Wednesday, 25 June 2008

Changing the focus of the treatment system: helping it achieve much more success

Last week, I had a long phone conversation with Bill White, a major player in the Recovery Movement in America, updating him on what is happening in the UK as he is very interested. He also talked about some of the things that had happened on his side of the big pond.

Here are some of his thoughts in our discussion.

Government-led treatment systems tend to be based on a social cost model. This model focuses on manipulating and controlling people who are addicted to drugs, toward the aim of reducing crime, threats to public safety, medical care costs and other community-born costs of addiction.

However, a quite different organising framework is to organise the treatment system with a primary focus on personal and family recovery. That focus generates long-term reductions in social costs, but it does so as a side-effect, rather than a substitute for recovery. The recovery approach empowers and transforms people with substance use problems from community deficits to community resources.

The focus should move beyond what people are not doing (e.g. committing crime) to what recovering individuals and their families are adding to the life of communities. Control is about pathology reduction; recovery is about the addition and multiplication of assets.

Think about where the treatment system in the UK is today, and where it needs to go! And join us in that journey to place recovery to the fore in the treatment system.


Anonymous said...

I had a conversation with David Clarke last week. I share his passion for the work of Bill White. We said how we needed to keep the recovery tent (or the umbrella) as big as possible for as long as possible. Civil war between different recovery pathways will not help the user in the end or the end user. BUT, I do have to put on my local authority Chief Executive Department hat on here to respond to this blog. Investment in easy access methadone maintenance does provide a crime reduction yield and it does keep people alive. And, as Kev has said on his blog, the better methadone programmes can introduce ideas of recovery and start recovery journeys. But, my point is, if you were the CEX of a Local Authority that had a large group of socially excluded, heroin addicted, criminals, you might want to try and offset the harm they do to the community (crime and BBV etc) by first and foremost providing easy access methadone. You might want to do this as part of your community safety strategy. You might also want to invest in something more specifically geared to recovery. But, if you had a limited amount of money, what proportion would you direct to crime reduction and public health and safety compared to individual and family recovery. Moreover, if you suspect that most recovery comes from mutual aid self help that is fed by a form of "street darwinism" you might not be keen to direct too much of the resources towards the recovery side. Most of the funding in the current English treatment system is geared toward crime reduction and public health and safety. If we move away from this (as Paul Hayes has said many times) the resource may go with it. Now, it might be that some would say "que sera". Let the money go and lets start again. Dont worry I'm still under the recovery umbrella but I am also in the harm reduction tent too. But, I do spend a lot of time with senior people in Local Authorities and even some PCTs who are vaguely interested in recovery - as long as it doesnt compromise the crime reduction, public health and the reduction in drug rekated deaths. I suppose what I am saying is - reality check time. Mark Gilman

tim1leg said...

Mark I am not following, can you spell out exactly what it is you are saying? Im as subtle as a brick and find it difficult to understand those who possess this skill.

Anonymous said...

I think it was Prof. Max Glatt, the pioneer of alchoholism treatment in the UK who said, "no one can live with an active alcoholic and expect to retain their own sanity".

He held strong views on recovery interventions which included each member of the immediate family.

His words have always stuck in my mind, never more so than when I meet the partner of the addicted, the resentment, the anger, the bafflement, all are palpable, and yet like the addicted the partner is often in denial.Or, at best the partner is unaware of how, or to the extent that their partner's addiction has affected them. Without intervention, all the above and the
disappointment can fester and continue for many years after the addicted is well into recovery.

The founding members of AA realised this early on, hence the establishing of Alanon,and subsequently Alanteen for the children of alcoholics. The former is sometimes jestingly referred to as the church of 'Our lady of perpetual revenge'.

I don't know if there is any empirical evidence which indicates how effective these organisations are in the recovery process, but I do know from observation of my clients over the years that those who do attend the fellowships, appear to be much happier than those who choose not to.

I also know I've lost count of the number of non addicted partners, who when their addicted partners entered treatment, were on anti depressants and, or sleeping pills, yet with a few therapy sessions they came to understand that it was not so much depression they were suffering from, but anger and disappointment, and started to attend Alanon, no longer felt the need for their 'medication'.

Yes, i believe addicion is a family disease.

Anonymous said...

Where on the continuum of substance use do the intervetions lie? It takes a lot for people to get the point where they contemplate and then decide to change. Many people enjoy using, even apparently to their detriment.
People often say 'I wish I had this or that intervention then and things would have been different'; I suggest they probably wouldn't just like when people say they wish they hadn't messed about at school - it's just the human condition.

Mark Gilman said...

Tim1 Leg,

I'm glad you asked for clarification. I need to explain myself better to understand my own position. Apart from a few years in Bradford, West Yorkshire (University) I have lived and worked in and around Manchester all my life (I'm 52 next). I have watched brown powder heroin sweep through the socially excluded. I am now watching Crack Cocaine grip the same people (or their children and Grandchildren). I have watched as alcohol has joined heroin, crack and benzos in the cocktails of oblivion for the socially excluded. I have seen methadone (often without any psycho-social) improve people's lives because they no longer have to go out "grafting" (committing crimes). About 2 months ago I was in a house with a guy who was on 40mls methadone. He was drinking alcoholically, using heroin and crack daily. I asked him what role did the methadone play in that mix and in his life. The answer was simple - he had a choice whether or not to go out grafting. If he wanted he could take the methadone and stay in and watch telly. His mates who were not in treatment were "grafting" pretty much every day. He only went out grafting when his Crack use was out of control. So, lets say the cost to the DAT of his treatment is about £2000 per year (it is a bit less I think) it could be seen as a wothwhile investment on the grounds of the crime reduction yield. This guy has not been to prison since he has been on methadone. Most of those around him who are not on methadone have been in prison many times. So, he is IN TREATMENT but he looks terrible and he wouldnt be a poster bot for methadone maintenance. He has tried total abstinence and didnt like it. Of course, we all hope and pray he tries again (personally I believe he will). The point I am trying to get at is that we must carry on providing the methadone and the needles to people like him whilst at the same time offering abstinence based recovery to him and everyone else. In theory, we could turn off the methadone taps and offer everyone abstinence and recovery. But, we suspect that crime would go up and more people would die. So, we have two pathways. One pathway is dominated by methadone and the other by abstinence based recovery. Currently, most people are on the methadone pathway. We would like to see all those that can move across to the abstinence recovery pathway, get a job, look after their kids etc...etc. I have another issue going on as well. I think we are confusing people who have problems with drugs (Problem Drug Users - PDUs) with REAL ADDICTS as described in the 164 pages of the book. I know people who are dependent on heroin and other drugs who do not identify with the definition of the real alcoholic/addict. As you know the 12 step programme of recovery is a spiritual programme to solve the spiritual malady that defines the plight of the real addict. I am coming to believe that real addiction (as described in the book as real alcoholics) is an equal opportunity employer and recruits from across most of society. But, Problem Drug Use (including dependency) is disproprtionatley located in socially excluded communities. I'll stop there before I confuse myself. All the best. Mark

Francis Cook said...

Following on from Mark's comment: I agree with the practical measures proposed by White et al (never forget Al), but strategically/philosophically it only gets you half way. Here's my argument:
Just as it seems some may never achieve their 'full potential' and, having gained control of their drinking/drug use may, if they wish drink or imbibe in a manner deemed Socially Acceptable, having to halt at the abstention stage of recovery and proceeding no further owing to the nature of their particular demons, so users of narcotic drugs-some of them- may proceed no further in the recovery process described than the Substitution /medically treated stage.
In either or both cases I am convinced that health and quality both exists and may improve with assistance.
Francis Cook

Francis Cook said...

But others lead a normal (medicated, as so many of us are and always have been) life with less than 40mLs MTD. A small percentage I'll grant you, but a minority significant enough to shed light on 'the problem' and be part of the treatment continuum.
Francis Cook

tim1leg said...

Thanks for that Mark, essentially we agree then that there is a place for methadone with proper support and a pathway that gives the user the choice of abstinence should they so wish.

I too have watched my own community in Ayrshire be devastated firstly by Brown(not the prudent one) then watched in horror as former heroin addicts in treatment turn into alcoholics who use methadone become ever more bloated and sick but hey "I'm only grafting twice a week now instead of every day". As you said yes this will undoubtedly reduce crime but the health and well being of those in "treatment" and i use that term lightly, continues to suffer, but who cares they are only addicts, right as long as they are not mugging your granny and stealing bacon out of Iceland let them get on with it!

To bring in to the debate those who are not real addicts, ie those who have not lost control of their substance use is muddying the water my friend.

But thanks for the clarity.
As we know political and diplomacy skills are well valued in our field but they can also allow fence sitting and circular discussion. I personally would like to see a whole lot less of this.

Anonymous said...

What do you mean by 'street darwinism' - and the rest of that sentence. I would like to be sure before I make up my mind as to whether you are being derogatory, patronising,both or opaque in your discription of self help groups such as NA and AA. It doesn't seem likely that you view them particularly positively.
I agree some people are not so much real addicts as problem drug users - when though, does generations of substance misuse in socially deprived and excluded communities become real addiction? For the communities I think you are referring to, that line was crossed many generations back. The addicts we work with today from deprived and excluded commuities nearly all describe coming from alcoholic/addicted parentage and grandparentage. Real addiction can always be attributed in part to learned behaviour and possibly to genetics. The client you described is in desperate active addiction. It is not being arrested or even managed very well by him being on methadone - his life is still very much controlled by his addiction and he is no doubt pretty miserable.
The fact that he is living in social deprivation makes his predicament even more desperate - in the long term that does not give him much of a chance of living a productive and fulfilled life on a methadone script. But that isn't important to the policy makers so long as he is in treatment or going round and round that revolving door. Never mind, what he wants that is too expensive - hang on a minute! Just had a brain wave! - it costs nothing to suggest 12 step meetings to people, to tell them what they are about, to give them the helpline number and a where to find, tell them about how much they have helped alot of people, even go so far as to invite some people who are in recovery into your service to speak to clients who are interested. All that for absolutely nothing!! But I guess if you believe that 'mutual aid self help' groups are 'street darwinism' and possibly don't really know what they are all about never having been to more than one or two and basing your opinions on very little information and experience at all - you would'nt give very sound and free information to desperate people that may save some of their lives.
It is possible to get the motivation, hope and support in meetings to stop using drugs, services should enhance that process rather than obstruct it.

Anonymous said...

Tim 1 leg,

We agree. What you see in your part of the world is what I see. My point was that as long as there is a demonstrable crime reduction dividend from the investment in that kind of treatment it is defensible - from a Community Safety, Public Health and Harm Reduction perspecyive - do I think its the kind of treatment I would want for me and mine - absolutely not! As for the real addiction stuff. I was reading the Big Book of AA again in preparation for opening last night's Candle Light Vigil in Liverpool for thise lost to Addiction and Alcoholism and I was reflecting on how alcoholism seems to affect a much wider range of people. I have been a "friend of recovery" (see Bill White's work) since 1995. I guess I must have been to over a hundred AA/NA/CA open meetings since then as well as conventions etc. I was wondering why heroin and crack problems are so obviously disproportionatley a feature og social exclusion whereas alcohlism does not discriminate in that way. A good friend of mine (Stuart Honor) rang me to say "legal status stupid". To which I went "doh!". So, I spologise for throwing the real addict bit in. Served only to confuse - sorry. My refernce to "street Darwinism" refers to my experince of the last 2 or 3 years. There is a disproportinate number of PDUs entering 12 Step recovery and doing really well who were once PPOs (Prolific and Priority Offenders). They usually beging their journey to Recovery in prison. At last nights vigil in Liverpool it felt like being in the midst of a really tight "firm". Last word - thanks to all at last night's vigil. It was fantastic. There is hope. There is recovery. BUT, the consumers are going bto have to demand it. A recovery revoltion led by the consumers. Mark Gilman

Anonymous said...

Maybe 'street darwinism' means 'street theory of evolution'. In which case I assume Mr Gilman IS being derogatory and patronising. Am I right to come to the conclusion that he feels because there is no intellectual might overseeing meetings, dictating recovery and scientfically and empirically evidencing that it works, that therefore recovery in fellowships and other mutual aid groups is unevolved!
If this is his angle, then quite clearly I am right - he has never been to meetings or met many people in recovery, because unevolved emotionally, intellectually or spiritually we are not!
But there lies the key my friends! It is precisely because of this that so many professionals find the recovery movement so threatening.
We challenge their belief in the current treatment policies coherently and robustly, revealing the very weak arguments they hide the truth of their failure to really intelligently manage the crisis our society is in regarding substance misuse.
Once again I acknowledge that abstinence is not going to be for everyone. However if services were expected to be truthfully and positively encouraging attendence at meetings and other support groups and staff were properly trained and informed about the 12 steps instead of being fed uninformed prejudicial anecdotal tales about cults and religion, god squad, brainwashing etc, if services routinely invited recovering people in to speak to clients, if harm reduction services were less discriminatory about employing people in recovery, then I beleive some clients would be able to change the course of their lives.

Anonymous said...


OK you win.

God Bless You.

Tim 1 Leg,

We will probably meet up in real life when David gets back or via Kev.

Mark Gilman

Anonymous said...

It is not the case that crack and heroin addiction are more likely to affect the socially disadvantaged, it's just that we are more likely to see those people in services. More middle class clients tend to end up in rehab, side stepping community services. Believe me crack and heroin addiction is alive and thriving in all classes, it is simply easier to hide it and not get arrested when you have money, education, job etc to hide it all behind. Addicts from more advantaged bacgrounds are mor likely to get help through their family and gp. I myself am a case in point. I will say that in London the client group is a very mixed bag demographically speaking both in sevices and in NA. Sorry but still don't get the street darwinism thing!Is it something to do with the ppo thing and convicts and darwin and australia? Am i a bit thick, just don't get it!!

tim1leg said...

cheers Mark i look forward to meeting you and always good to meet another who regards Bill whites work highly. If only the whole field were educated in his teaching we would not be so blocked, as we are now. Respect and thanks for your thoughtful reply, and for being a "friend" we need more.

JJL said...

What a great topic and healthy debate.

Its all about choices. But if you dont know youve got any because people refrain from telling you have them, actually have you got any choice at all?

The old story of if a tree tumbles down in a forest and there is no-one there to hear it does it even make a noise?

I think its time a very big noise was made.

I agree with Mark, that at the vigil on Friday in Liverpool, there was a remarkable feeling in the air. One of being in the presence of something very positive, warm, loving and open. Its called recovery!

There were over 200 names on that memoriam roll call. How many more people have to die before we fianlly get that we have a legal, moral and ethical responsibility to always offer CHOICES!!!!

Bill White, Mark Gilman, David Clark, Tim Leighton.....please keep making a noise and hopefully many of will join you in the caucus.

Anonymous said...

What a great debate. I think we have enough experience in the UK treatment system to now understand that abtinence as a single offering has flaws and that offering methadone as a single offering has flaws.

As someone who has decided to pursue an abstinent path for my life I also respect any persons free will and rights to pursue recovery via a medically assisted pathway. If it works for them and that is their ambition in life then I would advocate for their right to achieve that.

I think what every decent human being working in this very difficult field would want is for addicts and alcoholics to have the ability to pursue recovery of their own choice. To do that they need to have access to ALL of the information about what recovery choices are on offer.

I run a 12 step orientated rehab and day programme service. So if they came to me I'd be advocating my service and way of life...hardly surprising there! If they went to a CDT and met a key worker used to scripting clients they'd be offered a surprises there either.

What about having a treatment system where all clients are shown all of the potential routes for recovery and supported in making their own infomed choice.

That to me is the goal of the current recovery movement. Not advocacy of abstinence versus methadone. That is a fruitless argument which polarises people rather than creating unity in fighting addiction.

Tom Kirkwood