sense?

David Clark said...

Dr Dave,
No the cupboard effect may work for some, but probably not for most. They need guidance, support, discussion, empathy, reflection, to help them find where they are going and to get there (this is what treatment is, I thinks, professional assistance). Although I know many people argue that the form of professional assistance needed is not there in a lot of treatment agencies - or people are not being allowed to use their skills to the full extent.
Have you read "How Clients Make Therapy Work' by Arthur Bohart and Karen Tallman?. Mike Ashton put me onto it and it has really made me think in different ways about what is going on.
Your third paragraph, I don't know if I like the word disease, because it is interpreted in bad ways by some people and can end being stigmatising and leading people to develop inappopriate interventions. NIDA have spent multi-millions promoting the idea of it being a disease and the value of drug treatments, etc. Now as a former successful neuroscientist, I think what NIDA is doing is wrong. They are not educating people properly, in fact they are misleading people. It is wrong!! There is far more to addiction then they portray - it's like they are in a marketing exercise, a poor one at that.
There are no doubt that drugs produce changes in the brain - my colleague Paul Overton and I developed a theory of addiction based on plasticity changes in teh brain. But so do memories and the process of learning to ride produces long-term changes in the brain. We have to be careful here.
I agree that biological and social changes can be fitted together. The trouble is with this field is there are so many inflexible people, who can only think in blacks and whites.
I love your second last paragraph but your last paragraph should read 'long live good treatment'. But I know you know that.

David Clark said...

Timmy-one-leg as we've come to know you,
There are going to be a number of agendas out there in the UK about recovery, some of them not genuine. People will want to maintain the status quo and will therefore pay lip service.
They will join us and then deliberately misinterpret us, and say we said this when we said that. This will be par for the course.
We will get the message out there and make sure people know what we are saying. And we will be strong!
We know it can work. And we know who we are working for, the people who have been affected by substance use problems.
Yes, the English plan hasn't really changed - they've thrown in families, but would have been killed if they had not - and probably won't change a great deal. It will be portrayed to have changed.
The real thing for the Scots is whether they will really take the path to recovery, at all levels of the system. Education and training will be key. It will be interesting to see whether the leaders and people at all levels engage with what we are doing. That will be one little test of whether Scotland is really engaged.
But you know there is a small group of us who will push, push, push the agenda in Scotland.
Keep the passion, the writing, etc going. I am learning from you, and you are feeding my passion.